After the Heart Manual: new After the Heart Manual: new challenges to cardiac rehabilitationchallenges to cardiac rehabilitation

Bob LewinBob Lewin

CCAREARE ANDAND E EDUCATIONDUCATION R RESEARCHESEARCH G GROUPROUP

What is the Heart Manual?What is the Heart Manual?6 week, home based post MI rehabilitation programme

A work book, diaries, record sheets and information

2 audio tapes, advice for family, a stress management course on tape

A specially trained ‘Facilitator’

Exercise programme - walking

Secondary prevention – written advice

Cognitive behavioural techniques

change patients beliefs and attributions (cardiac misconceptions)

self recording

self help for psychological problems

relaxation and stress management

Initial face-to-face session, then phone calls or home/clinic visits at week 1, 4, 6 after discharge.

Multi-centred RCT of HM vs. Hospital based. Equal gain on all measures including 2 Met gain in fitness, HM fewer readmissions. Andrew Coats, Jenny Bell

Recommended by - WHO: BHF: Department of Health: Scottish Office

Initial RCT - less anxiety & depression: better quality of life: fewer readmissions to hospital: less contact with GP. Lewin B, Lancet, 1992.

The Heart Manual the evidence baseThe Heart Manual the evidence base

Stand in Exhibition Hall

3,000 trained HM facilitators in UK, 80 healthcare providers approximately 12,000 patients a year 0

2,0002,000

14,00014,000

19941994 20032003

ScotlandScotland

Eng/WalesEng/Wales

OverseasOverseas

Uptake 1994 - 2003Uptake 1994 - 2003

Choice trial. Hospital or HM. 44% chose HM of whom 87% completed Delal H, BMJ, 2003 33% chose Hospital, 49% made <=4 attendances

Two challenges for CR in the UKTwo challenges for CR in the UK

1. To move to individualised, menu based programmes

2. To incorporate the best techniques from:

‘cognitive-behavioural chronic disease management’

e.g. Kaiser Permanente MULTIFIT

‘self-management’ e.g. Stanford Expert Patient Programme

health behaviour change techniques e.g. ‘Motivational Interviewing’ William Miller, Stephen Rollnick

“A menu-based approach recognises the need to tailor the delivery of services to the individual, and .. to include specific education to reduce cardiac misconceptions…”

SIGN Guideline for CR, 2001

• Comprehensive cardiac rehabilitation should embrace a case management approach. (A) • Hospital based cardiac rehabilitation must be comprehensive and should be individualised to meet the needs of each patient. (D)

New Zealand Guidelines 2002

Working Group on Rehabilitation, British Cardiac Society, 1995

“Rehabilitation should be tailored to the individual needs of thethe patient…”

Individualised menu driven CR. A decade of guidelinesIndividualised menu driven CR. A decade of guidelines

“The process begins with assessments regarding all relevant aspects of the patient's status: medical, nutritional, psychosocial, educational, and vocational. The implementation of cardiac rehabilitation, based on these initial assessments, is designed to address the individual patient's needs as he or she works toward achieving optimal outcomes.”

Wenger NK, Froelicher ES, et al. Clinical Practice Guideline No. 17. October 1995.

Principles of cognitive-behavioural chronic disease Principles of cognitive-behavioural chronic disease managementmanagement

Von Korff M, Annals of Internal Medicine, 1997

• anxiety management • recognition and treatment of depression • cognitive behavioural principles of step by step change [self-efficacy]• collaborative problem definition• goal setting• motivational techniques• outcome measurement

Von Korff M, Organising care for chronic illness, BMJ, 2002;325:92-94

“Common elements of effective chronic illness management • A personalised written care plan • Tailored education in self management • Monitoring of outcome and adherence to treatment • Targeted use of specialist consultation of referral • Protocols for stepped care”

1 Assessment • Assess patient's self management beliefs, attitudes and knowledge • Identify personal barriers and supports • Collaborate in setting goals • Develop individually tailored strategies and problem solving

2 Goal setting and personal action plan • List goals in behavioural terms • Identify barriers to implementation • Make plans that address barriers to progress • Provide a follow up plan • Share the plan with all members of the healthcare team

Von Korff M, Organising care for chronic illness, BMJ, 2002;325:92-94

3 Active follow up to monitor progress and support patient

The processThe process

A hospital based programme incorporating cognitive-A hospital based programme incorporating cognitive-behavioural chronic disease managementbehavioural chronic disease management

The Angina Management Programme

12 week group, hospital based, rehabilitation programme

Eliciting & challenging unhelpful health beliefs (cardiac misconceptions)

Goal setting and pacing to return to a fully active life

Overactivity-rest cycle addressed

Self-recording of progress

Simple self-paced home exercise programme based on common

Built in rewards for success with goals and better coping

Relaxation, breathing retraining, meditation, biofeedback

Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462

Crossover trial - waiting list to treatment - 82 patients, main findings at 1 year after treatment

57% improvement in exercise duration 72% reduction in self reported disability (SIP) 30% no angina 70% reduction in episodes of angina

50% of patients taken off CABG list

no patient looking for further treatment

The Angina Management Programme: trial 1The Angina Management Programme: trial 1

Lewin, B, 1995, British Journal of Cardiology, 2, 219-26

The Angina Management Programme: trial 2The Angina Management Programme: trial 2

Depression(HAD)

Episodes of Angina

Anxiety(HAD)

Disability(SIP)

Treadmill workload(METS)

*

* †

†

*

-14-12-10-8-6-4-2024

routine care control Exercise programme Angina Management Programme

6 months post treatment ( * = p<0.01, = p<0.001)†

226 patients randomly allocated to 226 patients randomly allocated to

Angina PlanAngina Plan 6868

142 randomised to treatment142 randomised to treatment

90% at 6 month follow-up90% at 6 month follow-up

education education sessionsession 7474

6363 6767

-1.2

-1

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

Anxiety Depression

anxiety & depression

-4.5-4.0-3.5-3.0-2.5-2.0-1.5-1.0-0.50.00.51.0

Angina GTN

angina and use of GTN

-2-10123456789

physical activity: SAQ

40% reduction

Lewin RJP, British Journal of General Practice, 2002, 52, 194-201

The Angina PlanThe Angina Plan

home based programme, a patient held home based programme, a patient held manual & trained facilitator manual & trained facilitator

30-60 minutes introduction session30-60 minutes introduction session

and 4, 10-15 minute phone calls / and 4, 10-15 minute phone calls / home /clinic visits, to set further goals, home /clinic visits, to set further goals, praise progress, encourage adherencepraise progress, encourage adherence

RCT

Final task.Reassess using same measures Discuss long term maintenance & a plan in case of relapse, refer on if necessary, share outcomes.

Third task. provide method for patient self-recording progress, set initial easy targets with patient.

Second task. Check for cardiac misconceptions, discuss and agree goals using motivational techniques, jointly choose a method from the menu.

First task. Assessment*Medical, lifestyle, psychological, social.

Repeated (brief) contactTo: review goals; set new targets; provide rewarding feedback; encourage problem solving of any barriers to progress.

After a few weeks Change menu choices if agreed method not working.

Fade out support.

Individualised menu based cardiac rehabilitationIndividualised menu based cardiac rehabilitation

*BHF BACR Minimum dataset for cardiac rehabilitation. Lewin, BJC, (in press) www.cardiacrehabilitation.org.uk

Discuss Menu, negotiate actions

Other services / Professions1.1. Sexual medicine clinicSexual medicine clinic2.2. Welfare rights bureauWelfare rights bureau3.3. Social workerSocial worker4.4. Marriage guidance servicesMarriage guidance services5.5. specialist heart failure nursespecialist heart failure nurse

A sample A sample menumenuActivity / Fitness

• hosp exercise grouphosp exercise group• home exercise programmehome exercise programme• advice on resumption of active lifeadvice on resumption of active life• Age Concern Health MentorAge Concern Health Mentor• Walk for HealthWalk for Health• Phase 4 exercise programmePhase 4 exercise programme• Tai Chi classesTai Chi classes

Smoking• Willpower aloneWillpower alone• smoking cessation clinicsmoking cessation clinic• Nicotine replacementNicotine replacement• Referral for medicationReferral for medication• Internet programmeInternet programme

Diet / Weight loss• Self-management of diet / medicationSelf-management of diet / medication• dietetics referral dietetics referral • Weight WatchersWeight Watchers• Internet programmeInternet programme• Coach ProgrammeCoach Programme

Education

hospital educational programmehospital educational programme• home educational programmehome educational programme• Mentor / volunteer / lay-workerMentor / volunteer / lay-worker• InternetInternet

Psychological adjustment• Self help advice materialsSelf help advice materials• Stress management classStress management class• Stress management on tapeStress management on tape• Counselling psychologistCounselling psychologist• Clinical Psychology / PsychiatryClinical Psychology / Psychiatry

Social support• Buddy systemBuddy system• Patient support groupPatient support group• Mentoring schemeMentoring scheme

ConclusionsConclusions

The writers of CR guidelines have been extolling the necessity of these changes for nearly 10 years - but little has changed.

Chronic disease management programmes that follow the patient pathway will become a major activity in health systems in the coming century.

Simple models of self-management of a chronic illness relying on education alone are being replaced by more sophisticated techniques for helping people manage a lifelong chronic illness.

Cardiac rehabilitation must incorporate these methods or become an evolutionary curiosity.

CARDIAC REHABILITATION IN THE OLD DAYS

do everything I tell you, when I tell you, and you’ll be alright