Cardiac Rehabilitation Program-Related Factors Associated with Mortality and Morbidity Among Patients in Low-Resource Settings: Analysis from The International Cardiac Rehabilitation Registry

Abstract

Background and objective: Cardiovascular disease (CVD) is a global health concern, particularly in low- and middle-income countries (LMICs). The effectiveness of cardiac rehabilitation (CR) programs is well-documented in reducing mortality and morbidity and improving quality of life and psychological well-being. However, global access to CR programs remains limited, especially in LMICs. The nature of CR services in low-resource settings differs from high-resource ones in terms of comprehensiveness, dose, staffing, and other factors. Therefore, the aims of this study were to identify program characteristics associated with a) cardiac and all cause-mortality and (b) cardiac and all cause-mortality among CR participants in low-resource settings. Method: This is a prospective observational study and registry-based on the International Council of Cardiovascular Prevention and Rehabilitation’s (ICCPR) and International Cardiac Rehabilitation Registry (ICRR). Patients with annual data at the time of study were included. Multilevel models were used to account for clustering of patients within CR programs. Multilevel modified Poisson regression model was used to estimate the adjusted Incident Rate Ratios or Relative Risks (IRRs) of morbidity. Result: Our study included 637 patients (85% male, average age 58.2 years) participating in six CR programs with one-year follow-up. By one-year follow-up, there were only seven cardiac death-related. Patients who reported any morbidity at one-year follow-up had significantly lower years of formal schooling, unemployed, diagnosed with Acute Coronary Syndrome (ACS), and completed fewer CR sessions. An analysis of program related factors affecting morbidity at one-year follow-up revealed significantly lower probability of morbidity associated with the following factor: higher number of assessed risk factors (IRR 0.12, 95%CI: 0.09, 0.15), more number of supervised sessions completed (IRR 0.94, 95%CI: 0.92, 0.95), program duration (IRR 0.74, 95%CI: 0.69, 0.80), and number of patient education sessions (IRR 0.55, 95%CI: 0.51, 0.59). On the other side, the following program-related factors were associated with higher risk of morbidity: location of the CR program in an academic/referral CR institution (IRR 8.68, 95%CI: 6.65, 10.01) compared to non-academic/non-referral institutions, and patient out of pocket payment or cost-sharing source of reimbursement (IRR 3.68, 95%CI: 2.48, 5.48). Conclusion: results of the study CR programs should prioritize comprehensive risk assessment, longer durations, and provide more number of patient education to reduce morbidity. Additionally, government funding sources should be considered to optimize patient outcomes.