Establishing an integrated and seamless system for cardiac rehabilitation following a myocardial infarction

Integrated care for patients who survive a myocardial infarction (MI) is lacking. Many patients are not offered cardiac rehabilitation, and secondary prevention is not optimal. We set up a novel, integrated, and seamless system for cardiac rehabilitation. Our key aims for improvement were to increase the proportion of patients who complete a cardiac rehabilitation programme after a MI and through this to increase the proportion of patients with optimal secondary prevention, as measured by smoking status, body mass index, cholesterol <5.0 mmol/l, and blood pressure <140/85 mm Hg.

A local conference identified several areas for improvement in the county's cardiac rehabilitation services. It recommended that coordination of services between primary and secondary care be improved and that a community based rehabilitation service be set up for patients who find it difficult to access hospital facilities. As in many areas in the United Kingdom, provision of cardiac rehabilitation in Cornwall was patchy, with funding available to provide rehabilitation to less than half of patients who survived MI. The service provided did not adhere to national guidelines and uptake of cardiac rehabilitation was poor. Patients were offered only a hospital based rehabilitation programme that had limited places due to lack of funds. No formal link existed between secondary and primary care, so patients discharged after MI did not have systematic long term follow up and may have 'fallen though the net'. Our aim was to develop an integrated rehabilitation service (home and hospital) with secondary prevention clinics in primary care to facilitate long-term structured care and optimal secondary prevention across a single primary care trust (PCT) area.

Over a two year period, all patients admitted to the Royal Cornwall Hospital with a suspected heart attack were identified and assessed by a cardiac liaison nurse (CLN), who was trained as a Heart Manual facilitator and was employed for 24 hours a week. The CLN identified patients by checking a daily printout of cardiac enzyme results (creatinine kinase and troponin I) produced from the hospital's clinical chemistry database. The CLN collected data to be used to determine appropriate secondary prevention measures, including age, sex, smoking status, body mass index, and serum cholesterol, on admission to hospital.

Patients were offered a choice of home based rehabilitation using the Heart Manual or hospital based rehabilitation involving six weekly outpatient classes (exercise, education, counselling, and relaxation) conducted as a group in the hospital. Exclusion criteria for participation in programmes involving the Heart Manual were also applied to patients offered hospital based classes.

All patients were assessed individually at the bedside by the CLN, and those who were excluded from formal rehabilitation were given an alternative customised package. This included verbal and written information on chest pain, lifestyle (including exercise, diet, and smoking), drugs (the importance of compliance), general secondary prevention, stress management, coronary heart disease (CHD), and return to normal activity. The package was offered before discharge from hospital.

Practice nurses were trained on secondary prevention of CHD by Heartsave. Discharge details were faxed to the patient's primary care nurse, who entered them onto the practice based register of patients with CHD. Follow up data were collected 12-15 months post-MI through a survey of all 13 practices in the PCT. Height, weight, and blood pressure were measured by practice nurses. Concentrations of serum total cholesterol and self-reported smoking status were taken from practice records. The project was managed by a general practice coordinator. One practice ran a pilot of the programme, and then it was rolled out to the whole PCT after extensive discussions with general practitioners, the PCT board, local cardiologists, and the hospital based rehabilitation team. Each Heart Manual cost £22. The total cost of the project was estimated at <£60 000; when this figure is compared with the costs of statins and interventional cardiological techniques, it is relatively small.

We took a detailed audit of the 179 patients who suffered an MI in the second year. Of these, 46 (26%) patients died; 17 (9%) patients were >85 years, had significant comorbidity, and were considered not suitable for conventional rehabilitation; and 10 (6%) patients had transferred out of the practice, moved out of the area, or had not been seen by their practice since they were discharged from hospital. At 12 months, therefore, follow up data were available for 106 patients. Eighty two (77%) patients were male, the mean age was 66 years, and 32 (30%) patients were <60 years.

Rehabilitation-The patient's log within the Heart Manual was used to measure adherence to the home based programme. Attendance at four or more rehabilitation classes in the hospital was regarded as a marker of good compliance and of completion. Forty seven (44%) patients chose rehabilitation with the Heart Manual and 41 (87%) of these completed the programme; 35 (33%) chose hospital based rehabilitation and 17 (49%) of these completed the programme. In total, 24 (23%) patients were suitable only for the alternative package.

Secondary prevention-All four secondary prevention outcome measures had improved at 12 month follow up. The largest change was recorded in the number of patients with total cholesterol <5 mmol/l, which increased from 30 (28%) to 69 (75%). In 71 (72%) patients, blood pressure was at, or lower than, the desirable 140/85 mm Hg at follow up. An increase in the use of all prophylactic drugs and a statistically significant increase in statin use was seen between discharge and follow up. This seems to contradict the accepted wisdom that drug use "falls off" after discharge into primary care.

Traditionally, cardiac rehabilitation (CR) programmes have been run from outpatient departments in hospital. With a combination of the self-help manual for use at home and the proven effectiveness of nurse led coronary heart disease clinics in primary care, comprehensive CR can be provided in the community.

Identification of potential recipients of CR remains a problem for some areas. Daily printouts of cardiac enzyme data from the hospital's database of clinical chemistry results allowed early and accurate identification of patients with acute MI. The CLN made sure that all patients were assessed before discharge and were referred to a nurse at their own general practice.

We gave patients the choice of home based or hospital based CR and thus offered a more patient friendly service. As far as we are aware, this is not commonplace. The large proportion of patients who elected for (47%) and completed (87%) home based CR reflects the importance of tailoring service provision to the local context.

A brief survey showed that those aged >60 years and the self-employed tended to prefer home based CR. No significant sex differences were noted between the two groups. Peer support and discipline were the main reasons for patients opting for group based CR in hospital. Distance to hospital and parking issues were factors that favoured the use of the Heart Manual. Provision of a home based service in rural communities, such as Cornwall, where access to hospital may not be easy because of lack of transport, may increase the uptake of CR.

Our audit confirms that integration of rehabilitation services with secondary prevention clinics in primary care allows NICE targets for CR in patients who survive a myocardial infarction to be achieved.