Discussion
This nationwide survey formally documents the characteristics and type of exercise training delivered in Australian CR practice. While exercise training was consistently identified as a core component of CR delivery, the characteristics of this training varied widely. Despite this national variation in exercise interventions, most individual programmes offered participants little choice, and most of Australia's CR service is provided within traditional models of care.
This study contributes an Australian perspective to the body of research which has examined the provision of exercise training during CR in other nations.14–17 ,27–33 Many of these earlier studies, however, are over a decade old, and the nature of CR has evolved over this time. Nevertheless, the characteristics of exercise training in Australian CR programmes identified in this study were similar to those observed in England,16 ,28 Wales16 and Ireland17 in terms of duration, frequency, number of sessions, session time and supervision team. While the proportion of hospital-based programmes was also similar across these nations, Australian services made less use of community and commercial settings for exercise. Development of Australian CR services to make better use of these locations, could potentially provide a resource-saving and more accessible exercise option, particularly for patients at lower risk of a new vascular event.
By contrast with our findings, surveys conducted in Europe,14 ,30 Canada,31 the USA32 ,33 and South America29 reported greater volumes of exercise training, with both longer duration programmes and more frequent sessions. European and American programmes contained, on average, twice as many exercise sessions as Australian programmes, which is possibly explained by differences in healthcare systems and funding models.32 ,34 Additionally, recommendations in the Australian CR framework require a minimum of 6–8 exercise sessions,19 ,34 while other international guidance recommends at least 12–36.35–37 The reason for such a wide variation in international guideline recommendation is unclear, and should be explored in further research.
Implications for practice
Concerns have been raised that a continuing emphasis on traditional models of CR presents substantial barriers for physician acceptance, patient uptake, programme accessibility, resourcing and funding.2 ,38 ,39 Calls for a ‘re-engineering’ of the CR model have occurred internationally38 ,40 and at a local level.41 Within Australia, the need for a more flexible, accessible and integrated approach was highlighted in 2009, when a brief audit of CR services20 found the majority provided outpatient, time-limited programmes with little flexibility. One aim of our survey was to expand on this audit by providing a more detailed snapshot of CR practice, as well as exploring if progress had been made towards delivering more flexible models of care.
It appears that Australian programmes are now more flexible in their overall approach to CR, with many providing the core components in a modular fashion. However, our findings indicate that for exercise training, flexibility of service delivery is yet to reach a tipping point. While the nationwide variation in exercise offered is congruent with the recent recommendation to offer CR using an individualised, ‘menu-based approach’,11 it must be reiterated that the individual programmes themselves provide limited choices for patients. For the most part, exercise interventions are still duration limited and group based, with the proportion of programmes providing flexible exercise settings generally unchanged. The increase in home-based programmes in the past 6 years (from 4%20 to 15%) is encouraging, and congruent with the growing body of research demonstrating greater access and comparable effectiveness of home-based models to traditional CR formats.42 However, this shift may have also evolved out of necessity, as the survey identified 24 services which had ceased operations, and many more which had reduced operating hours and staff due to funding cuts. As the demand on staffing and resources is typically less for home-based programmes, they may have become the default means of providing care in settings with limited funding.
This decline in programme funding may also be contributing to the failure to redesign and offer more flexible CR models. Without adequate support and seed funding, delivering a true menu-based approach for all patients in practice is often unfeasible.43 ,44 The type of programme offered is less likely to be influenced by patient preferences and, instead, constrained by what can be provided within available funding and service frameworks. This problem was raised by CR providers in our survey who reported service provision was hampered by time, support and resourcing constraints. This finding is not unique to Australia, with surveys of clinical practice in England15 ,43 also highlighting substantial underfunding; leading to decreased staffing, session availability, facilities and personnel training.
CR practitioners are faced with the difficult challenge of reconfiguring services in a climate of competitive healthcare funding. Fortunately, successful local initiatives which attempt service redesign with minimal impact on staffing and resources45 have already begun. Additionally, uptake of evidence-based technologies (such as text messaging,46 or smartphone CR47) recently trialled locally, needs to be encouraged and coupled with an increased use of existing infrastructure to deliver all or part of CR programmes (such as partnerships with community centres, gyms and commercial entities, or referral to exercise physiologists). In doing so, it may be possible to provide increased flexibility for patients without an additional resource drain on services. This may be particularly beneficial for rural or small programmes which comprise a significant proportion of Australian CR services, and are often the first at risk of closure.
While flexible models are strongly advocated, this approach also comes with the important caveat that providers ensure that all components delivered, including exercise training, meet the minimum level required to achieve benefit. In the deconditioned populations most often attending CR, benefits may occur with relatively small amounts of training, however, it is still concerning that a large proportion of Australian programmes are only able to offer formal exercise sessions once per week. While evidence suggests that ‘hybrid’ programmes containing one formal weekly group session with two additional and equivalent home-based sessions, may be just as effective as three hospital-based sessions,35 it is not clear if Australian programmes are providing equivalent home-based sessions. In our study, only one-third reported formally monitoring or encouraging exercise outside of prescribed classes. To reap the full potential of exercise training, programmes should take an active role in providing participants with a detailed and individualised exercise prescription for use outside of formal sessions (based on risk and functional status), and routinely monitor and encourage its use. While Australian programmes currently meet the majority of exercise recommendations prescribed in their own nominal guidelines, it is also pertinent to examine further whether the ‘real-life provision’ of exercise training in Australian CR, like that in the UK, fails to meet the levels observed in RCTs and recommended in international clinical guidelines.48 ,49
Strengths and limitations
A major strength of this study is its high response rate with 86% of all known CR sites contributing to the survey. Hence, this study provides a representative and comprehensive reflection of current exercise provision in Australia. While every effort was made to locate all eligible CR services, it is possible that not all providers are listed in the ACRA directories. Given the directories are considered the main resource for referral nationwide, there would likely be only a handful of sites receiving limited numbers of referrals if not listed. Additionally, our survey only captured exercise interventions which were delivered by programmes in-house, however, approximately 10% of sites referred to external providers, such as exercise physiologists, who may have provided a more individualised, increased level of exercise training. A review of exercise training delivered by external providers may be warranted in the future if the number of patients referred to this type of service increases.