Cardiovascular disease (CVD) is among the leading burdens of disease and disability globally.1 As a result, secondary prevention is crucial. Cardiac rehabilitation (CR) is the recommended program model designed to reduce future risk.2,3
CR services are provided through a multicomponent interdisciplinary approach.4,5 The core components of CR are risk factor assessment, patient education, lifestyle risk factor management (physical activity and weight management, diet, and smoking cessation), psychosocial health, and medical risk factor management.4–8
There are many benefits to CR participation, with the most significant being a 26% reduction in cardiovascular mortality and 18% reduction in rehospitalization reported in the most recent Cochrane review.9 Considering it is such a complex intervention, it is understandable that there may be considerable variability in the nature of services delivered and by which type of health care providers, resulting in inconsistent care quality.10 This inconsistency could negatively impact patient outcomes.
According to the Institute of Medicine, quality of care is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”11(p1-8) Care quality is a multidimensional construct that incorporates the concepts of safety, equity, evidence-based medicine, timeliness of care, efficiency, and patient-centeredness.
To quantify the quality of CR care, evidence-based recommendations need to be translated into well-defined, evidence-based, and measurable elements of practice performance, known as quality indicators (QIs).12 Donabedian's13 framework highlights the importance of considering structure, process, and outcome indicators. “Structures” of health care are characterized as the physical and organizational components of care settings (eg, facilities, equipment, personnel). “Processes” rely on structures to provide means and resources to perform patient care activities. “Outcomes” are improvements in patient health (eg, promoting recovery, functional restoration, survival, and patient satisfaction).
With knowledge regarding where quality of CR services is low, we can work toward improving the quality of services for patients. Quality improvement is defined as “the effort to improve the degree to which health services increase the likelihood of desired health outcomes.”11 Thus, the purpose of this article was to review (1) ways in which we measure CR quality around the globe; (2) what we know about the quality of CR; (3) what CR quality improvement approaches have been tried; and, finally, (4) potential ways to improve CR quality, specifically where it is lowest, followed by broad recommendations for quality improvement in the context of CR.
For this narrative review, first, key informants from the International Council of Cardiovascular Prevention and Rehabilitation were approached to identify CR QIs in their countries. Second, the literature was searched for CR QIs and studies on CR quality and quality improvement. Third, data from the Canadian Cardiac Rehabilitation Registry (CCRR) were mined for QIs (objective 2). Finally, research on health care quality improvement strategies and how they might apply in CR settings was sought (objective 4).
Literature was identified by searching the PubMed, Scopus, and Cochrane Library databases from inception. Examples of search terms included “quality of care,” “quality improvement,” “quality indicators,” “performance measures,” “health outcomes,” “cardiac care,” “cardiac rehabilitation,” and “improve practice.” To ensure relevant studies were not missed, the “related articles” feature in PubMed was used to identify further similar articles.
For the first 3 objectives, studies had to pertain to outpatient, phase 2 CR, delivered to adults. Studies of any design were included. Articles that were not in English or were not peer reviewed were excluded.
CARDIAC REHABILITATION QUALITY INDICATORS
In the field of CR, QIs have been developed by several professional associations, namely, the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR)14,15 with the American Heart Association/American College of Cardiology Foundation (ACCF/AHA),16 European Association of Preventive Cardiology (EAPC),17 Australian Cardiovascular Health and Rehabilitation Association (ACRA),18 and Canadian Cardiovascular Society (CCS) with the Canadian Association of Cardiovascular Prevention and Rehabilitation (CACPR).19 Furthermore, a Dutch group has developed QIs,20 as well as Japan (through its government Ministry of Health).21 The British Association for Cardiovascular Prevention and Rehabilitation (BACPR) has 6 “minimum standards,”22 which are similarly used to ensure program quality (eg, wait time, initial assessment, program duration, discharge assessment). The QIs developed, such as CR referral as outlined earlier, are fairly consistent across these national organizations (http://globalcardiacrehab.com/public-resources/quality-indicators; Table 1). These QIs are outlined later in chronological order of development (except the Canadian indicators, which were developed third are presented last in the greatest detail).
The AACVPR (along with the ACCF/AHA) developed a subtype of QIs called performance measures (ie, QIs that are more formally vetted such that they could be suitable for public reporting).12 There were 15.14 The first performance measures were related to referral to CR from inpatient and outpatient settings. There were also measures specific to the delivery of CR such as assessment of risk for adverse cardiovascular events and individualized assessment of blood pressure and lipid control. The performance measures included both structure and process indicators; however, measures focusing on outcomes were lacking. These performance measures were updated in 2010.14,15 They worked to demonstrate the reliability of the referral measures23 so that the National Quality Forum would endorse them and they could potentially be reported publicly and used for pay-for-performance measures.
They were recently reviewed and revised by the AHA/ACCF, in collaboration with the AACVPR, resulting in 5 performance measures (measuring referral and enrollment, including for patients with heart failure) and 3 quality measures (measuring wait time, adherence, and communication about patient outcomes).16 In addition, the AACVPR developed and tested 3 outcomes measures (improvement in functional capacity, improvement in depressive symptoms, and optimal blood pressure control) and 1 process measure (tobacco cessation intervention).24
A group under the leadership of Dr Niels Peek in Europe applied a RAND methodology to develop a set of 18 QIs; 5 structure QIs, 8 process QIs, and 5 outcome QIs.20 The group has gone on to use these indicators to inform quality improvement, through development of an online system to report on quality in real time.25 The EAPC has developed a QI for the referral of patients to an inpatient or outpatient CR program.17 In the supplemental appendix of that article, the authors also present some structure QIs and loosely proffer a checklist of process indicators.
The ACRA has developed key performance indicators related to its 5 core components; namely, access to services, assessment and monitoring, recovery and long-term management, lifestyle modifications, and, most centrally, evaluation and quality improvement.18 It has suggested 71 QIs, each reported as a percentage.
QIs have most recently been developed in Japan.21 A review of the literature and guideline clearinghouses was undertaken and identified 16 indicator sets and 23 guidelines, presenting 27 unique indicators. These were then assessed using a modified Delphi process. The final set of 13 QIs are primarily process-related. They field-tested the QIs in a small pilot to confirm the measurability of the proposed indicators in real-world clinical practice.
In Canada, there is a set of 30 CR QIs.19 They were developed in accordance with the CCS Best Practice methodology.26 In phase 1, experts in the field from across Canada and representatives of stakeholder organizations were invited to serve on the working group to plan and organize the QI development initiative. The CR QI working group created subtheme or domain groups (outlined later) to ensure expert representation across all CR core components. In phase 2, a long list of QIs was developed and a literature review undertaken to establish the evidence base for the candidate QIs. The working group considered candidate QIs from the American and Dutch measures available at that time. The subtheme groups then drafted the QIs, specifying numerators and denominators and providing the evidence basis to support the QI. The drafted QIs underwent formal expert panel review and rating, followed by public consultation. In phase 3, the QIs were submitted to the CCS QI Steering Committee and the CACPR for approval and knowledge translation was undertaken. This included field-testing of 2 QIs.27
The final set of QIs is categorized into 5 domains: (1) referral, access, and wait times (4 QIs); (2) secondary prevention: assessment, risk stratification, and control (10 QIs); (3) behavioral change, program adherence, psychosocial issues, education, and return to work (11 QIs); (4) CR model and structure (2 QIs); and (5) discharge transition, linkage, and communication (3 QIs).19 Overall, there are 2 structure QIs, 25 process QIs, and 3 outcome QIs. Given this may be unwieldy for programs to use, a “top 5” was denoted.19
Unfortunately there are only a couple of publications reporting on CR quality to our knowledge.28 These are all from Canada, except for 1 recent study from the United Kingdom.22 Using data from the 170 programs in BACPR's National Audit of Cardiac Rehabilitation from 2013 to 2014, each program was scored 1 point for meeting each of the 6 minimum standards. CR quality varied significantly, with 30% of programs considered “high” quality (ie, met ≥5 standards).
There have been a handful of other studies reporting on whether programs offer all core components among other guideline criteria related to quality29,30 but not assessing QIs specifically. The AACVPR registry has now been in existence for several years,31 so it is hoped that it can be used to assess CR quality in future.32 Finally, a group in Australia is developing a CR registry, with the minimum data set based on Canadian QIs.33
The greatest source of multisite CR data in Canada is the CCRR, which is governed through the CACPR. Capturing data at program intake and discharge, approximately 200 data elements are collected on each patient.34
The first version of the CCRR data dictionary enabled assessment of 14 of 30 CR QIs in 3 domain areas. As per Donabedian's framework, 10 were considered “process” QIs and the rest “outcome” QIs. At the time of assessment, there were 5447 patient records in the CCRR.35
Results showed that wait times exceeded the 30-d QI target at a median of 84 d from referral to enrollment. Assessments of blood pressure (90%) and adiposity (85%) were high; however, those for lipids (41%), blood glucose (23%), and depression overall (13%) were low. Most of the participants (68%) achieved a 0.5 metabolic equivalent of task (MET) increase in exercise capacity from CR program entry to exit. Of smokers, only 61% were offered smoking cessation therapy. Thirty percent of participants were offered stress management. The CR program completion QI was met in 90% of patients. If we consider 90% as a benchmark of “quality,” clearly again there is considerable variability across indicators (we have also shown significant variability between programs).28
The CCRR has since formed a task force to update data elements and definitions to (among other reasons) enable greater assessments of the QIs. Through the CCRR Data Dictionary 2.0, 27 of 30 QIs can now be assessed (Table 2); the 2 structure QIs still cannot be assessed (because of no program-level data), nor can the inpatient referral QI as only data from CR intake are collected. Therefore, we are now poised to, for the first time, more fully characterize the quality of CR in Canada.
CR programs contributing data to the CCRR receive a quarterly report on the quality of its program across these 30 QIs, and this is compared with similar programs and national benchmarks. Thus, an update on the quality of CR in Canada was obtained through the CCRR following the first quarter of 2016 (about 8000 patients from 17 of ∼170 programs nationally; in 3 provinces). However, caution is warranted in interpreting some of the indicator values. For instance, QI-4 (Risk assessment for adverse CVD events) and QI-20 (Meeting the physical activity guideline target) had very low values, likely because variables to assess these QIs have just recently been added to the CCRR with Data Dictionary 2.0. Furthermore, the QIs for secondary prevention medications were likely artificially low as the CCRR needs to be improved regarding the ability to enter recent medications and to document contraindications. In addition, QI-22 (Assessment of depression) may have been low due to the recent controversy in the literature about assessing depression in CVD patients.36 Finally, QI-3 (Enrollment) and QI-37 (Completion) were likely artificially inflated, as data stewards may only take the time to enter data for patients who are fully engaged in the program and not dropouts (refer to Cochrane review for evidence-based interventions to increase these QIs).37 For this reason, exact indicator values are not reported in this review. However, we have confidence that the trends observed for the other QIs accurately reflect the nature of CR quality in Canada.
Overall, the quality of CR was particularly high in relation to QI-21 (Promotion of post-CR physical activity), QI-13 (Assessment of blood pressure control), and QI-34 (Communication with the primary health care practitioner). Low quality was observed for several QIs. In particular, QI-16 (Assessment of blood glucose control), QI-30 (Stress management), QI-27 (Smoking cessation), QI-2a (Wait time from hospital discharge), QI-23 (Referral of patients screening positive for possible depression), and QI-35 (Recommended elements in discharge summaries) were all of poor quality.
CR QUALITY IMPROVEMENT
QI studies in the field of CR provide evidence that improving care would significantly improve outcomes. For instance, the utilization rate of CR in patients with post-myocardial infarction (MI) was only 15% in Ontario. Wijeysundera et al38 demonstrated that improving CR enrollment from 15% to the 90% quality benchmark would prevent or postpone 135 deaths per year and would yield a 1.3% reduction in CVD mortality. Indeed, the contribution of CR to reducing post-MI mortality appears to be higher than other CVD QIs such as prescription of pharmacological therapies.39
A survey of CR programs in the United States showed that CR programs are using the performance measures to evaluate the quality of their programs and, where low, as the basis for quality improvement initiatives.40 For example, three-fourths of programs reported measuring program enrollment and completion rates in the past 5 yr, with two-thirds implementing an associated quality improvement initiative to address enrollment and completion rates in the same time period.
There is now some preliminary data in the literature reporting on the impact of quality improvement in the CR setting. Pack et al41 evaluated a series of quality improvement initiatives on CR attendance and completion. Three approaches, namely, program policy changes, a patient video, and motivational incentives, were applied over a 2-yr period. Results showed significant increases in attendance and completion of their CR program compared with pre-initiation levels. These findings demonstrate that quality improvement initiatives can be effective in the CR setting.
The work by Peek and colleagues25 shows how an online system/dashboard to monitor CR program quality can be used to identify areas that require improvement in order to inform improvement efforts. An audit and feedback strategy refers to the provision of summative data on clinical performance over a specified period of time to health care professionals to incite improvements in performance.42 In a Cochrane review on this approach, compliance of health care professionals with desired practice was found to be significantly increased with audit and feedback, although the effect was small.42 The recent cluster-randomized trial of the group in 18 centers failed to show that an online audit and feedback strategy with educational outreach can reliably improve CR care quality.43 Professionals disagreeing with benchmarks, deeming improvement infeasible, having their own views of what constitutes quality of care, as well as personal preferences and beliefs about quality and improvement targets, were barriers to CR quality improvement.44–46
RECOMMENDATIONS FOR CR QUALITY IMPROVEMENT
Given the quality of CR as outlined earlier, potential evidence-based interventions that could improve quality in areas where it is lowest are now considered. We focus on provision of stress management training to all CR participants, smoking cessation, informational elements in the CR discharge summary, and assessment of blood glucose. Approaches to quality improvement more broadly are then summarized as pertinent to the CR context (Figure).
Conceptual overviews in the quality improvement field, and the closely related area of knowledge translation, categorize models or approaches to improvement. These primarily include educational, linkage and exchange, audit and feedback, informatics, organizational, and patient-mediated interventions.47 Other quality improvement strategies include facilitated relay of clinical data to providers, patient and provider education, promotion of self-management, as well as financial incentives, regulation, and policy.48 It is recommended to implement a multipronged approach addressing patient, provider, and health system factors in order to achieve sustained improvement. Finally, we must also consider CR context and quality improvement barriers identified in the work by Peek and colleagues.43–46
Stress Management (QI-30)
Stress management is a core component of CR.4–8,17,18 This is important because mental, not just physical, stress has been shown to induce myocardial ischemia.49,50 It is suspected that less than half of patients in the CCRR received stress management because CR programs may not have the resources to deliver this component. Indeed, CR is highly underresourced relative to other cardiac interventions.
To improve quality in this area, it is suggested that CR programs collaborate with a mental health care professional at their institution to identify web-based resources relevant to their population that can be provided to patients at no cost. Indeed, previous research has shown that counseling delivered via information and communications technologies improve well-being to a similar degree as face-to-face counseling with a mental health care professional.51,52 This would be considered an organizational change and provider education approach to quality improvement.47,48
Smoking Cessation (QI-27)
Smoking is the primary preventable risk factor in the development of CVD, and smoking cessation is the behavior change that accounts for the greatest reductions in mortality in CVD patients.53,54 Despite this, an alarming 70% of smokers fail to quit after hospital discharge for MI.55 Evidence suggests that only 30% to 40% of CVD patients stop smoking after a coronary event.56,57 In the CCRR, we observed 25% of patients quit.
To improve this QI, programs need to ensure they have the resources available to support smokers in quitting and to apply evidence-based approaches. Several strategies for smoking cessation have proven to be effective, namely, pharmacotherapies,58 nicotine replacement therapy,59 and behavioral support interventions such as individual counselling.60 Nicotine replacement therapy has been shown to increase the rate of quitting by 50% to 70% regardless of the setting.59 Pharmacological interventions such as bupropion also significantly increase long-term cessation by 60%.58 A Cochrane review suggests that a combined intervention consisting of behavioral support and medications could potentially increase smoking cessation by 70% to 100% compared with usual care.61
To improve quality in this area, education is needed for CR program staff on how to counsel patients on smoking cessation, considering even brief advice from a health care professional can trigger a cessation attempt and lead to quitting.62 This would require provider education. Furthermore, incentives could be provided where possible to encourage patients to quit. The use of incentives has previously been shown to be effective in promoting health behavior.63 Organizational change may also be required to ensure the CR team has the appropriate skill mix and staff have the time for cessation counseling.
Recommended Elements in Discharge Summaries (QI-35)
To ensure long-term risk factor management and secondary prevention, it is imperative that primary care providers receive complete information on care provided during CR. Patient discharge summaries should include the following 4 recommended elements: (1) a description of the patient's lifestyle risk factors (physical activity, diet, and smoking); (2) medical risk factors (blood pressure, lipids, and glucose as relevant); (3) cardiac medications; and (4) long-term management goals. These elements were selected on the basis of previous research where primary care providers were interviewed regarding the information they need to support secondary prevention in CR graduates.64
A quality improvement strategy to overcome the lack of inclusion of these elements in the discharge summaries is organizational change. Programs should institute changes to the discharge summary template so that it includes all 4 elements. In addition, electronic CR records may be used to generate standard discharge summaries that report on the 4 elements identified earlier.
Assessment of Blood Glucose in Patients With Diabetes (QI-16)
Diabetes mellitus is associated with poorer outcomes in patients with CVD, yet it is highly common in this population.65 Knowledge of fasting blood glucose and/or glycated hemoglobin A1c (HbA1c) values informs CR providers how well patients are controlling their diabetes, as well as how their exercise sessions may be impacted (eg, hypoglycemia).
Given that diabetes is associated with CVD onset, many patients with diabetes likely have another health care provider who is managing their diabetes and hence assessing blood glucose. Low quality for this indicator suggests that CR programs may be relying on these other health care providers outside the CR program to manage diabetes. CR program staff may be reluctant to order another blood glucose assessment over concerns of the wasted resources expended with duplicate testing. Therefore, it is suggested that CR programs request the HbA1c results from these other providers. Then this information can be used by CR staff to ensure patients are receiving appropriate advice regarding exercise and self-management of their blood glucose levels. This could be achieved by facilitated relay of clinical data to providers.
RECOMMENDATIONS FOR CR PROGRAM IMPROVEMENT OF ANY QUALITY INDICATOR
As outlined earlier, the CCRR provides quarterly reports to participating CR programs across Canada that display their performance on 27 QIs (Table 2). This could be considered an audit and feedback strategy.42 It is hoped that by providing quarterly reports to participating programs, they will initiate quality improvement efforts such as those that have been suggested herein. This could be tried by other CR registries.32 However, the CR community should not rely solely on such a strategy, as the work by Peek and colleagues43–46 summarized previously demonstrates that there are barriers to achieving quality improvement following receipt of feedback. The AACVPR and the BACPR also have certification programs, and whether these result in quality improvement also warrants investigation.66
Some QIs, particularly structure QIs, would be best addressed with change at the level of the health system itself. With regard to health care providers, reminder systems could be particularly impactful, such as computer-based reminders and decision support.48 Indeed, results of the QI survey of CR programs outlined in the introduction show such approaches were often implemented to augment referral.40 Within CR programs, reminders could be used to trigger program staff to monitor response to a newly initiated treatment for example (ie, patient reports initiating bupropion, so the provider could check in with the patient 2 wk later to discuss how the patient is tolerating it and how the patient is faring with cessation attempts). Furthermore, facilitated relay of clinical data to providers should be applied to facilitate transmission of clinical data among CR team members, given programs are interprofessional, and also between CR staff and primary and specialty care providers of the patient to ensure long-term management of all CVD risk factors. Programs should make full use of electronic patient records to enable timely relay of clinical data to providers.48
Finally, advocacy initiatives are warranted for improved funding policy for CR programs. CR services are variably funded across the country and around the globe.67 Advocacy is needed to ensure programs are properly resourced to deliver all core components of CR (such as stress management and smoking cessation). The International Council of Cardiovascular Prevention and Rehabilitation has recently developed some recommendations and tools for CR reimbursement advocacy (http://globalcardiacrehab.com/advocacy/).
This was a narrative review. Given this search strategy was not fully specified (ie, PICOs) and registered, and a systematic search of the literature was not performed, it is possible that articles were missed. Moreover, the approach to making recommendations for CR quality improvement was based more on author/expert consensus than on evidence, given the state of science in this area.
The major CR societies internationally have developed CR QIs through rigorous processes. There is quite a large variation in the number, but not nature, of indicators. However, there remains little evidence regarding the link between the indicators and patient outcomes.
Although CR is shown to be very effective, where characterized, there are some gaps between recommended CR care and CR care delivered. To address the areas of low quality in CR, quality improvement initiatives are required. Some key approaches to improve quality should include patient and provider education, reminder systems, organizational change, and advocating for improved CR reimbursement. These recommendations require testing to assess whether they can improve quality.
Finally, CR programs should be encouraged to join registries in their jurisdictions and trained to provide complete, high-quality data. This will enable us to report in a more generalizable way on the quality of CR, to be confident in quality reports, and to work with interested programs to implement these quality improvement recommendations and test their impact. It is hoped that through CR quality improvement, we can ensure patients achieve the best health outcomes and we can have high-performing chronic CVD care systems globally.
The authors thank Rajiv Nariani for his help with the literature search.
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