7th June 2019, Volume 132 Number 1496

Brendon H Roxburgh, Marta Supervia, Karam Turk-Adawi, Jocelyne R Benatar, Francisco Lopez Jimenez, Sherry L Grace

Cardiovascular diseases (CVD) account for approximately 10,000 deaths per annum (31.2% of all deaths) in New Zealand.1 Patients afflicted with CVD are at increased risk of recurrent cardiovascular events and other comorbidities, and report a reduced quality of life.2,3 Cardiac rehabilitation (CR) is a cost-effective intervention for reducing these sequelae,4 with a Class I recommendation (ie, strongly recommended) from the American Heart Association, American College of Cardiology and European Society of Cardiology, among others.5,6 Long-term lifestyle changes, including cessation of smoking, healthy dietary patterns, increased exercise and medication adherence are crucial to reduce CVD mortality and morbidity. Successful CR programmes play a role in facilitating these lifestyle and risk factor modifications through individualised treatment plans and patient education.4,7

Despite the well-documented benefits of a structured and individualised programme,8 a recent survey of New Zealand CR programmes indicated that only 72% of programmes offer an individualised treatment plan for patients, only 33% conducted an end-of-programme assessment, and only a handful follow the guidelines of offering 24 sessions to patients.9 Possible reasons for this are not known, but are likely to include geography and resource allocation. While this research has provided insight into CR in New Zealand,9 it is the only assessment of CR delivery in New Zealand.10 Furthermore, no research has compared the nature and delivery of CR programmes within New Zealand, or with other countries around the globe. Benchmarking of CR services in New Zealand with comparable countries (ie, same country income classification, similar healthcare systems) is necessary to identify strengths and/or disparity of care, to inform future CR delivery.

Therefore, the purpose of this study was to compare the nature and delivery of CR programmes within New Zealand, and with those in other high-income countries (HIC), specifically with regards to: 1) volume indicators (ie, number of sessions, dose, annual volume etc.), 2) accepted indications, 3) types of healthcare professional on the CR team and healthcare professional with programme oversight, 4) elements delivered, 5) delivery of alternative models (ie, community-based), and 6) barriers to delivery. We also sought to examine whether differences were present between CR programmes in the North Island (NI) and South Island (SI) of New Zealand.

Methods

Design and procedure

This paper presents secondary analysis of a global survey of CR programmes; its methodology is described in detail, and the survey available elsewhere.11 Identified leaders of national CR societies/organisations were contacted via email to administer the survey to each programme in their country. The survey was administered between June 2016 and December 2017, via a secure web-based application (REDCap, Nashville, US). All CR programmes received two email reminders, sent at two-week intervals. Ethical review for this study was carried out by York University’s Office of Research Ethics (Toronto, Canada) and Mayo Clinic’s Institutional Review Board (Rochester, US); both institutions provided an ethics approval exemption given the study methodology. Informed consent was obtained via an online form.

Sample

All programmes globally identified as providing phase II CR (ie, outpatient services to patients following an acute cardiac event or hospitalisation) were included in the Global CR Program Survey Study. Forty-three CR programmes in New Zealand were invited to complete the survey. Programme location was categorised as NI or SI based on the city/town listed for each New Zealand programme.

Countries classified as HICs by the World Bank in North America and Europe, as well as Australia were included as a comparative group, due to their similarity in income and healthcare systems to New Zealand.12 Forty-three countries were included, of which 31 (72%) offered CR.11

Measures

Development of the survey was based on previous national/regional surveys of CR programmes.13–15 Forced-choice response was used for most items and skip logic used where applicable to obtain further details.

The following variables were assessed: (1) locality of programmes (ie, urban [larger city, town], suburban [a residential district located on the outskirts of a city] or rural [located outside city/town]), (2) programme and volume-related indicators (ie, time to CR commencement, number of patients per annum), (3) dose of CR (in hours; ie, sessions per week x duration in weeks x duration of exercise sessions in minutes), (4) accepted indications (ie, myocardial infarction, as well as non-cardiac indications), (5) the types and number of healthcare professionals on CR team, and whom has programme oversight (ie, cardiologist, nurse, physiotherapist etc.), (6) the type and number of elements delivered (of 24; ie, initial assessment, patient education), (7) whether the programme offers alternative CR models (ie, home or community-based programmes), and (8) perceived barriers to delivery.

Statistical analysis

All statistical analyses were performed using IBM SPSS software, version 23.0 (IBM, Chicago, US). All initiated surveys were included. The number of responses for each question varied due to missing data (ie, respondent did not answer a question due to lack of willingness or potential inapplicability, use of skip logic); for descriptive analyses, percentages were computed with the denominator being the number of responses for a specific item.

Descriptive statistics were expressed as either mean ± standard deviation, median, interquartile range, (IQR, quartile 25th–75th percentile) or number and percentage. Differences (ie, New Zealand vs other HICs, and NI vs SI) in continuous variables were analysed using independent-sample t-tests, or Mann-Whitney U tests if data normality and/or homogeneity of variance were violated. Differences in categorical variables were analysed using Chi-squared tests. Due to the small number of New Zealand programmes, multi-level analyses could not be performed. The level of statistical significance was set at p<0.05.

Results

Responses were received from 27 (programme response rate = 62.7%) out of 43 New Zealand CR programmes. Eighteen (66.7%) responses were from NI (31 approached), and eight from SI (12 approached) CR programmes; one response was excluded from the NI vs SI analysis because no city/town was provided.

Twenty-eight out of 31 other HICs (country response rate = 90.3%) responded to the survey: Australia, Austria, Belgium, Canada, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, the Netherlands, Poland, Portugal, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, the UK and the US. There were a total of 619 surveys initiated (programme response rate = 43.1%).11

Nature of CR programmes

Comparison of programme characteristics and indications for CR are provided in Table 1 and 2. New Zealand (n=19, 73.1%) and other HIC (n=92, 61.5%; p=0.468) programmes were primarily based in urban locations; this was similar for NI (n=14, 77.8%) and SI (n=6, 75.0%; p=0.813) CR programmes. The time from hospital discharge to first visit was a median of 3.25 weeks and was not different from other HICs (p=0.131) or between the NI and SI (p=0.291).

Table 1: Programme characteristics by island, nationally and in other high-income countries.

 

NZ

 

NI (n=18)

SI (n=8)

Total (n=27)

Other HICs (n=619)

Weeks from hospital discharge to first visit

3.0 (2.0–4.8)

3.5 (3.0–5.0)

3.25 (2.5–4.8)

3.0 (2.0–4.0)

Annual volume (n)

270 (110–640)

220 (100–340)

270 (83–640)

250 (120–600)

Number of education sessions/programme

6.0 (6.0–8.0)

4.5 (3.0–6.0)

6.0 (6.0–8.0)

8.0 (5.0–12.0)**

Duration of education session (minutes)

60 (60.0–60.0)

45 (30.0–60.0)

60 (52.5–60.0)

52.5 (40.0–60.0)**

CR programme duration (weeks)

8.0 (6.0–9.0)

7.5 (5.0–10.0)

8.0 (6.0–9.5)

8.0 (6.0–12.0)

Sessions per week (n)

2.0 (1.0–2.0)

1.5 (1.0–2.0)

2.0 (1.0–2.5)

2.5 (2.0–3.0)*

CR session duration (minutes)

60.0 (60.0–60.0)

50.0 (40.0–60.0)

60.0 (52.5–60.0)^

60.0 (60.0–60.0)

Patients per session (n)

10 (8.0–15.0)

15 (15.0–15.0)

10.0 (8.0–15.0)

10.0 (6.0–13.0)

CR programme overseen by

Cardiologist

2 (12.5%)

0 (0.0%)

2 (8.3%)

288 (49.7%)**

Other physician (ie, internal medicine, physiatrist etc.)

0 (0.0%)

0 (0.0%)

0 (0.0%)

70 (12.1%)

Nurse

11 (68.8%)

7 (87.5%)

18 (75.0%)

150 (25.9%)**

Exercise physiologist

3 (18.8%)

0 (0.0%)

3 (12.5%)

17 (2.9%)

Other

0 (0.0%)

1 (12.5%)

1 (4.0%)

45 (7.4%)

Alternative models of CR offered

Yes

9 (56.3%)

4 (57.1%)

14 (58.3%)

190 (36.5%)*

Community-based

8 (88.9%)

3 (75.0%)

11 (78.6%)

75 (39.5%)**

Home-based

6 (66.7%)

1 (25.0%)

7 (50.0%)

108 (56.8%)

NI = North Island; SI = South Island; NZ = New Zealand; HIC = high-income country; IA = initial assessment; CR = cardiac rehabilitation.
Data are presented median (IQR) or n (%). ^ = p<0.05 NI vs. SI; * = p<0.05 NZ vs. HIC; ** = p<0.005.
Note: Due to missing data, percentages are computed where the denominator is the number of valid responses from responding programmes.
 

New Zealand CR programmes see a median of 270 patients per annum, offering a median 2.0 sessions per week, for 8.0 weeks. Accordingly, median programme dose was 16.0 hours (IQR=12.0–36.0) in New Zealand, which was lower than other HICs (21.6 hours; IQR=12.0–36.0; p=0.016). There was no difference in CR dose between NI (16.0 hours; IQR=6.0–24.0) and SI (16.0 hours; IQR=6.0-18.0; p=0.193) CR programmes.

Revascularisation patients were universally accepted, with heart failure and stable coronary disease patients (which are also a guideline indication) accepted by ~90% and 70% of programmes, respectively (Table 2). New Zealand programmes were significantly less likely to accept myocardial infarction/acute coronary syndrome, ventricular assist device, rhythm device (ie, pacemaker) and cardiomyopathy patients, compared to other HICs. New Zealand CR programmes were more likely to only serve patients with cardiac conditions, compared to other HICs; other HICs had a greater proportion of programmes accepting patients with vascular claudication (n=208, 42.5% vs. n=3, 13.6% in New Zealand; p=0.007). NI programmes were more likely to accept high-risk primary prevention patients than SI programmes, and there was a trend towards more often accepting patients with other non-cardiac conditions such as stroke (n=4, 25.0%; p=0.214), diabetes (n=4, 25.0%; p=0.214) and lung disease (n=5, 31.3%; p=0.152), compared to SI programmes (all n=0, 0.0%).

Table 2: Indications for CR by island, nationally and in other high-income countries.

 

NZ

 

NI

SI

Total

Other HICs

Coronary artery bypass graft surgery

16 (100.0%)

5 (100.0%)

22 (100%)

470 (96.1%)

Percutaneous coronary intervention

16 (100.0%)

5 (100.0%)

22 (100%)

472 (96.5%)

Valve surgery/repair or procedure

16 (100.0%)

5 (100.0%)

22 (100%)

451 (92.2%)

Heart failure

14 (87.5%)

5 (100.0%)

20 (90.9%)

436 (89.2%)

Post-myocardial infarction/acute coronary syndrome

15 (93.8%)

4 (80.0%)

20 (90.9%)

482 (98.6%)*

Stable coronary artery disease, without a recent event or procedure

11 (68.8%)

4 (80.0%)

16 (72.7%)

370 (75.7%)

Heart transplant

9 (56.3%)

3 (60.0%)

13 (59.1%)

320 (65.4%)

Rhythm devices

11 (68.8%)

2 (40.0%)

13 (59.1%)

399 (81.6%)*

Arrhythmias

10 (62.5%)

2 (40.0%)

12 (54.5%)

306 (62.6%)

High-risk primary prevention

11 (68.8%)

0 (0.0%)

11 (50.0%)^

243 (49.7%)

Cardiomyopathy

8 (50.0%)

2 (40.0%)

10 (45.5%)

380 (77.7%)**

Rheumatic heart disease

7 (43.8%)

2 (40.0%)

9 (40.9%)

215 (44.0%)

Congenital heart disease

7 (43.8%)

1 (20.0%)

8 (36.4%)

276 (56.4%)

Ventricular assist devices

7 (43.8%)

0 (0.0%)

7 (31.8%)

268 (54.8%)*

Non-cardiac chronic diseases

Stroke

25% (4)

0% (0)

18% (4)

25% (121)

Claudication

19% (3)

0% (0)

14% (3)

43% (208)*

Cancer

19% (3)

0% (0)

14% (3)

14% (69)

Diabetes

25% (4)

0% (0)

18% (4)

37% (180)

Lung disease

31% (5)

0% (0)

23% (5)

30% (148)

None (ie, only cardiac chronic diseases served)

56% (9)

80% (4)

64% (14)

36% (175*)

CR = cardiac rehabilitation; NI = North Island; SI = South Island; NZ = New Zealand; HIC = high-income country.
Data are presented n (%). ^ = p<0.05 NI vs SI; * = p<0.05 NZ vs HIC; ** = p<0.005. 

Delivery of CR programmes

In New Zealand, CR programmes were most commonly overseen by nurses, followed by exercise physiologists and cardiologists (Table 1); conversely in other HICs, almost half of CR programmes were overseen by cardiologists, followed by nurses and other physicians. No differences were observed by island.

The number and nature of healthcare professionals on CR teams is shown in Table 3. New Zealand CR teams had fewer staff and most commonly comprised dietitians, pharmacists, nurses and physiotherapists. New Zealand CR programmes were more likely to include pharmacists, but less likely to have cardiologists, physiatrists, other physicians, nurse practitioners, psychiatrists, kinesiologists and administrative assistants/secretaries than other HICs. There were no differences by island.

Table 3: Types of healthcare professional on CR team by island, nationally and in other high-income countries.

 

NZ

 

NI

SI

Total

Other HICs

Cardiologist

9 (52.9%)

2 (28.6%)

11 (44.0%)

386 (72.3%)**

Physiatrist

1 (6.3%)

0 (0.0%)

1 (4.2%)

191 (36.7%)**

Sports medicine physician

0 (0.0%)

0 (0.0%)

0 (0.0%)

68 (13.3%)

Other physician

1 (6.3%)

0 (0.0%)

1 (4.2%)

201 (39.0%)**

Physiotherapist

13 (81.3%)

5 (71.4%)

19 (79.2%)

422 (78.9%)

Nurse

13 (76.5%)

7 (100%)

21 (84.0%)

482 (89.8%)

Nurse practitioner

3 (18.8%)

0 (0.0%)

3 (13.0%)

185 (36.6%)*

Psychiatrist

0 (0.0%)

0 (0.0%)

0 (0.0%)

97 (18.9%)*

Psychologist

7 (50.0%)

2 (33.3%)

9 (42.9%)

325 (61.4%)

Social worker

7 (43.8%)

4 (57.1%)

12 (50.0%)

254 (48.3%)

Dietitian

14 (87.5%)

6 (85.7%)

21 (87.5%)

447 (83.6%)

Kinesiologist

0 (0.0%)

0 (0.0%)

0 (0.0%)

111 (21.5%)*

Pharmacist

13 (81.3%)

7 (100%)

21 (87.5%)

220 (42.2%)**

Exercise specialist

8 (50.0%)

3 (50.0%)

11 (47.8%)

249 (47.8%)

Community health worker

2 (12.5%)

0 (0.0%)

3 (12.5%)

93 (18.0%)

Admin assistant/secretary

9 (56.3%)

2 (33.3%)

11 (47.8%)

370 (70.2%)*

Total number of staff (/16)

6.0 (5.5–7.5)

5.0 (5.0–6.0)

6.0 (5.5–7.0)

7.0 (5.0–9.0)*

CR = cardiac rehabilitation; NI = North Island; SI = South Island; NZ = New Zealand; HIC = high-income country.
Data are presented median (IQR) or n (%). ^ = p<0.05 NI vs SI; * = p<0.05 NZ vs HIC; ** = p<0.005. 

Nationally, programmes had a median of 1.5 staff (IQR=1.0–2.0) present during exercise sessions (fewer than other HICs (2.0; IQR=1.0–3.0; p=0.012)), overseeing 8.0 patients (IQR=4.0–15.0; vs other HICs, 9.0 patients; IQR=5.0–12.0; p=0.522) per one staff. In the NI, there was a median of 1.0 staff (IQR=1.0–2.0), with a median of 6.0 (IQR=4.0–12.0) patients per one staff during exercise. While in the SI, there was a median of 2.0 staff (IQR=2.0–2.0; p=0.276), with a median of 9.0 (IQR=8.0-15.0; p=0.236) patients per one staff.

As shown in Table 4, of the 24 elements assessed, New Zealand CR programmes offered a median of 17.0, which was significantly fewer than CR programmes in other HICs. Specifically, New Zealand CR programmes were significantly less likely to include an initial assessment, individual consultation with a physician, exercise stress or other functional capacity test, assessment of muscular strength, supervised exercise training, heart rate measurement training, resistance training and end-of-programme assessment, compared with CR programmes from other HICs. Domestically, initial assessment, supervised exercise training, resistance training and depression screening were significantly more prevalent in NI CR programmes, compared to the SI.

Table 4: Programme elements delivered by island, nationally and in other high-income countries.

 

NZ

 

NI

SI

Total

Other HICs

Initial assessment

17 (100.0%)

6 (75.0%)

 24 (92.3%)^

545 (98.9%)*

Individual consultation with a physician

7 (43.8%)

1 (12.5%)

8 (32.0%)

347 (63.0%)**

Individual consultation with a nurse

14 (82.4%)

6 (75.0%)

21 (80.8%)

475 (86.7%)

Exercise stress test

4 (25.0%)

1 (12.5%)

5 (20.0%)

343 (62.8%)**

Other assessment of functional capacity

7 (43.8%)

2 (28.6%)

9 (37.5%)

448 (82.7%)**

Assessment of strength (ie, handgrip)

2 (14.3%)

2 (28.6%)

4 (18.2%)

231 (42.7%)*

Exercise prescription

13 (81.3%)

 5 (71.4%)

19 (79.2%)

534 (97.1%)**

Physical activity counselling

16 (100.0%)

7 (100.0%)

23 (95.8%)

545 (98.6%)

Supervised exercise training

16 (100.0%)

5 (71.4%)

 22 (91.7%)^

544 (98.7%)*

Heart rate measurement training for patients

10 (62.5%)

2 (28.6%)

13 (54.2%)

510 (93.2%)**

Resistance training

13 (81.3%)

2 (28.6%)

15 (62.5%)^

510 (93.2%)**

Management of cardiovascular risk factors

16 (100.0%)

7 (100.0%)

24 (100.0%)

538 (98.2%)

Prescription and/or titration of secondary prevention medication

11 (68.8%)

3 (42.9%)

14 (58.3%)

415 (75.5%)

Nutrition counselling

16 (100.0%)

7 (100.0%)

24 (100.0%)

525 (95.3%)

Depression screening

16 (100.0%)

5 (71.4%)

22 (91.7%)^

516 (93.8%)

Psychological counselling

14 (87.5%)

5 (71.4%)

19 (79.2%)

472 (85.7%)

Smoking cessation interventions

12 (80.0%)

5 (71.4%)

17 (73.9%)

434 (78.8%)

Vocational counselling/support for return-to-work

11 (68.8%)

4 (57.1%)

15 (62.5%)

375 (68.9%)

Stress management/relaxation techniques

14 (87.5%)

6 (85.7%)

21 (87.5%)

497 (90.4%)

Alternative forms of exercise (ie, yoga, dance, or tai-chi)

6 (37.5%)

3 (42.9%)

9 (37.5%)

185 (34.1%)

End of programme re-assessment

13 (81.3%)

2 (28.6%)

15 (62.5%)^

507 (92.7%)**

Electronic patient charting

6 (37.5%)

3 (42.9%)

9 (37.5%)

239 (57.7%)

Communication to primary care provider

14 (87.5%)

5 (71.4%)

20 (83.3%)

489 (90.2%)

Follow-up after outpatient programme

10 (66.7%)

5 (71.4%)

15 (65.2%)

349 (63.9%)

Total number of CR elements per programme (/24)

18.0 (14.0–20.0)

17.0 (7.0–18.0)

17.0 (14.0–20.0)

19.0 (17.0–20.0)*

CR = cardiac rehabilitation; NI = North Island; SI = South Island; NZ = New Zealand; HIC = high-income country.Data are presented median (IQR) or n (%). ^ = p<0.05 NI vs SI; * = p<0.05 NZ vs HIC; ** = p<0.005. 

Alternative models of CR, particularly community-based programmes, were more commonly offered in New Zealand programmes, compared to other HICs (Table 1). There was a trend for more NI programmes to offer home-based CR, compared to SI CR programmes (p=0.164).

Delivery barriers

Similar to other HICs, lack of financial and human resources were the greatest barriers to CR delivery in New Zealand (Table 5). Barriers were consistent across the country. Other barriers reported by New Zealand respondents included transportation/access (n=4, 16.0%), and access to other multi-disciplinary staff/services (n=2, 8.0%) (ie, specialists, dietitians and psychologists).

Table 5: Barriers to delivery by island, nationally and in other high-income countries.

 

NZ

 

NI

SI

Total

Other HICs

Lack of patient referrals

2.6 ± 1.4

3.4 ± 1.2

3.0 ± 1.4

3.1 ± 1.5

Lack of equipment

2.7 ± 1.4

3.1 ± 1.6

3.0 ± 1.4

2.4 ± 1.3

Lack of space

2.9 ± 1.6

3.3 ± 1.8

3.0 ± 1.6

2.8 ± 1.4

Lack of human resources

3.3 ± 1.5

4.0 ± 1.1

3.4 ± 1.2

3.2 ± 1.4

Lack of financial resources

3.7 ± 1.2

4.3 ± 1.5

3.8 ± 1.4

3.5 ± 1.4

Note: scores range from 1 = Definitely not an issue, 5 = Major issue.
NI = North Island; SI = South Island; NZ = New Zealand; HIC = high-income country.
Data are presented mean ± SD. No differences (ie all p>0.05) were found for barriers by island or NZ vs Other HICs. 

Discussion

This study is the first to investigate the nature of CR delivery in New Zealand by island, and with those offered in other HICs. Overall, CR in New Zealand performed poorly over a number of metrics compared to countries with similar income levels. New Zealand programmes were less comprehensive, had fewer types and number of healthcare staff and provided a significantly lower dosage of CR per patient. Lack of financial resources was listed as one of the main barriers to CR delivery, which may be affecting the ability to deliver CR according to national and international guidelines.5,6,8,16,17 Discrepancies in CR delivery within New Zealand are also evident; NI programmes are more likely to provide an initial and end-of-programme assessment, supervised exercise training, resistance training and screening for depression, compared to SI programmes. Conversely, New Zealand CR programmes accepted guideline-indicated conditions (except stable coronary artery disease) and were also more likely to offer CR in alternative settings, especially community, compared to other HICs.

Following a previous New Zealand CR audit,9 Benatar et al18 recommended New Zealand CR programmes initiate rehabilitation within one month of hospital discharge, as recommended by international guidelines.6 This study indicates that patient enrolment is now within this time frame. Time from hospital discharge to CR initiation is of critical significance; with every one-day increase in wait time, patients are 1% less likely to enrol in CR.19 Furthermore, for every one-day increase in wait time, the likelihood of improving fitness-related measures is reduced by 1%.20 To reduce the risk of non-attendance, New Zealand guidelines (published after data collection in this study) also recommend at least one patient engagement within the first week (ideally in-hospital, or by phone) to initiate risk factor modification and early adoption of a cardioprotective lifestyle prior to CR commencement.16

Australia,17 and more recently New Zealand,16 have defined aspects of CR that should be mandatory in all programmes. Unfortunately, CR programmes in New Zealand were significantly less comprehensive than other HICs; lessons could potentially be learned from programmes in Europe (ie, Netherlands, UK, Italy, Germany) that are among the most comprehensive in the world.11 One component agreed to both nationally and internationally,8,16,17 is the need for initial and end-of-programme assessments. In this study only approximately 90% and 60% of New Zealand CR programmes provide an initial assessment and end-of-programme assessment, compared with 99% and 93% in other HICs, respectively. In the NI, 100% of programmes offer an initial assessment, while only 75% in the SI. Initial assessments are integral for establishing the patient’s current physical and psychological status, and guide the formulation of a treatment plan, prioritising mutually agreed clinician and patient goals, and set out strategies for achieving these goals. Furthermore, end-of-programme assessments provide crucial information on progress and provide direction for future long-term secondary prevention plans. Noteworthy were the low rates of functional capacity assessment for both NI and SI CR programmes, indicating few services offer individually-tailored exercise prescription.

Previous meta-analyses and international guidelines state that the higher the dose of CR, the better the outcome,21,22 with data indicating that the minimum effective dose is 12 sessions and optimal dose 36 sessions.22 New Zealand patients do not receive the optimal dose and generally receive six sessions fewer than in other HICs. This indicates that New Zealand patients are disadvantaged with too few sessions. Programme dose is highest in the Americas,23 and hence New Zealand CR programmes could perhaps learn from their models.

While New Zealand has among the best density of CR globally, with one CR position for every two incident ischaemic heart disease cases/year (fourth best capacity globally),24 there are still relatively low patient uptake rates; geography is thought to be an important factor.18,25 New Zealand CR programmes have attempted to address this potential barrier with almost 60% of CR programmes offering CR in alternative settings, almost double that of other HICs. Technological advancement and utilisation of mobile technology (mHealth) are other novel strategies that in the future may promote patient uptake in the New Zealand context.26,27 Similarly, utilisation of community-based exercise-CR programmes have been shown to be safe and effective for improving physical and mental health in New Zealand,28,29 while also increasing uptake and long-term adherence to CR in Māori.30

Future directions

Future research is necessary to assess the efficacy of programmes and patient outcomes. While it is evident that aspects of programmes in New Zealand are inferior to those offered in other HICs, it is not known whether this translates to poorer patient outcomes following CR. Audit and publication of data from a newly established CR database will for the first time provide insight in to the effectiveness of CR within the New Zealand context. This survey did not focus on CR uptake in indigenous populations, which is important and warrants future investigation. In particular, it is not known how well traditional models of CR are meeting the needs of Māori in New Zealand; a model encompassing the concepts of Te Whare Tapa Whā may be a more effective model for Māori and should be explored. Lastly, while patient uptake is relatively high in New Zealand,24 it remains unclear how to engage those who are least likely to attend; novel interventions are necessary to target this group.

Limitations

As is normal with web-based surveys, the programme response rate in this study was low (40%), which limits the generalisability of findings. Second, despite respondents being informed that their responses were confidential, it is possible that respondents answered in such a way to reflect better provision of CR. Third, caution should be used when interpreting some results due to low sample sizes (in particular for the SI vs NI comparisons), and the large variability in some programme characteristics (ie, programme duration). Finally, multiple comparisons were performed, which increases the chances of Type 1 error.

Conclusion

New Zealand outperforms other HICs in terms of delivery of community-based CR, which enables more patients to access CR services. However, New Zealand CR programmes offer fewer sessions to patients, and these contain fewer elements; SI programmes in particular are less likely to offer initial and final assessments, depression screening and supervised exercise training, compared to NI programmes. Work needs to be done to address the disparity of CR programmes across New Zealand and more investment is needed to ensure CR in New Zealand meets international guidelines.

Summary

Cardiac rehabilitation (CR) is a cost-effective service to improve risk factors after a heart attack and/or cardiac surgery, reducing mortality and risk of rehospitalisation. We compared the nature of CR programs in New Zealand and with those of countries with similar incomes and health systems. We found New Zealand CR programmes had fewer types and number of staff, provided fewer sessions and were less comprehensive, compared to those in other high-income countries. New Zealand did well in providing alternate forms of CR, such as community based.

Abstract

Aim

To compare the nature and delivery of cardiac rehabilitation (CR) services within New Zealand by island (North vs South; NI, SI), and to other high-income countries (HICs).

Method

In this cross-sectional study, secondary analysis of an online survey of CR programmes globally was undertaken. Results from New Zealand were compared to data from other HICs with CR.

Results

Twenty-seven (62.7%) out of 43 CR programmes in New Zealand (n=18/31, 66.7% respondents from NI) and 619 (43.1%) from 28 other HICs completed the survey. New Zealand CR programmes offered a median of 16.0 sessions/patient (interquartile range (IQR)=12.0–36.0; vs 21.6 sessions in other HICs, IQR=12.0–36.0, p=0.016), delivered by a team of 6.0 staff (IQR=5.5–7.0; vs 7.0 staff; IQR=5.0–9.0, p=0.012). New Zealand programmes were significantly less comprehensive than other HICs (p=0.002); within New Zealand, NI programmes were more likely to provide an initial and end-of-programme assessment, supervised exercise training and depression screening, compared to SI programmes (all p<0.05). New Zealand more often offered CR in an alternative setting (n=14, 58.3%), compared to other HICs (n=190, 36.5%), p=0.03).

Conclusion

CR programmes in New Zealand offer fewer sessions and have fewer elements compared to other HICs, and disparity exists in programmes across New Zealand. More investment is needed to ensure CR in New Zealand meets international guidelines.

Author Information

Brendon H Roxburgh, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin; Marta Supervia, Department of Physical Medicine and Rehabilitation, Gregorio Marañón General University Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain; Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States; Karam Turk-Adawi, Department of Public Health, QU Health, Qatar University, Doha, Qatar; Jocelyne R Benatar, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland; Francisco Lopez Jimenez, Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States; Sherry L Grace, School of Kinesiology and Health Science, York University; University Health Network, University of Toronto, Toronto, Ontario, Canada.

Acknowledgements

On behalf of the International Council of Cardiovascular Prevention and Rehabilitation through which this study was undertaken, the Global CR Program Survey Investigators are grateful to all other national champions who collaborated to identify and reach programmes in other HICs, namely Drs Karl Andersen, Birna Bjarnason Wehrens, Vilnis Dzerve, Stefan Farsky, Hareld Kemps, Anna Kiessling, Evangelia Kouidi, Maria Mooney, Lis Neubeck, Bruno Pavy, Attila Simon, Eliska Sovova, Juan Castillo Martin, Jacqueline Cliff, Susan Dawkes, Eva Prescott and Egle Tamuleviciute-Prasciene. We also thank the CSANZ Secondary Prevention Working Group for assisting with programme identification and the World Heart Foundation who formally endorsed the study protocol.

Correspondence

Prof Sherry L Grace, School of Kinesiology and Health Science, York University; University Health Network, University of Toronto, 4700 Keele Street, Toronto, ON, Canada.

Correspondence Email

sgrace@yorku.ca

Competing Interests

Nil.

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