Improving Access to Rehabilitation for under-represented groups in Lothian

1. Improving Access to Rehabilitation for under-represented groups in Lothian BACR October 2010

2. Previous studies of deprivation • Nine papers and 2 reviews • None showed a correlation between invitation and deprivation • 6/8 studies showed a correlation between uptake and deprivation • 2/3 showed a correlation between completion and deprivation • Lower levels of uptake amongst women and the elderly • Pell and Morrison – 1996 &1998 • No correlation between deprivation and referral • Lower uptake and completion among more deprived • Not having transport commonest reason cited 1. Cooper AF, Jackson G, Weinman J, Horne R. Factors Associated with Cardiac Rehabilitation Attendance: a Systemic Review of the Literature. Clin Rehabil 2002;16:541-552 2. Pell J, Pell A, Morrison C, Blatchford O, Dargie H. Retrospective Study of the Influence of Deprivation on Uptake of Cardiac Rehabilitation. BMJ 1996;313:267-268 3. Wyer S, Earl L, Joseph S. Predicting Attendence at Cardiac Rehabilitation. A Review and Recommendations. Coronary Health Care 2001;5(4):171-177 4. Harrison WN, Wardle SA. Factors Affecting the Uptake of Cardiac Rehabilitation Services in a Rural Locality. Public Health 2005;119:1016-1022

3. Seeds of Change Redesign Project • Develop an equitable CR service in Lothian • Establish a single integrated CR service • Define a single CR pathway of care • Provide training for all staff involved in the CR pathway • Move the balance of care to home and community venues • Manage the pathway centrally from Astley Ainslie Hospital • Implement the recommendations in SIGN 57 • Assessment of need • Based on use of HBC approach • Using a menu of educational and behavioural interventions

4. Phase I – Encourage referral by cardiology nurses trained in use of the Heart Manual and Health Behaviour Change Phase II – Home-based input for all referred from similarly trained Community Cardiac Rehabilitation Nurses using the HM where appropriate over 2-5 visits over 4-12 weeks CR Review Clinic – assessment of need by MDT for all those referred by C-CRNs Phase III – Menu of educational / behavioural options delivered in group and individual format in community venues easily accessible to patients Cardiac Rehabilitation Lothian

6. Public transport travel times from WL towns to CRL venues

7. Study 1 - aims • To compare the demographic profiles of patients discharged alive following MI or CABG with those referred to cardiac rehabilitation to identify “inequities” in referral by age, sex, or deprivation • To identify whether the redesigned service has reduced the impact of deprivation on access to each phase of the rehabilitation process after referral

8. Scottish Index of Multiple Deprivation (SIMD) • Score assigned to “data-zones” (post-codes) in Scotland with a median pop of 769 • 7 domains and 37 indicators used to derive a score • Income, employment, health, education, access to services, housing, and crime • Population divided into quintiles based on the raw score • Scottish quintiles and local quintiles

9. Comparison of SIMD categories of patients on cardiology and CRL databases P=0.06 There are significantly fewer women than men in the CRL database compared with the discharge database

10. Percentage of cases fewer in CRL database compared to cardiology data by age P<0.0005

11. Uptake of Phase II CR by SIMD category P=NS

12. Uptake of Phase II CR by SIMD category P=NS

13. Referrals to Review Clinic by SIMD category P=NS Women and patients in the >80 age group were less likely to be referred for review

14. Review clinic outcome by SIMD category P=NS

15. Current CRL database analysis by SIMD

16. Conclusions • There is no “bias” in referral to CRL on the basis of deprivation status • Women and the elderly are less likely to be referred to the service or the review clinic (perhaps appropriately) • Deprived patients will attend CR if you assess need and facilitate access locally