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Cardiac rehabilitation: fit to face the future?
  1. Alexander M Clark1,
  2. Julie Redfern2,
  3. Tom Briffa3
  1. 1Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
  2. 2The George Institute for Global Health, University of Sydney, NSW, Australia
  3. 3School of Population Health, The University of Western Australia, Perth, Australia
  1. Correspondence to Dr Alexander M Clark, Faculty of Nursing, University of Alberta, Level 3, Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Alberta, Canada T6G 1C9; Alex.Clark{at}ualberta.ca.

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The accessibility and effectiveness of health services for people with coronary heart disease (CHD) have never been more important: more people are living longer with symptomatic CHD in high-income, middle-income and low-income countries.1 Healthy behaviours can reduce likelihood of premature death in people with CHD by threefold.2 Yet, despite the existence of guidelines for cardiac rehabilitation for over 20 years, around 60%–70% of patients do not receive optimal secondary prevention.3 Possibly, as few as 1 in 10 eligible patients are referred to, participate in and then complete cardiac rehabilitation.4

Trials and meta-analyses support the general benefits to life expectancy and quality of cardiac rehabilitation interventions of various lengths, formats and delivery settings.5–8 Yet, recent trial findings9 have led to questions about the benefits of traditional centre-based cardiac rehabilitation and disagreement over whether these findings reflect true effects, confounded interventions or methodological weaknesses. Scepticism over the benefits of these interventions is not new—anecdotally many clinicians have expressed doubts that long-term behavioural change from time-limited cardiac rehabilitation is realistic for patients with CHD. These concerns are then reflected in clinicians’ interactions with patients and referral behaviours.

Doubts have also arisen less from the inherent effectiveness of cardiac rehabilitation interventions than their poor accessibility—particularly to groups in greater need of risk factor reduction and long-term management. Patients who are elderly, poor, female, from ethnic minorities or those who live remotely are least likely to participate.10 Viewed as a form of ‘systematic non-compliance’, can any intervention that so frequently fails to be used by most patients and their clinicians be championed fairly as being ‘effective’?

Responding to the challenge

How should proponents of health services for cardiac rehabilitation respond to these threats? Facing such challenging issues, groups tend to demonstrate a set of predictable yet ultimately counterproductive behaviours associated with polarisation.

Actions or strategies that have been unsuccessful in the past can be repeated with greater intensity or frequency.11 Like soldiers going ‘over the top’ of trenches in the First World War, the hope is that with more intense or greater amounts of the same activity, the outcome will somehow be different. Thus, it is proposed that more clinical guidelines and wider introduction of hospital -based traditional cardiac rehabilitation programmes will respectively improve outcomes and access12 despite a gamut of international evidence that this will have little or no effect on improving referral, uptake or practice.13 Very low rates of referral, attendance and completion of cardiac rehabilitation have been evident for two decades but surprisingly few trials have attempted to actually improve access.14

Polarisation also occurs due to the dismissal, suppression or avoidance of dissent.11 Indeed, it is tempting to dismiss trials of cardiac rehabilitation interventions with negative findings as being anomalies or weak—as proponents of services for heart failure disease management mistakenly did for some years—15and judge critics or their criticisms as meddlesome, mischievous or lacking in credibility. Yet, while past meta-analyses of trials can be cited as testifying to the general benefits of exercise-based cardiac rehabilitation16 and secondary prevention clinics,7 these same reviews also show past trials to be mostly of moderate quality, have short-term follow-up and to fail to separate the effects of medicines from education, support and exercise training. These methodological findings cast avoidable doubts on the independent effects of these interventions and their overall value. Too few trials describe interventions well, examine costs versus benefits or consider the cumulative influence of different intervention components.

Finally, when exposed to external threats, even the most conservative of professional groups (such as lawyers, politicians and physicians) tend to move from moderate to more extreme decisions—the tendency of extremisation.11 Thus, highly prominent national group-based scientific statements for improving cardiac rehabilitation outcomes seek to address poor referral and access by actually overriding clinical autonomy altogether by mandating referral to single types of centralised hospital or centre-based programmes.12

Getting fit to face the future

These reactions lose sight of what matters most: how to best ensure that the greatest proportion of eligible CHD patients can benefit from healthy behaviours, lifestyles and adherence to medicines. Through their specialist knowledge, those involved in providing and evaluating cardiac rehabilitation health services have a vital role to play in ensuring that more patients benefit from these services. The range of potentially effective interventions that can be used for this has grown increasingly more diverse over the last 10 years. Effective services can be dedicated or integrated with other services, provided by a variety of specialists or generalists, and delivered via a myriad of different ways, from home-based remote to face-to-face centre-based models.5–8 To strengthen future evidence around these interventions, existing limitations need to be addressed: the care provided to intervention and control groups should be described comprehensively, costs versus benefits calculated, and long-term effects examined.

Further, moving the debate away from arguments around ‘cardiac rehabilitation’ versus other care models, towards a shared focus on medium-to-long–term effective disease management and healthy behaviours, is likely to have greater resonance with patients, the public and other health professionals. Terminology to replace the term ‘cardiac rehabilitation’ (such as ‘lifetime heart health’) should be considered as the concept of rehabilitation is now associated with stigma and dependency. Moreover, this term fails to convey the long-term commitment and behaviours needed for sustained improvements in cardiovascular health and is not identified with by most other health professional groups.

Finally, a larger shift to lifelong risk reduction and disease management is required for effective future service delivery for the vast majority of people with CHD. Yet, the full potential for achieving this will only be realised by putting patients’ needs and access first. Given the colossal burden of CHD on low-income, middle-income and high-income countries, the future is best addressed together. To do this, more collaborative models of health services are needed that further integrate services with primary care and family medicine—as has occurred with diabetes—instead of drawing arbitrary distinctions between services provided to the same patients in hospitals and general practice. For patients with CHD, these organisational boundaries make little sense and often fragment care and communication. Through better organisation of services across sectors, care can be more readily integrated, systematised and individualised.17

References

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Footnotes

  • Contributors The editorial was conceived by AMC and contributions to all drafts were provided by JR and TB. AMC guarantors the final manuscript.

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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