Cardiac rehabilitation is an essential therapeutic step in ensuring patient reintegration into work-, social- and family life following acute cardiac incidents or cardiac surgical procedures. Currently in Austria, the Phase II cardiac rehabilitation that follows the inpatient Phase I cardiac rehabilitation conducted after an acute incident, is performed mainly in inpatient rehabilitation centers. A small portion of cardiac patients in Austria participate in outpatient rehabilitation programs; internationally the routine form of care of Phase II cardiac rehabilitation is outpatient.
The objective of the first part of this report, on the one hand, is to identify indicators which are suitable for the formative and summative evaluation of outpatient cardiac rehabilitation, and on the other hand, to analyze appropriate methods or instruments to measure the processes and results.
Using a systematic literature search, we identified theoretical concepts and evaluation studies. Next, the indicators for specific quality areas were comparatively analyzed and various evaluation approaches were presented.
In reference to the quality of the process, therapy processes of patients are evaluated from the time of a patient’s admission to the time of discharge. Specific treatment steps can be examined for their strengths or weaknesses. Alternatively, the proportion of patients can be determined who had undergone defined treatment steps. The analysis of the quality of results is based on defined objectives of the core components of cardiac rehabilitation. The results can be presented as changes of absolute numbers or proportions of patients in defined target areas at fixed measurement time points or over a period of time.
Appropriate documentation and a standardized compilation of data are the basis of all evaluation methods. An alternative to visitation and just reviewing patient charts is the peer-review process of individual therapy documentation to evaluate the process quality. The analysis of the quality of outcomes occurs through a selection of aggregate patient data. Results can be set in relation to national objectives or can be presented comparatively between individual rehabilitation programs.
Due to the minimal number of published studies that are directly transferrable to the Austrian health care system, a prioritization of appropriate indicators and instruments is not possible. The compilation of potential indicators and various approaches to quality assurance – from outcome comparisons of random samples with defined national objectives and from performance and outcome measures defined by international professional associations to the establishment of comprehensive quality profiles – can serve nevertheless as a basis for the development of Austrian quality assurance measures.
The objective of the second part of the report is the comparative analysis of various rehabilitation models of Phase II as well as an analysis of the efficacy of Phase III interventions.
The systematic literature search identified four cohort studies for the comparison of outpatient with inpatient Phase II cardiac rehabilitation, a systematic review, five RCTs, and two cohort studies for the comparison with “home-based” rehabilitation and three RCTs for the comparison of Phase III cardiac rehabilitation with routine care.
The 3 – 4 week inpatient cardiac rehabilitations were compared with 1 – 3 month outpatient cardiac rehabilitation programs. The reduction in total cholesterol and blood pressure achieved in Phase II could not always be sustained beyond the rehabilitation duration. Whereas Body Mass Index (BMI) and body weight were hardly influenced, physical performance improved significantly in all forms of care. The portion of smokers exhibited a sustained decline. Anxiety, depression and quality of life were positively influenced by both interventions. Rates of rehospitalization, myocardial infarction,-and revascularization did not differ between the two forms of care.
In the eight publications on outpatient, center-based cardiac rehabilitation versus home-based cardiac rehabilitation, we analyzed programs lasting from 6 weeks to 6 months. Cholesterol levels and physical performance improved in all forms of care but blood pressure and BMI/body weight were only slightly influenced. The portion of smokers declined significantly. Quality of life improved significantly but slightly in favor of the home-based rehabilitation patients. No differences between the forms of treatment could be determined in regards to the recurrence of cardiac events and total mortality.
Phase III cardiac rehabilitation occurred in the three randomized controlled studies following inpatient or outpatient Phase II cardiac rehabilitation and lasted 9 – 12 months. Noticeable was the great heterogeneity of the programs in regards to the contents and models of rehabilitation. Cholesterol and BMI/body weight did not change; blood pressure was slightly improved through intervention. No group differences were apparent in physical performance. Smoking behavior was not influenced in Phase III. Information on psychological health and quality of life was not given in the publications. The mortality in the intervention groups was a bit less but the significance of this difference was not provided.
So far, the available studies show no significant difference in efficacy between the different Phase II programs. None of the Phase III interventions analyzed in the studies could sustainably improve the effects achieved in Phase II; the worsening of cardiovascular risk factors could be minimized for some compared with routine care.
Randomized controlled studies with sufficient observation periods and a monitoring of current outpatients and inpatients would be necessary to prove differences in efficacy in forms of care as well as to evaluate their sustainability. Requirements for home-based rehabilitation programs in German-speaking regions should be reviewed. Austrian Phase III programs should be evaluated and research on effective alternatives to cardiovascular long-term prevention should be promoted.