|Year : 2019 | Volume
| Issue : 2 | Page : 75-78
Impact of a multicomponent strategy on utilization of cardiac rehabilitation services in a tertiary care hospital from a lower middle-income Country: A retrospective analysis
Veena Kiran Nambiar1, UN Nagamalesh2, Mukta Pitambare3, Gloria Alva1
1 Department of Physiotherapy, Ramaiah Medical College and Hospitals, Bengaluru, Karnataka, India
2 Department of Cardiology, Ramaiah Memorial Hospital, Bengaluru, Karnataka, India
3 Centre for Rehabilitation, Ramaiah Memorial Hospital, Bengaluru, Karnataka, India
|Date of Submission||25-Aug-2019|
|Date of Decision||16-Nov-2019|
|Date of Acceptance||16-Nov-2019|
|Date of Web Publication||23-Dec-2019|
Dr. Veena Kiran Nambiar
Department of Physiotherapy, M S Ramaiah Medical College, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Context: Globally, uptake of cardiac rehabilitation (CR) is low, more so in lower middle-income countries (LMICs) compared to developed nations. LMICs share a greater burden of cardiovascular diseases, and hence, there is an urgent need for enhancing CR services.
Aims: The objective of this retrospective study was to describe a multicomponent strategy employed in a tertiary care hospital from an LMIC and to improve CR services and its impact on CR availability, uptake, and barriers.
Materials and Methods: To ensure the CR availability and uptake, a multi-component strategy involving sensitization of all concerned health-care team members about the importance and need of CR, strengthening infrastructure and resources, laying down appropriate clinical pathways, and culturally adapting standard guidelines and protocols were put in place. For the present retrospective analysis, utilization of CR services by patients diagnosed with coronary artery disease (CAD) was extracted from the medical records of the hospital.
Results: Between February 2017 and December 2017, a total of 629 patients with diagnosis of CAD underwent percutaneous transluminous coronary angioplasty (PTCA) (78%) or coronary artery bypass grafting (CABG) (22%). All patients (629) received Phase I rehabilitation (rehab) (100%), 145 patients (23%) received Phase 2 rehabilitation, and 44 patients (7%) received Phase 3 rehabilitation. Residence location, gender, dependency on caregivers, and employment status were identified as barriers to Phase 3 CR uptake.
Conclusion: This multi-component strategy positively influenced CR uptake, and a few barriers were identified that need to be addressed.
Clinical Implication: Importance of multidisciplinary and multicomponent strategic management to increase the uptake in a CR program.
Keywords: Barriers to cardiac rehabilitation, Cardiac rehabilitation, Core components of cardiac rehabilitation, Phases of cardiac rehabilitation, Uptake of cardiac rehabilitation
|How to cite this article:|
Nambiar VK, Nagamalesh U N, Pitambare M, Alva G. Impact of a multicomponent strategy on utilization of cardiac rehabilitation services in a tertiary care hospital from a lower middle-income Country: A retrospective analysis. Indian J Phys Ther Res 2019;1:75-8
|How to cite this URL:|
Nambiar VK, Nagamalesh U N, Pitambare M, Alva G. Impact of a multicomponent strategy on utilization of cardiac rehabilitation services in a tertiary care hospital from a lower middle-income Country: A retrospective analysis. Indian J Phys Ther Res [serial online] 2019 [cited 2020 Apr 10];1:75-8. Available from: http://www.ijptr.org/text.asp?2019/1/2/75/273726
| Introduction|| |
The joint statement of the American Heart Association (AHA) and American Stroke Association defines cardiac rehabilitation (CR) as “a medically-supervised program consisting of exercise training, education on heart-healthy living, counseling to reduce stress, and helping patients return to an active lifestyle and recover sooner.” CR offers a multifaceted and highly tailored approach to boost the overall physical, mental, and social functioning of people with heart-related problems. It is recommended for both inpatient and outpatient settings for the following conditions such as myocardial infarct, heart failure, post CABG, PTCA, heart transplant, implantable cardioverter-defibrillator, and valve replacements. The WHO global action plan for prevention and control of noncommunicable diseases (2013–2020) recommends all patients with cardiac ailments to have an access to CR as a policy. Despite its clear and tangible benefits, CR uptake is suboptimal worldwide and is only available in approximately one quarter of the middle-income countries and one-tenth of the low-income countries (LICs). Only 38.8% of the countries globally have CR programs, 68% of the high-income countries, 23% of lower middle-income countries (LMICs), and 8.3% of LICs have CR. There is limited information on CR availability and uptake in India, and research studies on CR programs and uptake are lacking. In a national survey done by the American Association of Cardiovascular and Pulmonary Rehabilitation in 2016 on CR programs to increase CR but it was found that there were, participation rate gaps, infrequent quality improvement initiatives, and inconsistently underused strategies to improve the participation rates. The outpatient setting had the lowest reported referral rates, lowest monitoring of rates, and lowest utilization of systematic referral. In addition, many of the programs were not utilizing their inpatient program effectively, neither systematic referral nor liasoning as a part of the hospital referring strategy, all of which are the key factors to increase the CR referral.
To strengthen the availability and uptake in CR services, our hospital introduced a slew of measures in January 2017. This proposal, using a retrospective design, evaluated the impact of a focused multipronged strategy on utilization of CR services over an 11-month period. Using descriptive statistics, this study was analyzed. The number of patients who were eligible to receive CR during the 11-month period, the frequency and proportions of types of services received were reported and comments on the perceived challenges in implementing the program was documented. The goal of CR is to boost the overall physical, mental, and social functioning of people with heart-related ailments and helping them to return to lead an active and normal a life as possible in the community. It has been recommended as useful and effective by the AHA and the American College of Cardiology for both inpatient and outpatient settings for all heart conditions. Currently, there are limited data on availability of CR programs and related research in India. The existence of Phase I rehabilitation in many tertiary care settings is anecdotal and is not supported by the research reports on the availability of CR services, its utilization and impact. Neither reports on CR policies nor the recruitment strategies are available. Based on anecdotal evidence, it is observed that despite having requisite resources, CR availability and uptake are minimal. If CR programs exist, it is important to document and report its availability and uptake to ensure sharing of information on various strategies, impact and barriers for the benefit of all stakeholders. Thus, there is a need to strategize CR programs to facilitate its research and clinical implementation. This retrospective analysis, therefore, attempts to describe the strategies employed to improve CR services and its impact on availability, uptake, and barriers.
The uptake of CR has been very low globally. There are many strategies carried out by AHA like the million heart project to facilitate and improve adherence and participation in CR programs. However, there are no reported strategies used in the Indian context to improve participation of the patients into the CR program.
The purpose of this study was, therefore, to incorporate a multi-component strategic comprehensive CR program and to study its outcomes which were participation in the phases (1, 2, and 3) of the CR program. In addition, the purpose of the study was also to document the various barriers perceived to participate in a CR program.
Therefore, the objective of the study was to describe a multicomponent strategy employed to improve CR services and their impact on CR availability, uptake, and barriers.
| Materials and Methods|| |
Ethical approval was taken from the ethical review board of the institution. The data were included from the patients who underwent CABG or PTCA, and all other cases were excluded from the study.
Patient data from the period of February 2017 to December 2017 were extracted from the hospital records and analyzed for the uptake of CR services. The outcome measures assessed were number of patients treated, number of participants in all three phases of CR and services delivered. Descriptive statistics was used to study the population and analyze the results.
In January 2017, a policy decision by all stakeholders was taken that CR is essential and should be offered to all eligible patients. To ensure the CR availability and uptake, a multi-component strategy involving following steps was done.
(a) Sensitization of all concerned health-care team members about the importance and need of CR: the stakeholders including the caregivers were explained about the condition and importance of CR and these were disseminated in the way of educational booklets, counseling, audio-visual aids, and periodic follow-up, (b) Strengthening infrastructure and resources: this was achieved with a multidisciplinary approach by having all the professional resources which include cardiologist, cardiac surgeon, physical therapist, clinical psychologist, dietician, and a rehabilitation nurse, (c) laying down appropriate clinical pathways: which was carried out by the following clinical practice guidelines which were based on evidences, (d) culturally adapting standard guidelines and protocols were put in place: the protocols include CR, nutrition counseling, smoking cessation therapy, psychological counseling, and educational sessions for the patients and their caregivers. This was followed by regular team meetings of stakeholders to monitor the implementation and progress. For the present retrospective analysis, utilization of CR services by patients diagnosed with coronary artery disease (CAD) was extracted from the hospital medical records.
| Results|| |
Data analysis was done by descriptive analysis. Descriptive statistics was done using the SPSS Software (Statistical Package of Social Science Software (SPSS), IBM, version 10, India). The categorical variables were described in terms of frequencies and percentages. Between February 2017 and December 2017, a total of 629 patients with a diagnosis of CAD underwent PTCA (78%) and CABG (22%). All patients received Phase 1 rehabilitation (100%), 145 patients (23%) received Phase 2 rehabilitation, and 44 patients (7%) received Phase 3 rehabilitation [Table 1]. The barriers identified in this study toward participation to Phase 3 CR uptake were residence location, gender, dependency on caregivers and employment status [Table 2].
|Table 2: Barriers for attendance into the cardiac rehabilitation program|
Click here to view
| Discussion|| |
As a policy in this study, all patients mandatorily received Phase 1 rehabilitation. This was strategized in line with the core components of CR. It includes lifestyle modification counseling inclusive of smoking cessation when indicated, diet and physical activity, education on management of risk factors such as dyslipidemia, hypertension, and diabetes, exercise training, and psychological counseling. As referral rates being a concern to decreased participation rates into a CR program, a study was done which described the effects of CR referral strategies on referral and enrolment rates. It was concluded that strategies that use automatic or liaison strategies combined with a patient CR letter has shown 58%–86% enrolment rates.
There was only a 17.1% entry into Phase 2 CR program which includes exercise prescription based on the heart rate and rate of perceived exertion. In the Western model, CR program is often provided as a continuum to the cardiac care offered, beginning at the hospital as Phase 1 followed by Phase 2 and 3. At present, there is no official registry of these programs in India, making it difficult to quantify the number or structure of existing programs. However, many hospitals across the country do offer Phase 1 CR, but with less emphasis on the patient education.
Only 9.3% of the total patients enrolled into the Phase 3 CR program which was a customized outpatient exercise training program. Apparently, there are not much studies done on uptake in India.
In addition to the identified barriers in our study, other barriers for poor participation are several psychosocial factors, low-socioeconomic status, perception of importance of CR, lack of policy for CR, absence of central registry, poor CR density, limited centers offering CR, insurance coverage, and lack of awareness among health-care providers. All these are with regard to high- and middle-income countries; however, no one comes out with recommended strategies to deliver all core components of CR in low-resource settings in LMICs and LICs.
Strategies that can be employed to increase CR uptake by (1) increasing the patient demand for CR, then there will be pressure to increase provision (bottom-up approach) by low cost, (2) systematic CR referral as a policy, (3) providing reimbursement approaches, (4) supplement traditional CR programs with alternative models of delivery such as Internet-based, telehealth, group-based CR programs in community centers, and home-based programs. Out of all the barriers to participation in CR in this study, lack of awareness was ranked the topmost out of a patient perspective. Patients were unaware of the benefits of a CR program.
Strategies to improve uptake in a CR program should be carried out like improving awareness among the patients as well as the health-care providers in terms of evidence in the literature and global health-care practices, promoting advocacy by the physicians, and also working toward a low-cost model of rehabilitation to cater to all sections of the community. Thus, some of the other barriers in our Indian context such as financial constraints, transportation, and dependency could be tackled by building a low-resource model of CR in the community.
Future, the research could aim at evaluating the outcomes of a multi-component strategic CR program.
| Conclusion|| |
The multi-component strategy used in the present study, positively influenced CR uptake and a few barriers were identified that need to be addressed.
Similar strategic plans can be employed to carry out CR programs in other hospital settings and centers.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Turk-Adawi K, Sarrafzadegan N, Grace SL. Global availability of cardiac rehabilitation. Nat Rev Cardiol 2014;11:586-96.
Pack QR, Squires RW, Lopez-Jimenez F, Lichtman SW, Rodriguez-Escudero JP, Lindenauer PK, et al
. Participation rates, process monitoring, and quality improvement among cardiac rehabilitation programs in the United States: A national survey. J Cardiopulm Rehabil Prev 2015;35:173-80.
Gravely-Witte S, Leung YW, Nariani R, Tamim H, Oh P, Chan VM, et al
. Effects of cardiac rehabilitation referral strategies on referral and enrollment rates. Nat Rev Cardiol 2010;7:87-96.
Madan K, Babu AS, Contractor A, Sawhney JP, Prabhakaran D, Gupta R. Cardiac rehabilitation in India. Prog Cardiovasc Dis 2014;56:543-50.
Babu AS, Veluswamy SK, Contractor A. Barriers to cardiac rehabilitation in India. J Prev Cardiol 2016;5:871-6.
Grace SL, Turk-Adawi KI, Contractor A, Atrey A, Campbell NR, Derman W, et al
. Cardiac rehabilitation delivery model for low-resource settings: An international council of cardiovascular prevention and rehabilitation consensus statement. Prog Cardiovasc Dis 2016;59:303-22.
[Table 1], [Table 2]