Barriers to cardiac rehabilitation in India · preserve or resume when lost, as normal a place as...

871870 J. Preventive Cardiology Vol. 5 No. 3 Feb 2016J. Preventive Cardiology Vol. 5 No. 3 Feb 2016

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181. Gielen S, Sandri M, Kozarez I, et al. Exercise training attenuates MuRF-1 expression in the skeletal muscle of patients with chronic heart failure independent of age: The randomized Leipzig Exercise Intervention in Chronic Heart Failure and Aging catabolism study. Circulation. 2012;125(22):2716–27.

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184. European Association of Cardiovascular Prevention and Rehabilitation Committee for Science Guidelines; EACPR, Corrà U, Piepoli MF, et al. Secondary prevention through cardiac rehabilitation: Physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J. 2010;31:1967–74.

Address for correspondence:

Dr. Marcus Sandri: Email ID: [email protected]

Abstract

Cardiac rehabilitation (CR) is an essential component in the prevention and management of cardiovascular disease (CVD). High levels of evidence suggest significant benefits with respect to morbidity and mortality in addition to cost sav ings. However, CR is gross ly underutilized and has not received the attention it deserves in India. This underutilization of such an effective intervention is due to the various barriers that exist with respect to awareness and understanding of the benefits of CR among health-care professionals, referrals to CR, limited presence of specialized professionals trained in CR, and a lack of awareness among patients on the benefits of CR. This article describes barriers to CR and proposes some solutions to aid overcoming these.

Barriers to cardiac rehabilitation in India

†Dr. Abraham Samuel Babu*, MPT; Dr. Sundar Kumar Veluswamy , PhD; ‡

Dr. Aashish Contractor, MBBS, MED

*Assistant Professor, Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal, Karnataka, India

†Assistant Professor, Department of Physiotherapy, MS Ramaiah Medical College, Bangalore, Karnataka, India

‡Head, Department of Rehabilitation and Sports Medicine, Sir H.N. Reliance Foundation Hospital, Mumbai, India

Received: 07-11-2015; Revised: 04-02-2016; Accepted: 10-02-2016

Disclosures: This article has not received any funding and has no vested commercial interest

Acknowledgments: None

Key Words

• Cardiac rehabilitation

• Cardiovascular disease

• Exercise

• Lifestyle

• India

Introduction

Cardiovascular disease (CVD) is a disease of high mortality and morbidity with India reporting mortality rates as high as 386 and 283/100,000 for men and

1women, respectively. In addition, there is also a high morbidity associated with CVD with respect to years lived with disability (YLDs) and disability adjusted life

2,3years (DALYs). With CVD, YLD has increased by 47.8% from 1990 to 2010 (5.9 to 8.8 million), while DALYs went up by 29.2% (100.4 to 129.8 million) within the same time period. This has resulted in more individuals living with the morbidity associated with CVD. This brings to light the need for cardiac rehabilitation (CR), which has been defined by the World Health Organization as the “sum of activities required to influence favorably the underlying cause of the disease, as well as the best possible physical, mental and social conditions, so that they may by their own efforts, preserve or resume when lost, as normal a place as

4possible in the society.” Subsequently, the American Heart Association (AHA), put forward the various core

5components for CR. These include:

1. Patient assessment

2. Nutritional counseling

3. Weight management

Kirsch K, et al

Barriers to cardiac rehabilitation in IndiaBabu AS, et al

4. Blood pressure management

5. Lipid management

6. Diabetes management

7. Tobacco cessation

8. Psychosocial interventions

9. Physical activity counseling

10. Exercise training

Patient assessment

Nutritional counselling

Weight management

Blood pressure management*

Lipid management*

Diabetes management*

Tobacco cessation

Psychosocial management

Physical activity counseling

Exercise training

Risk reduction with regular follow-up to ensure goals of

prevention and control are met

Dietary modifications along with education and counselling

Lifestyle modifications and pharmacotherapy as indicated

Counselling and lifestyle modifications including diet and

exercise in addition to pharmacotherapy to attain

reductions in LDL and non-HDL cholesterol

Patient education and counseling along with lifestyle

modifications, exercise, and pharmacotherapy

Behavioral strategies, social support groups, and

pharmacological interventions as needed

Group support, counseling, and supportive rehabilitation

Strategies to improve physical activity to ensure meeting

recommended goals (30–60 min of moderate activity)

Aerobic and resistance training programs with warm up and

cool down

Establish short-term and long-term goals for weight reduction.

Develop a diet, exercise, and behavioral program

Component

Medical history, physical examination, and testing

Detailed dietary evaluation and caloric intake

Evaluation of weight, BMI, and waist circumference

Measurement of BP on ³2 visits

Fasting lipid profile

Blood sugar assessments and monitoring (important to obtain

blood sugars before exercise prescription)

Assess amount smoked (or chewed) and readiness to change,

along with identification of psychosocial factors that may

prevent success

Screen for psychological distress by assessing depression, anxiety,

hostility, and social isolation

Assessment using questionnaires and readiness to change

Evaluation of exercise capacity and cardiorespiratory fitness

Ensure adherence to treatment and adequate sugar control

without any symptoms (HbA 1c

Achieving targeted goals

Adherence to dietary changes

Adherence to the weight management program and

attainment of goals

Ensure regular monitoring of BP and modify interventions to attain

optimal BP

Attain goals of reduced LDL cholesterol between 70 and 100

mg/dl (target <70 mg/dl) and reduced non-HDL cholesterol between 100 and 130 mg/dl

(target <100 mg/dl)

Change in behavior toward willingness to stop smoking,

resulting in complete cessation

Improved emotional well-being

Improvement in the various domains of physical activity and

fitness levels

Improved exercise capacity

Evaluation Intervention Expected outcome

These components have also been adapted and used by 6–11

various leading CR organizations around the world. Each of the core components described by AHA provides possible directions for evaluation, intervention, and expected outcome. This has been in summarized in Table 1.

Benefits and utilization of CR:

Evidence from recent reviews has shown significant benefits for patients undergoing CR including improved

5Table 1: Description of the various core components of CR

Abbreviations: BMI, body mass index; BP, blood pressure; LDL, low-density lipoproteins; HDL, high-density lipoproteins; HbA glycosylated haemoglobin1c,

*Specific guidelines exist for their management

control of risk factors, improved quality of life, and 12–15 12–15

reduced mortality. Various benefits of CR are:

• Improves control of risk factors

• Reduction in obesity indices (BMI and body fat by 1.5% and 5%, respectively)

• Improves lipid profiles (5% reduction in total cholesterol, 2% reduction in LDL cholesterol, and 6% improvement in HDL cholesterol)

• Reduces metabolic syndrome by 37%

• Improves exercise capacity by 15% and 35% for peak VO and MET capacity2

• Improves quality of life

• Reduces cardiovascular-related mortality (OR: 0.64; 95% CI: 0.46–0.88)

• Reduces all-cause mortality (OR: 0.74; 95% CI: 0.58–0.95)

• Reduces 12-month mortality (RR: 0.82; 95% CI: 0.67–1.01)

• Reduces risk of re-infarction (OR: 0.53; 95% CI: 0.38–0.76)

• Reduces 12-month re-admissions (RR: 0.75; 95% CI: 0.62–0.92)

• Reduces heart failure-specific admissions (RR: 0.61; 95% CI: 0.46–0.8)

Available evidence has enabled CR to be considered as part of standard intervention for patients with CVD and heart failure. However, its role in certain conditions like pulmonary arterial hypertension is still growing, despite evidence showing benefits in terms of exercise capacity

16,17 and quality of life.

Despite all the evidence supporting CR, it remains grossly underutilized across the world. CR is available in only 38.8% countries worldwide: 68.0% of high-income, 28.2% of middle-income, and 8.3% of low-income

18countries. CR density (number of CR programs per inhabitant), which is a crude estimate of the number of patients who have access to CR, has shown that the CR density ranges from 1/100,000 to 1/300,000 inhabitants in high-income countries, while in middle-income countries, it has been found to range between 0.9 and 6.4

19,20million inhabitants per program. The international STABILITY study that included 15 middle-income countries revealed participation rates were <30% in 10

21(66.6%) of the 15 included countries. Other data on CR participation were reviewed by Turk-Adawi et al., and

22revealed rates ranging from 3% to 89%. This brings out the need for stronger advocacy for CR and has become the focus of various organizations like the International Counc i l o f Ca rd iovascu l a r P reven t ion and

23Rehabilitation (http://globalcardiacrehab.com/).

The Indian scenario

CR is in a nascent stage in India and very few research studies have addressed the status, feasibility, and barriers to CR in India. We recently reviewed the status of CR in

24India based on published literature. CR programs in India have targeted patients with coronary artery disease, heart failure, angina, heart transplant, congenital heart disease, and pulmonary arterial hypertension. Most programs limit CR to Phase-1 and Phase-2 CR and are delivered either through institutional- or home-based programs. Recently, the worksite has been used as a

25potential site for the delivery of CR. In India, the worksite has been used in various settings to help

26promote cardiovascular health. However, its use as a CR delivery model needs to be evaluated.

Barriers to CR in India

Despite its utility, many barriers to CR have been identified globally. However, in the Indian context, there is scarcity of data on proportion of eligible participants receiving CR and various factors influencing CR participation. In the absence of research data addressing barriers, most of the potential barriers identified are from specialists working in the area of CR. Potential barriers to CR can be classified as health-care system barriers (including infrastructure and staffing), health-care professionals-related barriers, and patient-related barriers

Health-care system- and health-care professionals-related barriers

There has been a significant increase in number of centers offering coronary interventions in India. Data from National Intervention Council indicate a

27tremendous increase in coronary interventions. For the year 2013, 216,817 coronary interventions were reported

28from 404 centers across the country. Despite the increase in number of centers offering coronary interventions and having a registry for centers offering such facilities, there is limited information on number of centers offering CR facilities. Though grey literature (hospital Websites, promotional services, etc.) indicates that prominent health-care centers in major cities of the country offer CR services; their availability in small cities and towns are sparse. There is a possibility that setting up a full-fledged CR facility is infrastructure-

4. Blood pressure management

5. Lipid management

6. Diabetes management

7. Tobacco cessation

8. Psychosocial interventions

9. Physical activity counseling

10. Exercise training

Patient assessment

Nutritional counselling

Weight management

Blood pressure management*

Lipid management*

Diabetes management*

Tobacco cessation

Psychosocial management

Physical activity counseling

Exercise training

Risk reduction with regular follow-up to ensure goals of

prevention and control are met

Dietary modifications along with education and counselling

Lifestyle modifications and pharmacotherapy as indicated

Counselling and lifestyle modifications including diet and

exercise in addition to pharmacotherapy to attain

reductions in LDL and non-HDL cholesterol

Patient education and counseling along with lifestyle

modifications, exercise, and pharmacotherapy

Behavioral strategies, social support groups, and

pharmacological interventions as needed

Group support, counseling, and supportive rehabilitation

Strategies to improve physical activity to ensure meeting

recommended goals (30–60 min of moderate activity)

Aerobic and resistance training programs with warm up and

cool down

Establish short-term and long-term goals for weight reduction.

Develop a diet, exercise, and behavioral program

Component

Medical history, physical examination, and testing

Detailed dietary evaluation and caloric intake

Evaluation of weight, BMI, and waist circumference

Measurement of BP on ³2 visits

Fasting lipid profile

Blood sugar assessments and monitoring (important to obtain

blood sugars before exercise prescription)

Assess amount smoked (or chewed) and readiness to change,

along with identification of psychosocial factors that may

prevent success

Screen for psychological distress by assessing depression, anxiety,

hostility, and social isolation

Assessment using questionnaires and readiness to change

Evaluation of exercise capacity and cardiorespiratory fitness

Ensure adherence to treatment and adequate sugar control

without any symptoms (HbA 1c

Achieving targeted goals

Adherence to dietary changes

Adherence to the weight management program and

attainment of goals

Ensure regular monitoring of BP and modify interventions to attain

optimal BP

Attain goals of reduced LDL cholesterol between 70 and 100

mg/dl (target <70 mg/dl) and reduced non-HDL cholesterol between 100 and 130 mg/dl

(target <100 mg/dl)

Change in behavior toward willingness to stop smoking,

resulting in complete cessation

Improved emotional well-being

Improvement in the various domains of physical activity and

fitness levels

Improved exercise capacity

Evaluation Intervention Expected outcome

These components have also been adapted and used by 6–11

various leading CR organizations around the world. Each of the core components described by AHA provides possible directions for evaluation, intervention, and expected outcome. This has been in summarized in Table 1.

Benefits and utilization of CR:

Evidence from recent reviews has shown significant benefits for patients undergoing CR including improved

5Table 1: Description of the various core components of CR

Abbreviations: BMI, body mass index; BP, blood pressure; LDL, low-density lipoproteins; HDL, high-density lipoproteins; HbA glycosylated haemoglobin1c,

*Specific guidelines exist for their management

control of risk factors, improved quality of life, and 12–15 12–15

reduced mortality. Various benefits of CR are:

• Improves control of risk factors

• Reduction in obesity indices (BMI and body fat by 1.5% and 5%, respectively)

• Improves lipid profiles (5% reduction in total cholesterol, 2% reduction in LDL cholesterol, and 6% improvement in HDL cholesterol)

• Reduces metabolic syndrome by 37%

• Improves exercise capacity by 15% and 35% for peak VO and MET capacity2

• Improves quality of life

• Reduces cardiovascular-related mortality (OR: 0.64; 95% CI: 0.46–0.88)

• Reduces all-cause mortality (OR: 0.74; 95% CI: 0.58–0.95)

• Reduces 12-month mortality (RR: 0.82; 95% CI: 0.67–1.01)

• Reduces risk of re-infarction (OR: 0.53; 95% CI: 0.38–0.76)

• Reduces 12-month re-admissions (RR: 0.75; 95% CI: 0.62–0.92)

• Reduces heart failure-specific admissions (RR: 0.61; 95% CI: 0.46–0.8)

Available evidence has enabled CR to be considered as part of standard intervention for patients with CVD and heart failure. However, its role in certain conditions like pulmonary arterial hypertension is still growing, despite evidence showing benefits in terms of exercise capacity

16,17 and quality of life.

Despite all the evidence supporting CR, it remains grossly underutilized across the world. CR is available in only 38.8% countries worldwide: 68.0% of high-income, 28.2% of middle-income, and 8.3% of low-income

18countries. CR density (number of CR programs per inhabitant), which is a crude estimate of the number of patients who have access to CR, has shown that the CR density ranges from 1/100,000 to 1/300,000 inhabitants in high-income countries, while in middle-income countries, it has been found to range between 0.9 and 6.4

19,20million inhabitants per program. The international STABILITY study that included 15 middle-income countries revealed participation rates were <30% in 10

21(66.6%) of the 15 included countries. Other data on CR participation were reviewed by Turk-Adawi et al., and

22revealed rates ranging from 3% to 89%. This brings out the need for stronger advocacy for CR and has become the focus of various organizations like the International Counc i l o f Ca rd iovascu l a r P reven t ion and

23Rehabilitation (http://globalcardiacrehab.com/).

The Indian scenario

CR is in a nascent stage in India and very few research studies have addressed the status, feasibility, and barriers to CR in India. We recently reviewed the status of CR in

24India based on published literature. CR programs in India have targeted patients with coronary artery disease, heart failure, angina, heart transplant, congenital heart disease, and pulmonary arterial hypertension. Most programs limit CR to Phase-1 and Phase-2 CR and are delivered either through institutional- or home-based programs. Recently, the worksite has been used as a

25potential site for the delivery of CR. In India, the worksite has been used in various settings to help

26promote cardiovascular health. However, its use as a CR delivery model needs to be evaluated.

Barriers to CR in India

Despite its utility, many barriers to CR have been identified globally. However, in the Indian context, there is scarcity of data on proportion of eligible participants receiving CR and various factors influencing CR participation. In the absence of research data addressing barriers, most of the potential barriers identified are from specialists working in the area of CR. Potential barriers to CR can be classified as health-care system barriers (including infrastructure and staffing), health-care professionals-related barriers, and patient-related barriers

Health-care system- and health-care professionals-related barriers

There has been a significant increase in number of centers offering coronary interventions in India. Data from National Intervention Council indicate a

27tremendous increase in coronary interventions. For the year 2013, 216,817 coronary interventions were reported

28from 404 centers across the country. Despite the increase in number of centers offering coronary interventions and having a registry for centers offering such facilities, there is limited information on number of centers offering CR facilities. Though grey literature (hospital Websites, promotional services, etc.) indicates that prominent health-care centers in major cities of the country offer CR services; their availability in small cities and towns are sparse. There is a possibility that setting up a full-fledged CR facility is infrastructure-

intensive and may not be financially sustainable for smaller facilities. An ideal CR clinic requires immense infrastructure to meet the requirements for assessment of the core components and also to meet the standards for certification by the American Association of

29Cardiovascular and Pulmonary Rehabilitation. For example, the cost for setting up a cardiopulmonary

30exercise testing unit is estimated to be at US$50,000. These amounts are not feasible in every setting. In a country like India, health-care facilities have the necessity to keep the costs affordable for patients as most rely on out-of-pocket expenses for meeting their health-care needs. It is crucial to validate alternative cost effective methods for CR delivery.

Studies in high-income countries such as the United States, Canada, and Australia have identified referrals to CR as a major barrier to participation in CR. A recent study in the United States found that the referrals to CR were much lower (57.9–61.2%) than the prescription of preventive medications like aspirin (97.5%) and statins

31(89.8%). This study also found that more than a quarter of hospitals referred <20% of their patients with percutaneous coronary interventions to CR. The study identified greater contribution from hospital factors like hospital size, procedure volume, private/community hospital status, and geographic location than patient-related factors toward poor CR participation. A study from Iran assessed physician-related factors and found that limited knowledge about CR programs as main

32factors affecting CR referral. A recent review identified physician endorsement, physician specialty, and physicians attitudes toward CR to influence referral and

33enrollment to CR. There is limited data on factors influencing CR referral and referral patterns from India. Understanding these factors and patterns could help us understand their role in facilitating CR participation.

Patient-related factors

Globally, many patient related factors have been identified to influence CR participation. Age, gender, comorbidities, type of cardiac pathology and intervention received, patients knowledge and positive beliefs about uses of CR, family support, socioeconomic factors, and rurality have all been shown to influence CR

34–36participation. Economic stability, translated into the need to resume work quickly by the bread-winner of the family, could be a deciding factor to prevent participation in CR, despite evidence showing how it

37will benefit in return to work. Reimbursement from insurance companies toward CR may also play a role

38toward the limited participation in CR. Limited

literature is available on patient-related factors influencing CR participation in India. Anecdotal evidence suggests that geographical factors, time constraints, additional costs of transport and rehabilitation, along with limited awareness on the benefits of CR contribute to poor participation in CR programs. A summary of the various potential barriers to CR have been summarized in Table 2.

Table 2: Potential barriers to CR in India

What can be done to overcome these barriers?

Addressing the various concern related to the health-care system, health-care professionals and patients should be a priority. A stronger emphasis for advocacy in CR at the policy-maker level is a requirement if CR can be made available to all patients with CVD. A change in policy will improve the state of CR training in India and will allow for greater use of workforce and specialized health-care professionals (viz., physiotherapists, exercise physiologists, occupational therapists, social workers, specialized nurses, nutritionists, and psychologists) in the delivery of a team-based CR program. Establishment of regional centers of team-based CR may have a role to play in ensuring various smaller centers can refer patients for both primary and secondary prevention of CVD. Greater staffing requirements for exercise specialists and nurses in small hospitals and primary health-care settings will help promote exercise and healthy lifestyles from the grass-root level.

At the health-care professional level, greater emphasis should be placed on development of core competencies

39and skills required for CR professionals. This requires more intensive training programs toward CR and education among all health-care professionals on the benefits and uses of CR.

Lack of policy for CRAbsence of a central registry/ databasePoor CR densityLimited centers offering CR

Lack of awarenessPsychosocial impactPoor outlook toward CRTime and financial constraints

Health-care system

Health-care professionals

Patients

Overcoming the poor referral rate requires a wide range of interventions. This can be achieved by improving awareness of CR and its benefits and by also ensuring that a standard operating procedure is in place to allow for all patients with CVD to be referred to CR. Studies have shown that automatic referrals along with a dedicated staff member improved CR referral rates as

40compared with usual systems (85% versus 32%). In addition, there should also be a focus on follow-up from outpatient clinics with the CR team to decide on supervised or home-based exercise programs. To run such a program, dedicated CR staff is of paramount importance. Improvement in the CR density, especially considering the very low density that currently exists,

19should be a priority.

From the patient perspective, patient education is the most important factor to be addressed. Patient education has been found to be useful in patients with CVD, lung

41–44 cancer, and pulmonary hypertension. Patient education should become an important part of in-hospital CR and should include a multidisciplinary team to ensure the best results. In relation to their attitudes, Horwood and colleagues showed that worry about one’s health was a major cue to action among both high and

30low attenders to CR. A strong desire to prevent a second coronary event was another driving factor among the high attenders to CR. Social factors like peer influence and family support further prompted participation in CR. A change in attitude and behavior is therefore crucial and can be obtained primarily through education.

Conclusions

CR is an essential component of holistic care for the patient with CVD. The effects and benefits of CR are abundantly clear. However, strategies need to be developed and implemented to overcome the major barriers to utilization of CR with respect to the health-care system, health-care professionals, and the patient. There continues to remain an extensive amount of work to be done in the area of CR in India and overcoming some these barriers will allow for greater benefits to patients with CVD.

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