NICE guidance CG147 recommends as a first line treatment offering 2 hours of supervised exercise a week for a 3 month period to patients with peripheral arterial disease (PAD).
Further, the guideline encourages patients with symptoms of intermittent claudication to exercise to the point of maximal pain to stimulate the development of the collateral circulation (recommendation 1.5.2). Surgical intervention should only be offered when supervised exercise has not led to a satisfactory improvement in symptoms.
Our exercise programme provides a weekly 2 hour exercise session for a 12 week period which includes an educational component to support healthy lifestyle interventions. On discharge patients are referred into community programmes for ongoing exercise.
Example
Aims and objectives
- For the Vascular Triage Service (VTS) to institute a supervised exercise programme for patients in Salford who have PAD and symptoms of Intermittent Claudication (IC)
- For the exercise programme to be managed by suitably qualified professionals similar to chronic obstructive pulmonary disease rehab and cardiac rehab programme where staff are experienced to; assess patients’ medical clearance for exercise, be able to identify vital signs and review their individual goals
- To provide an education component to increase patients’ awareness of PAD, associated Cardio-vascular (CV) morbidity and mortality and the importance of making lifestyle changes.
To provide exercise advice specific to PAD patients:
- With a local community setting which is convenient for patients to attend
- To improve patient concordance and empower them to make healthy lifestyle choices
- To provide patients with reassurance and motivation throughout the programme and peer support for patients with IC
- For VTS and Vascular Surgeons to be the gatekeepers to optimise appropriate referrals to the programme.
Reasons for implementing your project
Before the development of the structured exercise programme, suitable patients were referred to a local council-run exercise group. Although this support was good for cardiovascular health it was not PAD specific, did not comply with NICE guidance, uptake was poor and had significant drop out rates.
We identified that by developing a structured exercise programme specifically for our PAD patients, we would improve non-surgical treatment options, reduce surgical interventions, improve overall patient outcome and save costs incurred by surgery.
Commissioners were supportive and keen for us to develop a supervised exercise programme which should be up and running as soon as possible. Funding was provided provided for a 12 month pilot.
A meeting was attended by the clinicians and manager of the vascular triage service, the cardiac rehabilitation manager and the commissioning manager.
The NICE guidance 147 was referred to and it was agreed to:
- Develop a business plan to provide support for 2 hours a week for 3 months for patients with symptomatic PAD
- Include an individual assessment initially and agreement to an individualised exercise plan
- Support patients to make lifestyle changes.
On completion of the programme, the CRT would send a summary of the patients results to the VTS. The VTS agreed to undertake a post-exercise programme telephone consultation (appendix 3 in the supporting material) and offer those patients who report no improvement/deterioration of IC symptoms a referral to vascular surgeons. A post-exercise referral pathway was developed (Appendix 4 in the supporting material).
CRT clinicians attended some VTS clinics in order to understand and appreciate the vascular assessment process. The VTS members also attended some cardiac rehabilitation sessions in order to appreciate the components of an exercise and education class and be able to convey this to patients at their assessment. A meeting between the Central Manchester Foundation Trust (CMFT) Vascular Consultant, VTS and CRT manager took place to establish inclusion/exclusion criteria into the programme and that VTS and vascular surgeons were only gatekeepers for referral.
We were also involved in the development of education literature for patients attending the exercise programme to tailor it for our PAD patients and also involved in developing the PAD information that the Cardiac Rehab team provide on their website.
How did you implement the project
To increase our knowledge we initially investigated existing claudication exercise programmes in 2 other Trusts developed by Podiatry/Nurse led vascular services. Both programmes were developed specifically for PAD, complied with NICE guidance and were run by physiotherapists.
It would have been problematic to start a programme from scratch because of time constraints, and the issue of finding appropriately qualified staff who were prepared to sacrifice existing work for a 12 month pilot. Therefore we decided that the best way to proceed was to incorporate our PAD patients into an existing established exercise programme.
We discovered that the cardiac rehab service in Salford is a multidisciplinary team consisting of specialist nurses, physiotherapist, occupational therapists and specialist exercise trainers. It provides a district wide service seamlessly across primary and secondary care where patients who meet the referral criteria can access the services menu of options.
These include an initial home visit or telephone consultation, 12 week hospital or community based exercise programme including educational talks on risk factor management and relaxation, access to non-medical prescribers, weight management programmes, home based options, dietician advice, anxiety management and a stress management group.
The clinicians develop individualised packages of care and support with patients and motivate and empower patients to make lifestyle changes and encourage them to self-manage their condition. Uptake of the service was high (91%) as was completion of programme (75%+).
Once patients have completed the programme they are encouraged to maintain their lifestyle changes and a referral to ongoing exercise classes in community.
The proposed numbers for costing would be based on the number of patients the vascular triage clinicians had referred for exercise support during the preceding 12 month period. Negotiation regarding the costs took place between commissioners and the cardiac rehab manager and a cost of £50,000 was agreed for an 12 month pilot.
The Cardiac Rehab Team was an ideal service for our PAD patients and would enable us to fully comply with NICE guidelines.
Key findings
Patients are now offered recommended first line treatment for PAD. This has had the following impact:
- Improving non-surgical options for treatment which do not carry the risks of surgical interventions.
- Reduced referrals onto vascular surgeons saving patient’s travelling to CMFT/Bolton
- Reduced the costs of Vascular Surgeon’s consultation.
- Streamlined services allowing surgeons to deal with more appropriate cases.
- Local to patients and improves patient experience.
The quality of patient care has improved as the exercise programme includes a comprehensive educational component which supports advice given by the VTS for patients to make important lifestyle changes. The educational aspect to the programme provides a social environment offering the opportunity for patients to share experiences and enables them understand the link between the PAD and heart disease. The individualised approach allows patients to feel empowered to make to make important lifestyle changes which could potentially delay the progression of PAD.
Outcomes of initial patients referred to the Exercise Programme:
- 89 patients agreed a referral to the exercise programme
- 54 patients completed the 12 week programme
- 35 patients either declined the programme when contacted by the cardiac rehab team or failed to complete the programme. (39%). A take up rate of 61% is very positive when compared to a recent report by NICE (2014) that stated that less than 50% of patients offered a supervised exercise programme took up the option.
- Of the 54 patients who completed the programme 39 (72%) reported an improvement in their intermittent claudication symptoms 13 (24%) reported no change and 2 (4%) felt their symptoms had deteriorated.
- Of the 15 patients who reported deterioration or no improvement of their IC symptoms, 9 (17%) were referred to the vascular surgeons for consideration of surgery.
This indicates a high level of patient satisfaction and prevention of unnecessary surgical intervention.
The NICE guidance estimated that the cost of a 3 month exercise programme (for staffing costs only) for a PAD patient would be £255. The cost per patient for this service was £477 but it has to be considered that the cost for an angioplasty with elective stent is £3,687 and this does not address increased cardiovascular risks.
Key learning points
- We would suggest that investigating the cardiac rehab programme in your Trust before you consider any other possibilities to set up an exercise programme. However cardiac rehab programmes can vary greatly from Trust to Trust.
- Being able to visit their programme can provide you with valuable information and can help establish whether your IC patients would benefit from the programme and be easily integrated into the service.
- Check the professions involved in the programme. Are there: registered nurses, qualified exercise trainers and physiotherapists OT’s?
- Check the uptake and drop-out rate. Is there anyone with experience of claudication and PAD? Is there an educational component to the programme? Are patients encouraged to make lifestyle changes and referred to appropriate specialisms for example weight management and smoking cessation. Is there emotional support for patients?
- Finally, we recommend investigating whether patients from the programme were referred onto other exercise groups after the programme has been completed.