Evaluation of Qatar’s First Cardiac Rehabilitation Program: A Brief Report

Background: There are few studies on the impact of cardiac rehabilitation (CR) in the Eastern Mediterranean Region (EMR), where the burden of risk factors and context is somewhat different from Western countries where much of the evidence is derived. Objective: To evaluate patient engagement in, and outcomes associated with, participation in Qatar’s first and only CR program, from inception. Methods: This was a retrospective, observational study of patients referred to Heart Hospital’s CR program from January 2013-September, 2018. The program offered 3 sessions/week over 6–12 weeks, depending on patient risk. An initial assessment was performed, and outcomes (i.e., functional capacity, risk factors, and psychosocial well-being (quality of life [SF-36] and depressive symptoms) were re-assessed post-program in those who did not drop-out. Session attendance was recorded. Results: 682 patients enrolled; they attended 77.6% of prescribed sessions; 554 (81.2%) completed the program and post-assessment. Improvements in functional capacity were statistically and clinically meaningful (METs 9.3 ± 3.3 pre and 11.1 ± 3.7 post; p < 0.001). There were significant improvements in body mass index (28.7 ± 5.2 kg/m2 pre and 28.2 ± 5.4 post; p < 0.001), waist circumference (102.8 ± 13.0 cm pre and 101.8 ± 13.2 post; p < 0.001), low-density lipoprotein (LDL 1.9 ± 0.9 mmol/L pre and 1.6 ± 0.8 post; p = < 0.001), total cholesterol (3.6 ± 1.1 mmol/L pre and 3.3 ± 0.8 post; p < 0.001), systolic blood pressure (SBP 128.5 ± 17.7 mmHg pre and 123.7 ± 14.8 post; p < 0.001), hemoglobin A1c (6.8 ± 1.6% pre and 6.5 ± 1.3 post; p < 0.001) and depressive symptoms (Cardiac Depression Scale score 78.3 ± 23.9 pre and 66.3 ± 21.3 post; p < 0.001). Improvements on 7 of the 8 quality of life domains were also observed (all p < .05; e.g., physical functioning 68.2 ± 24.0 pre and 74.9 ± 24.4 post). Conclusion: The new Qatari CR program is very engaging to patients, and resulted in clinically significant risk factors (LDL, SBP, and cholesterol) as well as functional capacity and health-related quality of life improvements, which likely translate to reduced morbidity and mortality.

The program serves both Qataris and non-Qataris. Both have free and equal access to health services that are financed from public funds [3]. CR services are hence publicly covered ($0 out of pocket patient cost). The program was developed in accordance with the Canadian and the American CR Guidelines [1,2]. All referred patients are called and offered place to start the program within approximately five months; the wait list is long due to insufficient capacity of the sole program to treat all indicated patients in Qatar.
The CR program is managed by a cardiologist, who is assisted by a program manager and coordinator. The CR staff includes 2 cardiologists, 10 nurses, 4 dietitians, 3 kinesiologists/ exercise specialists, 2 occupational therapist, 2 physiotherapists, a pharmacist, and an administrative assistant/ secretary. All staff are involved in the initial and final assessments, and enter the relevant patient data in the system for their role. The program offers 18 sessions per week. The program serves approximately 200 patients /year, with 6 patients per session.
All patients undergo a symptom-limited exercise test. Most are conducted on a treadmill (some cycle ergometer) without gas exchange measurements; when the patient is unable to undergo a symptom-limited exercise test, a 6-minute walk test is conducted instead. To increase the capacity of the program in serving more patients, patients are offered sessions based on their risk status (low risk -18 sessions; moderate risk -24 sessions; high risk -36 sessions), 3 times per week.
The program components are assessment (pre and post-program), patient education, management of CVD risk factors, structured exercise, nutrition counseling, tobacco cessation sessions/classes, return-to-work counselling (the latter 2 as applicable). For exercise, the prescription is circuit-based using the following equipment: treadmill, cycle ergometer, arm ergometer, stepper, elliptical machine, rower, and free dumbbells. Exercise intensity is prescribed based on the maximum heart rate achieved during the symptom-limited exercise test.
Patients exercise at moderate intensity (55% -69% of peak heart rate or 45% -59% of peak oxygen consumption in case of cardiopulmonary exercise test). The duration of the exercise session is 60 minutes, of which 10 minutes warm-up and 10 minutes cool-down. Patients also do resistance training during the exercise sessions. The program offers female-only exercise sessions.

Measures
The 36-item Short-Form Health Survey (SF-36) is a self-administered, generic, comprehensive and frequently-used instrument to measure physical and mental QoL [4]. It includes eight sub-scales: physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy/fatigue, emotional well-being, social functioning, pain, and general health [5]. The SF-36 is a valid and sensitive instrument, and appropriate to be used among CR patients [6]. Scoring of the SF-36 is done in two steps. Firstly, coded values are given to each response category for all the 36 items; each item is scored between 0 to 100, where 0 represents the poorest health, and 100 represents the best [5]. Secondly, the average of all items for each subscale is calculated, to produce the eight subscale scores [5]. QoL was collected up to 2017 only.
Finally, depressive symptoms were measured through the Cardiac Depression Scale (CDS). This scale is appropriate for CR patients [7,8]. It consists of 26 items, scored on a 7point Likert scale ranging from "strongly disagree" (1) to "strongly agree" (7). The total CDS score is the sum of all items. Thus, it ranges from 26 to 182, and the higher the CDS score, the more severe the depression. Responses were categorized into 3 categories using cut-off values from the literature [7]: patients with scores less than 90 were considered to have subthreshold depressive symptoms, those with scores from 90 to <100 were considered to have mildmoderate severity depressive symptoms, and those with scores ≥100 considered to have severe depressive symptoms [7].

Implications
There is much development of CR in non-Western settings [9], where CVD rates are exploding. It is important that programs are developed in accordance with guidelines, despite more limited resources (for CR; Qatar is rich in other resources), for instance as suggested in the International Council of Cardiovascular Prevention and Rehabilitation"s (ICCPR) consensus statement for low-resource settings [10,11]. Therefore, it will be important to continue to evaluate outcomes, and even to benchmark against other programs. Indeed, ICCPR is currently developing an International CR Registry (ICRR; https://globalcardiacrehab.com/ICRR-Governance), which will be piloted in Qatar, to enable this. Moreover, our program is in the midst of developing a satellite site to increase our capacity and reach, given in Qatar there is a need for 6800 more spots each year to treat incident ischemic heart disease patients alone [12].
Through the registry, we will be able to test whether we have high-quality care across our program, no matter the location. For instance, we must monitor our wait times [13], and hopefully they can be shortened with the additional satellite capacity.
Through examining the data of the new program, we noted some deficiencies in completeness of data. We secured the paper files of patients, to capture any additional information to reduce this missingness. We have recommended the program ensure regular assessment and patient completion of all QoL measures at pre and post-program. Another key outcome that is missing from our data is return-to-roles (e.g., paid and unpaid work). These will be included in the ICRR. In future, it would also be important to test the impact of the program on morbidity and mortality, as well as cost-effectiveness. Indeed, evaluation is a key "core component" of CR [14].