cardiac rehabilitation and secondary prevention...–hd and risk factors –dietician – healthy...
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Cardiac Rehabilitation and
Secondary Prevention
©2018 National Heart Foundation of Australia
Heart Foundation - What do we do?
• Leading charity aiming to reduce death
and disability from coronary heart
disease.
• Produce information for the community
and health professionals.
• Work with decision makers to improve
services.
• Through donations, fund leading
research in Australia.
©2018 National Heart Foundation of Australia
Cardiovascular Disease
©2018 National Heart Foundation of Australia
• On average one Australian dies as a result of CVD every 12 mintues.1
• CVD has the highest level of health-care expenditure of any disease
group. Between 2000-01 and 2008-09, health-care expenditure
allocated to CVD increased by 48% from $5,207 million to $7,717
million, representing 12% of the total expenditure budget.
1. Australian Bureau of Statistics. Causes of Death 2013 (3303.0). March 2015.
2. Australian Institute of Health and Welfare 2014. Health-care expenditure on cardiovascular diseases 2008-2009. Cat no.
CVD 65. Canberra: AIHW.
Cardiovascular Disease in Australia
• Around half of all coronary events occur in those people who
have had a prior event
• People with existing CHD
– Have an increased risk of sudden death
– Have an increased risk of developing Chronic Heart
Failure
1. Australian Bureau of Statistics. Causes of
Death 2009 (3303.0). May 2011
©2018 National Heart Foundation of Australia
What is Cardiac / Cardiovascular Rehabilitation
and Secondary Prevention?
©2018 National Heart Foundation of Australia
▪ “all measures used to help people with heart disease return to an active and
satisfying life and to prevent the recurrence of cardiac events”
▪ “…..it involves medical care, control of biomedical and behavioural risk
factors, psychosocial care, education and support for self-management”
▪ These are all similar terms which are often interchanged.
▪ Cardiac Rehabilitation is often time-limited, a component of the Secondary
Prevention continuum that is lifelong.
It doesn’t matter so much what you call it as long as the patient gets referred to it!
©2018 National Heart Foundation of Australia
Cardiac Rehabilitation
• reduces mortality
• accelerates recovery
• improves clinical outcomes (improved chol, BP)
• improves behavioural outcomes (ex tolerance, smoking cessation)
• reduces repeat cardiovascular events and hospital readmissions
• strengthens adherence to medication and enhances mental health
and QoL
Briffa T et al. An integrated and coordinated approach to preventing disease events in Australia.
Policy statement from the Australian Cardiovascular Health and Rehabilitation Association, 2009.
Med J Aust:190:683-6.
The evidence
• Systematic reviews
– Heran et al (2011) - improved overall and CV mortality, hospital
readmission rates, QoL
– Anderson et al. (2016) exercise based CR significantly reduced
hospital admission and cardiovascular mortality
– van Halewijn et al. (2017) found no effect on all-cause mortality,
but reduction in CV mortality by 58%. (2010-2015)
– Powell et al. (2018) re-examined the evidence yr 2000 onwards -
no sig difference in all- cause or CV mortality and only borderline
statistical difference in hospital admissions
The evidence
• RCT
– West et al. 2011- trial of 1813 patients in the UK no significant
differences in mortality, cardiac events or level of PA.
• Cohort
– reduced all-cause mortality and hospital re-ad rates following CR
widely reported in large population studies (de Vries et al. 2015;
Dunlay et al. 2014; Pouche et al. 2016; Kureshi, 2016; Goel;2018,
Lee, 2016; Junger et al, 2010; Hammil et al. 2010; Jimmenez-
Navarro et al. 2017).
Different approaches to CR
• To address poor participation and access.
• Reviews - positive outcomes for telephone support, video
conferencing, home based programs, or internet based
programs.
– Clark et al., 2015; Dalal et al. 2010; Huang et al., 2015; Kotb et al.,
2014.
• RCT’s demonstrating similar benefits of alternative models of
CR.
– Jolly et al., 2009; Varnfield et al., 2014; Cossette et al., 2012.
Lack of referrals to CR
1. NHS Improvement Heart. Making the case for cardiac rehabilitation: modelling potential impact on readmissions, 2013.
2. Heart Foundation. Heart Attack Survivor Survey, 2015.
Only about 30% of patients
are referred to cardiac
rehabilitation1.
65% is the gold standard
target set by the UK
National Health Service
which meets international
best practice1
71% of patients would go to
cardiac rehabilitation if a
health professional
discussed it with them
before leaving hospital 2
• 27% acute coronary syndrome patients received optimal in-hospital preventive care.
• ‘Optimal care’ means receiving lifestyle advice, referral to rehabilitation and
prescription of secondary prevention drugs.
• STEMI, NSTEMI, PCI/CABG during admission or history of hypertension were more
likely to receive optimal preventive care.
• Older patients (>70yrs) or admitted to private hospital = less likely to receive
optimal care.
Redfern J, Hyun K, Chew DP, Astley C, Chow C, Aliprandi-Costa B, Howell T, Carr B, Lintern K, Ranasinghe I, Nallaiah K, Turnbull F, Ferry C, Hammett C, Ellis CJ, French J,
Brieger D and Briffa T. Heart 2014;01-8.
Australian evidence:
Costs
• Of the 54,000 heart attacks that occur each year, each
one costs around $30,000 in healthcare
• Cardiac rehabilitation program costs the health system an
average $885 per person to attend.
De Gruyter, Elaine., Ford, G., Stavreski B. (2016). Economic and Social Impact of Increasing Uptake of Cardiac Rehabilitation
Services – A Cost Benefit Analysis. Heart, Lung and Circulation, 25, 175–183, http://dx.doi.org/10.1016/j.hlc.2015.08.007
Cost benefits in WA
• If attendance rates increased from 30% to 65 the benefits in
WA after 5 years would be:
– $28.4 million in savings in healthcare costs
– $48 million in social and economic benefits
– Reduction in 1,700 hospital admissions for heart attacks.
De Gruyter, Elaine., Ford, G., Stavreski B. (2016). Economic and Social Impact of Increasing Uptake of Cardiac Rehabilitation
Services – A Cost Benefit Analysis. Heart, Lung and Circulation, 25, 175–183, http://dx.doi.org/10.1016/j.hlc.2015.08.007
What does Cardiac Rehab involve?
• Traditional programs
– Centre based – multi disciplinary team
– Exercise groups x2/wk for 6-8/52
– Individual support
– Group education sessions
– Medications
– Symptom Mx
– HD and Risk factors
– Dietician – healthy diet
– Stress Mx
– Adjustment and recovery
• CR is part of usual care
• Encourage self management
• Patient may not show interest until weeks, months, years
after initial event
What does Cardiac Rehab involve?
What does Cardiac Rehab involve?
• Alternative models of CR
– Telephone coaching or follow-up
– Internet / phone app based programs
– Telehealth
– Case management / modular approach
– Home based programs
Who’s responsibility is CR and SP?
• Everyone!
• Hospital
– Tertiary
– Secondary
• Primary Care
– GP
– Practice Nurses
– Allied Health
• Community support
– Walking groups
– Local pharmacist
• Private practitioners
– Psychologist
– Physiotherapist
– Dietician
– Diabetes educator
Where ever you work you have the opportunity to help start the ball rolling on
the journey of recovery and lifestyle change.
Teaching on the run
• Opportunistic education
• Engaging the family
• Use different approaches and resources
• Repeating messages in different ways
• Brief intervention motivational interviewing
What policy do we have?
http://www.healthnetworks.h
ealth.wa.gov.au/docs/1405_
CRSP_Pathway_Principles
_WA.pdf
©2018 National Heart Foundation of Australia
CRSP Pathway
Principles
CR can occur in
many different
settings
©2018 National Heart F
oundation of Australia
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
https://www.heartfoundation.org.au/images/uploads/publi
cations/HF.Cardiac_Rehab_Factsheet_WEBHR.pdf
©2018 National Heart Foundation of Australia
http://www.acra.net.au/why-cardiac-
rehabilitation-really-matters/
ACRA-WA
• Peak body
• Networking • http://www.acra.net.au/
https://www.heartfoundation.
org.au/cardiac-services-
directory
©2018 National Heart Foundation of Australia
Practical
resources
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
www.heartonline.org.au
The “go to” resource
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
Tips on how to communicate with patients inc difficult topics eg SEX
plus practical resources and tools
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
Online modules
MHML allow approx. 4-6hrs
HF 3hrs
©2018 National Heart Foundation of Australia
Sign up for the Heart Health Network
Newsletter (before next VC!)
©2018 National Heart Foundation of Australia
Heart Foundation HELPLINE
Qualified Health Professionals: supporting you & your patients
Phone: 13 11 12
Email: [email protected]
©2018 National Heart Foundation of Australia
Ordering resources: Website or Heart Foundation Helpline (by email or phone)
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
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CALD & Low literacy
©2018 Nati
onal Heart Foundation of Australia
©2018 National Heart Foundation of Australia
Guidelines
©2018 National Heart Foundation of Australia
Range of
CR posters. Please contact us in WA
©2018 National Heart Foundation of Australia
www.heartfailurematters.org (ESC)
©2018 National Heart Foundation of Australia
©2018 National Heart Foundation of Australia
St Vincent's heart health (www.svhhearthealth.com.au)
Includes videos: CR overview, exercise, quitting smoking, RF,
returning to activities, medications
www.getontrackchallenge.com.au
Teams track activity, fruit & veg
©2018 National Heart Foundation of Australia
www.myhealthybalance.com.au
Individual healthy lifestyle program
©2018 National Heart Foundation of Australia
Heart Foundation Walking App:
Prime Minister’s One million steps challenge
©2018 National Heart Foundation of Australia
C25k Couch to 5km in 9 weeks
Health app (iPhone) Activity, mindfulness, nutrition, sleep
©2018 National Heart Foundation of Australia
FoodSwitch Bupa, The George Institute
traffic-light’ labelling system or the new Health Star Rating system:
Saltswitch, glutenswitch, fatswitch, sugarswitch
Myfitness Pal Calorie counter and diet tracker,
assesses exercise to determine
needs
©2018 National Heart Foundation of Australia
My Quitbuddy
©2018 National Heart Foundation of Australia
Cardihab
©2018 National Heart Foundation of Australia
• CSIRO & Qu Health
• Cost $$$
• Scientifically validated Digital Cardiac Rehabilitation (DCR)
solution uses smartphone apps and web portals to give
clinicians the ability to deliver more convenient, flexible and
engaging CR services to patients
– Far more likely to participate than those who had to travel to an
outpatient clinic (80% vs 60%).
– More likely to adhere to the rules of the program (94% vs 68%) and
see it through to completion (80% vs 48%).
©2018 National Heart Foundation of Australia
Heart Maps • https://www.heartfoundation.org.au/for-professionals/heart-maps/australian-heart-maps
• What other useful tools or resources would you recommend?
• Evaluation forms: feedback & future topics please
Thank you
Please contact us at:
9388 3343
Secondary Prevention of Heart Disease, Thursday 9th August