Implementation of Evidence-Based, Person-Centered Alternative Delivery Models for Cardiac Rehabilitation in a Rural and Remote Population: The Country Heart Attack Prevention (CHAP) Project.

内容摘要

Access and adherence to cardiac rehabilitation (CR) remain suboptimal, particularly in rural and remote settings. This study evaluated the implementation of person-centred, evidence-based CR delivery model tailored to improve access and completion. The implementation framework utilised was the Model for Large-Scale Knowledge Translation. The Country Heart Attack Prevention (CHAP) project introduced evidence-based flexible CR including, face-to-face, telehealth, telephone, web-based and primary care options. A matched prospective cohort compared CR attendance, completion (primary outcomes), cardiovascular (CV) readmissions, mortality, and emergency department (ED) visits between CHAP rural services and standard metropolitan face-to-face CR. CR attendance was comparable between groups (24.2% vs 23.8%; odds ratio [OR] 1.15; 95% confidence interval [CI] 0.89-1.47; p=0.16), but completion rates were significantly higher in the CHAP Project (77.1% vs 57.5%; OR 1.69; 95% CI 1.30-2.18; p<0.001). Patient satisfaction was also greater (85.9% vs 77.1%; p<0.001). Median waiting times were similar (38 vs 36 days; p=0.008). Alternative delivery models were equivalent to traditional face-to-face modes for CV readmissions (hazard ratio [HR] 1.19; 95% CI 0.96-1.49; p=0.17), CV mortality (HR 1.70; 95% CI 0.92-3.16; p=0.09), and ED visits (HR 1.06; 95% CI 0.94-1.21; p=0.33). CR completion through CHAP was cheaper and more effective (costs: $6,542 vs $8,689; completions: 77.1% vs 57.5%). The CHAP model had over 50% probability of being cost-effective in improving CR completion. Uptake of the CHAP model would result in a cost reduction ranging from $2 million (m) at 20% uptake to $10m if all patients referred attended and completed CR. The CHAP Project significantly improved program completion and achieved satisfaction without compromising clinical outcomes and showed important levels of economic benefit. Broader implementation of person-centred models of CR, across all geographic areas to enhance uptake and impact of CR in underserved populations is recommended.