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The New BACPR Standards and Core Components Driving Forward more Effective Cardiovascular Prevention and Rehabilitation

The New BACPR Standards and Core Components Driving Forward more Effective Cardiovascular Prevention and Rehabilitation for Improved Outcomes. Promoting Excellence in Cardiovascular Disease Prevention and Rehabilitation. Jennifer Jones BACPR President Cheshire and Merseyside Clinical Networks

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The New BACPR Standards and Core Components Driving Forward more Effective Cardiovascular Prevention and Rehabilitation

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  1. The New BACPR Standards and Core Components Driving Forward more Effective Cardiovascular Prevention and Rehabilitation for Improved Outcomes Promoting Excellence in Cardiovascular Disease Prevention and Rehabilitation Jennifer Jones BACPR President Cheshire and Merseyside Clinical Networks Cardiac Rehab Practitioners Forum Wed 12th September 2012

  2. Aim Driving forward more effective cardiovascular prevention and rehabilitation in light of the new BACPR Standards and Core Components 7 core standards and 7 core components are set out which aim to improve uptake and quality of rehabilitation programmes nationwide www.bacpr.com With special thanks to: BHF, BSC, NHS Improvement, NACR, BANCC, BSH, HCP (UK), UK Heart Health and Thoracic Dietitians Group, the original 2007 and 2012 development groups as well as health care professionals from our consultation event and BACPR council members past and present.

  3. Overview • Meet our case • Background and evidence • NACR 2011 findings • Introducing to the 2012 update of the BACPR Standards and Core Components • Shaping future service delivery • Promoting excellence in cardiovascular disease prevention and rehabilitation

  4. Case Scenario • Mr BC is a 51-year-old male from Pakistan residing in London. Recent anterior STEMI with primary PCI (drug eluding stent). • He is currently sedentary, has recently quit smoking and has a family history of premature atherosclerotic cardiovascular disease (father died aged 54-years following an acute MI). Will taking up a cardiovascular prevention and rehabilitation programme offer benefit?

  5. Cardiac Rehabilitation Saves Lives There is overwhelming evidence that comprehensive cardiac rehabilitation is associated with a reduction in both cardiac mortality (26-36%) and total mortality (13-26%). • Heran BS, Chen JMH, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No: CD001800. DOI: 10.1002/14651858.CD001800.pub2. • Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med 2004; 116(10):682-697. • Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: A systematic review and meta-analysis of randomized controlled trials. Am Heart J Oct 2011; 162: 571-584.

  6. Recent

  7. Directly Standardised Mortality Rate per 100,000 – All Ages - Ischaemic Heart Disease/CHD - England & Three EU Comparators 1993 - 2008 Average Annual Reduction in DSR 1993-2006 – 5.6% Average Annual Reduction in DSR 1993-2006 – 3.8%

  8. Cardiac Rehabilitation Reduces Morbidity • There is emerging evidence that cardiac rehabilitation is also associated with a reduction in morbidity, namely recurrent myocardial reinfarction • Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: A systematic review and meta-analysis of randomized controlled trials. Am Heart J Oct 2011; 162: 571-584. • Clark AM, Hartling L, Vandermeer B, McAlister, F. Meta-Analysis: Secondary Prevention Programs for Patients with Coronary Artery Disease. Ann Intern Med 2010; 143(9): 659-672.

  9. British Heart Foundation “heart stats” 2010 www.bhf.org.uk Smolina et al. 2012 BMJ 2012;344doi: 10.1136/bmj.d8059(Published 25 January 2012) CHD Morbidity CHD Mortality 1940 1970 2010

  10. Cardiac Rehabilitation Reduces Hospital Readmissions 28-56% reduction in costly unplanned readmissions. Lam G, Snow R, Shaffer L, La Londe M, Spencer K, Caulin-Glaser T. The effect of a comprehensive cardiac rehabilitation program on 60-day hospital readmissions after an acute myocardial infarction. J Am Coll Cardiol 2011; 57:597, doi:10.1016/S0735-1097(11)60597-4. Heran BS, Chen JMH, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No: CD001800. DOI: 10.1002/14651858.CD001800.pub2.

  11. Chronic Disease Management Cardiac rehabilitation improves functional capacity and perceived quality of life whilst also supporting early return to work and the development of self-management skills. Yohannes AM, Doherty P, Bundy C, Yalfani A. The long-term benefits of cardiac rehabilitation on depression, anxiety, physical activity and quality of life. Journal of Clinical Nursing 2010; 19(19-20):2806-2813.

  12. Cardiac Rehab is Cost Effective Cost to achieve adding 1 year to a patients life • PPCI £6,054 – 12,057 • PCI £3,845 – 5,889 • CABG £3239 – 4,601 • Cardiac Rehab £1,957 • Aspirin/B-block <£1,000 Fidan et al 2007

  13. The future for CR Summary 1 • CR is one of the most clinically and cost-effective therapeutic interventions in cardiovascular disease management • More living and surviving with CVD or heightened risk of CVD • Increased survival from CHD events means greater numbers with heart failure in future • CR shifting from a “survival of the fittest” goal (reduced mortality) to one of prevention, chronic disease management and morbidity reduction

  14. Cardiovascular Prevention and Rehabilitation • Mr BC is a 51-year-old male from Pakistan residing in London. Recent anterior STEMI with primary PCI (drug eluding stent). • He is currently sedentary, has recently quit smoking and has a family history of premature atherosclerotic cardiovascular disease (father died aged 54-years following an acute MI). • Mediterranean Diet Score = 5 (fruit and veg 3 portions/day; no fish; savoury snacks+) • Pedometer: ~5,000 steps per day; Aerobic capacity ~ 7 METs • BMI = 33; Waist circumference = 116cm • HAD: Anxiety=9 Depression = 5 • BP: 140/83; Cholesterol: TC 5.0 mmol/l, LDL 3.3 mmol/l, HDL 1.2 mmol/l, Triglycerides 1.1mmol/l, Glucose: FBG 5.8 mmol/l • Bisoprolol 2.5mg; Simvastatin 40 mg; Aspirin 75mg; Clopidogrel 75mg; Ramipril 1.25mg Offers detailed comprehensive and integrated assessment of lifestyle, psychosocial health, medical risk factor management and cardioprotective therapies

  15. SO..... how well are we doing?

  16. Number of Programmes Submitting and Data Collected 213 rehab programmes in the UK uploaded some level of patient data in 10/11 *Data still being collected/entered Over 8,000 new patient records entered every month

  17. Who actually gets cardiac rehabilitation? www.cardiacrehabilitation.org.uk/nacr/ Stable angina? Heart failure? Other opportunities e.g. PAD, TIA, high multifactorial risk?

  18. Smoking Diet Physical activity and exercise

  19. Smoking 10-11 IA = Initial assessment EOP = End of programme 11.6% 6.3% * 11.7% 6.3% * n IA EOP EOP IA EOP IA * p< 0.001 ALL Male Female

  20. BMI (kg/m2) 10-11 n= 12905 p>0.05 for all BMI >=30 (at assessment 1) Mean Weight assess 1 = 97.92kg (se=0.269) at assessment 2 = 97.04kg (se=0.276): Change = -0.883kg (95% CI = -1.100 to-0.665)

  21. Waist 10-11n = 5532 % with Target Waist (< 94cm men, <80cm women) p < 0.001 p= 0.08 p < 0.001

  22. Physical Activity (5x30mins moderate)10-11 n * p<0.001

  23. How much benefit? • 1 serving/day increase in intake of fruits or vegetables is associated with a ?% lower risk of CHD • A 2-point increase in the Mediterranean diet score is associated with a ?% reduction in mortality. • Every 1 cm increase in waist circumference is associated with a ?% increase in risk of future CVD events including fatal and non-fatal CHD and stroke. • Every MET gain in physical fitness is associated with a ?% reduction in mortality.

  24. How much benefit? • 1 serving/day increase in intake of fruits or vegetables is associated with a 4% lower risk of CHD (Joshipura et al., 2001, Ann Int Med) • A 2-point increase in the Mediterranean diet score is associated with a 9% reduction in mortality (Sofi et al., 2008, BMJ) . • Every1 cm increase in waist circumference is associated with a 5% increase in risk of future CVD events including fatal and non-fatal CHD and stroke (de Konning et al., 2007 EHJ). • Every MET gain in physical fitness is associated with a 12% reduction in mortality (Myers et al., 2004, Am J Med).

  25. Blood pressure Cholesterol Medications

  26. Blood Pressure 10-11n=7310 n p=0.2

  27. Blood Pressure BP diastolic >=80 (at assessment 1) • Mean diastolic BP assess 1 = 87.08mmHg (se=0.123) at assessment 2 = 81.56mmHg (se=0.138): • Change = -5.518mmHg (95% CI = -5.818 to-5.219) BP systolic >=130 (at assessment 1) • Mean systolic BP assess 1 = 146.63mmHg (se=0.200) at assessment 2 = 137.71 mmHg (se=0.247): • Change = -8.923mmHg (95% CI = -9.422 to-8.424)

  28. Cholesterol at Target 10-11 TC : n= 5252 LDL : n= 1987 * p<0.001

  29. Medications 10-11Aspirin: n= 15095Statins: n= 14985 Ace: n= 14604 BBn= 14815 p=0.57 *p=0.001 p=0.948 p=0.33

  30. Outcomes for impact! • Mr X’s reduction of -7/4 mm Hg • Law et al., (2009) (meta-analysis) would suggest this is linked to ~ a 20% reduction in risk of CHD and 35% reduction in the risk of stroke (BMJ) • An LDL-C reduction of 0.6 mmol/L • would be expected to reduce cardiovascular events by 14% (Baigent et al., 2005, Lancet).

  31. Anxiety and Depression: HAD-A n * p<0.001

  32. Anxiety and Depression: HAD-D n * p<0.001

  33. A challenging environment • 16% access to psychologists in 2009/10 compared with 34% in 2007/08. • 55% of programmes included access to a physiotherapist in 2009/10 compared with 75% in 2007/08, • <50% included access to a dietitian

  34. Current UK Service Delivery: Is there really an asymmetry? Taylor, R., Bethell, H. & Jolly, K. 2003

  35. The future for CR Summary 2 Shaping future cardiovascular prevention and rehabilitation services

  36. Key Alliances Assuring Quality • NICE guidelines (Post-MI, Heart Failure) • DH Commissioning Pack for CR • NICE commissioning guides for cardiac rehabilitation and heart failure services • BACPR Standards and Core Components • NACR • NHS Improvement CR Resource + for England Post-discharge Tariff – uptake + completion + outcomes

  37. Quality, innovation and value in cardiac rehabilitation: commissioning for improvement” http://www.improvement.nhs.uk

  38. BACPR Standards 2012Patients, healthcare professionals and commissioners should expect the following from high quality cardiac rehabilitation services • The delivery of seven core components employing an evidence-based approach. • An integrated multidisciplinary team consisting of qualified and competent practitioners, led by a clinical coordinator. • Identification, referral and recruitment of eligible patient populations. • Early initial assessment of individual patient needs in each of the core components, ongoing assessment and reassessment upon programme completion. • Early provision of a cardiac rehabilitation programme, with a defined pathway of care, which meets the core components and is aligned with patient preference and choice. • Registration and submission of data to the National Audit for Cardiac Rehabilitation. • Establishment of a business case including a cardiac rehabilitation budget which meets the full service cost.

  39. Criteria

  40. Rationale for early commencement • Anxiety and depression, untreated leads to poor uptake, adherence and outcomes • Education is key for those with ACS rapidly discharged following PPCI – do they know they’re not fixed and their disease still exists?! • Exercise commenced within one-week post MI (stable) is safe – every week delay potentially requires 1 month more training to +ve affect ventricular remodelling

  41. Early goal setting is key Cognitive behavioural approaches

  42. Criteria (continued)

  43. What if................ • Mr BC is a 51-year-old male found to be at high multifactorial risk who is currently sedentary, has recently quit smoking and has a family history of premature atherosclerotic cardiovascular disease? • Mr BC is a 51-year-old male with stable angina who is currently sedentary, has recently quit smoking and has a family history of premature atherosclerotic cardiovascular disease? • Mr BC is a 51-year-old male with intermittent claudication who is currently sedentary, has recently quit smoking and has a family history of premature atherosclerotic cardiovascular disease?

  44. The future for CR Summary 3 • Ensuring referral of all eligible patients by cardiologists and/or specialist cardiovascular health care physicians to a prevention and rehabilitation programme as a standard (not optional) policy that is held in the same regard as the prescribing of cardioprotective medications. • Tighter control of service audit (e.g. through NACR), not only to ensure these standards and core components are being met but to demonstrate that improved practice, clinical effectiveness and health outcomes have been achieved • The continuing of a national campaign that raises the profile and need for comprehensive integrated cardiovascular prevention and rehabilitation programmes to be properly funded as a cost-effective means and obligatory element to any modern cardiology or vascular health care service.

  45. BACPR supporting implementation • Performance Indicators’ Tool • Providing resources for service development e.g. tool-kits for business case development, exemplary assessment frameworks and mechanisms for effective knowledge transfer and training. • Developing competency frameworks that are fully supported by high quality education and training programmes and research where required.

  46. BACPRPromoting Excellence in Cardiovascular Prevention and Rehabilitation BACPR Annual Conference in collaboration with CRIGS Thursday 4 & Friday 5th October, 2012, Edinburgh University Pollock Halls Campus Setting the Standard – Challenges and Achievements

  47. Coming soon…..

  48. The BACPR Standards and Core Components Continue to strive for our ultimate goal, namely to ensure that all eligible patients receive high quality care in cardiovascular disease prevention and rehabilitationConsolidating, Collaborating & Championing for High Quality Care THANKYOU Promoting Excellence in Cardiovascular Disease Prevention and Rehabilitation

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