cardiac rehabilitation provision in rural wales: demonstrating the benefits of a service

Cardiac Rehabilitation Provision in Rural Wales: Demonstrating

the benefits of a Service

Gwenllian Parry Community Cardiac Rehabilitation Specialist Nurse

Ceredigion and Mid Wales NHS Trust

• Population- 78,000

• NHS Trust catchment of 120,000

• Geographical area of 696 square miles

• 1 DGH in Aberystwyth

Demographics: Ceredigion

Project Team• Denise Lewis- Cardiac Rehabilitation Coordinator,

Ceredigion and Mid Wales NHS Trust

• Gwenllian Parry- Cardiac Rehabilitation Specialist Nurse, Ceredigion and Mid Wales NHS Trust

• Justyn Robbins- Specialist Fitness Instructor Ceredigion and Mid Wales NHS Trust

• Rachel Rahman- Research Assistant University of Wales Aberystwyth

• Professor Jonathon Doust- Head of Chelsea School University of Brighton

The Beginning• Heart Manual

• Angina Plan

• Hospital Based Phase III - One class per week in Physiotherapy gym

• No Phase IV Provision

Collaborative Bidding- Physical Activities Forum

• Ceredigion and Mid Wales NHS Trust

• Ceredigion County Council

• University of Wales Aberystwyth

• CAVO Ceredigion Association of Voluntary Organisations

• Dyfed/Powys Health Promotion Unit

Result

• Big Lottery Fund Grant £289.000 over 2½ years

• Working in Partnership with our Sister project “Ceredigion Exercise For Life Scheme”

• Research Assistant Commissioned

Aims of the Project• Reduce inequalities for Cardiac Patients within

Ceredigion.

• Improve quality of life for Cardiac Patients and their families in and around the county.

• Promote social integration

• Promote long term adherence to a healthy lifestyle

Aims of the Project• Provide a non institutionalised approach to health

promotion.

• To be inclusive for those who have acute or chronic cardiac disease, and their families

• To provide a Cardiac Rehabilitation Specialist Service that is accessible for all residents of Ceredigion

Project Structure

• Three Key Organisations

• Two Sister Schemes

• Management Board

• Operational Team

• Research Evaluation

Practicalities of the Project

• 3 Cardiac Rehabilitation Staff - Nurse /Exercise Instructor/Administrative Assistant

• Free Leisure Centre Based classes Gym and Circuit ( twice weekly X12 weeks)

• Education and Relaxation Sessions

Practicalities of the Project

• Health Walks

• Maintenance package

• Partner/Spouse/friend welcomed

• Numbers in accordance with Risk Stratification

Data and Results • 577 participants referred in 30 months

• 71% referrals commenced classes

• 69% of those completed classes

• 80% (209) of those completing the program agreed to participate in the research

Measured Psychological Outcomes

Measure Change pre to post scheme

Desired direction for change for

improved Health

Health Related Qol (Euro Qol)

Self-rated health (EQ VAS)

SF-36V2 Physical component summary

SF-36V2 mental component summary

Anxiety

Depression

Life satisfaction

Physical self-worth

Global self-worth

Habitual physical activity

Measured Physiological Outcomes

Measure Change pre to post scheme

Desired direction for change for

improved health

Hip Circumference

Waist Circumference

Weight

Skin fold measurements

Resting heart rate

Resting blood pressure

Heart rate post exercise

Blood pressure post exercise

Treadmill test time

Adherence at 6 months follow up

• 136 randomly invited to 6 month follow up

• 86 (63%) responded to follow up questionnaires

• 71 participants were still exercising

• 15 reported they were not exercise

Sustainability of Psychological Outcomes: 6 months follow up

Measure Change from pre to post scheme

Change from pre scheme to

6 months

Health related QoL (EuroQol)

Self-rated health (EQ-VAS)

SF-36V2 Physical component summary

SF-36V2 Mental component summary

Anxiety

Depression

Life Satisfaction

Physical self-worth

Global self-worth

Habitual physical activity

Sustainability of Physiological Outcomes: 6 months follow up

Measure Change from pre to post scheme

Change from pre scheme to 6 months

Hip circumference

Waist circumference

Weight

Skin fold measurements

Resting heart rate

Resting blood pressure

Heart rate post exercise

Blood pressure post exercise

Fitness test duration

Participants feedback: At 6 months assessment

Main Reasons for not exercising:

• ill health

• time

• lack of group support

Participants feedback at 6 months

Changes suggested by patients to help maintain exercise:

• Regular check ups on progress• Maintenance classes• More help from staff during transition from group

to individual session.• Take home safety tips common problems,

exercise tips and guidance.• Taster sessions for other activities

Outcomes

• Statistically significant physical and psychological Improvements during the period of the scheme

• Provided Phase IV provision where none existed in Ceredigion

• Demonstrated need by recruiting 577 participants in 2½ years

• Identified the importance of a local community-base and an emphasis on patient confidence and independence in achieving high participation and low attrition

• Demonstrated a sustained impact at 6-month follow-up once participants had left the scheme

• Demonstrated significant improvements in physical and psychological health

Outcomes

Cost Analysis

• The scheme cost £722 per participant

• (NICE) National Institute of Clinical Excellence judges effective treatment as costing less than £20,000 per quality adjusted life year

• The cost of the scheme was £8,112 per quality adjusted life year, well within guidance issued by NICE

Discussion

• Provision in a rural area needs to be patient and not condition driven

• Importance of an inclusive service for all those with cardiac related disease

• Does a Cardiac Rehabilitation service need to have a huge multi-disciplinary team to achieve standards and significant outcomes? This is as stated in the recently released NSF and BACR recommendations

Changes following Project End

• Patient Driven

• Reduce to three Centres

• Participant Payment

• Maintenance Classes

• Maintenance Booklets

• Obesity-Body fat analyzer

What Now?• Continued funding for our community based

service for those in and around Ceredigion

• National CCAD database

• Measure benefits of continued inclusion of those with controlled arrhythmias into the service

• Continue to Improve cross boundary communications

For more information contact

mair.parry@ceredigion-tr.wales.nhs.uk

Thank you for Listening