Cardiac Rehabilitation

1
East riding project - the impetus
Health authorities should purchase cardiac
rehabilitation for all those who may benefit and
provide good quality discharge care Audit
Commission. Dear to our hearts? Commissioning
services for the treatment and prevention of
coronary heart disease. London HMSO. 1995.
2
East riding project - the brief
provide equitable and universal CR for all MI
patients in the health authority area be
evidence based and guideline compliant be
acceptable to clinicians and patients build on
existing local provision implicit - cost
neutral! create potential model for others to
adopt Thompson DR, Bowman GS, De Bono DP, et
al. Cardiac Rehabilitation Guidelines and Audit
Standards. London Royal College of Physicians,
1997.
3
East riding project - the method
literature review national survey to,
identify potential models (70 of HAs had
no strategy) phone survey of all UK
rehabilitation programmes local needs
assessment (HA statistics) local focus and
discussion groups with - patient support groups,
cardiologists, CR clinicians, GPs Lewin RJ,
Ingleton R, Newens AJ, et al. Adherence to
cardiac rehabilitation guidelines a survey of
cardiac rehabilitation programmes in the United
Kingdom. BMJ 19983161354-5.
4
East riding project - the national picture
Equity not universally provided (50,000 of
150,000 survivors) patchy geographical provision
many patients fall through net, e.g. transport
problems, MI identified to late for admission,
early discharges, general physician
discharge elderly, female, ethnic rural
populations particularly under represented in CR
programmes attendees are volunteers - often the
well motivated most likely to be OK anyway
(smokers, the depressed, manual workers all
underrepresented)
5
East riding project - the national picture
Quality most programmes fail to meeting UK
guidelines little - individual assessment of
needs, setting of goals, checking their
attainment limited attention to secondary
prevention through medical care, (eg. 30 of MI
patients not on asprin or Beta-Blockers)
Lewin RJ, Ingleton R, Newens AJ, et al. Adherence
to cardiac rehabilitation guidelines a survey of
cardiac rehabilitation programmes in the United
Kingdom. BMJ 19983161354-5. ASPIRE Steering
Group. A British Cardiac Society survey of the
potential for the secondary prevention of
coronary heart disease ASPIRE principal results.
Heart 199675334-42.
6
East Riding Project - the national picture
Other problems often no help for the first 6
weeks (when many going to work) patients receive
conflicting advice (hospital / GP) little or no
follow-up after discharge, no acute/community
dialogue no training for CR and poor knowledge
amongst staff no identifiable budget for CR lack
of support from cardiology Thompson DR, Bowman
GS, Kitson AL. Cardiac rehabilitation services in
England and Wales a national survey. Int J
Cardiol 199759299-304. Campbell NC, Grimshaw
JM, Ritchie LD, et al. Outpatient cardiac
rehabilitation are the potential benefits being
realised? J R Coll Physicians Lond 199630514-9.
7
East riding project - the area
8
East riding project - key solutions
identify and follow patients - hospital
information systems too slow and inaccurate -
central MI register updated daily transport -
too far for many patients to travel, some
unwilling/unable to come back to hospital - home
based programme cost effectiveness - provide
appropriate level of help - 30 of patients 12
weeks after MI report life as good or better
than before without rehab - provide only the
care required long term compliance and secondary
prevention - traditionally poor - improve
acute/community dialogue, annual audit, use
sports centres and self help groups
9
The Heart Manual
150 NHS locations 110 Hospitals 6 health
authority wide schemes 9 health districts 5
PCGs 20 single handed GPs 5,000 patients
families pa. 1,650 trained facilitators in
UK available across USA, RCTs underway in
Holland Italy
Information from Heart Manual Project,
Edinburgh. 0131 537 9127
10
East riding project - system
Confirmed MI Hospital based facilitator
introduces patient and partner to HM
Community based Facilitator guides patient
through 6 week HM programme. Home visits week
1,3,6. Final visit gathers assessment data.
Triage meeting
Discharge to support group and gym
Refer to hospital based programme
Refer to GP / specialist (psychologist, dietician
etc)
Community facilitator visit at 6 months to
reassess
Annual GP checks
11
East riding project - database
12
East riding project - assessments
Measure week 1 week 6 6 months BP BMI Smokin
g Medication Anx / Dep (HAD) Diet / Exercise
(DINE) QOL / symptoms (CLASP)
13
East riding project - system
14
East riding project - costs
Costs in first year cont. Heart Manuals 700
pa. 7,000 14,000 Training facilitators 3,000
1,000 Admin costs 3,000 2,000 Community
facilitators 38,540 40,000 Admin
clerical 10,346 12,000 Total
61,886 69,000 approx.. 100.00 per patient
15
East riding project - results
April 1st 1999 - March 13th 2000 798
confirmed MIs Hospital based facilitator
introduced 82 patients discharged with HM
95 completed 6 week assessment after HM
Programme (22 died 12 withdrawn from HM for
variety of reasons)
443 patient have been triaged
78 discharged to support group 23 assessed for
gym
15 referred to hospital based programme 9 to
rehab nurse 2 hospital dietician
15 referred to GP
16
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17
East riding project - audit of users

• Patients appreciated
• a structured approach to recovery
• information Heart Manual was easy to understand
• facilitator back-up and the link between hospital
  home
• continuing support during the early days at home
• the possibility of family involvement
• the liaison between different sectors
• Margaret Crawley - East Riding Health Audit
  Co-ordinator

18
East riding project - problems
The main challenges in implementing the system
included developing accurate reporting of
admissions (12 sites involved) poor discharge
procedures (e.g.. patients not knowing they have
had an MI) maintaining agreed response times
for first visits quality of hospital
facilitation esp. winter pressures
19
East riding project - benefits
Benefits of the system include evidence based
treatment equitable service to all post MI
patients in East Riding individual assessment
and triage to limit the use of scarce resources
to those in need, this has improved access and
waiting times for hospital based CR has
established networks between secondary and
primary care and improved relationships in
primary health care teams contains a built in
audit for reporting and also to improve the system