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Cardiac Rehabilitation (CR) in General Practice

Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Cardiac Rehabilitation (CR) in General Practice. Karen Kjær Larsen MD, PhD student Department of General Practice School of Public Health Aarhus University.

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Cardiac Rehabilitation (CR) in General Practice

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  1. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Cardiac Rehabilitation (CR) in General Practice Karen Kjær Larsen MD, PhD student Department of General Practice School of Public Health Aarhus University Karen Kjær Larsen kkl@alm.au.dk

  2. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. The effect of Cardiac Rehabilitation is very well documented. However, due to organisational and psychosocial issues, the uptake of CR is low. How can we improve attendance? Take on the role as main coordinator for patients with chronic diseases. Screen patients with chronic diseases for psychosocial vulnerability and offer them treatment and extra attention. Karen Kjær Larsen kkl@alm.au.dk

  3. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Effect of Cardiac Rehabilitation Quality of life ↑ All-cause mortality ↓ OR=0.80 (0.68-0.93) Cardiac mortality ↓ OR=0.74 (0.61-0.96) Taylor,R.S. et al. Am.J.Med.2004 Karen Kjær Larsen kkl@alm.au.dk

  4. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Cardiac Rehabilitation, is ”the sum of activities required to influence favourably the underlying cause of the disease, as well as to ensure the patients the best possible physical mental and social conditions, som that they may, by their own efforts, preserve, or resume when lost, a place as normal as possible in the life of the community” WHO Regional Offices for Europe.1993 Karen Kjær Larsen kkl@alm.au.dk

  5. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. The 5 components Exercise training Patient education Psychosocial care Smoking cessation Diet changes Medication Karen Kjær Larsen kkl@alm.au.dk

  6. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Post-AMI Major Depression: 20 % Depression and Anxiety: 50 % Thombs,BD. et al. J Gen Intern Med.2006 Karen Kjær Larsen kkl@alm.au.dk

  7. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Prognosis of post-AMI depression All-cause mortality ↑ OR=2.38 (1.76-3.22) Cardiac mortality ↑ OR=2.59 (1.77-3.22) Cardiovascular events ↑ OR=1.95 (1.33-2.85) Van Melle JP. et al. Psychosom Med.2004 Karen Kjær Larsen kkl@alm.au.dk

  8. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Effect of Cardiac Rehabilitation Quality of life ↑ All-cause mortality ↓ OR=0.80 (0.68-0.93) Cardiac mortality ↓ OR=0.74 (0.61-0.96) Taylor,R.S. et al. Am.J.Med.2004 Karen Kjær Larsen kkl@alm.au.dk

  9. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Attendance rates Only 10-47 % of eligible patients participate in comprehensive CR Ades, P.A et al. N.Engl.J.Med.2001 Karen Kjær Larsen kkl@alm.au.dk

  10. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Attendance rates 3 % in a full rehabilitation programme 47 % in parts of the rehabilitation programme 19 % no attendance at all Danish Heart Association. 2009 Karen Kjær Larsen kkl@alm.au.dk

  11. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Organisation Patient Depression Anxiety Living alone Lower educational level Factors associated with non-attendance Lack of support from GPs and cardiologists Lack of co-operation across the primary/secondary boundaries Wyer,S. et al. Coronary Health Care. 2001 Karen Kjær Larsen kkl@alm.au.dk

  12. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Organisation Meet the organisational challenges Lack of support from GPs and cardiologists Lack of co-operation across the primary/secondary boundaries Wyer,S. et al. Coronary Health Care. 2001 Karen Kjær Larsen kkl@alm.au.dk

  13. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Organisation Meet the challenge Encourage the patient Meet the organisational challenges Lack of support from GPs and cardiologists Lack of co-operation across the primary/secondary boundaries Wyer,S. et al. Coronary Health Care. 2001 Karen Kjær Larsen kkl@alm.au.dk

  14. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Encourage the patient CR participation by primary physician recommendation: No or weak recommendation, entry rate: 1,8 % Strong recommendation, entry rate: 66 % Ades,P. Arch Intern Med. 1992 Karen Kjær Larsen kkl@alm.au.dk

  15. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Organisation Meet the challenge Take on the role as main coordinator Meet the organizational challenges Lack of support from GPs and cardiologists Lack of co-operation across the primary/secondary boundaries Wyer,S. et al. Coronary Health Care. 2001 Karen Kjær Larsen kkl@alm.au.dk

  16. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Take on the role as main coordinator The 2 sectors need to collaborate and communicate effectively to reduce treatment gaps and build on established models of integrated care with proved effectiveness Dalal,H. BMJ 2004 Karen Kjær Larsen kkl@alm.au.dk

  17. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Patient Depression Anxiety Living alone Lower educational level Meet the psychosocial challenges Wyer,S. et al. Coronary Health Care. 2001 Karen Kjær Larsen kkl@alm.au.dk

  18. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Meet the challenge Patient Depression Anxiety Living alone Lower educational level Meet the psychosocial challenges Screen for psychiatric illness and social vulnerability Wyer,S. et al. Coronary Health Care. 2001 Karen Kjær Larsen kkl@alm.au.dk

  19. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Screening of psychosocial vulnerability Karen Kjær Larsen kkl@alm.au.dk

  20. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Meet the challenge Patient Depression Anxiety Living alone Lower educational level Meet the psychosocial challenges Screen for psychiatric illness and social vulnerability Treat psychiatric illness Karen Kjær Larsen kkl@alm.au.dk

  21. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Treat psychiatric illness Standard treatment of depression → effect on depressive symptoms → lower risk for subsequent cardiac events for responders Carney,RM et al. Psychsom Med. 2004 Karen Kjær Larsen kkl@alm.au.dk

  22. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Meet the challenge Patient Depression Anxiety Living alone Lower educational level Meet the psychosocial challenges Screen for psychiatric illness and social vulnerability Treat psychiatric illness Offer extra attention to socially vulnerable patients Karen Kjær Larsen kkl@alm.au.dk

  23. Are patients with chronic diseases a new challenge togeneral practice? Cardiac Rehabilitation in general practice. Offer extra attention to socially vulnerable patients Extra attention to the socially vulnerable → social equality (attendance rates, adherence to medication and achieving treatment goals) Meillier,L. I gang igen efter blodprop i hjertet - socialt differentieret hjerterehabilitering. Region Midtjylland. 2007 Karen Kjær Larsen kkl@alm.au.dk

  24. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. The effect of Cardiac Rehabilitation is very well documented. However, due to organizational and psychosocial issues, the uptake of CR is low. How can we improve attendance? Take on the role as main coordinator for patients with chronic diseases. Screen patients with chronic diseases for psychosocial vulnerability and offer them treatment and extra attention. Karen Kjær Larsen kkl@alm.au.dk

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