Simplified Strategies of CR in
Low-Resource Settings:
Perspectives from ICCPR
Sherry L. Grace, PhD
Secretary/Treasurer, ICCPR
Full Professor, York University
Director of Research, Cardiac Rehab
University Health Network
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Disclosure Statement of Financial Interest
I, Sherry Grace DO NOT have a financial
interest/arrangement or affiliation with any
healthcare related companies that could
be perceived as a real or apparent conflict
of interest in the context of the subject of
this presentation.
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WHO Global Atlas CVD Prev & Control,2011
Availability of CR Globally
Adawi et al., (accepted in
principle) Nature Reviews:
Cardiology
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Global Availability of CR by
Country Income Classification
High-income countries: 68.0%
(51/75 countries)
Middle-income countries: 28.2% (29/103 countries)
Low-income countries:
8.3%
(3/36 countries)
LMICs: 23.0%
Globally: 38.8% (83/214 countries)
Turk-Adawi, K., Sarrafzadegan, N., & Grace, S.L. (accepted in principle). Nature
Reviews: Cardiology.
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21 Associations of the
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1993
• “define health system-related
opportunities … to access for …
rehabilitation … and develop feasible and
integrated approaches to apply costeffective NCD interventions at all levels of
health care”
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2011; p. 46
CR delivery model for low-resource
settings: A consensus statement
• Primary Writing Panel
• Grace, S.L., Turk-Adawi, K., Contractor, A., Atrey, A.,
Campbell, N., Derman, W., Ghisi, G.M.G., Hu, D.,
Lopez, F., Mendis, S.,(WHO) & Sarrafzadegan, N.
• Secondary Writing Panel
• Buckley, J., Akinroye, K. (WHF), Mola, A., Neubeck,
L., Pogosova, N., & Rivas-Estany, E.
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Literature Review: Search Strategy
1. Comprehensive search using
Medline and Embase
a- cardiac diseases
b- rehabilitation
c- LMICs
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2. Grey literature search for
reports, guidelines
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Buckley et al ., Heart, 2013
Literature Search Results
Component
CR in LMICs
CR models
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# citations
1417
130
Psychological therapy
566
Obesity
295
Lipids
152
Blood pressure
215
Education interventions
318
Smoking cessation
237
Nutrition interventions
274
Alternative Models of CR Delivery
 Low-cost, accessible models:
Home-based (Dalal etal., 2010)
Community-based (Mandic et al., 2013)
 Use of technology (evidence lacking, weak)
Internet-based (Munro et al., 2013)
telehealth, and mobile (Beatty et al., 2013)
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Implementation Considerations
 Developing national policies support CR provision
 Randomized controlled trials of CR in LMICs
 Provide cost-effectiveness data
 CR part of integrated cardiology service
 Expanding health human resources & service delivery
 Integration of CR in the curricula of medical schools
 Training of healthcare professionals (“Task-shifting”)
 Increasing the hours of operation of existing programs
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Next Steps
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•
•
•
Literature review
Writing
2ndary Panel review, revision
Submission to Nature Reviews:
Cardiology
• WCC 2016 – launch?
• Field and feasibility testing in low-resource
settings
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Acknowledgments
• Lit search: Maureen Pakosh, MIst
• Nizal Sarrafzadegan, MD (co-chair)
• Contact: sgrace@yorku.ca
• Funding:
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