2. Reveal whether the referral process is responsible for introducing any inequalities

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1 Black Country Cardiovascular Network Cardiac Rehabilitation Uptake Audit 2010 Executive Summary WolverhamptonWalsall Dudley Walsall

2 Background Cardiac rehabilitation is one of the most cost effective treatments available for heart patients and research demonstrates a 26% relative reduction in cardiac mortality for those patients that participate. Cardiac rehabilitation can also improve the physical and psychological quality of peoples lives, with evidence suggesting that participants are less likely to be readmitted to hospital for unplanned treatment. Unfortunately, national statistics published annually by the National Audit for Cardiac Rehabilitation (NACR) identify disappointing uptake by patients that are eligible to participate. The NACR Annual Report suggests this poor uptake may be due to a number of factors including:- Sub optimally developed programmes with insufficient capacity Poorly defined and inconsistently applied referral pathways Inequitable provision for particular sections of the population Introduction The Black Country Cardiovascular Network (BCCN) hosts three long-standing cardiac rehabilitation (CR) services within its catchments area, all of which experience sub optimal uptake rates. Accordingly, the three BCCN services decided to undertake a comprehensive audit with sufficient power to identify any potential barriers or health inequalities that may exist in the referral/participation pathway. It was expected that this audit would assist health professionals, commissioners and patients in making informed decisions, when considering future development of their CR services. Specifically the key aims of the audit were to:- 1. Inform commissioners whether all eligible patients within the BCCN are being offered the opportunity to attend a cardiac rehabilitation programme 2. Reveal whether the referral process is responsible for introducing any inequalities 3. Assess uptake rates to services across the Network 4. Reveal whether the reasons given by patients declining rehabilitation identify any common barriers/ inequalities to participation 1

3 Methods The audit captured the information of patients that were discharged from the Network s coronary care units with a particular ambition to capture all patients discharged with a diagnosis of myocardial infarction (MI) or following a revascularisation procedure. Each cardiac rehabilitation centre used the most appropriate Phase I or Phase II coordinator to collect the patient data, which was then forwarded to the Network Service Improvement Team in preparation for statistical analysis. The data included patient details with respect to age, gender, ethnicity, employment status, deprivation status, diagnosis/procedure, travel distance, with reasons for non referral and patient decline also collected. Summary Findings and Results The audit was successful in collecting data from 1606 patients, including all patients discharged with a diagnosis of MI or following a revascularisation procedure. This total enabled statistical analysis to be undertaken at both a Network and locality level. The following results describe the main findings. 1) Are all eligible patients within the BCCN being offered cardiac rehabilitation services? NSFCHD target P < 0.02 The chart above demonstrates a high referral rate of 90% for the Network which exceeds the target of 85% set by the National Service Framework for Coronary Heart Disease (NSFCHD). Although Walsall has a statistically significantly lower referral rate it is above the NSFCHD target. 2

4 Reasons for Non Referral to Cardiac Rehabilitation n = 163 The reasons illustrated in the chart above appear reasonable for non-referral to a typical Phase III outpatient cardiac rehabilitation programme, particularly as the majority are in the 76 and above age group. 73 patients (44%) were not referred due to physical incapacity and of this number, 59 patients (81%) were aged 76 years or over. 2) Is the referral process responsible for introducing any inequalities? Statistical analysis was completed with respect to the referral pathway for variables of age, gender, ethnicity, diagnostic group, deprivation, employment status and distance to travel to a Phase III centre. No statistically significant difference was found in relation to ethnicity, deprivation, employment status or distance to travel. The following factors however, did reveal statistically significant differences. Age Referral to Rehabilitation by Age Group P < 0.01 The above chart demonstrates statistical significance with respect to age. However, there are consistent and high referral rates to the age of 75, after which there is a marked and progressive decline, which is in line with current available evidence. Although higher levels of incapacity would be anticipated with increasing age, rehabilitation programmes need to ensure, that age alone, does not preclude referral. 3

5 Gender Referral to Rehabilitation by Gender The above chart demonstrates statistical significance with respect to gender, with females less likely to be referred than their male counterparts. On further analysis, there was no statistically significant difference up to the age of 80, although after this point females were less likely to be referred. Cardiac rehabilitation programmes need to ensure that elderly female patients are being given proper and equal consideration in the referral process. Diagnosis Referral to Rehabilitation by Diagnosis Group P <0.01 *Valve repair/replacement The above chart demonstrates statistical significance with respect to diagnostic group. However, this is primarily explained by lower referral rates in the non PPCI MI group. Although this group was statistically older than the other diagnostic groups, this did not fully explain the difference in referral patterns, and it is therefore important, that programmes ensure that non PPCI MI patients are appropriately and equitably referred. 4

6 3) Assessment of uptake rates to cardiac rehabilitation across the Network Statistical analysis was undertaken with respect to whether patients accepted or declined rehabilitation, taking into account the same variables of age, gender, ethnicity, diagnostic group, deprivation status, employment status and travel distance. Although statistical significance was found with respect to gender and employment status, further bivariate analysis demonstrated that this statistical difference was purely a function of age. General Uptake Uptake of Rehabilitation by Area NACR Uptake P <0.01 The chart above demonstrates a high acceptance rate of 75% across the Network which is significantly higher than the participation rate reported in the NACR. Although Wolverhampton has a statistically significantly lower acceptance rate, it is above the participation rate reported in the NACR. Age Uptake of Rehabilitation by Age Group P <0.01 The chart above demonstrates statistical significance with respect to age. However, there are consistent acceptance rates to the age of 75, at which point, there is a marked and progressive decline. 5

7 Reasons for Decline N = 125 (age 76+ cohort) and N = 239 for age 76 and under cohort. The above chart illustrates the reasons given by the 76 years and over age group for declining rehabilitation compared with the under 76 years age group. The older age group represented 34% of the total population that declined. Although physical incapacity and transport reasons were more common in the older age group, being not interested was easily the most common reason for declining in both groups. Gender Uptake of Rehabilitation by Gender P <0.01 The chart above illustrates a statistically significantly lower uptake rate in the female population, as might be expected from recently published evidence. However, further bivariate analysis demonstrated that this statistical difference was purely a function of age. 6

8 Ethnicity Uptake of Rehabilitation by Ethnicity The above chart illustrates a lower uptake in the Black and Minority Ethnic (BME) group compared with the White group. Although this difference did not reach statistical significance at Network level, it did reach a level of statistical significance for the Wolverhampton service. Although the 2010 NACR report suggests uptake by BME groups is increasing, programmes need to remain vigilant in monitoring of these groups, to ensure services meet the needs of their diverse population. In the Network, this is particularly relevant in Wolverhampton, which has the highest BME population (22%). Diagnosis Uptake of Rehabilitation by Diagnosis Group P <0.01 The chart above illustrates that diagnosis does have a statistically significant impact on uptake. Similar to referral, the non PPCI MI Group is primarily responsible for this difference having the lowest uptake rate of 69%. Once again, although this group is statistically significantly older than the other diagnosis groups, age does not explain the reason for this group having a lower uptake rate. 7

9 4) Do the reasons for patients declining to accept uptake reveal any barriers or inequalities for participating in rehabilitation? n = 337 The above chart illustrates the reasons for those patients that declined rehabilitation. It is disappointing that no reason was documented for a third of those patients that declined CR. It is important for health professionals to capture this information as it will help them to understand the reasons for which patients are declining their CR service. In addition, another third of patient declines were recorded as not interested/refused, which is in line with NACR reports and suggests there is a hardcore of patients that will require additional encouragement to participate in CR. Conclusion This collaborative audit has proved invaluable in bringing the dynamics of the Network s CR services into focus. In the main, the audit has been reassuring, demonstrating high referral rates and finding few health inequalities. However, the audit has delivered a powerful message with respect to older patients (76 years and over) and their under representation in the Network s CR services. Older patients were less likely to be referred and were also less likely to participate when referred. It may be that older patients are being non referred appropriately and that they are making fully informed decisions when choosing not to participate. However, it seems apparent that the Network s CR services need to investigate this finding further and possibly explore ways of attracting more older patients to CR. Although female, retired and medically disabled patients were less likely to participate, statistical analysis also showed this to be a function of age. The only other group to have a statistically significant under representation in CR was the non PPCI group, i.e. those patients diagnosed with an MI that did not receive primary angioplasty. Although this group was statistically significantly older than the other diagnostic groups, this did not fully explain their under representation and it appears this group also warrants further investigation. Another powerful message may be the fact that patients with very similar characteristics will make different decisions with respect to CR participation. Furthermore, one third of patients that decline CR do so because they report to being not interested. 8

10 The only intra-network health inequality occurred with respect to ethnicity. In Wolverhampton, the BME population was statistically significantly less likely to participate and this is a finding the Wolverhampton team need to consider. In final conclusion, the considerable collaborative effort involved in conducting this audit has proved to be extremely productive and will likely inform the constructive development of the Network s CR services both in the short and medium term. It has enabled the Network to identify the health inequalities that apply to its populations as opposed to assume that all nationally accepted health inequalities exist and apply equally. The audit has already resulted in the development of new projects with respect to customised provision for older patients, customised provision for patients from BME populations and the selling of CR services generally. The full report will soon be available on the BCCN website at 9

11 Acknowledgements The Network would like to thank all those involved in the development of this audit. The project would not be possible without their dedication and support: Russ Tipson Cardiac Rehabilitation Clinical Lead, Action Heart & Dudley Group of Hospitals Antonis Stavropoulos Clinical Research, Dudley Group of Hospitals Dr Jane Flint - National Clinical Advisor, Cardiac Rehabilitation, NHS Improvement Ruba Walilay Service Improvement Manager, Black Country Cardiovascular Network Mark Walsh Network Director, Black Country Cardiovascular Network Terence Read - Data and Information Lead, Black Country Cardiovascular Network Debbie Spruce Network Administrator, Black Country Cardiovascular Network Rosalind Leslie - Clinical Physiotherapist Specialist, Royal Wolverhampton Hospitals NHS Trust Suzanne Ursell Manager of Walsall Heart Care Thanks also go to the teams in each of the cardiac rehabilitation centres, who collected data, and provided evidence to support the audit. Action Heart, Dudley Walsall Heart Care Cardiac Rehabilitation Team, Wolverhampton Cardiac Rehabilitation Network Standard Group, Black Country Cardiovascular Network 10

12 NHS Improvement Black Country Cardiovascular Network Mi