CARDIAC REHABILITATION Winnipeg Region Annual Report 2013-14

CARDIAC REHABILITATION Winnipeg Region Annual Report 2013-14

PROGRAM OVERVIEW The Cardiac Rehabilitation Program (CRP) operates out of two medical fitness facilities in Winnipeg, the Reh- Fit Centre and the Wellness Institute at Seven Oaks General Hospital. Both sites endeavor to provide programming that is accessible to all. Program subsidies are available to those who are in need. The Cardiac Rehabilitation Program utilizes an inter- disciplinary team of health professionals to deliver an evidence- based program that helps individuals with cardiovascular disease acquire the skills and confidence to lead a healthier life. The Cardiac Rehabilitation Program is a 16- week program that includes education and exercise classes offered at various times throughout the week. The education sessions address topics ranging from understanding the function of the cardiovascular system, cardiac medications, the central importance of exercise to other topics such as stress management, heart healthy nutrition and action planning to achieve behaviour and lifestyle change. The supervised exercise program aims to safely increase each person s cardiovascular conditioning, flexibility and strength under the careful guidance of the exercise professionals and the rest of the cardiac rehabilitation team. Through this combination of education and exercise, participants learn how to safely manage their risk factors for heart disease and improve their quality of life. The overall approach emphasizes self- efficacy and is based on a model of self- management. The cardiac rehab program has reinforced what I knew to be important prior to my heart attack and it has helped to motivate me to keep focused on my personal health goals. I have returned to full time work, but instead of fitting my exercise into my day, I am fitting the rest of my day around my exercise. The Cardiac Rehabilitation Program extends the continuum of care from hospital to the community During the past year both sites have worked to effectively and efficiently incorporate the new electronic medical record system and access to echart into the program. Their use further integrates this community based program into the broader network of other medical and community resources providing services and health care to cardiac patients. Cardiac Rehabilitation continues to be an excellent example of community partnership which includes the WRHA, Reh- Fit Centre, Wellness Institute at Seven Oaks General Hospital, the WRHA Clinical Psychology and Cardiac Sciences Programs, all working together with the medical and surgical hospital staff to augment care for cardiac patients. The program receives automatic referrals from cardiac surgery, medical wards at all Winnipeg hospitals, as well as the Heart Failure Clinic and the St. Boniface Heart Catheter Lab. The programs also participate in research initiated by the University of Manitoba and Cardiac Sciences which aims to strengthen patient care. 2

QUALITY INDICATORS/BENEFITS TO PARTICIPANTS Participants in Cardiac Rehabilitation programs across Canada typically show improvement in their mortality and morbidity upon completion of cardiac rehabilitation, which means a lower risk for death, another cardiac event or additional surgery. More specifically participants gain improved quality of life and well- being, increased exercise tolerance and functional ability, improvement in their cardiac risk factors (e.g.. better lipid profiles, blood sugar levels and blood pressure, and reduced tobacco use) as well as improved psychological symptoms such as mood or depression. This fiscal year the Cardiac Rehabilitation program selected the following six indicators to track program efficacy as well as demonstrate the significant and positive benefits of participation in this program: - - - - - - Brief Symptoms Inventory (BSI) Total blood cholesterol levels Waist girth, MET levels, SF- 36 Mental Health Summary Score and SF- 36 Physical Health Summary Score. Changes in outcome variables were examined only for those participants with both pre- and post- data. Each outcome variable was analyzed through a repeated- measures analysis, which examined each individual s change pre- and post- program rather than comparing changes in the average scores of the group as a whole. Overall, the CRP participants showed significant improvement in five of the six Doctors referred me to the Cardiac indicators. Rehab program after my heart attack and then I just kept going with more exercise and changes to my diet. Now my cardiologist is very happy with my condition. He says I m a role model and wishes all his patients would take care of themselves like I am. 3

Brief Symptoms Inventory (BSI) BSI provides an overview of a participant s psychological symptoms and their intensity at a specific point in time. The BSI- Grand Severity Index is computed by dividing the sum of the 53 items by the number of items answered. The resulting index ranges from 0 to 3, with higher scores indicating more intense symptoms. A positive post- intervention outcome relates to the reduction in the BSI Grand Severity Index score. Overall, there was no significant change in the overall BSI scores from the beginning of the CRP to the conclusion of the program. Cardiac Rehabilitation has been life changing for me in terms of being present to my body and attending to its needs. I have felt a slow and steady improvement that has given me more energy than I ve had in years. Total Blood Cholesterol Total blood cholesterol is a cardiac risk factor that should decrease following the cardiac rehabilitation intervention. This positive outcome was observed for 2013/14 program participants. Overall, participants experienced a decrease in their total blood cholesterol by the end of the program (t=- 5.48, p<.001), from an average of 3.91 mmol/l to 3.59 mmol/l. Waist Girth Waist girth has been shown to be a strong predictor of heart disease, stroke, high blood pressure, high blood cholesterol and type- 2 diabetes.! Even a modest reduction in waist girth can translate into reduced risk of disease and disability. Both exercise and heart healthy nutrition, which is emphasized in this program, can affect a reduction in waist girth. The average waist girth of participants decreased significantly over the course of the CRP, from 99.6 cm at the beginning to 96.8 cm at the conclusion of the program (t=- 3.54, p<.001). 4

MET Levels MET levels, or the amount of energy expended during a graded exercise test, is a key indicator of functional capacity. The higher the MET level upon program completion the better the functional capacity and cardiovascular conditioning. MET levels should ideally increase following the cardiac rehabilitation program. This positive outcome was established this year from the data collected. Overall, there was a statistically significant increase in MET level following the CRP (t=13.74, p<.001). The peak MET level increased from an average of 6.81 METS to 7.88 METS over the course of the CRP. SF- 36 Summary Measures The SF- 36 is a widely used Health Survey that produces an 8- scale profile of functional health and well- being. These 8 scales can be further reduced to an overall Mental Health Summary Score, and a Physical Health Summary Score. This year participants benefitted from improved Mental and Physical Health Summary Scores. Higher scores on the Mental Health Summary Measure indicates the absence of psychological distress and limitation due to emotional problems, so ideally there should be an increase in this score over the course of the Cardiac Rehabilitation program. The average Mental Health Summary Score for CRP participants increased significantly over the course of the program, from 50.8 to 51.9 (t=- 1.99, p<.05) Higher scores on the Physical Health Summary Measure indicate the absence of physical limitations or decrements in well- being, high energy levels, and excellent self- rated health, making an increase in score a positive outcome. CRP participants saw a significant increase in their Physical Health Summary Score, from an average score of 37.0 at the beginning of the program to 45.6 at the program s conclusion (t=- 16.91, p<.001). This is a great program. My husband feels so much better since he started exercising. I find it helps your state of mind. He doesn t like exercise but he is anxious to get better and stronger. 5

REFERRALS The total number of referrals received by the Cardiac Rehabilitation Program consisted of all referrals that were received between April 1, 2013 and March 31, 2014. Overall, there were 2445 Winnipeg referrals to the CRP. There were another 160 referrals to the Brandon Cardiac Rehabilitation Program. 2445 2535 2270 Who was referred to the Wellness Institute at SOGH or the Reh- Fit Centre in 2013/14? 70.4% were male, 29.6% were female Average age was 63.6 years (range 16 97 years) 73.1% lived within the Winnipeg perimeter. 75.0% of participants were married. 46.0% were employed, and 42.5% were retired or semi- retired. 6.8% of participants were on Disability benefits. 6

Referral Types: In 2013/14, 23.0% of CRP referrals were from the Acute Myocardial Infarction (AMI) care map. This includes all referrals generated from the 5A unit at St. Boniface General Hospital. About one- quarter of the referrals (27.5%) were post- surgical referrals from St. Boniface General Hospital. The majority of referrals were classified as other referrals. This includes non- surgical referrals that do not fall under the category of AMI care map, such as individuals with unstable angina. This also included all referrals from the Cath lab and the Heart Failure Clinic. The table below shows the percentage of referrals received overall and by site (Reh- Fit Centre and Wellness institute at Seven Oaks General Hospital), by type of referral, with comparisons to the previous two years. Referral Type Site 2013/14 2012/13 2011/12 Acute Myocardial Both sites 23.0% 22.1% 27.7% Infarction (AMI) care map Reh- Fit Centre 18.5% 21.3% 31.5% referrals Wellness Institute 28.2% 23.2% 22.3% Post- surgical referrals Both sites 27.5% 30.2% 38.9% Reh- Fit Centre 27.8% 30.1% 42.4% Wellness Institute 27.2% 30.3% 34.0% Other referrals (such as unstable angina, including referrals from Cath Lab and Heart Failure Clinic) General referrals (self- referred or physician- referred) Both sites 34.5% 32.0% 16.7% Reh- Fit Centre 34.5% 32.7% 7.9% Wellness Institute 33.5% 31.1% 28.9% Both sites 15.0% 15.7% 16.7% Reh- Fit Centre 18.4% 15.9% 18.1% Wellness Institute 11.2% 15.4% 14.8% For a breakdown of referrals by referral type and hospital referring site, see Appendix C 89% of the 549 cardiac surgical cases within the WRHA* received a referral to the CRP 47% of the 856 AMI cases within the WRHA* received a referral to the CRP * Due to missing data, the CRP referral rate was compared to WRHA case data for the period July 2013 to March 2014 only 7

PROGRAM STARTS Program starts are the participants who actually start the CRP between April 1, 2013 and March 31, 2014. The participant may have been referred during the previous fiscal year, but started the program during the current fiscal year. In 2013/14, 1083 people started the CRP in Winnipeg. In addition, 53 of the individuals who received a referral to the Brandon Cardiac Rehabilitation Program started that program. 1083 1099 1038 For a breakdown of program starts by month/quarter, see Appendix B. Who started the CRP the Wellness Institute at SOGH or the Reh- Fit Centre in 2013/14? 72.6% were male, 27.4% were female Average age was 61.9 years (range 21-96) 84.7% of participants lived within the Winnipeg perimeter 79.5% of the participants were married. 48.7% were employed, and 41.6% were retired or semi- retired. 5.8% of CRP participants were on Disability benefits. Cardiac Rehabilitation has made me realize how important exercising your heart really is. It was helpful for me because I have stopped smoking (4 months), eat less salt and red meat, and understand that the heart is the most useful muscle. 8

Program Starts by Referral Type: In 2013/14, participants who had received referrals to the CRP post- surgery (28.4%), or who had been self- referred or referred by their physician (28.4%) made up the largest proportion of program starts. 20.1% of individuals who were referred from the AMI care map started the CRP. The table below shows the percentage of CRP starts overall and by site (Reh- Fit Centre and Wellness institute at Seven Oaks General Hospital), by type of referral, with comparisons to the previous two years. Referral Type Site 2013/14 2012/13 2011/12 Acute Myocardial Both sites 20.1% 22.7% 26.3% Infarction (AMI) care map Reh- Fit Centre 16.9% 23.4% 29.9% referrals Wellness Institute 23.7% 21.7% 21.1% Post- surgical referrals Both sites 28.4% 31.6% 34.7% Reh- Fit Centre 23.7% 28.9% 34.0% Wellness Institute 33.4% 35.0% 35.7% Other referrals (such as unstable angina, including referrals from Cath Lab and Heart Failure Clinic) General referrals (self- referred or physician- referred) For a breakdown of starts by referral type and hospital referring site, see Appendix C 40.4% of the 473 cardiac surgical cases within the WRHA* started the CRP Both sites 23.1% 17.7% 10.7% Reh- Fit Centre 23.7% 16.1% 6.4% Wellness Institute 22.5% 19.9% 14.8% Both sites 28.4% 28.0% 28.3% Reh- Fit Centre 35.7% 31.6% 29.7% Wellness Institute 20.4% 23.4% 28.4% 17.9% of the 758 AMI cases within the WRHA* started the CRP * Due to missing data, CRP program starts were compared to WRHA case data for August 2013 to March 2014 only. 9

CRP PROGRAM ATTENDANCE One- fifth (20.1%) of the program participants in 2013/14 attended the CRP 40 or more times. A participant attending 40 or more sessions would have attended an average of 2.5 times per week for the full 16- week program. Such frequent attendance represents a significant commitment of time and energy on the part of the participant, their family and supports. Many barriers, such as transportation, family support or return to work, can interfere with participants attending more than an average of 2 times per week. Consequently the program encourages clients to incorporate physical activity into their lives outside of the structured program. There was a trend toward older participants, males, and those living in Winnipeg making 40 or more visits to the CRP, which is consistent with previous years. However the differences in attendance based on participants age, gender or place of residence did not reach statistical significance. I spent my birthday in the hospital having a quadruple heart bypass, remembers Sam. They gave me a 50% chance of survival. It s a good thing I m stubborn! Two months later, Sam joined the Cardiac Rehabilitation program. It s a fantastic program unbelievable. I listened to what they told me and lost 20-25 pounds. I feel better than I ever did. Now Sam spends 45 minutes on his cardio workout and 30 minutes on weight training. I started with 25 pound weights and found that difficult. Now I m up to lifting 55 pounds and I m looking for more. Before I had loose skin and now there s muscle all over the place. I even like to take my shirt off at the pool! In addition to losing weight, Sam now sleeps better and feels younger. My doctor tells me I m in better shape than most 55 year olds. This just improves your outlook on life. 10

Appendix A: Definitions This report includes information on relevant referral and outcome data for the 2013/14 fiscal year. There are several types of data collected to track Cardiac Rehabilitation Program (CRP) activity. In general, the main types of data collected are referrals, and program starts. During the 2013/14 year, the CRP implemented new electronic medical records software. This replaced the Max Gold and Oracle databases to track all referral, attendance and outcomes data. Information about the total number of AMI and cardiac surgical cases in the region is obtained from Winnipeg Regional Health Authority (WRHA) data. Due to challenges that were experienced by the Cardiac Rehabilitation program during the transition to and implementation of the new electronic medical records software, a portion of client data from the Max Gold database, related to referral source, attendance and outcomes of the 1 st and 2nd quarter of the 2013/14 fiscal year, was permanently lost. This data is consequently not included in this report. Reporting and statistical analysis of outcomes was completed for available data only. Referral and starts data was not affected and accurately reflects the full four quarters. REFERRALS: There are two types of referrals received by the CRP: Hospital and General. Hospital Referrals: Hospital referrals are automatic referrals made by the hospital system using the Cardiac Rehabilitation Referral Form. This form is faxed to the CR site. The following hospital programs automatically refer to CR: Types: Post Surgical: Cardiac surgery patient referrals from SBGH. AMI Care Map: MI patient referrals using the Acute Myocardial Infarction (AMI) Care Map that originate from Winnipeg Hospitals only. For the purposes of this report, referrals received from 5A at St. Boniface General Hospital were included with the AMI referrals. Other: Initiated at a hospital source using a referral form similar to the MI Care Map but for other diagnosis, e.g. Unstable Angina or CHF. In this report, referrals from the Cath Lab and the Heart Failure Clinic were included in the Other category. Hospital referrals are received from one of the following Winnipeg hospitals: St. Boniface General Hospital (SBGH), Health Sciences Centre (HSC), Concordia Hospital (CH), Grace General Hospital (GGH), Seven Oaks General Hospital (SOGH), and Victoria General Hospital (VGH). General Referral : Using the Cardiac Rehabilitation General Referral Form, a participant may self- refer or may be referred by a physician. In the case of a self- referral, a physician must sign a CR General Referral Form to confirm a cardiac diagnosis and the participant s suitability for the program. Referral forms may be faxed to the physician s office for signature. 11

OTHER DEFINITIONS: Total Referral Types: The total sum of hospital, general, and referral refusal. Referring Hospital: The hospital from which the referral originated. For purposes of reporting, the data in this report are presented based on referral type (acute MI care map, post- surgery, general and other). All referral data are based on the participants referral date between April 1, 2013 and March 31, 2014. Program starts: Program starts are the participants who, after receiving a referral or self- referring, actually start CRP. For purposes of reporting, the data in this report are presented based on start date between April 1, 2013 and March 31, 2014. The participant may have been referred during the previous fiscal year, but started the program during the current fiscal year. Therefore, the percentage of starts out of referrals cannot be calculated. Utilization Data: The number of referrals and program starts are compared to the total number of AMI and surgical cases reported within the WRHA. The number of AMI referrals and program starts are compared to the number of AMI cases as provided by the WRHA. AMI cases Include cases in which AMI was Most Reasonable Diagnosis, and in which patient was discharged home, or discharged to a home setting with support. The number of post- surgical referrals and program starts are compared to the number of cardiac surgeries that were performed, as provided by the WRHA. Because some referral data was lost during the implementation of the EMR, AMI and surgical referrals were compared to the WRHA data between July 1, 2013 and March 31, 2014. Program starts were compared to the WRHA data between August 1, 2013 and March 31, 2014. 12

Appendix B: Referrals and Program Starts, Monthly, Quarterly and Year- end, Total and by Site Referrals and 1st 2nd April May June July Aug. Sept. Program Starts Qtr Qtr. TOTAL # of referrals 227 221 185 633 184 194 205 583 Wellness Institute at SOGH 93 96 86 275 82 82 85 249 Reh- Fit Centre 134 125 109 368 102 112 120 334 TOTAL # of program starts 99 100 91 290 93 82 84 259 Wellness Institute at SOGH 39 40 30 109 33 38 35 106 Reh- Fit Centre 60 60 61 181 60 44 49 153 Referrals and 3rd 4th Oct. Nov. Dec. Jan. Feb. March Program Starts Qtr Qtr. Year- end TOTAL # of referrals 187 221 188 596 229 182 222 633 2445 Wellness Institute at SOGH 83 103 80 266 101 71 98 270 1060 Reh- Fit Centre 104 118 108 330 128 111 124 363 1395 TOTAL # of program starts 85 87 83 255 120 89 70 279 1083 Wellness Institute at SOGH 35 42 34 111 49 45 28 122 448 Reh- Fit Centre 50 45 49 144 71 44 42 157 635 * Referrals based on referral dates (discharge dates) between April 1, 2013 and March 31, 2014 Program starts based on start dates between April 1, 2013 and March 31, 2014 13

Appendix C: Referrals and Program Starts by Referral Type and Quarter* Referrals to CRP by Hospital, Type 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Year End* (final 3 quarters) AMI: TOTAL: 404 Concordia General Hospital n/a 15 8 10 33 Grace Hospital n/a 7 8 3 18 Health Sciences Centre n/a 18 14 13 45 Seven Oaks General Hospital n/a 25 19 18 62 St. Boniface General Hospital n/a 6 82 118 206 Victoria General Hospital n/a 8 15 17 40 Surgical: TOTAL: 486 St. Boniface General Hospital n/a 180 165 141 486 Brandon Cardiac Rehab Program 43 30 45 42 160 Other: TOTAL: 615 Concordia General Hospital n/a 12 15 25 52 Grace Hospital n/a 15 13 25 53 Health Sciences Centre n/a 8 14 14 36 Seven Oaks General Hospital n/a 12 13 17 40 St. Boniface General Hospital n/a 176 119 116 411 Victoria General Hospital n/a 8 6 9 23 General n/a 65 103 108 276 CRP Starts by Hospital, Type 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Year End* (final 2 quarters) AMI: TOTAL: 108 Concordia General Hospital n/a n/a 4 2 6 Grace Hospital n/a n/a 7 5 12 Health Sciences Centre n/a n/a 5 7 12 Seven Oaks General Hospital n/a n/a 13 8 21 St. Boniface General Hospital n/a n/a 3 43 46 Victoria General Hospital n/a n/a 5 6 11 Surgical: TOTAL: 143 St. Boniface General Hospital n/a n/a 75 68 143 Brandon Cardiac Rehab Program 10 10 19 14 53 Other: TOTAL: 110 Concordia General Hospital n/a n/a 6 4 10 Grace Hospital n/a n/a 9 10 19 Health Sciences Centre n/a n/a 0 2 2 Seven Oaks General Hospital n/a n/a 4 3 7 St. Boniface General Hospital n/a n/a 35 29 64 Victoria General Hospital n/a n/a 3 5 8 General n/a n/a 78 84 162 * Complications in the transition to the electronic medical record system resulted in the permanent loss of some data. Referral type and hospital source data is only available for part of the 2013/14 year. Information on referrals is available from July 2013 to March 2014, and information on program starts is available from August 2013 to March 2014. 14