Effective solutions for rural cardiac rehabilitation

Low attendance and completion of cardiac rehabilitation by people living in rural and remote areas is an acute problem that is being cleverly addressed by the Country Heart Attack Prevention (CHAP) project driven by Flinders Caring Futures Institute.

Professor Robyn Clark has steered the CHAP project, which is now in its fourth year with funding support from the National Health and Medical Research Council. As the project enters its final six months, an audit report has catalogued patient-reported outcomes and experiences ­- and has identified that its solutions are working.

The project is a collaboration with SA Health, Heart Foundation, the Australian Cardiovascular Health and Rehabilitation Association (ACRA) and the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) to establish an accreditation program for cardiac rehabilitation programs in SA, with the aim of improving their quality and standardising practices across the services.

“These types of partnerships provide the impact that improve how we care for people,” says Flinders Senior Research Fellow Dr Alline Beleigoli.

Dr Alline Beleigoli

Effective cardiac care is complicated, because despite high levels of evidence showing that cardiac rehabilitation (CR) reduces mortality, hospitalisations and improves quality of life, only 3 out of 10 people discharged from hospital after a heart attack receive education around risk factors control, lifestyle management, medication use and receive exercise to improve their fitness.

As a result, people who are not engaging with cardiac rehabilitation programs are more likely to have anxiety, depression, be re-admitted to hospital or die than the people who are receiving CR.

To help rectify this situation, the CHAP project involved 74 patients in co-designing a web-based CR program, through conducting 12 workshops across the six regional local health networks in South Australia. The resulting new CR model of care includes a continuous development program delivered over two years for CR clinicians across rural SA, implementation of a web-based CR program that was developed using co-design methods with patients and clinicians, and an evaluation of patient outcomes.

The project has linked data between the state-wide CR clinical database and SA Health Administrative and Death databases to evaluate the project’s health economics outcomes, and has developed a business model to enhance GP participation in supporting patients who receive telehealth-based CR.

The CHAP project also created opportunities for two spinoff projects that target increased attendance and completion of cardiac rehabilitation among specific groups: The Cardiac Rehabilitation Especially for Women (CREW, which focuses on tailoring CR to the needs of women) and the Cardiac Rehabilitation for All (CR4ALL, focused on people with low socioeconomic status).

CREW is funded by the Hospital Research Foundation (led by chief Investigators Robyn Clark, Alline Beleigoli, John Beltrame from University of Adelaide and Rosy Tirimacco from iCCnet) and CR4ALL by Flinders Foundation (with chief Investigator Alline Beleigoli, Claire Hutchinson, Maria Alejandra Pinero de Plaza, Robyn Clark).

Solutions in the CHAP, CREW and CR4ALL projects are promoting CR endorsement among clinicians to increase referrals, and have developed an accreditation program for quality improvement and feedback of CR programs. They also expand CR delivery options to patients through the new co-designed web-based program and have been able tailor this program to the needs and preferences of women and people with low socioeconomic status.

Dr Beleigoli says that while cardiac rehabilitation is seen as a highly effective way of preventing recurrent events, hospitalisation and deaths of people with cardiovascular diseases after a cardiac event, it is alarming that less than 50 per cent of those referred to CR programs choose to participate, and that women are less likely to be referred to and complete CR programs than men.

“Furthermore, we know that patients of low socio-economic status are at highest risk of poor cardiovascular outcomes but are the least likely to access cardiac rehabilitation,” she says.

On the positive side, the findings show that people enrolled in telehealth-enabled programs are more likely to complete CR, and that CR completion reduces the risk of cardiovascular re-admissions and deaths.

The broad network of health partners involved in these projects are working in close collaboration with Flinders Caring Institute to swiftly implement outcomes.

“It can take many years for new evidence to be implemented into practice, which could mean that possibly millions of people miss the opportunity of living a better and longer life after a cardiac event,” says Dr Beleigoli.

“This is why it’s so satisfying to be working on a project that aims to reduce the gap in translation of evidence into practice through engagement with patients and clinicians.”

The team is now working closely with the Statewide Clinical Cardiovascular Network to scale up CHAP’s model of care, confident that final project results will show increases in attendance and completion of CR across rural SA – and then be proposed as a model for all South Australia’s metropolitan and rural areas.

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Cardiac Health