CAPTURE Cornwall: Improving access to cardiac rehabilitation in the elderly

1. CAPTURE Cornwall: Improving access to cardiac rehabilitation in the elderly Hasnain Dalal, GP, Truro BACR Annual Conference 2010Crowne PlazaLiverpool8 October

2. CAPTURE Cornwall Core Team • Teresa Jago, Physiotherapist • Gill Payne, Cardiac Rehabilitation Nurse • Cathy Proctor, Cardiac Rehabilitation Liaison Nurse • Jenny Wingham, Research Nurse • Cornwall & Isles of Scilly PCT • Royal Cornwall Hospitals Trust • Peninsula Medical School

3. Death rates from CHD per 100,000 population CHD=coronary heart disease. Source: British Heart Foundation, 1997.

4. Increasing prevalence of CHD • Increases between 1994 and 2005 in the >75 years :1 • 22.7% to 26.4% in men • 15.9% to 18.4% in women • The over 65s are the fastest growing subgroup of cardiac patients

5. Why CAPTURE? • Patients aged >75 years form increasing part of CR service workload • Conventional CR programmes may not always be appropriate to their needs • Systematic reviews indicate that older patients benefit from CR at least as much as younger patients

6. CAPTURE Cornwall CArdiac Professionals Together Utilising Rehabilitation services for the Elderly

7. Drivers for CAPTURE Cornwall • Two audits presented at annual meeting of BACR in 2001 and 2003 • Funding from BHF and BLFin 2004 BACR=British Association for Cardiac Rehabilitation. BHF=British Heart Foundation. BLF=Big Lottery Fund.

8. First audit Achieving NSF milestones for cardiac rehabilitation and secondary prevention BACR Annual Conference, 28 Sep 2001 Imperial Hotel, Blackpool

9. Quality improvement reportAchieving national service framework standards for cardiac rehabilitation and secondary preventionHasnain M Dalal, Philip H Evans 1Dalal HM, Evans PH. BMJ 2003;326:481–484.

10. Lessons learnt1 • Not all patients were suitable for rehabilitation • 23% unable to attend classes or use the Heart Manual • Common reasons: • Comorbidity associated with advanced age • Arthritis, heart failure and stroke Heart Manual Hospital-based rehabilitation Alternativepackage 1Dalal HM, Evans PH. BMJ 2003;326:481–484.

11. Second audit • Poster presentation at BACR in 2003 • Audit of 908 patients post-MI between 1999and 2003 • 44% (mean age 80 years) were not suitable for ‘conventional’ CR • Main reasons for exclusion: • Severe CHF (20%) • Mobility problems (14%) Not suitable for conventional CR Heart Manual Hospital-based rehabilitation CHF=congestive heart failure. CR=cardiac rehabilitation. MI=myocardial infarction.

12. Proportion of patients unable to access CR is increasing

13. The NSF goal • Every hospital should ensure:1 • >85% of patients discharged from hospital with a primary diagnosis of acute MI should be offered cardiac rehabilitation • At 1 year after discharge, 50% of people should be non-smokers with BMI <30 kg/m2 BMI = body mass index. NSF = national service framework. 1Department of Health. NSF for CHD. London: DoH, 2000.

14. What is CAPTURE? • In 2005, Central and West Cornwall PCTs secured funding to improve access to CR in under-represented groups • BHF/BLF provided funding for 3 years from November 2005 • PCT agreed to continue funding if beneficial outcomes demonstrated • Home-based CR service for elderly patients who had suffered heart attack or undergone CABG surgery • After 1st year, age criteria of >75 years dropped and eligible valve surgery patients also seen BLF=Big Lottery Fund. CABG=coronary arrtery bypass graft.

15. CAPTURE aims • Increase access and uptake of CR services, particularly among elderly patients who have low use of existing services • Offer individualised support packages/programmes to patients to increase choice • Develop comprehensive individualised CR plans for patients who cannot access or are not suitable for the Heart Manual or current phase III programme • Continue to provide seamless care across acute and primary care services, with emphasis on long-term secondary prevention

16. CAPTURE intervention Patient’s typical management Community care (after discharge) • Week 2–8 • Home visit by CAPTURE physiotherapist: 1-hour assessment • Band 7 physiotherapist visits patient at home, typically within 4 weeks after discharge • Assessment includes: • Cardiovascular factors • Heart rate • Blood pressure • Oximetry • Mobility and function • HADS, Dartmouth Co-op QoL • Planning activity/exercise • Weeks 4–12 • Further 3 –6 home visits • 1st follow up within 2 weeks: • Goal setting • Assess adherence/motivation • Weeks 7–12 • Further follow-up visits if necessary • Secondary prevention factors checked • Referral to GP if appropriate • Annual follow up • Patient encouraged to attend nurse-led practice CHD clinic or see GP HADS=hospital anxiety and depression scale. QoL=quality of life.

17. Key measures for improvement • Proportion of patients seen by CAPTURE • Proportion of patients with improvements from baseline in: • Physical activity • Quality of life • Anxiety and depression .

18. Results: Age and gender profile *Sex not recorded for one patient.

19. Results: Proportion able to access CR after CAPTURE

20. Results: Women attending CR • Although more than one third of people with CHD are women, only 15% of those who attend CR programmes are women • Ratio of men to women accessing CR programmes in Cornwall estimated at 7:3 • CAPTURE demonstrated: • more equitable proportion of women • higher than national average proportion of women

21. Results: NSF outcomes • Number of patients exercising for at least five 30-minute sessions a week increased from 20.5% to 35.6% • Increase of 15% for 73 patients with data for both assessments • 32 patients had smoking status recorded • One smoker at Assessment 1 had ceased smoking at Assessment 1 • Only 14 patients had valid BMI measurement at both assessments • All had BMI <30 kg/m2, which did not alter at Assessment 2

23. Results: Dartmouth COOP–Quality of Life • Fewer than half of patients had data at both assessments • 65 patients completed Dartmouth COOP–Quality of Life scale for both assessments • Improvement in all scales except social support(measured at Assessment 2) • Largest improvement in social activities scale – proportion in normal range • Assessment 2: 68.3% • Assessment 1: 54% • Increase of 14% .

24. Results: Summary (Nov 2005–June 2008) • 289 patients (61% >75 years old; no sex difference) • Proportion of post-MI survivors not suitable for conventional CR was reduced by 15% • 11% more patients, mainly elderly people and women, were able to access CR • Improvements from baseline in: • physical activity • quality of life • anxiety and depression .

25. Home-based cardiac rehabilitationis as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial Bodil Oerkild, Marianne Frederiksen, Jorgen Fischer Hansen, Lene Simonsen, Lene Theil Skovgaard and Eva Prescott 1Oerkild B et al. Age Ageing 2010;15 Sep:10.1093/ageing/afq122

26. Conclusion • Innovative programmes such as CAPTURE can help to improve the current low uptake of CR by: • reaching the elderly and women who have difficulty in accessing conventional CR • offering a home based exercise programme and long term follow up in the community through good links between primary and secondary care have been key to the success of CAPTURE .

27. 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

28. Next steps • Make a business case for CAPTURE so it is commissioned by GP consortia • Improve CR services for people with CHF • Bring BACR to Cornwall • Present findings of REACH-HF! . REACH-HF=Rehabilitation Enablement in Chronic Heart Failure.