Highlights
- •Cardiac rehabilitation (CR) is most often funded by public sources globally.
- •In 60% of programs patients are paying out-of-pocket for CR costs.
- •The median cost to treat one patient is $945.91 globally.
- •CR costs are driven by personnel, exercise equipment and stress testing.
- •Factors associated with higher cost include CR team composition, stress test and telemetry.
Abstract
Background
Cardiac rehabilitation (CR) reach is minimal globally, primarily due to financial
factors. This study characterized CR funding sources, cost to patients to participate,
cost to programs to serve patients, and the drivers of these costs.
Methods
In this cross-sectional study, an online survey was administered to CR programs globally.
Cardiac associations and local champions facilitated program identification. Costs
in each country were reported using purchasing power parity (PPP). Results were compared
by World Bank country income classification using generalized linear mixed models.
Results
111/203 (54.68%) countries in the world offer CR, of which data were collected in
93 (83.78% country response rate; N = 1082 surveys, 32.0% program response rate). CR was most-often publicly funded (more
in high-income countries [HICs]; p < .001), but in 60.20% of countries patients paid some or all of the cost. Funding
source impacted capacity (p = .004), number of patients per exercise session (p < .001), personnel (p = .037), and functional capacity testing (p = .039). The median cost to serve 1 patient was $945.91PPP globally. In low and middle-income
countries (LMICs), exercise equipment and stress testing were perceived as the most
expensive delivery elements, with front-line personnel costs perceived as costlier
in HICs (p = .003). Modifiable factors associated with higher costs included CR team composition
(p = .001), stress testing (p = .002) and telemetry monitoring in HICs (p = .01), and not offering alternative models in LMICs (p = .02).
Conclusions
Too many patients are paying out-of-pocket for CR, and more public funding is needed.
Lower-cost delivery approaches are imperative, and include walk tests, task-shifting,
and intensity monitoring via perceived exertion.
Keywords
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References
- The global burden of disease study and the preventable burden of NCD.Glob. Heart. 2016; 11: 393-397
- Global Atlas on Cardiovascular Disease Prevention and Control, Geneva, Switzerland.
- Social and economic implications of noncommunicable diseases in India.Indian J. Community Med. 2011; 36: S13-S22https://doi.org/10.4103/0970-0218.94704
- Exercise-based cardiac rehabilitation for coronary heart disease.J. Am. Coll. Cardiol. 2016; 67: 1-12https://doi.org/10.1016/j.jacc.2015.10.044
- 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.J. Am. Coll. Cardiol. 2011; 58: 2432-2446https://doi.org/10.1016/j.jacc.2011.10.824
- 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J. Am. Coll. Cardiol. 2012; 60: e44-e164https://doi.org/10.1016/j.jacc.2012.07.013
- Cost-effectiveness of cardiac rehabilitation after myocardial infarction.J. Cardpulm. Rehabil. 1997; 17: 222-231https://doi.org/10.1097/00008483-199707000-00002
- Cardiac rehabilitation—a cost analysis.J. Intern. Med. 1991; 230: 427-434
- Long-term cost-benefit ratio of cardiac rehabilitation after percutaneous coronary intervention.Acta Cardiol. 2008; 63: 451-456https://doi.org/10.2143/AC.63.4.2033043
- Optimizing value from cardiac rehabilitation: a cost-utility analysis comparing age, sex, and clinical subgroups.Mayo Clin. Proc. 2015; 90: 1011-1020https://doi.org/10.1016/j.mayocp.2015.05.015
- Global availability of cardiac rehabilitation.Nat. Rev. Cardiol. 2014; 11: 586-596https://doi.org/10.1038/nrcardio.2014.98
- Psychometric validation of the cardiac rehabilitation barriers scale.Clin. Rehabil. 2012; 26: 152-164https://doi.org/10.1177/0269215511410579
- Do cardiac rehabilitation programs offer cardiopulmonary resuscitation training in Australia and New Zealand?.Heart Lung Circ. 2015; 25: 607-612https://doi.org/10.1016/j.hlc.2015.11.009
- Availability and characteristics of cardiac rehabilitation programmes in China.Heart Asia. 2016; 8: 9-12https://doi.org/10.1136/heartasia-2016-010758
- Poor implementation of cardiac rehabilitation despite broad dissemination of coronary interventions for acute myocardial infarction in Japan: a nationwide survey.Circ. J. 2007; 71: 173-179https://doi.org/10.1253/circj.71.173
- Cardiac rehabilitation in Scotland: is current provision satisfactory?.J. Public Health Med. 1996; 18: 478-480
- Incorporation of cardiac rehabilitation programs and their characteristics in the Spanish National Health Service.Rev. Esp. Cardiol. 2003; 56: 775-782https://doi.org/10.1157/13050331
- Current status of cardiac rehabilitation in Latin America and the Caribbean.Am. Heart J. 2009; 158: 480-487https://doi.org/10.1016/j.ahj.2009.06.020
- Availability and characteristics of cardiovascular rehabilitation programs in South America.J. Cardiopulm. Rehabil. Prev. 2013; 33: 33-41https://doi.org/10.1097/HCR.0b013e318272153e
- National registry of cardiac rehabilitation programs in Mexico II (RENAPREC II).Arch. Cardiol. Mex. 2016; 27: 27
- Cardiac rehabilitation in Canada and Arab countries: comparing availability and program characteristics.BMC Health Serv. Res. 2015; 15: 521https://doi.org/10.1186/s12913-015-1183-7
- Advocacy for outpatient cardiac rehabilitation globally.BMC Health Serv. Res. 2016; 16: 471https://doi.org/10.1186/s12913-016-1658-1
- Availability, use, and barriers to cardiac rehabilitation in LMIC.Glob. Heart. 2016; 12: 323-334
- The costs and benefits of technology-enabled, home-based cardiac rehabilitation measured in a randomised controlled trial.J. Telemed. Telecare. 2014; 20: 419-422https://doi.org/10.1177/1357633X14552376
- Economic evaluation of cardiac rehabilitation soon after acute myocardial infarction.Am. J. Cardiol. 1993; 72: 154-161
- Economic evaluation of the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) randomized controlled trial: an exercise training study of patients with chronic heart failure.Circ. Cardiovasc. Qual. Outcomes. 2010; 3: 374-381https://doi.org/10.1161/CIRCOUTCOMES.109.907287
- Cardiac rehabilitation services in Ontario.J. Cardiovasc. Med. 2012; 13: 727-734https://doi.org/10.2459/JCM.0b013e32835794c1
- Dose of Cardiac Rehabilitation Across the Globe.Toronto Gen. Res. Inst. Res. Day, Toronto, Canada. 2016
- 2016 European guidelines on cardiovascular disease prevention in clinical practice.Eur. Heart J. 2016; 37: 2315-2381https://doi.org/10.1093/eurheartj/ehw106
- Cost-effectiveness of cardiac rehabilitation program delivery models in patients at varying cardiac risk, reason for referral, and sex.Eur. J. Cardiovasc. Prev. Rehabil. 2008; 15: 347-353https://doi.org/10.1097/HJR.0b013e3282f5ffab
M. Supervia Pola, K. Turk-Adawi, F. Lopez Jimenez, E. Pesah, D. Rongjing, R. Britto, B. Bjarnason-Wehrens, W. Derman, A. Abreu, A. Babu, C. Santos, J. Khiong, L. Cuenza, T. Yeo, D. Scantlebury, K. Andersen, G. Gonzalez, V. Giga, D. Vulic, E. Vataman, J. Cliff, E. Kouidi, I. Yagci, B. Benaim, E. Rivas-Estany, C. Kim, R. Fernandez, B. Radi, D. Gaita, M. Mooney, A. Simon, S. Chen, B. Roxburgh, J. Castillo Martin, M. Hafizullah, S. Mendis, L. Maskhulia, G. Burdiat, R. Salmon, R. Lomelí, M. Sadeghi, E. Sovova, A. Hautala, E. Prasciene, M. Ambrosetti, L. Neubeck, E. Asher, H. Kemps, C. DeMaeyer, Z. Eysymontt, S. Farsky, J. Hayward, E. Prescott, K. Cradock, S. Dawkes, C. Santibanez, C. Zeballos, B. Pavy, Y. Goto, A. Kiessling, N. Sarrafzadegan, C. Baer, R. Thomas, D. Hu, S.L. Grace, Nature of cardiac rehabilitation around the globe, eClinicalMedicine (Under Review).
- Cardiac rehabilitation costs.Int. J. Cardiol. 2017; 244: 322-328https://doi.org/10.1016/j.ijcard.2017.06.030
- Narrative review comparing the benefits of and participation in cardiac rehabilitation in high-, middle- and low-income countries.Heart Lung Circ. 2015; 24: 510-520https://doi.org/10.1016/j.hlc.2014.11.013
- A review of cardiac rehabilitation delivery around the world.Prog. Cardiovasc. Dis. 2017; 60: 267-280https://doi.org/10.1016/j.pcad.2017.08.007
- Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey.Eur. J. Cardiovasc. Prev. Rehabil. 2010; 17: 410-418https://doi.org/10.1097/HJR.0b013e328334f42d
- Statistical Package for the Social Sciences (SPSS).2016
- Cardiac rehabilitation availability and density around the globe. World Congress of Cardiology & Cardiovascular Health. Dubai, United Arab Emirates. December.Glob. Heart. 2018; 13: 381
- Cardiac rehabilitation delivery in low- and middle-income countries: availability, characteristics and barriers. World NCDs Congress. Chandigarh, India. November.Int. J. Non-Communicable Dis. 2017; 2: s57-s58
- Financing Global Health: Development Assistance, Public and Private Health Spending for the Pursuit of Universal Health Coverage.2016
- Economic analysis of treatments reducing coronary heart disease mortality in England and Wales, 2000–2010.QJM. 2007; 100: 277-289https://doi.org/10.1093/qjmed/hcm020
- Heart disease and stroke statistics—2013 update: a report from the American Heart Association.Circulation. 2013; 127: e6-e245https://doi.org/10.1161/CIR.0b013e31828124ad
- A review of guidelines for cardiac rehabilitation exercise programmes: is there an international consensus?.Eur. J. Prev. Cardiol. 2016; 23: 1715-1733https://doi.org/10.1177/2047487316657669
- Cardiac rehabilitation delivery model for low-resource settings: an International Council of Cardiovascular Prevention and Rehabilitation consensus statement.Prog. Cardiovasc. Dis. 2016; 59: 1-20https://doi.org/10.1016/j.pcad.2016.08.004
- Cardiac rehabilitation delivery model for low-resource settings.Heart. 2016; 102: 1449-1455https://doi.org/10.1136/heartjnl-2015-309209
- Simple approaches to assessing exercise readiness in cardiac rehabilitation in low-resource settings: validity of the Incremental Shuttle Walk Test.J. Cardiovasc. Rehabil. Prev. 2018; (Under Revision)
The World Bank. World Health Organization Global Health Expenditure Database. http://apps.who.int/nha/database.
Article info
Publication history
Published online: October 31, 2018
Accepted:
October 25,
2018
Received in revised form:
September 5,
2018
Received:
July 24,
2018
Footnotes
☆This project was supported by a research grant from York University's Faculty of Health.
Identification
Copyright
© 2018 Elsevier B.V. All rights reserved.
