7th York Cardiac Care Conference York Racecourse 25 April 2007

1. How we met the NSF targets for cardiac rehabilitation and what patients valued about itDr H Dalal, MD FRCGP GP, Truro, Cornwall 7th York Cardiac Care Conference York Racecourse 25 April 2007

2. Cardiac rehabilitation: Is it working?Hasnain M Dalal 4th York Cardiac Care & Rehabilitation Conference University of York 17 April 2003

3. Not rocket science

4. How we met NSF targets for CR • Listened to patients and practitioners • Listened to experts • Pilot project in one general practice • Worked with the PCT to roll out a ‘seamless’ service

5. Problem with CR1 • CR provision patchy in Cornwall • Funding for <50% of patients who survive MI • Hospital-based programme with limited places • No formal link between 1 and 2 care • Cornwall and Isles of Scilly Health Authority identified areas for improvement: • Coordination of services between 1 and 2 care • Community-based CR service for patients who find it difficult to access hospital facilities 1Dalal HM, Evans PH. BMJ 2003;326:481–4.

6. What the experts said • Calls for different ways to provide traditionally hospital-based CR1 • Integration of 2 and 1 care services2 • “Rehabilitation after heart attack should be more flexible and integrated with cardiac aftercare and primary care” • WHO3 • “Rehabilitation cannot be regarded as an isolated form or stage of the therapy but must be integrated within secondary prevention services of which it forms only one facet” 1De Bono DP. BMJ 1998;316:1329-30. 2Mayou R. BMJ 1996;313:1498-9. 3WHO, 1993.

7. CR after heart attack… “…should be more flexible and integrated with cardiac aftercare and primary care” Richard MayouBMJ 1996;313:1498-9

8. NSF goal1 • >85% of patients discharged from hospital with primary diagnosis of acute MI should be offered CR • At one year after discharge, 50% of people should be non-smokers with BMI <30 kg/m2 1Department of Health. NSF for CHD. London: DoH, 2000.

9. How we met NSF targets for CR • Identified patients with MI in hospital • Patients seen by CR nurse before discharge • Patients offered choice of CR programme • Patient discharge information passed to community/practice nurse • Links maintained between hospital and 1º care

10. Identification of patients after acute MI • Inpatient CR nurse given daily printout of cardiac enzymes

11. Patients seen before discharge • Patients assessed at bedside by CR nurse • Education , lifestyle advice and data collected for appropriate secondary prevention measures and psychological status (HADS)

12. Choice of CR

15. Choice of CR • Patients offered choice of: • Hospital-based rehabilitation (8x once weekly outpatient classes) • Home-based rehabilitation with Heart Manual • Patients not suitable for either offered tailored package (CAPTURE Cornwall)

16. Discharge details sent to 1º care • Standard form sent by CR nurse to practice CHD nurse and GP

17. Practice nurses: Trained in secondary prevention of CHD by Heartsave Biannual study updates Follow-up data collected 12–15 months post-MI Height, weight and BP measured Serum total cholesterol and smoking status from practice records Patient’s typical management Primary care (after discharge) • Week 1 • Cardiac liaison nurse visits or calls patients who chose Heart Manual • Weeks 2–6 • Heart Manual patients have telephone contact • Hospital-based patients given: • Appointment for assessment • Times to attend programme • Weeks 7–12 • Follow up by dedicated CHD nurse • Secondary prevention factors checked • Referral to GP if appropriate • Annual follow up • Patient seen in practice CHD clinic by nurse or doctor Links maintained between hospital and 1º care 1Dalal HM, Evans PH. BMJ 2003;326:481–4.

18. Two key measures for improvement1 • Proportion of patients completing CR programme after MI • Proportion of patients with optimal secondary prevention measured by: • Smoking status • BMI • Cholesterol <5.0 mmol/l • BP <140/85 mmHg 1Dalal HM, Evans PH. BMJ 2003;326:481–4.

19. Effects of change1 • Detailed audit of 179 patients with MI in 2000–1 • At 12 months, follow-up data availablefor 106 patients • 82 (77%) male • Meanage 66 years • 32 (30%) patients <60years Data available Died >85 years, comorbidity, not suitable for rehabilitation Transferred out of practice, moved out of area, not seen since discharge 1Dalal HM, Evans PH. BMJ 2003;326:481–4.

20. Effects of change1 • Follow-up data available for 106 patients at 12 months • Patients aged >60 years and self-employed preferred home-based CR • No significant sex differences between groups Hospital-based rehabilitation Heart Manual Alternative package 1Dalal HM, Evans PH. BMJ 2003;326:481–4.

21. Effects of change1 • All four secondary prevention measures improved at 12 months • Largest change in number of patients with cholesterol <5 mmol/l • Data compare favourably with those from EUROASPIRE II survey2 Percentage of patients achieving modifiable risk factors NSF target‡ *† *EUROASPIRE II included two patients with MI, coronary revascularisation and myocardial ischaemia. †EUROASPIRE II set a target of <140/90 mmHg. ‡No specific target set by national service framework. 1. Dalal HM, Evans PH. BMJ 2003;326:481–4. 2. EUROASPIRE II study group. Eur Heart J 2001;22:554–72.

22. What patients valued about our scheme

23. Listening to patients: choice in cardiac rehabilitation Wingham J et al. Eur J Cardiovasc Nurs 2006;5:289-94

24. What patients feel after a heart attack • Disbelief • Fear of death • Loss of confidence

25. Patient expectation of CR • Seeking to change lifestyle: • “Change your way of living to go on living” • Need for specific guidance from healthcare professional

26. Choice in CR Hospital? Home?

27. Preference for home or hospital based CR1 • Hospital-based CR • Peer support and group discipline • Home-based CR • Travel and parking problems 1. Wingham J et al. Eur J Cardiovasc Nurs 2006;5:289-94.

28. Hospital-based CR group: supervision by experts • Someone else in control in case something happens – eg chest pain • Exercise set at correct level • Lack of self-discipline • Group camaraderie – an opportunity to meet others

29. Home-based CR group: Heart Manual supported by nurse • Flexibility – fits in with lifestyle • Dislike groups – “may not measure up to others” • Self-disciplined • Transport/parking problems

30. Lessons learnt1 • Daily cardiac enzyme printouts accurately identified patients with acute MI • Seeing patients before dischargeimportant • Offering choicehelps increase uptake of CR • Integrationof 2 and 1 care services allowed NSF targets for CR to be met • Links through nurse educationmeetings strengthen service 1Dalal HM, Evans PH. BMJ 2003;326:481–4.

31. Next steps • Campaign for continued funding for CR • Roll out scheme to all localities within new PCT boundary • Closer collaboration • Engage GPs, staff in 1º and 2º care • Business case for practice-based commissioning

32. CR, secondary prevention or CDM?Do we need a name change? “…reasons cited for a lack of success of current secondary prevention programmes are a lack of consideration of patients’ and carers’ perspective…” Austin and ClossEur J Cardiovasc Nursing 2007;6:6–8 [Editorial]

33. The big question:One year to save the NHS…what would you do? “There is huge potential in the NHS for integrated care…There needs to be better collaborative management between primary care trusts and hospital trusts, and this will lead to an improved patient journey” Donald Beswick, President, Institute for Healthcare Improvement, Cambridge, Massachusetts, USABMJ 2007;334:180

34. Our health, our care, our say “...aims to bring care ‘closer to home’ with a series of initiatives to improve local community based services” Department of Health white paper, 2006

35. Message from President of BACR “To survive in today’s NHS it will become necessary to provide CR to a wider range of patients in a variety of settings” Bernie DowneyCardiac Rehab UK newsletter, January 2007