The aim of this study was to assess the extent to which programs met the national QIs. This study surveyed 23 cardiac rehabilitation services in South Australia, Australia for program and personnel characteristics and quality performance adherence, comparing country and metropolitan, telephone and face to face programs. In 2019, of the 69.5% of programs that could provide data, there were 1,972 patients enrolled with 66.7% of these patients completing. Country and metropolitan enrolments were similar with 42.8% of country patients attending the telephone program. Country completions were higher than metropolitan (76.7% v 56.5%, p < 0.001) and the telephone program had higher completions than face to face programs (92.9% v 59.6%, p < 0.001). We were unable to measure total patients eligible in this dataset and this is something that our quality improvement initiatives hope to address in the future. However, an audit conducted between 2013- 2015 amongst the same programs showed that approximately 16,600 patients per year are eligible and of these 5,000 are referred. [16].
Program and personnel characteristics
Mean total program length was 7.0 weeks (± SD 1.11) across country and metropolitan, telephone and face to face. Program length and sessions were similar amongst country and metropolitan, telephone and face to face programs (mean 7.0 weeks or 10.5 sessions) and indeed 6–8 weeks (12–16 sessions) is the norm across Australian programs.(5, 7) However, if we look at international benchmarks, program duration is far less in Australia than our international counterparts in the UK and Europe, who have a standard of ≥ 24 -36 sessions or around 12 -18 weeks, raising the question of what ‘dose’ of CR is most effective to improve outcomes? [19, 36] Total median wait time was 27.0 days (IQR 19.3–46.0), where Australian QI 2 recommends 28 days from hospital discharge (Fig. 2).(31) While metropolitan programs were within the limit of this benchmark (23.0 days, IQR 18–37), country programs, including telephone, were a longer wait time (median 33.0 days IQR 21–45 and 36 days IQR 36–36, respectively). Internationally, the recommended wait time from referral to start of CR is 14–28 days [19].
The ideal cardiac rehabilitation program consists of a multidisciplinary team. In South Australia where programs do not have all types of professionals as part of their team, this is enabled by referral pathways. The multidisciplinary team amongst country, metropolitan, telephone and face to face programs consisted of a nurse and either a physiotherapist or exercise physiologist and to a slightly lesser degree a dietician or pharmacist. Where they were not part of the team, they were accessible via a referral pathway, with the exception of the telephone program (Table 3), which could be an area for improvement, as well as increased access to social workers and psychologists overall.
Quality indicator adherence
The most measured QI was comprehensive assessment across country, metropolitan, telephone and face to face programs, followed by depression screening, smoking assessment and counselling thereof (Table 5). There is room for program improvement however, as health-related quality of life was the least measured and most programs (73.9%) scored a medium level of performance across country and metropolitan, telephone and face to face services in health-related quality of life, exercise, and comprehensive re-assessment (Table 4). Comparing South Australian performance scores with 3 other combined Australian jurisdictions, representing 39 programs (New South Wales, Australian Capital Territory and Tasmania) showed higher levels of performance than South Australia (High- Aust: 18% versus SA: 13%, Medium/moderate—Aust. 76.9% versus SA: 73.9% and Low-Aust.: 5.1% versus SA: 13%) (Table 5) [37]. Comparing South Australian (SA) program performance scores with the United Kingdom (UK) (6), showed more programs in the middle/medium category (SA: 73.9% versus UK: 45.9%) and SA showing zero poor performance programs compared to the UK’s 5.3%, but the UK showing more programs in the high performance category (UK: 30.6% versus SA: 13.0%) (Table 4). Building exercise capacity measurement into the telephone program could also be done by using a 13-item self-report measure called the Specific Activity Questionnaire (SAQ) [38]. The scoring method of the tool can be used to estimate Metabolic Equivalent of Task (METS) and the questionnaire is publicly available, free of charge and has been validated against exercise stress testing in cardiac patients [38, 39]. Exercise advice could be delivered through mobile health applications or websites in combination with telephone support [40].
Are the quality indicators and performance score an accurate measure of quality?
A key finding of this survey was the higher completion rates in country compared to metropolitan, and telephone compared to face to face programs. This was likely driven by 42.8% of patients accessing country programs attending the telephone option. While this measure reflects a process indicator, we also know from the survey that the telephone program delivers only one exercise session, where efficacy evidence tells us that exercise is a significant driver of improved CR outcomes [8, 11, 12, 14, 23]. More rigorous data in the form of objective validation is therefore required to confirm the self-reported survey responses and associations with clinical outcomes.
Quality improvement measurement and comparisons often require a multi-component approach of standardisation, measurement, reporting and change management. We were not able to conduct a validation process because of the variability of data entry into the CATCH database. This identifies the need for universal data entry to accurately measure program quality and will require a change management strategy to achieve. Accreditation can be a tool to promote change management among clinicians to drive standardisation of care and deliver evidence-based scope of practice, qualifications, and program content delivery [19].
Limitations
This survey was self-reported for each program and thus is subject to reporting bias. We were not able to objectively validate the questionnaire responses nor correlate these with clinical outcomes, thus we don’t know whether QI adherence is associated with better quality program content. Further, as the performance score is derived from program adherence to the QIs, the discriminatory capacity of the score may be limited. Since data entry into the CATCH database is not mandatory across the 23 programs, not all survey items measured have 23 programs as the denominator. Further enrolment and completion numbers are underestimated. We were not able to measure enrolment against eligible or referred patients for 2019, though we know from our previous audit work that approximately 5,000 patients are referred to cardiac rehabilitation each year in SA. (16) The sample size of 23 programs is small to measure any meaningful differences between country and metropolitan, telephone and face to face programs. Further the Australian Quality Indicators were only published in 2020 and therefore programs have not had time to implement improvements.(31) Despite this we have surveyed 23 CR programs across SA, evaluating program and personnel characteristics and determining adherence with the Australian Quality indicators, giving us an indication of the level of program quality to inform development of an accreditation system.
