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Rehabilitation Makes You Look Good

Rehabilitation Makes You Look Good. Gabor Gyenes MD PhD Interim Director of the JPCHH aka “The Jim” Leslie Wilson, Msc . HP Program Manager, Northern Alberta Cardiac Rehabilitation Program Cardiology Update May 2014. Objectives.

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Rehabilitation Makes You Look Good

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  1. Rehabilitation Makes You Look Good Gabor Gyenes MD PhD Interim Director of the JPCHH aka “The Jim” Leslie Wilson, Msc. HP Program Manager, Northern Alberta Cardiac Rehabilitation Program Cardiology Update May 2014

  2. Objectives • Review the value of Cardiac Rehabilitation (CR) in the patient journey • Introduce current utilization • Understand common barriers to CR • Discuss current and future strategies to improve CR services

  3. The value of CR • integral component of comprehensive cardiac care • reduces morbidity and mortality • improves quality of life • the burden of cardiovascular disease results in a substantial drain on health care resources. • CR is not only cost effective, but can be cost saving Thompson and Clark (2009), Canadian Coordinating Office for Health Technology Assessment (2003), policy statement from the American Heart Association, Journal of the American Heart Association, Circulation 2011.

  4. CR Reduces Mortality 25% risk reduction O’Connor G. Meta-analysis Circ 1989;80:234

  5. CR Reduces Mortality • Cochrane review of 8440 patients • 27% reduction in all-cause mortality • 31% reduction in cardiac mortality • Local outcomes Cardiac Wellness Institute of 5886 patients over 10 yrs • 40% reduction in mortality • 25% reduction in all cause hospitalizations • 40% reduction in cardiac specific hospitalizations • 20% reduction in ER visits Joliffe et al., (2000) Taylor et al., (2004), Martin, B., (2012)

  6. Mortality Reduction Krumholz JAMA Aug 2009;302:767

  7. Exercise in Heart Failure • Belardinelli et al. found a 32% ↓CV mortality in HF patients after 10 years of “supervised, moderately intense exercise training” – 88% compliance! • VO2max was one of the independent predictors of mortality • The recommendation is 30 min of mod int ex 5-7 days/week, even 15 min/d is a/w ↓mortality • In a recent study HI-AIT was also found to be safe and the VO2max achieved was higher

  8. Promotion of Exercise in Children (14+) and Adults with Congenital HD • For healthy kids: 60 min exercise x3/week • Authors emphasize the psychological aspects: promote positive behavior, readiness to change, fears from SD in CHD pts (rarely happens during exercise) • Xcise-related syncope – no dangerous sports • Hypoxia (shunts) may limit ability • Detailed assessment before prescription Circulation; 2013:127:2147-2159.

  9. Benefits of CR • Mortality reduction • Improved functional capacity • Improved risk factor profile • Enhanced return to work • Psychosocial wellbeing • Stress reduction • Improved knowledge, skills and • confidence for self management Taylor R et al. Eur J CardiovascPrev Rehab 2006;13:369

  10. Do you talk about CR with your patients? • Yes – great, keep doing it • No – think about the benefits at no costs to you

  11. Underutilization • Of the 11,824 unique patients that received qualifying cardiac services (2010/11) , only 2100 accessed CR at the GRH or GNCH • 17.7 % of the total CR population • 1,028 pts were from outside Alberta (BC, Sask, and NWT/ NT)

  12. Underutilization • Only 15-25% of eligible patients participate in CR • Despite proven effectiveness of CR limited enrolment • <30% of eligible patients join CR programs UtilizationGap Am Heart J, 2006 Dafoe W et al Can J Cardiol 2006;22:905

  13. Barriers to Inclusion • Low referral rates for women, the elderly, the social deprived and ethnic minorities • Significant comorbidities • Distance from rehab centre • Lack of physician endorsement Nguyen T et al. Cdn Journal of Cardiol 2013; 29: 1604Grace S et al. Nat ClinPractCardiovascMed 2008;5:653

  14. Barriers to Inclusion • Denial of disease severity • Lack of convenience, interest or belief “that rehab will work” • Work obligations • Transportation Beswick A et al. Health Technol Assess 2004;8:1

  15. Referral/Admission Data

  16. Referral/admission Data

  17. Referral/Admission Data

  18. Referral/Admission Data

  19. Opportunities To Improve • Part of the patient journey

  20. Opportunities To Improve • Part of the patient journey • Ease of referral

  21. Ease of referral • Update referral criteria and algorithm • Simplified, Edmonton/Central/North zone referral form • Enhanced population for transition team • Increased resources for transition team

  22. Referral form

  23. Opportunities To Improve • Part of the patient journey • Ease of referral • Meeting the patients where they are at

  24. Meeting the Patients • Formal inclusion of goals setting and attainment • Emphasis on home start up for long term adherence

  25. Comprehensive CR

  26. Program Model Multidisciplinary team approach Case Management Global risk reduction Holistic in scope Goals of functionality and reintegration into work and community

  27. Program Goals “Participating in a Cardiac Rehabilitation Program is one of the best ways to quickly and safely return to your life and all of the activities you enjoy. These programs provide guidance and information on returning to working, nutrition, anxiety, exercise and reduce your chances of having future heart troubles”

  28. Programming Available • Hospital – Assessment, Medical follow up, Clinician one to ones, telemetry monitored exercise, Group education • Hospital Shared Care – provide all items in ‘a’ as needed to support patients existing relations ship with a specialized clinic i.e., HF clinic, arrhythmia clinic, TAVI clinic, PCN’s • Community – group exercise and group education, formal family/friend involvement • Assessment Only – assessment, report to physician for follow-up

  29. Meet the CR Team • Pharmacist • Physiotherapist • Psychologist • Psychiatry • Physician • Social worker • Clerical • Cardiology technologist • Dietitian • Exercise specialist • Nurse case manager • Occupational therapist

  30. Typical Patient Journey through CR • Referral received • Patient contacted in 3-5 working days • Initial appointment with nurse case manager booked • Active program - 1 day to 3 months • Follow up at 3, 5 and 6 months • Discharge at 6 months

  31. Opportunities To Improve • Part of the patient journey • Ease of referral • Meeting the patients where they are at • Accessibility

  32. Accessibility • Early Access - early appt to CR increases attendance at CR orientation by 18% Circ. 2013

  33. Accessibility • Expansion of Services • Program Access/Options • Special Populations

  34. Referral Relationships Inuvik Peace River Dawson Creek Slave Lake Lac La Biche Cold Lake Barrhead/Westlock Grande Cache Bonnyville Whitecourt Edson St.Paul Jasper Vegreville Leduc

  35. NZ/CZ/Out of Province Zone, Rural and Provincial CR EZ Urban / Suburban/ Rural

  36. Edmonton Zone Options • Two outpatient programs across three sites • Eligibility criteria, risk stratification and patient choice will facilitate decision making around program options. • Jim Pattison provides for populations that previously had limited rehabilitation options

  37. Improving Accessibility with Technology • Xbox • Telehealth • Heart manual • Pedometer/ accelerometers • Online health portals • Online webinars

  38. Special Populations • Heart Failure/VAD • CRT • Pre-hab • Congenital HD – 14+ • TAVI • A-fib and other arrhythmias • South Asians • Cardio-oncology • Pre-habilitation

  39. Prehab • Surgical wait times are increasing up to 4-6 months for elective patients • Pts on the waitlist are fearful of symptoms and problems d/t exertion therefore, become deconditioned Pts with lower exercise capacity stay in Hosp longer and have more post-op morbidities than fitter pts (Cook 2001)

  40. Prehab 2 • 30 min of activity 3-4x/week significantly decreased hospital stay and postop event rates • 6-minute walk test good negative indicator of adverse events Preop (up to 12 months) “leisure-time” activity was shown to influence post-CABG outcomes in 200 pts (Nery & Barbisan – 2010)

  41. Prehab 3 • Small studies showed similar benefits of prehab – lower risk of infections, shorter hospital stay, less a-fib, more pts attending Rehab • Pts stayed in Hosp 1 day less, cost less and had better QOL The largest study (Arthur et al Ann Int Med 2000) randomized pts to an 8-week, 2/week CR program preop vs. ”usual care”

  42. “Downstream” Community • Subdivide Edmonton zone into quadrants • Partner with existing exercise facilities • Close to home for ease of long-term, life long maintenance • Foster family involvement 1 2 3 4

  43. Opportunities To Improve • Part of the patient journey • Ease of referral • Meeting the patients where they are at • Accessibility • Provider recommendation

  44. The Effect of Provider Recommendation • Quantitative review, 32 studies • 16, 804 patients • Main predictor of referral was physician endorsement • Lit review, MEDLINE, PsycINFO, CINAHL, EBM • 17 articles • Physician endorsement and physician attitude key to referral and enrollment Heart; 2005:91:10-14. ClinCardiol; 2013: 36:323-335

  45. Opportunities To Improve • Recognize and communicate CR as part of the patient journey • Recognize the value of your recommendation • Meet patients where they are at (bedside and in CR) • Answer questions • Respect wishes but inquire about their motivation(s) • Assist patients and their families to acquire the best outcomes with the choices they make • Refer, refer, refer

  46. Opportunities to Improve • Everybody has a role in increasing awareness, referrals, attendance and compliance • RNs will have many teachable moments • OT/PTs assessment can “show the way” to pts • Dieticians initiate the process of diet improvement to be f/u in CR • MDs mention CR as part of the pts’ journey, acknowledge attendance, affirm patient goals, follow up on patient goals Arena et. al. AHA Science Advisory. Circulation 2012;125:1321-1329.

  47. Looking Good Enthusiastic about this because we know that rehab gives an opportunity for everyone to improve outcomes. We can help you look good!

  48. Looking Good “Until good quality CR is available to the majority of patients with heart disease they will continue to die prematurely and many others will live unnecessarily symptomatic and disabled lives.” Bethel H. Heart 2009;95:271

  49. Rehab Makes You Look Good

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