CR Quality Standards

The following quality standards were selected based on ICCPR’s consensus statement on CR delivery in low-resource (1,2), a review of CR quality indicators (3) , clinical practice guidelines (4), WHO’s Package of Rehabilitation Interventions for Ischemic Heart Disease (to be released), as well as recent EAPC standards and quality indicators (5,6). They were also informed by ICRR’s delphi process for variable selection and subsequent quality indicators (Chowdhury et al., Global Heart, 2022).

Quality standards will be reviewed at a regular interval by the ICCPR Program Certification committee, and may be revised based on evidence, among other considerations (e.g., applicability, verifiability of quality standards, commonality across low-resource settings).

“Patients” refers only to cardiac patients, as per ICRR inclusion criteria stated in the ICRR protocol found here.

To be recognized by ICCPR, programs must meet the 3 mandatory standards (*), and 70% of all standards.

Program-level / Structure & Process Indicators (assessed based on responses to ICRR on-boarding survey available here, as well as during site visit, or based on patient-level data entered into ICRR, as specified for each below)

1. *Comprehensive program, including (a) initial assessment, (b) structured exercise training (supervised or unsupervised) and (c) ≥1 other strategy to control CVD risk factors; evidenced based on program survey and during site visit (demonstration of at least one other component)

2. Multidisciplinary team (i.e., ≥2 different regulated professions available to support patients at least on a part-time or referral basis): evidenced based on program survey, provision of current job descriptions with regulatory body membership (or equivalent), and confirmed during site visit

3. *Cardiac emergency policies in place: evidenced based on program survey and site visit

4.  Assessment of the following CVD risk factor: tobacco use; evidenced based on program survey, responses in ICRR, and patient chart)

5.  Assessment of the following CVD risk factors: blood pressure; evidenced based on program survey, responses in ICRR, and patient chart)

(assessed based on ICRR data, and some confirmed during site visit)

6. Program completion rate: <50% of patients lost to follow-up / dropped out for non-clinical reasons other than return-to-work

7. *Mean peak METs increase of ≥.5 from pre to post-program, in 75% of program completers

8. Mean post-program quality of life score > pre-program score, in program completers

9. Mean minutes of moderate to vigorous-intensity activity per week post-program /progress ≥150, in program completers

10.  ≥70% of patients reporting yes they know what heart pills they should be taking post-program, in program completers that have coverage for medication

11.  ≥70% of patients reporting yes they know their cholesterol level and how to control it post-program, in program completers

12.  ≥70% of patients reporting yes they know how to follow a heart-healthy diet post-program, in program completers

13.  ≥70% of patients reporting yes they have been supported to get back to their important life roles post-program, in program completers

References

1. Grace SL, Turk-Adawi KI, Contractor A, Atrey A, Campbell NRC, Derman W, et al. Cardiac rehabilitation delivery model for low-resource settings: An International Council of Cardiovascular Prevention and Rehabilitation consensus statement. Progress in Cardiovascular Diseases. 2016;59(3):1–20.

2. Grace SL, Turk-Adawi KI, Contractor A, Atrey A, Campbell N, Derman W, et al. Cardiac rehabilitation delivery model for low-resource settings. Heart. 2016;102(18):1449–55.

3. Moghei M, Oh P, Chessex C, Grace SL. Cardiac Rehabilitation Quality Improvement: A Narrative Review. Journal of Cardiopulmonary Rehabilitation and Prevention. 2019;39(4):226–34.

4. Mehra VM, Gaalema DE, Pakosh M, Grace SL. Systematic review of cardiac rehabilitation guidelines: Quality and scope. European journal of preventive cardiology. 2020 Jun 4;27(9):912–28.

5. Abreu A, Frederix I, Dendale P, Janssen A, Doherty P, Piepoli MF, Völler H; Secondary Prevention and Rehabilitation Section of EAPC, Davos CH. Standardization and quality improvement of secondary prevention through cardiovascular rehabilitation programmes in Europe: The avenue towards EAPC accreditation programme: A position statement of the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology (EAPC). European Journal of Preventive Cardiology. 2020 Jun 1:2047487320924912. doi: 10.1177/2047487320924912. Epub ahead of print.

6. Aktaa S, Gencer B, Arbelo E, Davos CH, Désormais I, Hollander M, Abreu A, Ambrosetti M, Bäck M, Carballo D, Crawford C, Deaton C, Dendale P, Eijsvogels TMH, Galbraith M, Piepoli MF, Salzwedel A, Smulders Y, Wilhelm M, Biondi-Zoccai G, Mach F, Visseren FLJ, Gale CP. European Society of Cardiology Quality Indicators for Cardiovascular Disease Prevention: developed by the Working Group for Cardiovascular Disease Prevention Quality Indicators in collaboration with the European Association for Preventive Cardiology of the European Society of Cardiology. European Journal of Preventive Cardiology. 2021 Oct 23:zwab160. doi: 10.1093/eurjpc/zwab160. Epub ahead of print.