Helen Stokes PhD CARDIAC REHABILITATION: It s a Wonderful Life! Director, Regional Initiatives Cardiac Sciences Integration Regional Manager, Cardiac Rehabilitation Services
YOUR PERSPECTIVE? How many of you have visited a cardiac rehabilitation program? Do you know what the core components are? Have you had the opportunity to talk to a patient who has participated in cardiac rehab? Are you aware of the common misconceptions after CABG? www.capitalhealth.ca 2
CONTENT OUTLINE not linear. WHAT is cardiac rehabilitation? WHERE is it delivered? WHO delivers / receives it? WHY is it important? WHEN should patients be referred? HOW can we improve what we do? www.capitalhealth.ca 3
What is Cardiac Rehabilitation? The enhancement and maintenance of cardiovascular health through individualized programs designed to optimize physical, psychological, social, vocational and emotional status. This process includes the facilitation and delivery of secondary prevention through heart hazard identification and modification in an effort to prevent disease progression and recurrence of cardiac events [CACR 2004]. www.capitalhealth.ca 4
TWO KEY COMPONENTS Regional Cardiac Rehabilitation Services aims to provide hope, confidence & improved health status to all eligible cardiac patients through the provision of flexible, safe, effective and sustainable cardiac rehabilitation services. www.capitalhealth.ca 5
Canadian Cardiovascular Society Cardiac Care Continuum Can J Cardiol 2005; 21(14) 1272-6 Onset of symptoms Non-invasive testing General practitioner PERIOD 1 Specialist consult PERIOD 2 Emergency department or hospital admission Secondary prevention and rehabilitation Non-invasive testing PERIOD 3 Subspecialist consult Total Patient Wait Time = PERIOD 1 + 2 + 3 + 4 + 5 Invasive and/or non-invasive testing PERIOD 4 Therapeutic procedure (e.g., surgery, angioplasty, pacemaker, ICD, ablation) PERIOD 5 Rehabilitation Palliative / End of Life care www.capitalhealth.ca 6
National Guidelines NB: The guidelines apply from the date of the event, not when the referral is received Category Recommended Acceptable Urgent < 24 hours 1-3 days Severe depression; severe anxiety related to fear of exercise Semi Urgent 1-2 days 7 days Geographical; moderate depression; RTW <1-3 wks Elective < 30 days 30 days Most patient groups Dafoe, Arthur, Stokes et al. Universal access: but when? Treating the right patient at the right time: access to cardiac rehabilitation. Can J Cardiol 2006, 22(11): 905-11 www.capitalhealth.ca 7
CLIENT GROUPS CONDITIONS Coronary Artery Disease Congestive Heart Failure Cardiomyopathy Valvular Disease Congenital Heart Disease INTERVENTIONS Coronary Artery Bypass Surgery Percutaneous Interventions (Stents) Pacemaker / Resynchronization Therapy Implantable Defibrillators Transplant Adapted from: ELIGIBILITY SPECIAL FACTORS Gender Age Ethnicity Socio-Economic Status Demographics High-risk primary prevention CO-MORBIDITIES Diabetes Obesity Pulmonary Disease Arthritis Cancer Chronic Renal Failure Peripheral Artery Disease Mental Health CACR Guidelines (2004), AACVPR (2004), AHA Position Statement (2005) www.capitalhealth.ca 8
CR SERVICES Oct 2005 GRH HF STGN RAH HFSP KEY CR Co-Ord GOALS Program Exercise MCH UAH MAZ HFC COMMUNITY GNCH NB: Regional coverage for nutrition services Maintenance OT/ voc l Research Psych/SW Dietician Special popn. (e.g. CHF) Telehealth www.capitalhealth.ca 9
Staffing Model (incl FTEs) M.D. variable S.W. 1.00 Dietitian 1.20 O.T. 1.00 Psych 0.40 Physio 0.08 Cardiac Tech 1.00 Exercise Specialist 1.20 RNs (Case Mgr) 3.20 Exercise Specialist 1.20 RNs (Case Mgr) 3.20 Pharm 1.00 Sec 1.00 Sec 1.00 Performance Improvement Lead 1.00 Data Entry 1.00 I.S. support 0.50 Reception / Clerk 1.00 Reception / Clerk 1.00 www.capitalhealth.ca 10
Regional C.R. Services Model Assessment Intervention ALL ELIGIBLE REFERRALS Telephone / Internet / email CONTACT TRIAGE Capital Health Maintenance Programs Community MAINTENANCE Programs REGIONAL INTAKE BASELINE ASSESSMENT comprehensive health history & risk factors Clinical Assessment Psycho-social Assessment Physical Assessment Functional / Vocational Assessment Stress Management Nutritional Counseling Supervised Exercise / Training Social Support Smoking Cessation RESEARCH e.g. APPROACH Electronic infrastructure incl. links with databases CLINICAL (netcare) Identify / Assess Goals Nutritional Assessment Evaluate Readiness to Change Link with CDM programs Motivational Interviewing www.capitalhealth.ca 11
RISK vs. NEED? High Risk Assess appropriate option(s) Full Program Low Need Patient Choice High Need One Day Program / Community Resources Assess appropriate option(s) Low Risk www.capitalhealth.ca 12
Northern Alberta Cardiac Rehabilitation Program Needs-Based Service Delivery Options Short Program Condensed Program Full Program (1 day) (2 wks) (5-12 wks) GOALS Program (Phone & Internet coaching) Heart Failure Program (24 wks) (12-26 wks) Referral to community-based options* (6 wks +) * e.g. Stanford Self-Management Program, Weight Wise, Diabetes Program etc. www.capitalhealth.ca 13
CR after Cardiac Surgery Benefits: Improved outcomes Clinical stability Functional independence Reality: CR post-surgery is underutilized 10-20% participation rates in US 35% participation in Europe Risk factor modification Temporelli, P.L. & Gianuzzi, P. Cardiac rehabilitation after cardiac surgery: a valuable opportunity that should not be missed. Eur J CV Prevention & Rehab 2008, 15: 128-9 www.capitalhealth.ca 14
Potential Patient Volumes 10000 Patient numbers 4.3% 8000 6000 4000 2000 0 Potential 2005-06 Actual 05-06 Proj 06-07 Proj 07-08 Proj 08-09 CH Region GNCH NACRP 11.6% Years Based on CH Inpt. Separations using relevant ICD codes www.capitalhealth.ca 15
NACRP: Trends in referrals after CABG surgery 1400 1200 26% 1000 800 600 Total referrals CABG referrals 400 200 19% 0 2005 2006 2007 2008 www.capitalhealth.ca 16
Mortality, Morbidity & Readmission post CR 49 CABG patients followed for 10 years Study group (SG) = CR program Matched controls 2:1 (MC) = usual care Cardiac events: SG 18.4% vs. MC 34.7% [p<0.01] Readmissions: SG 2.1 vs. MC 3.5 [p<0.01] Length of stay: SG 11 days vs. MC 26 days Hedback et al. J Cardiovasc Risk 2001, 8: 153-8 www.capitalhealth.ca 17
Strategies US: Medicare: Has included coverage for CABG since 1982, expanded to valves & transplant in 2006*; American Association of Cardiovascular and Pulmonary Rehabilitation standards & guidelines UK: National Service Framework: explicit goals and expectations (Dept. of Health); British Association for Cardiac Rehabilitation guidelines Canada: CCS guidelines; Canadian Association of Cardiac Rehabilitation: guidelines for cardiac rehab pre- and postintervention * Temporelli et al. 2008 www.capitalhealth.ca 18
UK: National Service Framework (2000, Chap 7, p14) NSF GOAL: Every hospital should ensure that: a) more than 85% of people discharged from hospital with a primary diagnosis of AMI or after coronary revascularization are offered cardiac rehabilitation; b) one year after discharge at least 50% of people are non-smokers, exercise regularly and have a BMI <30 kg/m2; these should be demonstrated by clinical audit data no more than 12 months old. http://www.dh.gov.uk/en/healthcare/nationalserviceframeworks/ Coronaryheartdisease/index.htm www.capitalhealth.ca 19
UK: National Service Framework (2000, Chap 7, p8) an explicit agreement between teams undertaking revascularization (i.e. surgical teams and invasive cardiac teams) and the cardiac rehabilitation team, as to how patients undergoing revascularization will be identified to the cardiac rehabilitation team (e.g. by sending a copy of surgical lists sent to the rehabilitation team); and when and how the rehabilitation team should make contact with patients (e.g. preoperatively or postoperative visit to the patient s bed side) www.capitalhealth.ca 20
CACR GUIDELINES (2004,Chap 14, p263) Revascularization - Key Points: Pre-operative lifestyle behaviour modification and risk factor identification programs prepare the patient for the lifelong changes necessary for the long-term preservation of graft patency. Pre-operative CR programs may help to maintain fitness prior to surgery. Outpatient CR can commence as soon as possible after discharge. www.capitalhealth.ca 21
PRE-OP SYMPTOMS & MISCONCEPTIONS Many patients have described distressing physical symptoms such as fatigue, shortness of breath and chest pain during the waiting period. Patients have also reported a reduction in physical activity because of fear of causing chest pain or a heart attack. Anxiety, fear and uncertainty were prominent features of the waiting period (Fitzsimons et al, 2003) Uncertainty regarding the timing of the operation has been found to be even more disturbing than chest pain. Patients have misconceptions regarding the benefits of CABG regarding it as a cure for their condition. www.capitalhealth.ca 22
PRE-HAB Patients waiting at home for elective CABG or PCI represent a population not often considered for CR. This group is at high risk for coronary artery disease progression before intervention and for adverse events with exercise.however, stable cardiac patients awaiting surgery or PCI may benefit from participation in structured CR programs by reducing the likelihood of deconditioning prior to and preparing the patient both physically and psychologically for surgery. Preoperative preparation may prevent post-operative respiratory and mobility complications that often extend hospital stays..with increasingly older patients undergoing CABG and PCI, the importance of pre-operative exercise and education in reducing post-operative delays in recovery and in facilitating the discharge planning process should be considered by major cardiac referral centers. CACR, p 264 www.capitalhealth.ca 23
Potential for Automatic Referral to Cardiac Rehabilitation Assessment Counseling Education Exercise Follow-up Buy-in from MDs & other HCPs Eligible Referrals 100% of all eligible referrals (CACR, AHA gls) Filter #1 Cannot be fixed Filter #2 Unstable clinical condition may be referred when stable Filter #3 Internal factors Filter #4 External factors Uncomplicated Referrals > 40%? Primary Care CONTINUUM OF CARDIAC / HEALTH CARE C.D.M. www.capitalhealth.ca 24
Cardiac Rehabilitation: Review of Referral (1) CR services are effective in reducing mortality after a cardiac event: (1-3 yr reduction of 20%) as well as resulting in significant improvements in lowering lipid values, systolic blood pressure and self-reported smoking rates. CR may also reduce rates for rehospitalization and the need for invasive procedures. CR services are significantly underutilized: referral rates range from as low as 10% to 30% of eligible patients. Rates can be as high as 60%. The mean referral rate is 34%. Highest rates are reported in studies that used an automatic referral process. N.B.: Referral is an equitable system of offering access to CR services to all eligible patients. Enrollment relates to the number of patients who choose to participate after they have been referred. www.capitalhealth.ca 25
Cardiac Rehabilitation: Review of Referral (2) Role of socio-demographic factors: Higher rates of referral are associated with: English speaking, male, married, white, higher income, higher education level, place of residence Lower rates of referral are associated with: age > 75 years, female, non-white, lower income, depression, low self-esteem Role of health status factors: Higher rates of referral are associated with: MI (particularly Q wave), cardiac cath, CABG; diagnosed CV risk factors (smoking, hypertension, hypercholesterolemia); treated with ACEI, aspirin, BB or calcium channel blockers Lower rates of referral are associated with: PTCA or medical treatment only; treated with digoxin, diuretics, thrombolytics www.capitalhealth.ca 26
Cardiac Rehabilitation: Review of Referral (3) Role of health system factors: Higher rates of referral are associated with: being referred to a hospital with a CR program; having insurance coverage; belonging to an HMO (USA); previous participation in CR; being treated by cardiology services Lower rates of referral are associated with: being treated by internal medicine and cardiovascular surgery specialists; absence of a CR program and/or coordinator; insufficient time to arrange referrals; lack of awareness or familiarity with CR by the treating physician / other healthcare provider. www.capitalhealth.ca 27
Cardiac Rehabilitation: Review of Referral (4) Referral rates without an automatic system are low and inconsistent thus: there is inequity in patient care there is inaccurate measurement of the effect of CR as an intervention Referral procedures are not well-defined: This may be interpreted as advice, a prescription or a recommendation. Referral procedures need to be defined as to when, where, how patients should be referred and by whom. www.capitalhealth.ca 28
Cardiac Rehabilitation: Review of Referral (5) Strategies to improve referral include: the development of standardized referral forms for use at the time of patients hospital discharge the utilization of standardized patient care maps improved communication among tertiary care, community care and CR providers to facilitate access to CR programs the referral of patients by physician-delegates such as nurse practitioners www.capitalhealth.ca 29
Eligible Referrals Eligible Referrals 100% of all eligible referrals (CACR, AHA etc.) CONDITIONS Coronary Artery Disease Congestive Heart Failure Cardiomyopathy Valvular Disease Congenital Heart Disease INTERVENTIONS Coronary Artery Bypass Surgery Percutaneous Interventions (Stents) Pacemaker / Resynchronization Therapy Implantable Defibrillators Transplant Adapted from: CACR Guidelines (2004), AACVPR (2004), AHA Position Statement (2005) www.capitalhealth.ca 30
FILTER #1: Cannot be Fixed Assess Advise Agree Assist Arrange Refs Filter #1 Cannot be fixed CHALLENGES: Terminal co-morbidity Co-morbidities as a limiting factor Ethno-cultural factors (non-negotiable) Substance abuse (depending on risk & severity) Psychiatric disorder (unsafe/disruptive behaviour) Out of province visitors (may be referred to local services in own province) Patient refusal to participate (may or may not be doing well without CR support) SOLUTIONS: Utilize 5 A s framework Liaise with appropriate healthcare services Refer to appropriate community programs / support services www.capitalhealth.ca 31
FILTER #2: Unstable Clinical Conditions Assess Advise Agree Assist Arrange Filter #2 CHALLENGES: For example: Unstable angina Unstable arrhythmias Awaiting surgery Refer -rals Filter #1 Unstable clinical condition may be referred when stable SOLUTIONS: Use 5A s framework (see above) Refer to appropriate acute care services Follow up re progress Refer to relevant components of CR services when stabilized www.capitalhealth.ca 32
FILTER #3: Internal Factors Assess Advise Agree Assist Arrange Refs #1 #2 Filter #3 Internal factors CHALLENGES: Fear Denial Lack of motivation Lack of understanding of CR as a normal component of care Health beliefs / self-efficacy Ethno-cultural beliefs / language barriers Perception of responsibilities to e.g. family, work etc. Perception of dependency on others Perception of age limitations Perception of physical disability as a limitation Co-morbidities as a limiting factor Gender issues (multiple factors) SOLUTIONS: Use 5A s framework to address barriers identified Facilitate participation in appropriate components of CR services Refer to alternative services if more appropriate www.capitalhealth.ca 33
FILTER #4: External Factors Assess Advise Agree Assist Arrange Refs #1 #2 #3 Filter #4 External factors Patient-oriented CHALLENGES: Distance to services (time & effort) Travel / other costs incurred Lack of communication (phone, internet etc.) Lack of family / social support Work commitments Physician and other healthcare professionals influence (may be negative) Service-oriented CHALLENGES: limited hours, staffing, facilities, parking, # of patients per session Lack of flexibility re program options Inadequate processes, communication & follow-up See next slide for solutions www.capitalhealth.ca 34
FILTER #4: External Factors Assess Advise Agree Assist Arrange Refs #1 #2 #3 Filter #4 External factors Patient-oriented SOLUTIONS: Utilize 5A s framework to identify specific barriers Refer to appropriate services e.g. social work re financial assistance etc. Use problem-solving approach to choosing the most flexible service option to fit individual needs Service-oriented SOLUTIONS: Review program delivery model and processes to ensure maximum flexibility Review business planning process to ensure optimum use of available resources Review communication strategies to ensure optimum liaison with relevant stakeholders www.capitalhealth.ca 35
Cardiac Rehabilitation Services: NAVIGATION? Assessment Counseling Education Exercise Follow-up Buy-in from MDs & other HCPs Eligible Referrals 100% of all eligible referrals (CACR, AHA gls) Filter #1 Cannot be fixed Filter #2 Unstable clinical condition may be referred when stable Filter #3 Internal factors Filter #4 External factors Uncomplicated Referrals Primary Care CONTINUUM OF CARDIAC / HEALTH CARE C.D.M. www.capitalhealth.ca 36
Cardiac Rehabilitation Services: NAVIGATION? Assessment Counseling Education Exercise Follow-up Buy-in from stakeholders PCPs / PCNs Bedside / Home Care RNs / ANPs Cardiologists / Internists / Residents Allied Healthcare Professionals Administration / Management Primary Care CONTINUUM OF CARDIAC / HEALTH CARE C.D.M. www.capitalhealth.ca 37
REGIONAL QUALITY FRAMEWORK? Globally - yes? Locally? TBC www.capitalhealth.ca 38
It s a Wonderful Life! My family doctor indicated that my progress after two heart attacks was awesome Iris Wilkins, Patient Now I m feeling better and I m getting up in the morning and doing things. I m able to walk at the speed I used to walk at Annie Kenny, Patient I m sleeping without a need for medication. I m doing weights and walking at home. I never would have done this on my own. I notice an increase in strength, although my general fatigue is unchanged. Al Southwell, Patient www.capitalhealth.ca 39
References for Automatic Referral Grace SL, Evindar A, Kung T et al. Increasing Access to Cardiac Rehabilitation. J Cardiopulm Rehab 2004; 24:171-174 Grace SL, Evindar A, Kung T et al. Automatic Referral to Cardiac Rehabilitation. Medical Care 2004; 42(7) 661-669 Smith KM, Harkness K & Arthur HM. Predicting cardiac rehabilitation enrollment: the role of automatic physician referral. Eur J Cardiovasc Prevention & Rehab 2006; 13: 60-66 Arthur, HM. Improving Secondary Prevention of Cardiovascular Disease through Increased Referral to Cardiac Rehabilitation. J Clinical Outcomes Measurement 2006; 13(10): 572-577 Cortes O, Arthur HM. Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: A systematic review. Am Heart J 2006; 151:249-56 www.capitalhealth.ca 40