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      Cardiac Rehabilitation Availability and Density around the Globe

      research-article
      a , b , c , c , d , e , f , g , h , i , j , k , l , m , n , o , p , q , r , s , t , u , v , w , x , y , z , aa , ab , ac , ad , ae , af , ag , ah , ai , aj , ak , al , am , an , ao , ap , aq , ar , as , at , au , av , aw , ax , ay , az , ba , bb , al , bc , bd , c , be , d , bf , *
      EClinicalMedicine
      Elsevier
      Cardiac rehabilitation, Capacity, Density, Preventive cardiology, Global health, Health services

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          Abstract

          Background

          Despite the epidemic of cardiovascular disease and the benefits of cardiac rehabilitation (CR), availability is known to be insufficient, although this is not quantified. This study ascertained CR availability, volumes and its drivers, and density.

          Methods

          A survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Factors associated with volumes were assessed using generalized linear mixed models, and compared by World Health Organization region. Density (i.e. annual ischemic heart disease [IHD] incidence estimate from Global Burden of Disease study divided by national CR capacity) was computed.

          Findings

          CR was available in 111/203 (54.7%) countries; data were collected in 93 (83.8% country response; N = 1082 surveys, 32.1% program response rate). Availability by region ranged from 80.7% of countries in Europe, to 17.0% in Africa (p < .001). There were 5753 programs globally that could serve 1,655,083 patients/year, despite an estimated 20,279,651 incident IHD cases globally/year. Volume was significantly greater where patients were systematically referred (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.35–1.38) and programs offered alternative models (OR = 1.05, 95%CI = 1.04–1.06), and significantly lower with private (OR = .92, 95%CI = .91–.93) or public (OR = .83, 95%CI = .82–84) funding compared to hybrid sources.

          Median capacity (i.e., number of patients a program could serve annually) was 246/program (Q25-Q75 = 150–390). The absolute density was one CR spot per 11 IHD cases in countries with CR, and 12 globally.

          Interpretation

          CR is available in only half of countries globally. Where offered, capacity is grossly insufficient, such that most patients will not derive the benefits associated with participation.

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          Most cited references16

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          Cost-effectiveness of cardiac rehabilitation: a systematic review

          Patients may be offered cardiac rehabilitation (CR), a supervised programme often including exercises, education and psychological care, following a cardiac event, with the aim of reducing morbidity and mortality. Cost-constrained healthcare systems require information about the best use of budget and resources to maximise patient benefit. We aimed to systematically review and critically appraise economic studies of CR and its components. In January 2016, validated electronic searches of the National Health Service Economic Evaluation Database (NHS EED), Health Technology Assessment, PsycINFO, MEDLINE and Embase databases were run to identify full economic evaluations published since 2001. Two levels of screening were used and explicit inclusion criteria were applied. Prespecified data extraction and critical appraisal were performed using the NHS EED handbook and Drummond checklist. The majority of studies concluded that CR was cost-effective versus no CR (incremental cost-effectiveness ratios (ICERs) ranged from $1065 to $71 755 per quality-adjusted life-year (QALY)). Evidence for specific interventions within CR was varied; psychological intervention ranged from dominant (cost saving and more effective) to $226 128 per QALY, telehealth ranged from dominant to $588 734 per QALY and while exercise was cost-effective across all relevant studies, results were subject to uncertainty. Key drivers of cost-effectiveness were risk of subsequent events and hospitalisation, hospitalisation and intervention costs, and utilities. This systematic review of studies evaluates the cost-effectiveness of CR in the modern era, providing a fresh evidence base for policy-makers. Evidence suggests that CR is cost-effective, especially with exercise as a component. However, research is needed to determine the most cost-effective design of CR.
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            Global availability of cardiac rehabilitation.

            Cardiovascular disease (CVD) is the most-prevalent noncommunicable disease and leading cause of death globally. Over 80% of deaths from CVD occur in low-income and middle-income countries (LMICs). To limit the socioeconomic impact of CVD, a comprehensive approach to health care is needed. Cardiac rehabilitation delivers a cost-effective and structured exercise, education, and risk reduction programme, which can reduce mortality by up to 25% in addition to improving a patient's functional capacity and lowering rehospitalization rates. Despite these benefits and recommendations in clinical practice guidelines, cardiac rehabilitation programmes are grossly under-used compared with revascularization or medical therapy for patients with CVD. Worldwide, only 38.8% of countries have cardiac rehabilitation programmes. Specifically, 68.0% of high-income and 23% of LMICs (8.3% for low-income and 28.2% for middle-income countries) offer cardiac rehabilitation programmes to patients with CVD. Cardiac rehabilitation density estimates range from one programme per 0.1 to 6.4 million inhabitants. Multilevel strategies to augment cardiac rehabilitation capacity and availability at national and international levels, such as supportive public health policies, systematic referral strategies, and alternative models of delivery are needed.
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              ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practical Guidelines

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                Author and article information

                Contributors
                Journal
                EClinicalMedicine
                EClinicalMedicine
                EClinicalMedicine
                Elsevier
                2589-5370
                03 July 2019
                August 2019
                03 July 2019
                : 13
                : 31-45
                Affiliations
                [a ]QU Health, Qatar University, Al Jamiaa St, Doha, Qatar
                [b ]Gregorio Marañón General University Hospital, Gregorio Marañón Health Research Institute, Dr. Esquerdo, 46, 28007 Madrid, Spain
                [c ]Mayo Clinic, Rochester, 200 First St. SW, Rochester, MN 55905, USA
                [d ]York University, 4700 Keele Street, Toronto, Ontario M3J1P3, Canada
                [e ]Peiking University People' Hospital, 11 Xizhimen S St, Xicheng Qu, Beijing Shi, China
                [f ]Universidade Federal de Minas Gerais, Av. Pres. Antônio Carlos, 6627 - Pampulha, Belo Horizonte, MG 31270-901, Brazil
                [g ]Institute for Cardiology and Sports Medicine, Dep. Preventive and Rehabilitative Sport Medicine and Exercise Physiology, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933 Cologne, Germany
                [h ]Stellenbosch University & International Olympic Committee Research Center South Africa, Francie Van Zijl Drive, Stellenbosch 7599, South Africa
                [i ]Hospital Santa Marta, 1169-024, R. de Santa Marta 50, Lisbon, Portugal
                [j ]Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal - 576104, Karnataka
                [k ]Mediagnóstica Duitama, Cra16 #14- 68 oficina 201, Duitama, Boyacá, Colombia
                [l ]Hospital Raja Isteri Pengiran Anak Saleha, Bandar Seri Begawan BA1710, Brunei
                [m ]Philippine Heart Center, East Avenue, Quezon City, Philippines 1100
                [n ]National University Heart Centre Singapore, National University Health System (NUHS) Tower Block, 1E Kent Ridge Road, Level 9, Cardiac Department, Singapore 119228, Singapore
                [o ]University of the West Indies at Cave Hill, St. Michael, Barbados
                [p ]University of Iceland, Saemundargata 2, IS-101, Reykjavik, Iceland
                [q ]Central Hospital of Social Security Institute, Asuncion, Paraguay
                [r ]Institute of Cardiovascular Diseases, Clinical Center of Serbia, Dr. Koste Todorovića 8, 11000 Beograd, Serbia
                [s ]University of Banja Luka, Faculty of Medicine, Save Mrkalja 14, 78000 Banja Luka, Bosnia and Herzegovina
                [t ]Institute of Cardiology, Str. Testemitanu, 20, Chisinau, Republic of Moldova
                [u ]Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Croesnewydd Road, Wrexham LL13 7TD, Wales, United Kingdom
                [v ]Laboratory of Sports Medicine, Aristotle University of Thessaloniki, Thessaloniki 57001, Greece
                [w ]Marmara University, School of Medicine, Department of Physical Medicine and Rehabilitation, Fevzi Çakmak Mah Muhsin Yazıcıoğlu Cad. No:10 Üst Kaynarca Pendik / İstanbul, Turkey
                [x ]Sanggye Paik Hospital, Inje University, Dongil-ro 1342, Nowon-gu, Seoul, Republic of Korea
                [y ]ASCARDIO, 17 Callejón 12, Barquisimeto 3001, Lara, Venezuela
                [z ]ICCCV Instituto de Cardiología y Cirugía Cardiovascular, No. 702 entre A y Paseo, Vedado, Calle 17, La Habana, Cuba
                [aa ]INCOR Instituto Nacional Cardiovascular, Jirón Coronel Zegarra, Jesus Maria, Lima 11, Peru
                [ab ]National Cardiovascular Center Harapan Kita, Kav 87, Jl. Letjen. S. Parman, Jakarta, Indonesia
                [ac ]University of Medicine & Pharmacy "Victor Babes "Cardiovascular Prevention & Rehabilitation Clinic, Bvd CD Loga 49, 300020 Timisoara, Romania
                [ad ]State Hospital for Cardiology, Balatonfüred, Gyógy tér 2, 8230, Hungary
                [ae ]Fu Jen Catholic University Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, No. 69, Guizi Road, Taishan District, New Taipei City 24352, Taiwan
                [af ]The University of Auckland, 71 Merton Road, Private Bag 92019, Auckland 1142, New Zealand
                [ag ]12 Octubre Universitary Hospital, Av. Cordoba, s/n, 28041 Madrid, Spain
                [ah ]Tbilisi State Medical University, 33 Vazha Pshavela Ave, Tbilisi, Georgia
                [ai ]Spanish Association Hospital, 11200, Bulevar Gral. Artigas, 1471 Montevideo, Uruguay
                [aj ]PHYSIS Prevencion Cardiovascular, Cdla Bolivariana Av. del Libertador - Mz I Villa 5, Guayaquil, Ecuador
                [ak ]Instituto Nacional de Cardiología, Belisario Domínguez Sección 16, Belisario Domínguez Secc 16, 14080 Tlalpan, CDMX, Mexico
                [al ]Cardiac Rehabilitation Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Hezar-Jerib Ave., Isfahan, IR 81746 73461, Iran
                [am ]University of Palacky, University Hospital Olomouc, I.P. Pavlova 185/6, Nová Ulice, 779 00 Olomouc, Czech Republic
                [an ]Cardiovascular Research Group, Division of Cardiology, Oulu University Hospital, University of Oulu, Finland
                [ao ]Lithuanian University of Health Sciences, A. Mickevičiaus g. 9, Kaunas 44307, Lithuania
                [ap ]Istituti Clinici Scientifici Maugeri, Care and Research Institute, Department of Cardiac Rehabilitation, Pavia, Italy
                [aq ]Edinburgh Napier University, 9 Sighthill Ct, Edinburgh EH11 4BN, Scotland, United Kingdom
                [ar ]Shaare Zedek Medical Center, the Hebrew University, Jerusalem, Israel
                [as ]Maxima Medical Centre, De Run 4600, 5504, DB, Veldhoven, Netherlands
                [at ]Ślaskie Centrum Rehabilitacji w Ustroniu, Zdrojowa 6, 43-450 Ustroń, Poland
                [au ]Heart House Martin, Bagarova 30, Martin (Podháj), Slovakia
                [av ]Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, United Kingdom
                [aw ]Bispebjerg Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 København, NV, Copenhagen, Denmark
                [ax ]Edinburgh Napier University, 9 Sighthill Ct, Edinburgh EH11 4BN, Scotland, United Kingdom
                [ay ]Sociedad Chilena de Cardiología, Alfredo Barros Errázuriz 1954, Providencia, Región Metropolitana, Chile
                [az ]Cardiovascular Institute of Buenos Aires, Av. del Libertador 6302, 1428 Buenos Aires, Argentina
                [ba ]Loire-Vendée-Océan hospital, Boulevard des Régents, 44270 Machecoul, France
                [bb ]Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
                [bc ]University of British Columbia,2206 East Mall, Vancouver, BC V6T 1Z3, Canada
                [bd ]Moncton Hospital, 135 Macbeath Ave, Moncton, NB E1C 6Z8, Canada
                [be ]Beijing United Family Hospital, 2 Jiangtai Rd, Chaoyang Qu, Beijing Shi, China, 100096
                [bf ]KITE-University Health Network, 399 Bathurst St, Toronto, ON M5T 2S8, Canada
                Author notes
                [* ]Corresponding author at: Bethune 368, York University, 4700 Keele Street, Toronto, ON M3J 1P3, Canada. sgrace@ 123456yorku.ca
                Article
                S2589-5370(19)30100-2
                10.1016/j.eclinm.2019.06.007
                6737209
                31517261
                f98a6758-833b-4e2e-a972-333dac1fa0a5
                © 2019 Published by Elsevier Ltd.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 2 January 2019
                : 6 June 2019
                : 12 June 2019
                Categories
                Research Paper

                cardiac rehabilitation,capacity,density,preventive cardiology,global health,health services

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