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Cardiac Rehabilitation in Latin America Claudia Victoria Anchique Santosa,⁎, Francisco Lopez-Jimenezb , Briseida Benaimc , Gerard Burdiatd , Rosalia Fernandez Coronadoe , Graciela Gonzalezf , Arthur Herdyg , Jose Medina-Inojosab , Claudio Santibañezh , Juan E. Uriona Villarroeli , Cecilia Zeballosi, j a
Division of Cardiovascular Diseases, Cardiac Rehabilitation, Mediagnóstica Duitama, Colombia Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA c Division of Cardiovascular Diseases, Cardiac Rehabilitation and Secondary Prevention (ASCARDIO),Venezuela d Department of Cardiology, Spanish Association's Quality of Life Center, Montevideo, Uruguay e Cardiac Rehabilitation Unit, National Cardiovascular Institute “Carlos Alberto Pashchiera”, Lima, Peru f Cardiovascular Prevention and Rehabilitation program, Central Hospital Institute of Social Welfare, Asuncion, Paraguay g Institute of Cardiology of Santa Catarina, Universidad e do Sulde Santa Catarina, Brazil h Prevention department, Chilean Society of Cardiology, Austral University of Chile, Chile i Cardiac Rehabilitation Service, Boliviano Belga Surgical Medical Center, Cochabamba, Boliviano, Bolivia j Cardiac Rehabilitation Service, Cardiovascular Institute of Buenos Aires, Argentinian Institute of Diagnostic and Treatment, Argentina b
A R T I C LE I N FO
AB S T R A C T
Keywords:
This article provides a description of the status of cardiovascular (CV) rehabilitation (CVR)
Cardiac rehabilitation
in Latin America (LA) and the potential impact on CV disease in the region. We discuss
Latin America
the insufficient number of CVR programs in the region and describe the components of CVR
South America
that are more commonly available, like exercise interventions, medical assessment and
Cardiovascular diseases
patient education. Additionally, we discuss the heterogeneity in other components,
Prevention
like the evaluation of depression, sleep apnea, and smoking cessation programs. Lastly, we provide a brief review on the main characteristics of the health systems of each country regarding access to CVR programs and compare the average cost of CV procedures and treatments with CVR. © 2014 Elsevier Inc. All rights reserved.
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. According to the World Health Organization (WHO) approximately one third of annual deaths in the world are due to CVD.1–3 In Latin America (LA), mortality secondary to CVD is 30%, resulting in 11 million deaths in 2010, 23% of whom represented people younger than 60 years of
age.2,4 The impact of CVD in LA is clear with an alarming increase in morbidity and mortality and the disturbing effects of secondary disability, decreased quality of life, and elevated health and social costs. The CV field has shown spectacular advances in the last several decades. From being historically a clinical field with
Statement of Conflict of Interest: see page 273. ⁎ Address reprint requests to Claudia Victoria Anchique Santos, M.D., Division of Cardiovascular Diseases and Cardiovascular Rehabilitation, Mediagnostica, Carrera #16 14-68, Duitama, Colombia. E-mail addresses: [email protected] (C.V. Anchique Santos), [email protected] (F. Lopez-Jimenez), [email protected] (B. Benaim), [email protected] (G. Burdiat), [email protected] (R. Fernandez Coronado), [email protected] (G. Gonzalez), [email protected] (A. Herdy), [email protected] (J. Medina-Inojosa), [email protected] (C. Santibañez), [email protected] (J.E. Uriona Villarroel), [email protected] (C. Zeballos). http://dx.doi.org/10.1016/j.pcad.2014.09.006 0033-0620/© 2014 Elsevier Inc. All rights reserved.
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few diagnostic tools, it has evolved to the AACVPR = American Association present day with soof Cardiovascular and phisticated diagnostic Pulmonary Rehabilitation tests, drugs and invasive treatment CV = cardiovascular methods available. In CVD = cardiovascular disease contrast to this, the CVR = cardiovascular progress achieved rerehabilitation garding preventative measures has been less IASC = Inter-American Society impressive, considering of Cardiology that the main risk facICCPR = International Council in tors for CVD disability Cardiovascular Prevention are preventable and and Rehabilitation modifiable and that shifting management LA = Latin America towards a healthy lifeor Latin American style has proven to be PAHO = Pan American of greatest impact on Health Organization reducing morbidity and mortality.5 Because of SA = South America this, CV rehabilitation SSCARDIO = South American (CVR) is a key preventaSociety of Cardiology tive strategy in CV medicine, with supporting UN = United Nations evidence of benefit in WHO = World Health terms of reduced adverse Organization outcomes and being cost-effective.6–8 Some reports have shown that CVR can reduce CVD mortality by 20% or even 40%, and achieve a 30% reduction in re-hospitalization and re-infarction 9–12 after myocardial infarction. Preventative strategies stem from current knowledge of the evolution of CVD from its molecular and cellular level when the atherosclerotic process begins at an early age, until when clinical manifestations become evident, usually in more advanced stages of the disease.6–10
269
Abbreviations and Acronyms
This knowledge has helped build the foundation of what is known as CVR, which is an integrated concept of comprehensive care that focuses on several key aspects like intervention and risk modification, management of risk factors including psychological support, promotion of healthy lifestyles, gender-specific issues, interventions adjusted for socio-economic status, and evaluation of interventions (Fig 1). Moreover, CVR programs must include a competent, multidisciplinary group of professionals who implements the program, monitors progress and obtains feedback of all necessary activities and strategies. It is a process with short, medium and long-term goals that are quantifiable, measurable, and susceptible to improvement, always with the end goal of rehabilitating the individual to his/her pre-events functional level. 13–19 In addition, CVR follows the objectives and strategies set by United Nations, the World Health Organization and the Pan-American Health Organization, aiming to reduce premature CVD mortality by 25% by the year 2025 and to increase health promotion, CVD prevention, and achieve an integrated control of chronic diseases. 20,21
Cardiac Rehabilitation in Latin America Despite evidence supporting CVR as an effective intervention to reduce CVD events and mortality, the establishment of CVR programs in LA has been slow, with very few programs available, not matching the needs of the region. The models and structure of health systems in LA are complex and quite heterogeneous, making comparison extremely challenging. Table 1 lists some general characteristics of healthcare systems in LA and whether CVR is covered by the national universal healthcare system. In all countries of LA, healthcare systems generally include two distinct models: the public and the private. Public systems, generally represented by a national universal healthcare program, offer 100% coverage for CVR in some countries as is the case of Bolivia, Venezuela, Peru and Argentina, meaning that patients who qualify for CVR have full coverage for CVR services when available. In other countries, coverage for CVR in the public system is only partial, where the patient pays out of pocket a percentage of the total cost and the public healthcare insurance pays for the rest. CVR coverage by private insurance companies is also variable in LA. In some countries private insurance companies provide full coverage while in others coverage is partial and the cost of CVR services is shared between the patient and the insurance company. Unfortunately, many and perhaps the majority of private insurance companies offer no coverage for CVR in LA.22,23 It is noteworthy that in some countries like Uruguay, there is only partial coverage for CVR regardless of whether the insurance is private or if covered by the universal (public) healthcare program. The irony is that coverage for any costly diagnostic or invasive cardiac procedure such as open-heart surgery, coronary angiography, pacemaker implantation or implantation of a defibrillator is covered at 100%, regardless of the health system to which the patient belongs. If coverage for CVR services is a major problem, access to CVR represents another major barrier for the universal implementation of CVR in the region, given the small number of CVR programs available in LA. South America (SA) has an estimated population of 393 million,23 and only about 172 CVR programs, equivalent to one CVR program for every 2,285,768 (Table 2).24 For example, in 2009, the availability of CVR programs per inhabitants, a concept we have coined as CVR programs' density, is highly variable in LA. Mexico registered 17 CVR programs for a population of 106.6 million25 while Costa Rica registered 1 CVR program for a population of 4,451,205.26 Because each CVR program sees an average of 180 new patients each year, it is obvious that the number of CVR programs is insufficient for the current needs of the region. Another limitation for the use of CVR services is their geographic distribution within each country and whether the CVR program is public versus private. Examples of challenges to access to CVR despite being covered by the public healthcare system are Argentina and Venezuela. Data from 2010 indicate that only one out of 28 centers in Argentina and only six centers in Venezuela belong to the public sector responsible for providing CVR services to the entire population covered.27,28 Chile has one of the lowest CVR referral rates (5%),
270
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Fig 1 – Comprehensive model of care of cardiac rehabilitation.
with 9 centers through the country, mostly located in large urban areas.29 Paraguay reported a single CVR program in 2010 and had the lowest density of CVR center per inhabitants.24,30 Similarly, Bolivia has 9 CVR centers concentrated in 3 areas, while in Peru all registered centers in 2010 were located in the capital city of Lima, of which 3 were eventually closed down due to insufficient funds and low patient referral.30 Brazil, the largest and most populated country in LA, provides partial coverage by both the public and private healthcare systems. Brazil also has significant difficulties to provide access to CVR to those who need it, not only because of its size but also because of the distribution of CVR centers. The highest concentration of CVR centers is located in the south and southeast areas of the country, regions with the highest economic development, compared with the poorer north and northeastern areas of the country where CVR centers are barely available.31,32 The different barriers to get CVR have been described in several publications, showing that, in addition to poor physician referral patterns, factors like distances to the CVR centers, limited financial support, and poorly trained personnel, also affect access to appropriate CVR.32–35 Restrictions in the referral process probably impact the availability of CVR in LA. In most countries of LA, the physician referring the patient to CVR needs
to be a specialist (cardiologist, interventional cardiologist, cardiovascular surgeon, physiatrist, sports medicine physician), while the general practitioner or any other specialist cannot refer patients to CVR programs. Many physicians and healthcare systems in LA consider CVR as “workout sessions”, not as a comprehensive program, but it is highly likely that it is the comprehensive approach that provides a meaningful medical intervention with the potential to improve quality of life and health. However, to date no LA country has a specific guideline in terms of the necessary components to call CVR “complete”, nor are there institutions regulating, monitoring or certifying CVR programs and their quality of care. The Latin American Cardiovascular Rehabilitation and Secondary Prevention Working Group has recently published a document called Consensus for CVR and Prevention for Latin America.36 This document and the Brazilian Cardiac and Pulmonary Rehabilitation Society Consensus are the only documents describing the components, competencies and expectations for CVR programs. Thus, not all components of CVR are the same among all centers, something expected given the heterogeneity of healthcare systems. However, some aspects of CVR are commonly available like prescribing and performing
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Table 1 – Coverage of CVR services by country in south america. Is CVR Covered by the Public Healthcare System? COUNTRY
Yes
Venezuela
X
Colombia
X
Peru
X
Bolivia
X
Chile
No
X
Uruguay
X
Brasil
X
Paraguay
X
Argentina
X
Coverage of CVR The entire population is covered by the public healthcare system that assumes100% of the cost of CVR in public hospitals where the service exists (6 hospitals); the rest should attend private institutions or non-profit associations. The patient would then rely on private insurance or absorb the cost of CVR. The public healthcare system covers 96% of the population. The CVR is included within the benefits of this mandatory healthcare plan. In some cases the coverage is 100% of the cost, and in others the patient must pay a percentage of the cost. Some private insurance policies have partial coverage for CVR and others are not covered. 60% of the population is covered by the public healthcare system and it covers 100% of the cost of CVR. 10% of the population has private insurance where the patient pays a deductible. The public healthcare system covers 40% of the population and it pays 100% of CVR cost. The private sector insures 10% of the population and provides no coverage for CVR. The rest of the population (50%) does not have any type of health coverage. The public healthcare system covers 70% of the population and the private 30%. There is no concept of CVR but rather homologates physical therapy (kinesiology). Public and private sector cover between 25 and 50% of the cost and the rest is covered by the patient. The medical care coverage includes prepaid medical assistance systems (majority), free medical assistance (public health) and medical insurance (minority). CVR is partially covered by the public system (37% of the population) and is not covered by prepayment private insurance or system and policies. 75% of the population is covered by the public sector and has full CVR coverage in public hospitals. The remaining 25% is covered by the private sector with very limited coverage for CVR. 16% of the population is covered by public health insurance, which covers all costs of CVR while private insurance provides partial coverage. The population coverage varies, with three sectors: public, private and binding. The public sector covers 35% of the population and covers all the cost of CVR, while the other two sectors can cover the CVR totally or partially depending on each case.
*Coverage: proportion of the population with health needs and that receives specific intervention.
supervised exercises, monitoring, control and follow up of an exercise plan, medical evaluations, risk factor education, as well as monitoring of blood glucose and lipids.24,25,26,29,37–39 Other program components convey significant heterogeneity like smoking cessation interventions and risk assessment for depression and sleep apnea, which are all evaluations of risk factors affecting the prognosis and treatment of several cardiovascular conditions.30,37–39 Exercise stress test with oxygen consumption assessment and specific CV health programs aimed at women are performed by less than 20% of centers. Moreover, tests like Apo lipoprotein B and screening for coronary calcification by computer tomography are performed in a handful of CVR programs in the region.24 Only a minority of CVR centers in LA offer all phases; however, 90% of the programs offer phases II and III, while 57% offer phase IV and less than 50% offer the inpatient phase I.24 Cardiac procedures and treatments in LA countries have variable costs and are generally expensive as they
include the use of pricey technology. For example, a cardiac catheterization with coronary angioplasty and stent placement costs about $3000 with an additional cost of $1000 for each stent implanted. For an implantable defibrillator or heart transplant, the costs would be around $40,000 to $60,000. In contrast, the cost of CVR sessions varies around $5 to $30 per session. This means that with the money spent in one of the common cardiac procedures, dozens or hundreds of patients in any LA country could get a full CVR program paid. Table 3 describes this comparative assessment in more detail.
Actions and Progress There is a significant opportunity to improve and strengthen CVR programs in LA. In 2010 the South American Society of Cardiology (SSCARDIO), the Inter-American Society of Cardiology (IASC), the Venezuelan Society of Cardiology, the Asociacion Cardiovascular Centroccidental (ASCARDIO), and
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Table 2 – Density of cardiovascular rehabilitation programs in latin america per inhabitants.
Mayo Clinic designed an action plan to train leaders in the field of CVR in LA to promote international collaborative work. The results of this effort include the creation of
the Latin American Working Group in CVR and prevention, the publication of the consensus as CVR36 and other publications promoting education and research in CVR Fig 2.
Table 3 – Approximate costs in US dollars for common cardiac procedures and cost of CVR sessions in south america. Cost of One CVR Cost of One CVR Coronary Permanent Implantable Session Covered Session When Cardiac Angioplasty Artery Bypass Pacemaker Cardiac by the Public Paid Out Catheterization and Stent Graft Surgery Implantation Defibrillator Healthcare System of Pocket Country Venezuela Colombia Peru Bolivia Chile Uruguay Brasil Paraguay Argentina
USD 4 10 9 6 25 5 10 25 7
USD 6 22 12 7 20 11 30 17 8
USD 2500 500 1400 1000 1500 500 1000 700
USD 12,000 3400 42,000 3600 4000 3500 1500 2500 3900
USD 23,000 23,000 4800 13,500 20,000–60,000 5000 10,000-20,000 15,000 11,000
USD 3300 4500 2800 1500 2000–3000 1500 3000–5000 4000 1500
USD 48,000 42,000 38,000 55,000 50,000 5000 20,000 35,000 40,000
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273
Fig 2 – Action plan and progress of the Latin American Cardiovascular Rehabilitation and Secondary Prevention Working Group.
Current Challenges Current challenges to improve CVR in LA include the following: • Promoting knowledge and sharing the scientific evidence of the benefits of CVR to improve referral rates. • Promoting collaborative research in the region to identify and solve problems specific to the execution of CVR in LA. • Achieving standardization of CVR services, identifying the core components with the highest benefit per dollar but also promoting the use of comprehensive CVR strategies, if possible. • Increasing coverage of CVR services for patients who need it the most by lobbying leaders in the healthcare systems, policy members, and insurance companies.
because of the scarcity of existing programs. The urgency to improve the current situation of CVR in LA is based on the current and growing local needs, backed by the scientific evidence showing the cost-saving nature of CVR. Those changes, however, will need to be individualized country by country. Strengthening of CVR requires the participation and coordination of professionals in the healthcare sector and policymakers in each country. More and better CVR programs are needed to expand the access, and improvements in the coverage of CVR services on the other hand will lead to increased demand and to the creation of more CVR centers. This will certainly lead to better CV health in the LA region.
Acknowledgments
Conclusions
Francisco Lopez-Jimenez is supported by the European Regional Development Fund—Project FNUSA-ICRC (No. Z.1.05/1.1.00/ 02.0123).
CVR is a cost effective strategy in secondary prevention of CVD proposed by the United Nations, the WHO, and the Pan-American Health Organization (PAHO). However, CVR remains underutilized not only because of the low patient referral, which is as low as 10% of those who need it, but also
Statement of Conflict of Interest All authors declare that there are no conflicts of interest.
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18. Roca-Rodríguez MM, García-Almeida JM, Ruiz-Nava J, et al. Impact of an outpatient cardiac rehabilitation program on clinical and analytical variables in cardiovascular disease. J Cardiopulm Rehabil Prev. 2014;34:43-48. 19. The BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 2012 2nd ed. 2012 [Available at: http://www.bacpr.com/resources/ 46C_BACPR_Standards_and_Core_Components_2012.pdf. Accessed August 27, 2014]. 20. Priorities for cardiovascular health in the Americas. Key messages for decision makers. OPS. 2011. [Available at: https://www.era-edta.org/images/ Priorities_for_CV_Health_in_the_Americas.pdf. Accessed August 27, 2014]. 21. United Nations General Assembly. Resolution adopted by the General Assembly:66/2:Political Declaration of The High Level Meeting of the General Assembly of the Prevention and Control of non Communicable Diseases. 2011. [Available at: http://www.who.int/nmh/events/ un_ncd_summit2011/political_declaration_en.pdf. Accessed August 27, 2014]. 22. Granero R. Four decades in mortality by coronary disease and myocardial infarction in Venezuela 1968–2008. Av Cardiológicos. 2012;32:108-111. 23. Health systems in Argentina, Bolivia, Brasil, Chile, Colombia, Mexico, Perú, Uruguay, Venezuela. Salud Publica Mex. 2011;53 (Suppl 2):s96-s108. 24. Cortes-Bergoderi M, Lopez-Jimenez F, Herdy AH, et al. Availability and characteristics of cardiovascular rehabilitation programs in South America. J Cardiopulm Rehabil Prev. 2013;33:33-41. 25. Korenfeld Y, Mendoza-Bastidas C, Saavedra L, et al. Current status of cardiac rehabilitation in Latin America and the Caribbean. Am Heart J. 2009;158:480-487. 26. Ilarraza Lomelí H, Herrera Franco R, Lomelí Rivas A, et al. National Registry of Cardiac Rehabilitation Programs in México. Arch Cardiol Mex. 2009;79:63-72. 27. Basic indicators. Argentinian Ministry of Health –Panamerican Health Organization. 2012. [Available at: http://publicaciones.ops.org.ar/publicaciones/indicadores/ IndicadoresNacion2012.pdf. Accessed August 27, 2014]. 28. Vital statistics. Basic information. Secretariat of policies, regulation and institutions. Direction of statistics and health information. Statistical system health. Series 5. Number 54. Buenos Aires, Argentina: Argentinian Ministry of Health. 2010. [Available at: http://www.deis.gov.ar/Publicaciones/Archivos/ Serie5Nro54.pdf. Accessed August 27, 2014]. 29. Santibáñez C, Pérez-Terzic C, López-Jiménez. Current status of cardiac rehabilitation in Chile. Rev Med Chil. 2012;140: 561-568. 30. Statistical yearbook of Paraguay 2012. General Directorate of Statistics, Surveys and Census. DGEEC, Asunción. 2012. [Available at: http://www.dgeec.gov.py/Publicaciones/Biblioteca/ anuario2012/anuario 2012.pdf. Accessed August 27, 2014]. 31. Santos AM, Giovanella L. Regional governance: strategies and disputes in health region management. Rev Saude Publica. 2014;48: 622-631. 32. Herdy AH, Marcchi PLB, Vila A, et al. Pre and postoperative cardiopulmonary rehabilitation in hospitalized patients undergoing coronary artery bypass surgery: A randomized controlled trial. Am J Phys Med Rehabil. 2008;87:714-719. 33. De Melo Ghisi GL, Oh P, Benetti M, Grace SL. Barriers to cardiac rehabilitation use in Canada versus Brazil. J Cardiopulm Rehabil Prev. 2013;33:173-179. 34. Ghisi GL de M, dos Santos RZ, Aranha EE. Perceptions of barriers to cardiac rehabilitation use in Brazil. Vasc Health Risk Manag. 2013;9:485-491.
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Available online at www.sciencedirect.com
ScienceDirect www.onlinepcd.com
Cardiac Rehabilitation in Latin America Claudia Victoria Anchique Santosa,⁎, Francisco Lopez-Jimenezb , Briseida Benaimc , Gerard Burdiatd , Rosalia Fernandez Coronadoe , Graciela Gonzalezf , Arthur Herdyg , Jose Medina-Inojosab , Claudio Santibañezh , Juan E. Uriona Villarroeli , Cecilia Zeballosi, j a
Division of Cardiovascular Diseases, Cardiac Rehabilitation, Mediagnóstica Duitama, Colombia Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA c Division of Cardiovascular Diseases, Cardiac Rehabilitation and Secondary Prevention (ASCARDIO),Venezuela d Department of Cardiology, Spanish Association's Quality of Life Center, Montevideo, Uruguay e Cardiac Rehabilitation Unit, National Cardiovascular Institute “Carlos Alberto Pashchiera”, Lima, Peru f Cardiovascular Prevention and Rehabilitation program, Central Hospital Institute of Social Welfare, Asuncion, Paraguay g Institute of Cardiology of Santa Catarina, Universidad e do Sulde Santa Catarina, Brazil h Prevention department, Chilean Society of Cardiology, Austral University of Chile, Chile i Cardiac Rehabilitation Service, Boliviano Belga Surgical Medical Center, Cochabamba, Boliviano, Bolivia j Cardiac Rehabilitation Service, Cardiovascular Institute of Buenos Aires, Argentinian Institute of Diagnostic and Treatment, Argentina b
A R T I C LE I N FO
AB S T R A C T
Keywords:
This article provides a description of the status of cardiovascular (CV) rehabilitation (CVR)
Cardiac rehabilitation
in Latin America (LA) and the potential impact on CV disease in the region. We discuss
Latin America
the insufficient number of CVR programs in the region and describe the components of CVR
South America
that are more commonly available, like exercise interventions, medical assessment and
Cardiovascular diseases
patient education. Additionally, we discuss the heterogeneity in other components,
Prevention
like the evaluation of depression, sleep apnea, and smoking cessation programs. Lastly, we provide a brief review on the main characteristics of the health systems of each country regarding access to CVR programs and compare the average cost of CV procedures and treatments with CVR. © 2014 Elsevier Inc. All rights reserved.
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. According to the World Health Organization (WHO) approximately one third of annual deaths in the world are due to CVD.1–3 In Latin America (LA), mortality secondary to CVD is 30%, resulting in 11 million deaths in 2010, 23% of whom represented people younger than 60 years of
age.2,4 The impact of CVD in LA is clear with an alarming increase in morbidity and mortality and the disturbing effects of secondary disability, decreased quality of life, and elevated health and social costs. The CV field has shown spectacular advances in the last several decades. From being historically a clinical field with
Statement of Conflict of Interest: see page 273. ⁎ Address reprint requests to Claudia Victoria Anchique Santos, M.D., Division of Cardiovascular Diseases and Cardiovascular Rehabilitation, Mediagnostica, Carrera #16 14-68, Duitama, Colombia. E-mail addresses: [email protected] (C.V. Anchique Santos), [email protected] (F. Lopez-Jimenez), [email protected] (B. Benaim), [email protected] (G. Burdiat), [email protected] (R. Fernandez Coronado), [email protected] (G. Gonzalez), [email protected] (A. Herdy), [email protected] (J. Medina-Inojosa), [email protected] (C. Santibañez), [email protected] (J.E. Uriona Villarroel), [email protected] (C. Zeballos). http://dx.doi.org/10.1016/j.pcad.2014.09.006 0033-0620/© 2014 Elsevier Inc. All rights reserved.
PR O G RE S S I N C ARDI O V A S CU L A R D I S EA S E S 5 7 (2 0 1 4) 26 8–2 7 5
few diagnostic tools, it has evolved to the AACVPR = American Association present day with soof Cardiovascular and phisticated diagnostic Pulmonary Rehabilitation tests, drugs and invasive treatment CV = cardiovascular methods available. In CVD = cardiovascular disease contrast to this, the CVR = cardiovascular progress achieved rerehabilitation garding preventative measures has been less IASC = Inter-American Society impressive, considering of Cardiology that the main risk facICCPR = International Council in tors for CVD disability Cardiovascular Prevention are preventable and and Rehabilitation modifiable and that shifting management LA = Latin America towards a healthy lifeor Latin American style has proven to be PAHO = Pan American of greatest impact on Health Organization reducing morbidity and mortality.5 Because of SA = South America this, CV rehabilitation SSCARDIO = South American (CVR) is a key preventaSociety of Cardiology tive strategy in CV medicine, with supporting UN = United Nations evidence of benefit in WHO = World Health terms of reduced adverse Organization outcomes and being cost-effective.6–8 Some reports have shown that CVR can reduce CVD mortality by 20% or even 40%, and achieve a 30% reduction in re-hospitalization and re-infarction 9–12 after myocardial infarction. Preventative strategies stem from current knowledge of the evolution of CVD from its molecular and cellular level when the atherosclerotic process begins at an early age, until when clinical manifestations become evident, usually in more advanced stages of the disease.6–10
269
Abbreviations and Acronyms
This knowledge has helped build the foundation of what is known as CVR, which is an integrated concept of comprehensive care that focuses on several key aspects like intervention and risk modification, management of risk factors including psychological support, promotion of healthy lifestyles, gender-specific issues, interventions adjusted for socio-economic status, and evaluation of interventions (Fig 1). Moreover, CVR programs must include a competent, multidisciplinary group of professionals who implements the program, monitors progress and obtains feedback of all necessary activities and strategies. It is a process with short, medium and long-term goals that are quantifiable, measurable, and susceptible to improvement, always with the end goal of rehabilitating the individual to his/her pre-events functional level. 13–19 In addition, CVR follows the objectives and strategies set by United Nations, the World Health Organization and the Pan-American Health Organization, aiming to reduce premature CVD mortality by 25% by the year 2025 and to increase health promotion, CVD prevention, and achieve an integrated control of chronic diseases. 20,21
Cardiac Rehabilitation in Latin America Despite evidence supporting CVR as an effective intervention to reduce CVD events and mortality, the establishment of CVR programs in LA has been slow, with very few programs available, not matching the needs of the region. The models and structure of health systems in LA are complex and quite heterogeneous, making comparison extremely challenging. Table 1 lists some general characteristics of healthcare systems in LA and whether CVR is covered by the national universal healthcare system. In all countries of LA, healthcare systems generally include two distinct models: the public and the private. Public systems, generally represented by a national universal healthcare program, offer 100% coverage for CVR in some countries as is the case of Bolivia, Venezuela, Peru and Argentina, meaning that patients who qualify for CVR have full coverage for CVR services when available. In other countries, coverage for CVR in the public system is only partial, where the patient pays out of pocket a percentage of the total cost and the public healthcare insurance pays for the rest. CVR coverage by private insurance companies is also variable in LA. In some countries private insurance companies provide full coverage while in others coverage is partial and the cost of CVR services is shared between the patient and the insurance company. Unfortunately, many and perhaps the majority of private insurance companies offer no coverage for CVR in LA.22,23 It is noteworthy that in some countries like Uruguay, there is only partial coverage for CVR regardless of whether the insurance is private or if covered by the universal (public) healthcare program. The irony is that coverage for any costly diagnostic or invasive cardiac procedure such as open-heart surgery, coronary angiography, pacemaker implantation or implantation of a defibrillator is covered at 100%, regardless of the health system to which the patient belongs. If coverage for CVR services is a major problem, access to CVR represents another major barrier for the universal implementation of CVR in the region, given the small number of CVR programs available in LA. South America (SA) has an estimated population of 393 million,23 and only about 172 CVR programs, equivalent to one CVR program for every 2,285,768 (Table 2).24 For example, in 2009, the availability of CVR programs per inhabitants, a concept we have coined as CVR programs' density, is highly variable in LA. Mexico registered 17 CVR programs for a population of 106.6 million25 while Costa Rica registered 1 CVR program for a population of 4,451,205.26 Because each CVR program sees an average of 180 new patients each year, it is obvious that the number of CVR programs is insufficient for the current needs of the region. Another limitation for the use of CVR services is their geographic distribution within each country and whether the CVR program is public versus private. Examples of challenges to access to CVR despite being covered by the public healthcare system are Argentina and Venezuela. Data from 2010 indicate that only one out of 28 centers in Argentina and only six centers in Venezuela belong to the public sector responsible for providing CVR services to the entire population covered.27,28 Chile has one of the lowest CVR referral rates (5%),
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Fig 1 – Comprehensive model of care of cardiac rehabilitation.
with 9 centers through the country, mostly located in large urban areas.29 Paraguay reported a single CVR program in 2010 and had the lowest density of CVR center per inhabitants.24,30 Similarly, Bolivia has 9 CVR centers concentrated in 3 areas, while in Peru all registered centers in 2010 were located in the capital city of Lima, of which 3 were eventually closed down due to insufficient funds and low patient referral.30 Brazil, the largest and most populated country in LA, provides partial coverage by both the public and private healthcare systems. Brazil also has significant difficulties to provide access to CVR to those who need it, not only because of its size but also because of the distribution of CVR centers. The highest concentration of CVR centers is located in the south and southeast areas of the country, regions with the highest economic development, compared with the poorer north and northeastern areas of the country where CVR centers are barely available.31,32 The different barriers to get CVR have been described in several publications, showing that, in addition to poor physician referral patterns, factors like distances to the CVR centers, limited financial support, and poorly trained personnel, also affect access to appropriate CVR.32–35 Restrictions in the referral process probably impact the availability of CVR in LA. In most countries of LA, the physician referring the patient to CVR needs
to be a specialist (cardiologist, interventional cardiologist, cardiovascular surgeon, physiatrist, sports medicine physician), while the general practitioner or any other specialist cannot refer patients to CVR programs. Many physicians and healthcare systems in LA consider CVR as “workout sessions”, not as a comprehensive program, but it is highly likely that it is the comprehensive approach that provides a meaningful medical intervention with the potential to improve quality of life and health. However, to date no LA country has a specific guideline in terms of the necessary components to call CVR “complete”, nor are there institutions regulating, monitoring or certifying CVR programs and their quality of care. The Latin American Cardiovascular Rehabilitation and Secondary Prevention Working Group has recently published a document called Consensus for CVR and Prevention for Latin America.36 This document and the Brazilian Cardiac and Pulmonary Rehabilitation Society Consensus are the only documents describing the components, competencies and expectations for CVR programs. Thus, not all components of CVR are the same among all centers, something expected given the heterogeneity of healthcare systems. However, some aspects of CVR are commonly available like prescribing and performing
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Table 1 – Coverage of CVR services by country in south america. Is CVR Covered by the Public Healthcare System? COUNTRY
Yes
Venezuela
X
Colombia
X
Peru
X
Bolivia
X
Chile
No
X
Uruguay
X
Brasil
X
Paraguay
X
Argentina
X
Coverage of CVR The entire population is covered by the public healthcare system that assumes100% of the cost of CVR in public hospitals where the service exists (6 hospitals); the rest should attend private institutions or non-profit associations. The patient would then rely on private insurance or absorb the cost of CVR. The public healthcare system covers 96% of the population. The CVR is included within the benefits of this mandatory healthcare plan. In some cases the coverage is 100% of the cost, and in others the patient must pay a percentage of the cost. Some private insurance policies have partial coverage for CVR and others are not covered. 60% of the population is covered by the public healthcare system and it covers 100% of the cost of CVR. 10% of the population has private insurance where the patient pays a deductible. The public healthcare system covers 40% of the population and it pays 100% of CVR cost. The private sector insures 10% of the population and provides no coverage for CVR. The rest of the population (50%) does not have any type of health coverage. The public healthcare system covers 70% of the population and the private 30%. There is no concept of CVR but rather homologates physical therapy (kinesiology). Public and private sector cover between 25 and 50% of the cost and the rest is covered by the patient. The medical care coverage includes prepaid medical assistance systems (majority), free medical assistance (public health) and medical insurance (minority). CVR is partially covered by the public system (37% of the population) and is not covered by prepayment private insurance or system and policies. 75% of the population is covered by the public sector and has full CVR coverage in public hospitals. The remaining 25% is covered by the private sector with very limited coverage for CVR. 16% of the population is covered by public health insurance, which covers all costs of CVR while private insurance provides partial coverage. The population coverage varies, with three sectors: public, private and binding. The public sector covers 35% of the population and covers all the cost of CVR, while the other two sectors can cover the CVR totally or partially depending on each case.
*Coverage: proportion of the population with health needs and that receives specific intervention.
supervised exercises, monitoring, control and follow up of an exercise plan, medical evaluations, risk factor education, as well as monitoring of blood glucose and lipids.24,25,26,29,37–39 Other program components convey significant heterogeneity like smoking cessation interventions and risk assessment for depression and sleep apnea, which are all evaluations of risk factors affecting the prognosis and treatment of several cardiovascular conditions.30,37–39 Exercise stress test with oxygen consumption assessment and specific CV health programs aimed at women are performed by less than 20% of centers. Moreover, tests like Apo lipoprotein B and screening for coronary calcification by computer tomography are performed in a handful of CVR programs in the region.24 Only a minority of CVR centers in LA offer all phases; however, 90% of the programs offer phases II and III, while 57% offer phase IV and less than 50% offer the inpatient phase I.24 Cardiac procedures and treatments in LA countries have variable costs and are generally expensive as they
include the use of pricey technology. For example, a cardiac catheterization with coronary angioplasty and stent placement costs about $3000 with an additional cost of $1000 for each stent implanted. For an implantable defibrillator or heart transplant, the costs would be around $40,000 to $60,000. In contrast, the cost of CVR sessions varies around $5 to $30 per session. This means that with the money spent in one of the common cardiac procedures, dozens or hundreds of patients in any LA country could get a full CVR program paid. Table 3 describes this comparative assessment in more detail.
Actions and Progress There is a significant opportunity to improve and strengthen CVR programs in LA. In 2010 the South American Society of Cardiology (SSCARDIO), the Inter-American Society of Cardiology (IASC), the Venezuelan Society of Cardiology, the Asociacion Cardiovascular Centroccidental (ASCARDIO), and
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Table 2 – Density of cardiovascular rehabilitation programs in latin america per inhabitants.
Mayo Clinic designed an action plan to train leaders in the field of CVR in LA to promote international collaborative work. The results of this effort include the creation of
the Latin American Working Group in CVR and prevention, the publication of the consensus as CVR36 and other publications promoting education and research in CVR Fig 2.
Table 3 – Approximate costs in US dollars for common cardiac procedures and cost of CVR sessions in south america. Cost of One CVR Cost of One CVR Coronary Permanent Implantable Session Covered Session When Cardiac Angioplasty Artery Bypass Pacemaker Cardiac by the Public Paid Out Catheterization and Stent Graft Surgery Implantation Defibrillator Healthcare System of Pocket Country Venezuela Colombia Peru Bolivia Chile Uruguay Brasil Paraguay Argentina
USD 4 10 9 6 25 5 10 25 7
USD 6 22 12 7 20 11 30 17 8
USD 2500 500 1400 1000 1500 500 1000 700
USD 12,000 3400 42,000 3600 4000 3500 1500 2500 3900
USD 23,000 23,000 4800 13,500 20,000–60,000 5000 10,000-20,000 15,000 11,000
USD 3300 4500 2800 1500 2000–3000 1500 3000–5000 4000 1500
USD 48,000 42,000 38,000 55,000 50,000 5000 20,000 35,000 40,000
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Fig 2 – Action plan and progress of the Latin American Cardiovascular Rehabilitation and Secondary Prevention Working Group.
Current Challenges Current challenges to improve CVR in LA include the following: • Promoting knowledge and sharing the scientific evidence of the benefits of CVR to improve referral rates. • Promoting collaborative research in the region to identify and solve problems specific to the execution of CVR in LA. • Achieving standardization of CVR services, identifying the core components with the highest benefit per dollar but also promoting the use of comprehensive CVR strategies, if possible. • Increasing coverage of CVR services for patients who need it the most by lobbying leaders in the healthcare systems, policy members, and insurance companies.
because of the scarcity of existing programs. The urgency to improve the current situation of CVR in LA is based on the current and growing local needs, backed by the scientific evidence showing the cost-saving nature of CVR. Those changes, however, will need to be individualized country by country. Strengthening of CVR requires the participation and coordination of professionals in the healthcare sector and policymakers in each country. More and better CVR programs are needed to expand the access, and improvements in the coverage of CVR services on the other hand will lead to increased demand and to the creation of more CVR centers. This will certainly lead to better CV health in the LA region.
Acknowledgments
Conclusions
Francisco Lopez-Jimenez is supported by the European Regional Development Fund—Project FNUSA-ICRC (No. Z.1.05/1.1.00/ 02.0123).
CVR is a cost effective strategy in secondary prevention of CVD proposed by the United Nations, the WHO, and the Pan-American Health Organization (PAHO). However, CVR remains underutilized not only because of the low patient referral, which is as low as 10% of those who need it, but also
Statement of Conflict of Interest All authors declare that there are no conflicts of interest.
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