The Dutch Clinical Algorithm For Risk Assessment of Patients in CRSP-patient Needs

Transcription

1 Dutch Clinical algorithm for assessment of patient needs in cardiac rehabilitation and secondary prevention English language version Technical report TR Dept. of Medical Informatics Academic Medical Center University of Amsterdam Mariëtte M. van Engen Verheul a, Hareld M. C. Kemps a,b, Nicolette F. de Keizer a, Irene M. Hellemans a, Rick Goud c, Roderik A. Kraaijenhagen d,e, Niels Peek a a Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands b Department of Cardiology, Maxima Medical Centre, Veldhoven, The Netherlands c Gupta Strategists, Ophemert, The Netherlands d Committee for Cardiovascular Prevention and Rehabilitation of the Netherlands Society of Cardiology and the National Multidisciplinary Assembly on Cardiac Rehabilitation e NDDO Institute for Prevention and Early Diagstics (NIPED), Amsterdam, The Netherlands Date: March 07, 2011 Version 1.0 Page count: 26 1

2 Contents Introduction 44 Dutch Clinical algorithm for assessment of patient needs in CRSP 44 Question 1: Is there a disruption/ potential problem of the physical functioning of the patient? 44 Question 2: Is there a disruption/ potential problem of the psychological functioning of the patient? 66 Question 3: Is there a disruption/ potential problem of the social functioning of the patient? 99 Question 4: What is the cardiovascular risk profile of the patient? 12 Question 5: Does the patient report an unhealthy lifestyle? 15 Attachments 18 Attachment 1 Clinical interview Stress 19 Instruction How to score the clinical interview Stress 20 Attachment 2 Clinical interview Resumption of work 21 Instruction How to score the clinical interview Resumption of work 22 Attachment 3 Clinical interview Smoking status 23 Attachment 4 Monitor Physical activity and Health 24 Attachment 5 Five Shot Questionnaire concerning alcohol consumption 25 Instruction How to score the Five Shot Questionnaire concerning alcohol consumption 26 2

3 Introduction Despite all available evidence of its effectiveness, cardiac rehabilitation and secondary prevention (CRSP) is still insufficiently implemented in current clinical practice. Based on an analysis of implementation problems, recently the Dutch clinical algorithm for the assessment of patient s CRSP needs was revised. The paper Revision of the Dutch Clinical algorithm for assessing Patient Needs in Cardiac Rehabilitation based on identified Implementation Problems describes the revision process and its results to improve CRSP guideline implementation. The revised algorithm advises to use assessment instruments, where possible, to determine patient needs. In this document the entire revised algorithm is translated into English. The algorithm can support other European countries in organizing the needs assessment procedure and in setting up a clinical algorithm for their CRSP program. 3

4 Question 1: Is there a disruption/ potential problem of the physical functioning of the patient? 1a. Is there an objective reduction in exercise capacity with respect to future functioning? Has the patient been diagsed with heart failure? Or: Is there an expected low exercise capacity with unexplained shortness of breath? Or: Is there an additional substantial lung disease? Exercise tolerance test under special supervision What is the patient's desired exercise capacity? (professional burden, hobbies) (expressed in METs 1 ) Results from maximal symptom-limited exercise tolerance test (Alternative: Shuttle Interval Test) Is the observed exercise capacity in concordance with (or higher than) the desired exercise capacity? Are there physical impediments to participation in group exercise training? Repeat the needs assessment for Question 1a at a later point in time or refer the patient to a specialized rehabilitation clinic. Are there cardiac contraindications for participation in group exercise training? (1) Get to kw your own physical limits (2) Learn to cope with physical limitations (3) Optimize exercise capacity (1) Get to kw your own physical limits (2) Learn to cope with physical limitations (3) Optimize exercise capacity Individual counseling by cardiologist, rehabilitation physician and/or physiotherapist When available: exercise training for patients with heart failure. Exercise training and optionally relaxation training No intervention related to objective exercise capacity 1 Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ, O'Brien WL, Bassett DR, Jr., Schmitz KH, Emplaincourt PO, Jacobs DR, Jr., Leon AS. Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc 2000;32(9 Suppl):S498-S504. 4

5 1b. Is the patient able to estimate his/ here current exercise capacity? Result MacNew Quality-of-life questionnaire: dimension physical functioning 2 Estimated exercise capacity High: 3 rd decile and higher Low: 1 st and 2 nd decile Sufficiency of objective exercise capacity for the desired exercise capacity (question 1a) Sufficient Insufficient Subjectively estimated exercise capacity High Low Correct estimation of exercise capacity Overestimation of exercise capacity Underestimation of exercise capacity Correct estimation of exercise capacity (1) Get to kw your own physical limits (2) Learn to cope with physical limitations overestimation correct estimation underestimation (1) Get to kw your own physical limits (2) Learn to cope with physical limitations (6) Conquering fear of exertion Eductaion followed by exercise training and relaxation therapy No intervention related to the estimation of the patiënts own exercise capacity Education followed by exercise training and relaxation therapy 2 Hillers TK, Guyatt GH, Oldridge N, Crowe J, Willan A, Griffith L, Feeny D. Quality of life after myocardial infarction. J Clin Epidemiol 1994;47(11):

6 Question 2: Is there a disruption/ potential problem of the psychological functioning of the patient? 2a. Is there a disruption or potential problem of the emotional functioning of the patient? Result MacNew Quality-of-life questionnaire: dimension emotional functioning 2 Disruption or potential problem of emotional functioning of the patient Severe: = 2 nd decile Moderate: = 3 rd and = 6 th decile None: = 7 th decile (4) Regain emotional balance (5) Learn to cope with cardiac disease in a functional manner severe moderate (4) Regain emotional balance (5) Learn to cope with cardiac disease in a functional manner ne Individual screening by a psychologist and/ or a social worker. He or she determines furher interventions. Educaton followed by lifestyle change counseling and/ or relaxation therapy No intervention related to emotional functioning 2 Hillers TK, Guyatt GH, Oldridge N, Crowe J, Willan A, Griffith L, Feeny D. Quality of life after myocardial infarction. J Clin Epidemiol 1994;47(11):

7 2b. Is there presence of anxiety and/ or depression? Determine risk on anxiety and/ or depression based on HADS and PHQ? Determine risk of anxiety and depression based on ather objective, validated measurement instrument suitable for cardiac patients Result Hospital Anxiety Scale (HADS 3,4 ) and question 1 and 2 from the Patient Health Questionnaire (PHQ-9 5 ) Depression (HADS depression subscale and PHQ-2) Severe: 8-21 points HADS or 4-6 points PHQ-2 Moderate: 5-7 points HADS or 2-3 points PHQ-2 Low: 0-4 points HADS or 0-1 points PHQ-2 Anxiety (HADS anxiety subscale) Severe: 8-21 points HADS Moderate: 5-7 points HADS Low: 0-4 points HADS Is there a severe risk of anxiety and/ or a severe risk of depression? Is there a moderate risk of anxiety and/ or a moderate risk of depression? (4) Regain emotional balance (5) Learn to cope with cardiac disease in a functional manner Individual screening by a psychologist and/ or a social worker. He or she determines furher interventions. No intervention related to anxiety and depression. Determine risk of anxiety and depression again during the evaluation of the cardiac rehabilitation program (4) Regain emotional balance (5) Learn to cope with cardiac disease in a functional manner Education followed by exercise training and/ or relaxation therapy 3 Zigmond A.S., Snaith R.P. The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavia 1983;67: Spinhoven P, Ormel J, Sloekers PP, Kempen GI, Speckens AE, Van Hemert AM. A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects. Psychol Med 1997;27(2): Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 1999;10;282(18):

8 2c. Is there presence of stress? Has the patient experienced one or multiple specific stress-causing events during the last year? (e.g. death/ illness of a close relative, severe illness, divorce, violence, dismissal from job, bankruptcy, retirement) To what extent is the patient still preoccupied by these events? (Never, sometimes, often, always) Often or Always answered Never or sometimes answered Results clinicial interview Stress, (see attachment 1) (4) Regain emotional balance (5) Learn to cope with cardiac disease in a functional manner severe Risk of stress Severe: 6-9 points Moderate: 3-4 points None: 0-2 points moderate (4) Regain emotional balance (5) Learn to cope with cardiac disease in a functional manner ne Individual screening by a psychologist and/ or a social worker. He or she determines furher interventions. Education followed by exercise training and/ or relaxation therapy No intervention related to stress 8

9 Question 3: Is there a disruption/ potential problem of the social functioning of the patient? 3a. Is there a disruption or potential problem of the social functioning of the patient? Result MacNew Quality-of-life questionnaire: dimension social functioning 2 (7) Regain emotional balance within one s relationship and/ or social environment (8) Optimal resumption of work and/ or household activities (9) Optimal resumption of leisure activities (10) Optimal resumption of family role and social relationships severe Disruption or potential problem of social functioning of the patient Severe: = 2 nd decile Moderate: = 3 rd and = 6 th decile None: = 7 th decile moderate (7) Regain emotional balance within one s relationship and/ or social environment (8) Optimal resumption of work and/ or household activities (9) Optimal resumption of leisure activities (10) Optimal resumption of family role and social relationships ne Individual counseling by a social worker and/ or a psychologist Education followed by lifestyle change counseling No intervention related to social functioning 2 Hillers TK, Guyatt GH, Oldridge N, Crowe J, Willan A, Griffith L, Feeny D. Quality of life after myocardial infarction. J Clin Epidemiol 1994;47(11):

10 3b. Is the patient supported by a partner for life or a confidential advisor? Is this partner of the patient worried about the cardiac disease of the patient? (No, sometimes, often or always) Goal: (7) Regain emotional balance in relationships and/ or the social environment Concerning to the patient, does the partner show anxiety in his or her behaviour to the patient? (No, sometimes, often or always) Education followed by lifestyle change counseling Often or always answered on one or both questions Sometimes answered on one or both questions No answered on both questions Goal: (7) Regain emotional balance within one s relationship and/ or social environment Goal: (7) Regain emotional balance within one s relationship and/ or social environment Individual counseling (directed at the partner): Social worker Education (if present, education involving the partner) (directed at the partner): Education (if present, education involving the partner) No intervention directed at regaining emotinal balance in relationships and/ or the social environment 10

11 3c. Does the patient expect problems during resumption of work? Did the patient perform a paid job before the heart disease? Is the patient planning to restart his or her job again? Results clinicial interview Resumption of work, (see attachment 2) severe Goal: (8) Optimal resumption of work and/ or household activities Expected problems with work resumption Severe: 7-12 points Moderate: 3-6 points None: 0-2 points moderate Goal: (8) Optimal resumption of work and/ or household activities ne Advice Contact company doctor (approval of patient necessary)* Advice Contact company doctor (approval of patient necessary) Individual screening by a psychologist and/ or a social worker. He or she determines furher interventions. Education followed by lifestyle change counseling and if necessary exercise training (in case of physcial work) No intervention directed at resumption of work * In the Netherlands each employer is obligated to facilitate a company doctor (for large companies within the company itself and for smaller companies by contracting a communal company doctor service). This company doctor is responsible for developping a reintergration plan, together with the employee, after eight weeks of sickleave. The company doctor should be informed about the cardiac rehabilitation programme so that the cardiac rehabiliation programme can be integrated into the reintegration plan (e.g. rerservation of time to rehabilitate). 11

12 Question 4: What is the cardiovascular risk profile of the patient? 4a. Is the patient obese? Results measurement of BMI (weight [kg]/ length [m] 2 ) Results measurement of waist circumference (cm) BMI (kg/m 2 ) 18,5-25 (rmal weight) (over weight) (obesity level I) (obesity level II) >40 (obesity level III) Waist circumference <102 cm (m), <88cm (w) =102 cm (m), =88 cm (w) Comorbidity* Register in the risk profile of the patient Goal: 16) Optimize weight Treatment advice General advice concerning lifestyle and health dietary habits. Treatment advice General advices concerning lifestyle and health dietary habits. Treatment advice Combined lifestyle interventions** Treatment advice Combined lifestyle interventions**; consider medication*** Treatment advice Combined lifestyle interventions**; consider medication; consider surgery*** Education Individual counseling Dietician, physiotherapist and psychologist** Optionally lifestyle change counseling * Comorbidity: Diabetes type II, hypertension, cardiovascular diseases, dyslipidemia, arthrosis and sleep apea ** Combined lifestyle interventions: inidividual guidance by a dietician, physical exercise and a psychological intervention, if necessary complemented with medication and/ or surgery (depending on BMI, waist circumference and comorbidity). The intensity of treatment of an overweight adult depends on the risk. *** Consider this intervention only if combined life style interventions are t sufficiently effective to provide eugh weight reduction after a year (<5% weight reduction) 12

13 4b. Does the patient have increased blood pressure? Result blood pressure measurement High blood pressure Systolic blood pressure = 140 mmhg Register in the risk profile of the patient 17) Optimize blood pressure 14) Develop healthy dietary habits 13) Develop and maintain a physical active lifestyle Individual counseling by a dietician Individual guidance by a cardiologist to optimize medication directed at high blood pressure. Exercise training No intervention directed at the blood pressure 4c. Does the patiënt have diabetes? Result clinical interview (If available: result HbA1c measurement) ja nee Register in the riskprofile of the patient 18) Optimize diabetic therapy 14) Development of healthy dietary habits 13) Development and maintenance of physically active lifestyle Individual counseling by a dietician Referral to a cardiologist or a diabetes nurse to adapt diabetes medication to physical exercise and follow-up. Exercise training No intervention directed at diabetes 13

14 4d. Does the patient have increased cholesterol levels? Result lipid measurement (TC, HDL, TC/HDL-ratio, LDL and triglycerides) High cholesterol levels Normal: TC < 5 mmol/l Increased: TC = 5 mmol/l Decreased: HDL < 0,9 mmol/l Increased: TC/HDL- ratio > 4 Increased: LDL = 2,5 mmol/l Increased: Triglycerides = 2 mmol/l increased rmal or decreased Register in the risk profile of the patient 19) Optimize cholesterol levels (14) Development of healthy dietary habits Individual counseling by a dietician Individual counseling by a cardiologist to optimize medication directed at high cholesterol levels. Exercise training No intervention directed at cholesterol levels 14

15 Question 5: Does the patient report an unhealthy lifestyle? 5a. Did the patient smoke before hospital admission? Register in the risk profile of the patient (11) Familiarity with nature of the disease and the risk factors (12) Smoking cessation Would the patient likes to quit smoking? (Clinical interview Smoking status, see attachement 3) Patient quit smoking already during hospital admission or patient would like to quit smoking as soon as possible. ja Patient would like to quit smoking, but t w or does t want to quit smoking at all. Treatment advice Behaviour-supporting intervention including nicotine replacement therapy if the patient smoked = 10 cigarettes a day before admission and or/ smoked the first cigarette within the first half hour after waking up in the morning. Monitor to prefent relapse. Treatment advice Provide education materials and keep trying to motivate the patient to quit smoking during all parts of the rehabilitation program. Education, lifestyle change counseling and exercise training Educaton and exercise training No intervention directed at smoking 15

16 5b. Does the patient meet the physcial activity rms? Does the patient meet the physcial activity rms? (Result Monitor Physical activity and health, see attachment 4) Exercise rm Does the patient perform physical exercise, both in summer and in winter, on at least five but preferably all days of the week, for at least 30 minutes a day at a moderately intensive level? Physical exercise at moderately intensive level: resulting in a slightly raised heartbeat and breathing. For example moderate to fast-paced walking or cycling. Fit rm Does the patient perform physical exercise, both in summer and in winter, on at least three days of the week, for at least 20 minutes a day at a strenuously intensive level? Physical exercise at a strenuously intensive level: resulting in a substantial raised heartbeat, deeper breathing and sweating. For example practice a sport or turn over the garden. Goals (11) Familiarity with nature of the disease and the risk factors (13) Development and maintenance of physically active lifestyle Education, lifestyle change counseling and exercise therapy No intervention directed at the physical acitivity rms 16

17 5c. Does the patient report excessive alcohol consumption or is there a risk of alcohol addiction? Has the patient cardiomiopathy, arrhytmias, heart failure and/ or hypertension? Advice: Advise against any alcohol consumption Excessive alcohol consumption Women: more than 1 alcoholic drink per day Men: more than 2 alcoholic drink per day excessive t excessive Goal: (11) Familiarity with nature of the disease and the risk factors Result Five Shot Questionnaire (see attachment 5) Score of 2,5 or above: Suspected alcohol abuse or alochol dependency Score below 2,5: No suspected alcohol abuse or alochol dependency Individual screening by a social worker If necessary individual counseling by social worker and/ or referral to assistance with alcohol addiction outside the cardiac rehabilitation program Education No intervention directed at alcohol consumption 17

18 Attachments To the Clinical Algorithm for the assessment of Patients CRSP Needs In this part of the document you can find the attachments belonging to the Dutch clinical algorithm for the assessment of patient s CRSP needs. The algorithm describes an extensive needs assessments procedure which can be used for all patients entering the CRSP program. The Dutch algorithm for CRSP describes a branching logic to assess data concerning patient health status in order to identify rehabilitation and secondary prevention goals for a patient tailored rehabilitation programme. For collecting the necessary data, the algorithm refers to use several assessment instruments. These instruments can be found below. 18

19 Attachment 1 Clinical interview Stress 1. Did you experience one or multiple specific stress causing events during the last year? (e.g. death/ illness of a close relative, severe illness, divorce, violence, dismissal from job, bankruptcy, retirement) Yes No 2. To what extent are you still preoccupied with these events? Never Sometimes Often Always For the next three questions, stress is defined as feeling irritated, feeling anxious, or having problems during sleep caused by problems at home or at work. Please select the answer which is most relevant in your situation. 3. How often did you feel stressed at home during the last year? Never Sometimes Often Always 4. To which extent are you stressed in relation to your financial situation? Not at all To some extend To an average extend To a large extend 5. How stressfully do you experience the fact of having a cardiac disease? Not at all To some extend To an average extend To a large extend 19

20 Instruction How to score the clinical interview Stress The total score is calculated by summing the scores on question 3 to 5. The first two questions are used to determine the route in the algorithm (see 2c. Is there presence of stress). All of the questions need to be filled in to calculate a total score on stress. The minimum score is 0, the maximum score is 9. This total score is used in the algorithm to determine patient specific goals and interventions. Scoring the clinical interview Stress 3. How often did you feel stressed at home during the last year? 0 = Never 1 = Sometimes 2 = Often 3 = Always 4. To which extent are you stressed in relation to your financial situation? 0 = Not at all 1 = To some extend 2 = To an average extend 3 = To a large extend 5. How stressfully do you experience the fact of having a cardiac disease? 0 = Not at all 1 = To some extend 2 = To an average extend 3 = To a large extend 20

21 Attachment 2 Clinical interview Resumption of work 1. Did you perform a paid job before your heart disease? Yes, I performed a paid job before my heart disease No, I did t perform a paid job before my heart disease No, I am retired 2. Are you planning to restart with your job again? Yes No If both question 1 and 2 have been answered positively, also question 3 to 6 need to be answered. For the next four questions, stress is defined as feeling irritated, feeling anxious or having problems during sleep caused by problems at home or at work. Please select the answer which is most relevant in your situation. 3. Do you feel you can soon restart your work without any problems? Yes Probably I doubt it No, because 5. Do you perform heavy physical work during your job? Never Sometimes Often Always 4. How often have you felt stressed at your work in the last year? Never Sometimes Often Always 6. Do you change shifts or work a shift other than the day shift? Never Sometimes Often Always 21

22 Instruction How to score the clinical interview Resumption of work The total score is calculated by summing the scores on question 3 till 6. The first two questions are used to determine the route in the algorithm (see 3c. Does the patient expect problems during resumption of work?). Only when these two questions have been answered positively, the other questions need to be filled in. All four questions need to be filled in to calculate a total score on resumption of work. The minimum score is 0, the maximum score is 12. This total score is used in the algorithm to determine patient specific goals and interventions. Scoring the clinical interview Stress 3. Do you feel you can soon restart your work without any problems? 0 = Yes 1 = Probably 2 = I doubt it 3 = No, because 4. How often have you felt stressed at your work in the last year? 0 = Never 1 = Sometimes 2 = Often 3 = Always 5. Do you perform heavy physical work during your job? 0 = Never 1 = Sometimes 2 = Often 3 = Always 6. Do you change shifts or work a shift other than the day shift? 0 = Never 1 = Sometimes 2 = Often 3 = Always 22

23 Attachment 3 Clinical interview Smoking status 1. Did you smoke before your hospital admission? Yes No If question 1 has been answered positively, also question 2 to 4 need to be answered. Smoking is an important risk factor for cardiac diseases. If you want to quit smoking there are several forms of support available. 2. Would you like to quit smoking? Yes, I quit already during my hospital admission Yes, I would like to quit smoking as soon as possible Yes, however, I would like to quit smoking on a longer term No, I do t want to quit smoking 3. On average, how many cigarettes do/did you smoke daily? On average cigarettes a day 4. Did you smoke your first cigarette within the first half hour after waking up in the morning? Yes No 23

24 Attachment 4 Monitor Physical activity and Health The following two questions will be dealing with moderately intensive physical exercise like walking, cycling, gardening, sports or exercise at work. It concerns all exercise which has a level of effort comparable to moderate to fast paced walking or cycling. 1. How many days a week in the SUMMER do you perform physical exercise for at least 30 minutes a day as mentioned above (the average number of days during a rmal week)? Number of days: 2. How many days a week in the WINTER do you perform physical exercise for at least 30 minutes a day as mentioned above (the average number of days during a rmal week)? Number of days: The following two questions will be dealing with strenuously intensive physical exercise. It concerns all exercise which requires faster breath taking like running, cycling, gardening, sports or other physical exercise at work, during household work, or in leisure time. 3. How many times a week in SUMMER do you perform strenuous sports or heavy physical exercise long eugh to get sweaty (heavy physical exercise which is maintained for at least 20 minutes)? Times a week: 4. How many times a week in WINTER do you perform strenuous sports or heavy physical exercise long eugh to get sweaty (heavy physical exercise which is maintained for at least 20 minutes)? Times a week: For the target groups youth and overweight persons, the rm is 60 minutes of physical activity per day. The first two questions are repeated, using a length of time of 60 minutes instead of 30 minutes. See: Douwes M, Hildebrandt VH. Questions on the amount of physical activity (in Dutch). Geneeskunde en Sport 2000;33(1):

25 Attachment 5 Five Shot Questionnaire concerning alcohol consumption 1. How often you drink alcoholic drinks? Never 1 time in a month or less 2 4 times in a month 2 3 times in a week More than 4 times in a week 2. On average, how many alcoholic drinks you drink on a day you drink alcohol? 1 or 2 3 or 4 5 or 6 7 till 9 More than Do you ever get anyed about other people making comments on your drinking habits? No Yes 4. Do you ever feel guilty about your drinking habits? No Yes 5. Do you sometimes drink alcoholic drinks in the morning to get rid of your hangover? No Yes 25

26 Instruction alcohol consumption How to score the Five Shot Questionnaire concerning The total score is calculated by summing the scores of all 5 items. All of the questions need to be filled in to calculate a total score. The minimum score is 0, the maximum score is 7. If there is a total score of 2.5 or higher, then alcohol abuse or alcohol dependency is suspected. The calculated total score does t give a final interpretation of the patient s alcohol consumption. Therefore a supplementary screening (for instance by a social worker or the managing physician) is necessary. This person should then decide if the patient needs further individual treatment for alcohol abuse outside the rehabilitation programme. Scoring the Five Shot Questionnaire 1. How often you drink alcoholic drinks? 0,5 = Never 0,5 = 1 time in a month or less 1,5 = 2 4 times in a month 1,5 = 2 3 times in a week 2,5 = More than 4 times in a week 2. On average, how many alcoholic drinks you drink on a day you drink alcohol? 0,5 = 1 or 2 0,5 = 3 or 4 1,5 = 5 or 6 1,5 = 7 till 9 2,5 = More than Do you ever get anyed about other people making comments on your drinking habits? 0 = No 1 = Yes 4. Do you ever feel guilty about your drinking habits? 0 = No 1 = Yes 5. Do you sometimes drink alcoholic drinks in the morning to get rid of your hangover? 0 = No 1 = Yes 26