A novel, integrated, and seamless system for cardiac rehabilitation was established to increase the proportion of patients who complete a cardiac rehabilitation programme after a myocardial infarction. The aim was 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. Follow up data of 106 patients after twelve months showed improvement in all four outcome measures.
Aims and objectives
Reasons for implementing your project
How did you implement the project
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.
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.
Key learning points
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.