Advocacy for outpatient cardiac rehabilitation globally

Government-reimbursed indications for CR were most often myocardial infarction, coronary artery bypass graft surgery and percutaneous coronary intervention (all 100 %), followed by heart failure, valve surgery/procedures, and heart transplant (all 87 %), as well as stable angina (73 %), and rhythm devices (60 %). Respondents reported that a mean of 32.0 (standard deviation; SD = 12.9) CR sessions were covered by government for each patient, and that a mean of 91.5 % (SD = 19.2 %) of the total CR program cost was covered by government (i.e., no deductible or out-of-pocket fee). Almost one-fifth of respondents reported that the government limits the components of CR covered.

Aspects of CR which were reimbursed most often included supervised exercise (93 %), followed by dietary counselling, mental health/psychological support, smoking cessation, hypertension control and hyperlipidemia control (all 80 %), education (73 %), weight control (67 %), and return-to-work/occupational therapy (53 %). When asked whether the government specified the type of professional treating the cardiac patient to be eligible for CR funding, over half responded yes; the type of professional was most often a cardiologist, nurse or physiotherapist (each 99 %).

Reimbursed indications for CR were synonymous with those reported with government funding. Respondents reported that mean of 22.2 (SD = 15.4) sessions were covered, and that mean of 48.3 % (SD = 50.5 %) of the total CR program cost was covered by private healthcare insurance. Where the patient paid some money toward CR, the average cost was USD$17.5 (SD = 6.9)/session or USD$345.0 (SD = 38.2)/program. Some respondents commented that the insurance companies only covered physical activity and exercise training.

Despite the large amount of evidence [15, 33, 34] showing the benefits of CR services to eligible patients, advocacy has been challenging. CR services are beneficial, yet relatively simple and low-cost, when compared to other services in the field of cardiovascular medicine. Arguably then, CR services have not generally attracted much attention from administrators, clinicians, and even patients, given the “low-tech”, lower budget nature of CR services.

In the past three decades, CR professionals from various countries around the world have been involved as advocates on behalf of their patients, helping to shape and implement important healthcare policies for the provision of CR to eligible patients. Advocacy messaging has been primarily based on what is in the best interests of eligible patients—to promote the delivery of CR services to the large number of individuals who are eligible for such services each year.

Components of a successful CR advocacy program are multi-faceted, and include the following:

Communications methods are critically important in the work of advocacy towards CR. The key to coverage negotiations is identifying the needs and benefits to the patient, government and/or insurance companies. By providing an explanation of the services and benefits of CR for insured clients, coverage may be considered by governments and insurance companies. Key points for communication in a CR advocacy campaign are presented in Table 1.

In countries where advocacy work has not yet resulted in insurance coverage policies for CR, healthcare systems could consider alternative CR models at least for the short-term, including home-based CR, mobile technology tools, and other forms of lower-cost delivery models (e.g., outdoor Asociacion Cardiovascular Centrooccidental CR program in Barquisimeto, Venezuela).

CR professionals have begun advocating for broader CR delivery and reimbursement. Relenting efforts have paid off in several countries such as Iran, Qatar, the United States and United Kingdom. A summary of these success stories is given in Table 2, and include CR-supportive funding policy and program initiation in countries where CR did not exist. For a detailed description, please refer to the online Additional file 1.

To promulgate successful advocacy efforts, organizations like the American Association of Cardiovascular and Pulmonary Rehabilitation [35] and World Heart Federation [36], have provided advocacy tools that can be found online. An ICCPR toolkit and accompanying pamphlet can be found in Additional files 2 and 3, respectively. Below evidence supporting the need for CR and its benefits, as per the first 2 CR-specific advocacy components (namely the “cause” and the sources of information to support it) are provided below.

In addition to its’ impact of on mortality and morbidity as mentioned in the introduction, CVD is also associated with a significant economic burden. Focusing on only direct cost (i.e., costs associated with hospital inpatient care, outpatient physician visits, and medications), CVD has the highest total costs of any health condition [37].

In the European Union, CVD was estimated to cost over €106,156,940,0002009 for health care-specific costs which included five categories: primary care, outpatient care, emergency, inpatient care, and medications. Non-health care costs were estimated at €26,963,326,000 due to mortality, €18,873,665,000 due to morbidity, and €43,560,202,000 in informal care. Overall, the cost of CVD to EU was approximately €196 billion annually in 2009 [38] which is a steep increase from €169 in 2003 [39].

A similar picture emerges in North America. In the United States, CVD also accounts for a large share of total spending. The average annual cost per person attributable to CVD is $4734 (2005 American dollars) [40]. By 2030, 40.5 % of the American population is projected to have some form of CVD, and total direct costs are projected to reach more than $800 billion in 2008 American dollars (from $273 billion in 2010). The indirect costs due to productivity loss are estimated to increase to $276 billion in 2030.

In low and middle-income countries, the burden of CVD is of epidemic proportions [41, 42]. Using economic growth models, which assess the effect of chronic diseases on national income, the estimated losses because of coronary heart disease, stroke, and diabetes ranged from $20 to 30 million in Ethiopia and Vietnam to almost $1 billion in larger countries such as India and China [41]. In the scenario with no support to reduce risk of chronic diseases, an estimated $84 billion of national income (American dollars) will be lost to heart disease, stroke, and diabetes alone in 23 selected low and middle-income countries between 2006 and 2015, namely China, India, Russia, Brazil, Indonesia, Mexico, Turkey, Pakistan, Thailand, Bangladesh, Ukraine, Egypt, Argentina, Burma, Iran, Poland, South Africa, Philippines, Colombia, Vietnam, Nigeria, Ethiopia, and Democratic Republic of the Congo [41].

From an individual’s perspective, CVD poses a great economic burden on the family and the community. This is not only due to productivity loss, but also care costs. Studies indicate that CVD drives approximately 10 % of affected families into poverty in a low and middle-income country like India [16]. Moreover, due to disability caused by CVD, individuals may require assistance with activities of daily living (which costs money), as well as financial support if their productivity decreases.

Overall, CR has consistently shown to be either cost-saving or to be cost-effective regardless of the country where it was examined, the perspective used, the costs included, and the year when it was analyzed [33]. In fact, European studies have demonstrated that CR may actually be a cost-saving intervention [25]. A cost-effectiveness analysis using pooled data from randomized clinical trials and cohorts demonstrated that CR would cost $4950 per year of life saved [26]. Systematic reviews of all the available evidence show savings of $12,000/CR patient over 5 years, to $9200 per quality-adjusted life year [33]. To put this in perspective, Table 3 shows cost-effectiveness values for common treatments and procedures for the secondary prevention of CVD.

Because CR has been demonstrated to decrease total mortality, cardiovascular mortality, cardiovascular events, procedures, and re-hospitalizations, and has shown to improve quality of life, the denominator in the cost-effectiveness equation is generally as good, or better, than many other cardiovascular interventions [33, 34, 43, 44]. In addition to these benefits, CR has also been reported to increase return to work [45]. Those values are presumably stable across countries and geographic regions, as the benefit of CR is expected to be similar (as long as the program is of good quality and similar to the programs used in the primary studies). On the contrary, the cost component of a cost-effectiveness analysis will vary from country to country, because the cost of major components of CR can be significantly different across geographic regions. For example, major components like the salary for nurses, physicians, and other healthcare providers are significantly higher in high-income countries when compared to low and middle-income countries. Likewise, costs related to use of physical space and other costs related to the overall expenses of CR can also be significantly higher in a high-income country.

Therefore, as the measure of effectiveness is expected to be similar but costs are expected to be lower in low and middle-income countries, it is safe to assume that the estimates of cost-effectiveness for CR will probably be more favorable in low and middle-income countries. For example, if the overall cost of CR in a low and middle-income country is only one-half of the total cost in a high-income country, the already favorable estimates for cost-effectiveness may actually become cost-saving. This suggests that in a low and middle-income country, not providing CR might actually be more expensive to payers and to society than providing CR. This can occur because the lack of a medical intervention (i.e., CR) meant to prevent adverse events and procedures would lead to major expenses, making the lack of CR more expensive than offering it itself. We do concede however that more data in this area is needed.