Australia, unlike most high-income countries, does not have published benchmarks for cardiac rehabilitation (CR) delivery. This study provides cross-state data on CR delivery for initial benchmarks and assesses performance against international minimal standards.
A prospective observational study March–May 2017 of CR programs in NSW (n=36), Tasmania (n=2) and ACT (n=1) was undertaken. Data were collected on 11 indicators (published dictionary), then classified as higher or lower performing using the UK National Audit of Cardiac Rehabilitation (NACR) criteria. Equity of access to higher performing CR was assessed using logistic regression.
Participants (n=2,436) had a mean age of 66.06±12.54 years, 68.9% were male, 16.2% culturally and linguistically diverse (CALD) and 2.6% Aboriginal and Torres Strait Islander peoples. At patient level, waiting time was median 15 (Interquartile range [IQR] 9–25) days, 24.3% had an assessment before starting, 41.8% on completion, a median 12 sessions (IQR 6–16) were delivered, which 59.1% completed and 75.4% were linked to ongoing care.
At program level, using NACR criteria, 18.0% were classified as higher performing and ≥87.1% met waiting time criteria, however, only 20.5% met duration criteria. Evidence of inequitable access to higher performing programs was present with substantially higher odds for participants living in major cities (OR 28.11 95%CI 18.41, 44.92) and with every decade younger age (OR 1.89–2.94) and lower odds by 89.0% for principal referral hospital-based services (OR 0.11 95%CI 0.08, 0.14) and 31.0% for people having a CALD background (OR 0.69 95%CI 0.49, 0.97).
This study provides initial national CR performance benchmarks for quality improvement in Australia. While wait times are minimised, few programs are higher performing or met minimum duration standards. There is an urgent need to resource and support CR quality and access outside of major cities, in principal referral hospitals and for older and diverse patients.
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- Cardiovascular disease snapshot.(Available at:)https://www.aihw.gov.au/reports/heart-stroke-vascular-disease/cardiovascular-health-compendium/contents/deaths-from-cardiovascular-diseaseDate accessed: August 21, 2019
- Exercise-based cardiac rehabilitation for coronary heart disease.Cochrane Database Syst Rev. 2016; : CD001800
- Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews.Int J Cardiol. 2014; 177: 348-361
- The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy: a systematic review and meta-analysis of randomized and non-randomized studies - The Cardiac Rehabilitation Outcome Study (CROS).Eur J Prev Cardiol. 2016; 23: 1914-1939
- Cost-effectiveness of cardiac rehabilitation: a systematic review.Heart. 2018; 104: 1403-1410
- National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016.Heart Lung Circ. 2016; 25: 895-951
- 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR).Eur Heart J. 2016; 37: 2315-2381
- AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation.Circulation. 2011; 124: 2458-2473
- AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services endorsed by the American College of Chest Physicians, American College of Sports Medicine, American Physical Therapy Association, Canadian Association of Cardiac Rehabilitation, European Association for Cardiovascular Prevention and Rehabilitation, Inter-American Heart Foundation, National Association of Clinical Nurse Specialists, Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons.J Am Coll Cardiol. 2007; 50: 1400-1433
- Nature of cardiac rehabilitation around the globe.EClinicalMedicine. 2019; 13: 46-56
- Social inequality and barriers to cardiac rehabilitation in the rehab-North register.Scand Cardiovasc J. 2017; 51: 316-322
- The impact of cardiac rehabilitation and secondary prevention programs on 12-month clinical outcomes: a linked data analysis.Heart Lung Circ. 2020; 29: 475-482
- Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand.Heart. 2014; 100: 1281-1288
- Evidence to service gap: Cardiac rehabilitation and secondary prevention in rural and remote Western Australia.BMC Health Serv Res. 2018; 18: 64
- Exercise training characteristics in cardiac rehabilitation programmes: a cross-sectional survey of Australian practice.Open Heart. 2016; 3: 1-9
- Cardiac rehabilitation in Australia: a brief survey of program characteristics.Heart Lung Circ. 2018; 27: 1415-1420
- 2018 ACC/AHA clinical performance and quality measures for cardiac rehabilitation: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.J Am Coll Cardiol. 2018; 71: 1814-1837
- Patient and program characteristics of early outpatient cardiac rehabilitation programs in the United States.J Cardiopulm Rehabil Prev. 2013; 33: 168-172
- Development of quality indicators for cardiac rehabilitation in Australia: a modified Delphi method and pilot test.Heart Lung Circ. 2019; 28: 1622-1630
- National Audit of Cardiac Rehabilitation.(Available at:)https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/national-audit-of-cardiac-rehabilitationDate accessed: August 21, 2019
- Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies.BMJ. 2007; 335: 806-808
- Australian Cardiovascular Health and Rehabilitation Association (ACRA) core components of cardiovascular disease secondary prevention and cardiac rehabilitation 2014.Heart Lung Circ. 2015; 24: 430-441
- Recommended Framework for Cardiac Rehabilitation 2004.2004
- Does cardiac rehabilitation meet minimum standards: an observational study using UK national audit?.Open Heart. 2017; 4: 1-5
- Cardiac rehabilitation wait times and relation to patient outcomes.Eur J Phys Rehab Med. 2015; 51: 301-309
- Does service timing matter for psychological outcomes in cardiac rehabilitation? Insights from the National Audit of Cardiac Rehabilitation.Eur J Prev Cardiol. 2018; 25: 19-28
- Reducing wait time from referral to first visit for community outpatient services may contribute to better health outcomes: a systematic review.BMC Health Serv Res. 2018; 18: 869
- Does the timing of cardiac rehabilitation impact fitness outcomes? An observational analysis.Open Heart. 2016; 3: e000369
- Cardiac rehabilitation availability and delivery in Canada: how does it compare with other high-income countries?.Can J Cardiol. 2018; 34: S252-S262
- Cardiac rehabilitation participation and mortality after percutaneous coronary intervention: Insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.J Am Heart Assoc. 2018; 7: e010010
- Effect of cardiac rehabilitation dose on mortality and morbidity: a systematic review and meta-regression analysis.Mayo Clin Proc. 2017; 92: 1644-1659
- Participation and adherence to cardiac rehabilitation programs. A systematic review.Int J Cardiol. 2016; 223: 436-443
- Cardiac rehabilitation services for people in rural and remote areas: an integrative literature review.Rural Remote Health. 2018; 18: 4738
- Cardiac rehabilitation barriers by rurality and socioeconomic status: a cross-sectional study.Int J Equity Health. 2013; 12: 72
- Access to cardiac rehabilitation and the role of language barriers in the provision of cardiac rehabilitation to migrants.BMC Health Serv Res. 2019; 19: 223
- Clinical Excellence Division Queensland state Govt Statewide Cardiac Clinical Network Queensland Cardiac Outcomes Registry 2017 Annual Report.(Available at:)https://clinicalexcellence.qld.gov.au/sites/default/files/docs/priority-area/clinical-engagement/networks/cardiac/qcor-annual-report-2017.pdf([accessed July 2019])
- Improving the monitoring of cardiac rehabilitation delivery and quality: a call to action for Australia.Heart Lung Circ. 2020; 29: 1-4
- Australian Commission on Safety and Quality in Healthcare Australian Atlas of Healthcare Variation Series.(Available at:)https://www.safetyandquality.gov.au/publications-and-resources/australian-atlas-healthcare-variation-series([accessed August 2019])
Published online: February 12, 2020
Accepted: January 11, 2020
Received in revised form: November 12, 2019
Received: August 25, 2019
© 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.