Closing the gap between WHO projections and actual need for cardiac rehabilitation in Europe

A ‘New Era in Cardiac Rehabilitation Delivery’ has recently been advocated, on the basis that cardiac rehabilitation (CR) is highly beneficial and yet underused.¹ However, according to WHO reports, cardiovascular disease is limited to only 1.2% of the required need for rehabilitation services, of about 400 million potential referrals in Europe. This is despite two major conditions, heart failure and myocardial infarction, being well known as leading causes of morbidity and mortality in the general population.²

Importantly, the WHO document correctly advocates rehabilitation as an ‘essential health service that cannot be achieved without the adequate provision of services’; thus, it is also true that adequate provision of CR services (with optimal quantitative delivery of programs according to structure- and process-based metrics) should be ensured.

However, a number of questions remain on the nature and scope of CR. These include how CR is defined, and identifying the area of interest of rehabilitation cover in the cardiac setting in the modern era. Identifying the best candidates for rehabilitation and which cardiac surgery interventions deserve rehabilitation is also necessary; do we prioritize, for example, rehabilitation for interventions for left ventricle devices, or heart transplantation? Issues of rehabilitation also need to be addressed for newer challenging populations, such as patients with recent endocarditis who may require functional recovery and monitoring through costly care pathways.

These questions may depict a new scenario in which CR should not only be simply promoted, but also, at least partially, rethought. Heart disease and ageing are intertwined in most cases and acutely decompensated heart failure patients account for a large proportion of elderly population. In the USA, the high cost of readmissions for heart failure prompted the Centers for Medicare and Medicaid Services, in 2012, to implement the Heart Failure Readmissions Reduction Program, which introduced economic penalties to influence delivery of care in this setting.³ Compliance with medication and lifestyle changes are the most relevant factors associated with preventing clinical deterioration, and CR has been recently been identified as the ‘fifth pillar’ of care in heart failure management.⁴ Cardiac rehabilitation has been shown to benefit the achievement of strong clinical end points.⁵ However, measuring functional outcomes in cardiovascular care is also complex; whether this can be achieved using, for example, the Barthel Index, the Cumulative Illness Rating Scale (CIRS) severity index, or the Complexity Rehabilitation Scale, require consideration.

Cardiac rehabilitation needs to be sustained by strategies for reimbursement that, although specific to this field, may be novel in many countries, where they may be more closely related to the acute setting than longer-term outcomes. As long as healthcare expenditure is reimbursed based on the cost of the procedures and not on patient outcomes, the impact of clinical and rehabilitative interventions will always be underestimated.

The catastrophic COVID outbreak placed immense strained on health systems, and the isolation strategies that came with the pandemic have left a legacy of early discharge from the acute setting to relieve hospital admission numbers. Such strategies imply changes in medical and nursing care paradigms and knowledge. Phenotypization from bench to bedside is also key to a new and personalized model of care and should be pursued in the rehabilitation setting.

Research initiatives supported by the post-COVID EU recovery plan may help to achieve CR aims. Our group has launched a new prospective multicentre registry for patients in Italy with acutely decompensated heart failure, the PROspective MulticEnter registry in patients with acutely dEcompensated heart failure admitted to cardiac rehabilitatiOn (PROMETEO), which also includes the Exercise aNd hEArt transplant (ENEA), a registry-based randomized controlled pilot trial with rehabilomic assessment. This initiative (PNRR-MAD-2022-12376159, funded within the call ‘Next Generation EU-PNRR M6C2—Investimento 2.1 Valorizzazione e potenziamento della ricerca biomedica del SSB’) is expected to provide new insights and promote best practice in this field.

Acknowledgements

Marzia Bedoni, Alice Gualerzi, Silvia Picciolini, Anastasia Toccafondi, Paolo Pedersini, Francesca Di Salvo, Arturo Cesaro, Marco Magnoni, and Giulia Novembre are acknowledged for being part of the research group.

References

Author notes