More honoured in the breach

Transcription

1 More honoured in the breach.. Bob Lewin CAREARE AND EDUCATION RESEARCH GROUPROUP Cardiac rehabilitation around the world (apart from Austria) is in a mess Austria % Holland 60% UK 40% (of angio,, CABG and MI) New Zealand (2003) 36% MI and Heart Failure Denmark 30% France 25% (MI only) Germany 20-25% 25% Greece 20% Japan (2004) MI 4%-8% Spain (2001) 2% of MI patients Portugal (1999) 0.7% of MI and coronary revascularisation patient One of the things that strikes you immediately is that most audits are out of date and conducted on different groups of patients. OK, it s 8.30, I m here when I could be in bed, what is this about? There is more evidence for CR than for almost any other cardiac intervention. Yet all around the world people don t get cardiac rehabilitation Even when the governments sets targets, (e.g. In England) it doesn t happen. Why? What are the Poms doing about it? National Target set in 2000 By % of patients having MI or revascularisation (angioplasty and CABG) should be receiving rehabilitation after which it should be extended to all cardiac patients except those with unstable angina. Complete this sentence by choosing one of these statements Cardiac rehabilitation is. A. a a bit of TLC for patients who ve had a rough time. B...something patients seem to like that does no harm. C....an exercise programme. D. a a multi-disciplinary, evidence-based, cost-effective way to save the lives of cardiac patients, with 36 randomised trials showing a pooled 26% reduction in cardiac mortality? Main Problems 1) Under treatment due to too few resources (staff) up to 70% not invited (missed on discharge, no protocol, etc) 20%-50% choose not to attend (inflexible delivery options) 2) Inequalities ethnic minorities, women, elderly place of residence, postcode lottery 3) Huge variation in resources and staffing cost per patient varies from aprox. 150 to 990 per patient! 4) Developing crisis in England because not in payment tariff price for an admission with MI or surgery not included in GP quality mechanism

2 Problems of delivery and quality Summary CR is a Cinderella service, short on resources, often poorly organised and directed but consuming a significant amount of NHS resource with an unknown number of programmes that may be delivering few if any of the very substantial gains in mortality and morbidity demonstrated by RCTs. The Scandal In last 10 years a huge increase spend on Angioplasty (no benefit in mortality possibly not cost effective) and CABG (10% reduction in mortality)? More than 1000 new consultant cardiology posts - NO additional spend on CR. CR tackles the underlying problems instead of being palliative. It is the only self-management of chronic disease programme with proven health benefits. Every survey of cardiac patients has said we want more rehabilitation. Flat lining of rehab The scandal the great majority of patients don t t get a chance to take part so every years many lives are shortened needlessly. Many patient lead needlessly disabled and symptomatic lives Far from improving things are getting worse no one with any power speaks up for it No drug companies or device manufacturers pushing for it. Are things getting better or worse? Is your programme under threat in any way? Is your service currently threatened with closure? Do you have an accepted business case and secure funding? Yes No Don t know 37% 40% 23% 10% 63% 27% 39% 30% 31% Central Cardiac Audit Database National Pacemaker & ICD Database Regional variations in ICD implantation rate. How do others get funding? Only health authorities shown in orange reach the new implant rate required by N.I.C.E. guidelines. NEW ARRHYTHMIA CHAPTER OF NSF PUBLISHED IN MARCH 2005 New DH Arrhythmia Task Force to improve services est. June 2005.

3 Aim to improve things for patients, in terms of access, equity, quality and clinical outcomes of cardiac rehabilitation. 1. NEEDS - showing where more money is needed. 2. NEEDS Identifying where groups of patients are disadvantaged locally and nationally. Postcode but also ethnicity, age, sex, rural, etc 3. BENEFITS Showing what patients gains from CR and setting benchmarks against which CR programmes can judge themselves. 4. Provide the bullets for the patients to fire, locally and nationally. 5. HOW TO DO CR BETTER Examining the reasons for differences in patient outcomes, uptake, completion etc. between programmes, so that guidelines for best practice can be produced. Media Primary care NEW. Access programme for Local reports DH Welsh Assembly Acute Trust Network BACR HCC Purchasers BHF York CCAD CR Programme staff enter data NICE Patient support groups BHF Campaigns Cardiac Rehab Patients fill in questionnaires 3 times, before, after CR and at 12 months after rehabilitation Principles of the NACR Improvement scores not raw outcomes - no unfair league tables change scores baseline to 12 weeks and 12 months Record resources (staff) available to each programme annual or letter Include local indices of deprivation and other health indices to ensure fair comparisons Download - dataset, questionnaires, how it was developed etc Feedback on performance limited to own view Analytical outputs National overview of CR Individual CR programme descriptions Extent to which NSF goals are being met locally, regionally and nationally Equity in the provision of CR locally, regionally and nationally Equity and representativeness of the uptake of CR locally, regionally and nationally Clinical, health, psychological, behavioural and social outcomes locally, regionally and nationally Individual, local, regional and national factors that impact upon outcome of CR Individual, local, regional and national factors that impact upon compliance with CR Table 11. The number and percentage of patients eligible for and the number and percentage receiving cardiac rehabilitation in England (April 2005-March 2006) and the NSF-CHD Target set for Eligible Receiving CR % Uptake Target % MI PCI CABG TOTAL

4 Figure 1 The number and percentage of Patients with Myocardial Infarction discharged alive and the number and percentage receiving Cardiac Rehabilitation by Strategic Health Authority in England. April 2005-March 2006 % Receiving Rehabilitation 80% - 100% 60% - 79% 40% - 59% 20% - 39% 0% - 19% Created a store finder for public, providing mapping for us and a webpage for every programme to advertise themselves (and automatically update the register) Table 21. Percentage of patients receiving various components of CR Activity % Psychosocial % Group Exercise Class 79 Relaxation training 53 Individual programme 27 Psychological - group talk 37 Home exercise plan 32 individual counsellor 3 Lifestyle OT group sessions 16 Education - written 46 OT individual referral 2 Education - Vocational assessment 57 Talks/Video <1 Dietary - group class 57 Home based / Other Dietary individual 18 Home based programmes 10 Angina plan 3 Home visits 9 The main tool to improve the situation [cardiac rehabilitation] is the National Audit. Without the evidence from that no improvement will be possible. You must all use it Professor Roger Boyle, (Heart Tsar) April 25 th, 2007 Why? So that we can describe the extent of the problem show where provision and quality are bad and where it is good measure if things are getting better Know when the campaign has succeeded and stop! Table 13. The number of patients with other cardiac conditions enrolled in the NACR database in the last 12 months and as a percentage of all patients seen (N=38,936) Cardiac arrest % angina % Heart failure % Implanted cardiac devices (LV assist, pacemaker, ICD) % Acute coronary syndrome % Nb. Annual incidence - Heart failure 66,000. Angina 247,000

5 5 demands of the campaign Summary The great majority of people with heart problems do not attend CR Around 55% of coronary artery by-pass patients 38% of heart attack patients and 45% of angioplasty patients took part in CR in Champion Patients Only a handful of the 66,000 people newly diagnosed with heart failure or 345,000 diagnosed with angina are referred to rehabilitation, people with heart failure, congenital heart disease, and implanted cardiac devices make up less than 1% of the patients taking part. There is a lottery for access across Strategic Health Authorities and Health Boards in England and Scotland. Patients in Scotland and Northern Ireland may be particular poorly served, or this may be an artefact due to significantly poorer survey return rates from those countries. The staffing rates and the range of professionals working with patients is poor when compared to clinical guidelines, doctors and psychologist are rarely involved Campaign for Cardiac Rehabilitation Leaflet for patients and the public The scientific evidence Annual Audit results showing where services are poor

6 Rehabilitation is NOT just secondary prevention and an exercise programme Secondary prevention is one part of CR. Secondary prevention Reduces the risk of future events, CR restores function, HRQOL reduces disability and reduces the risk of futher events. It is a chronic disease self-management programme the only one ever evaluated that provides medical benefits.

7 Conclusions how we hope to improve things Step 1 measure the shortfall and compare it across regions national audit programme Step 2 set up a patient charity or get existing patient groups involved d in a campaign to pulicise the deficit. Step 3 set up rolling press campaign to keep issue alive Step 4 publish the annual additional mortality figures by health authority across the UK