Implementation of Evidence-Based, Person-Centered Alternative Delivery Models for Cardiac Rehabilitation in a Rural and Remote Population: The Country Heart Attack Prevention (CHAP) Project

Background & Aims: Access and adherence to cardiac rehabilitation (CR) remain suboptimal, particularly in rural and remote settings. This study evaluated the implementation of person-centred, evidence-based CR delivery model tailored to improve access and completion. 

Methods: The implementation framework utilised was the Model for Large-Scale Knowledge Translation. The Country Heart Attack Prevention (CHAP) project introduced evidence-based flexible CR including, face-to-face, telehealth, telephone, web-based and primary care options. A matched prospective cohort compared CR attendance, completion (primary outcomes), cardiovascular (CV) readmissions, mortality, and emergency department (ED) visits between CHAP rural services and standard metropolitan face-to-face CR. 

Results: CR attendance was comparable between groups (24.2% vs 23.8%; odds ratio [OR] 1.15; 95% confidence interval [CI] 0.89–1.47; p=0.16), but completion rates were significantly higher in the CHAP Project (77.1% vs 57.5%; OR 1.69; 95% CI 1.30–2.18; p<0.001). Patient satisfaction was also greater (85.9% vs 77.1%; p<0.001). Median waiting times were similar (38 vs 36 days; p=0.008). Alternative delivery models were equivalent to traditional face-to-face modes for CV readmissions (hazard ratio [HR] 1.19; 95% CI 0.96–1.49; p=0.17), CV mortality (HR 1.70; 95% CI 0.92–3.16; p=0.09), and ED visits (HR 1.06; 95% CI 0.94–1.21; p=0.33). CR completion through CHAP was cheaper and more effective (costs: $6,542 vs $8,689; completions: 77.1% vs 57.5%). The CHAP model had over 50% probability of being cost-effective in improving CR completion. Uptake of the CHAP model would result in a cost reduction ranging from $2 million (m) at 20% uptake to $10m if all patients referred attended and completed CR. 

Conclusions: The CHAP Project significantly improved program completion and achieved satisfaction without compromising clinical outcomes and showed important levels of economic benefit. Broader implementation of person-centred models of CR, across all geographic areas to enhance uptake and impact of CR in underserved populations is recommended.