A national survey of cardiac rehabilitation programs in Australia: Program characteristics and psychosocial screening practices

Transcription

1 Improving the lives of people with heart disease A national survey of cardiac rehabilitation programs in Australia: Program characteristics and psychosocial screening practices Report to ACRA in compliance with ACRA endorsement policy Jackson AC, Murphy BM, Higgins RO, Beauchamp A, LeGrande M, Rogerson M May 2015

2 Background Centre-based group programs are the major systematic approach to cardiac rehabilitation (CR ) currently available in Australia. Typically group CR comprises low or moderate intensity physical activity; and education and discussion, with programs usually running for 6-8 weeks. CR aims to restore individuals to their optimal level of physi al, psy hologi al, so ial and o ational ell eing and is onsidered an essential part of the contemporary care of heart disease. CR has been shown to reduce the risk of further heart attack or death by 25-30%. Ideally, CR should involve multi-disciplinary teams of health professionals. There is a need for baseline data on centre-based CR program staffing, content and structure. Having such baseline data will enable tracking of trends in CR over time, for example with regard to distribution of services, staffing levels and staffing mix, program content and duration. A review of CR Guidelines with screening recommendations published between 2008 and 2014 was undertaken. This review, conducted prior to the release of the ACRA Core Components of Cardiovascular Disease Secondary Prevention and Cardiac Rehabilitation 2014, included:

3 Background American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: Recommendations for Screening, Referral, and Treatment (2008) Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation: Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper (2010) National Heart Foundation of Australia & the Cardiac Society of Australia & New Zealand: Guidelines for the prevention, detection and management of chronic heart failure in Australia (2011) French Society of Cardiology: Guidelines for cardiac rehabilitation in adults (2012) The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice: European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) Cardiac Rehabilitation Section of the European Association for Cardiovascular Prevention & Rehabilitation: Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery (2012) The National Heart Foundation of Australia: Screening, referral and treatment for depression in patients with coronary heart disease: A consensus statement (2013) Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology: Position paper on psychosocial aspects in CR (2014)

4 Physical and behavioural factors: what screening is recommended? Physical activity Smoking Functional capacity Diet AHA 2010 Sedentary behaviour EACPR 2010 NHFA & CSANZ 2011 French Soc. Card 2012 European Soc. Cardiol EACPR 2012 NHFA 2013 EACPR 2014

5 Psychosocial factors: what screening is recommended? AHA 2010 Depression Anxiety Stress QoL Social Support EACPR 2010 Sleep NHFA & CSANZ 2011 French Soc. Card 2012 European Soc. Cardiol EACPR 2012 NHFA 2013 EACPR 2014

6 Australian screening practices Limited data regarding screening practices in Australian cardiac rehabilitation (CR) programs Uncertainty over: Screening practices with regard to physical, behavioural and psychosocial factors Take up of screening recommendations including uptake of NHF/CSANZ depression screening guidelines Some risk factors, such as sleep and sedentary behavior, not yet included in most guidelines Aims of the national CR coordinators study To investigate and document: 1. Program and coordinator characteristics. 2. Current practice in CR in screening and assessment for a range of CHD risk factors; 3. Perceived barriers to undertaking screening and assessment in CR.

7 Method An online survey was created using Survey Monkey which asked about screening and assessment activities across a range of traditional and emerging CVD risk factors, as well as barriers to screening & assessment. A link to the survey was ed to the CR coordinator at each of the 350 CR programs currently operating across Australia, using contact details in the latest State Directories of Cardiac Rehabilitation Services. Responses were received over a 60 day period with two follow-up reminders after the initial /mail contact. Only one survey could be completed from each unique IP address. Ethics approval was granted by the University of Melbourne Human Research Ethics Committee (Ethics ID: ) and the project was endorsed by ACRA.

8 Areas covered in the survey Demographics: location, profession, qualifications, employment status, type of hospital / service. Program information: components and topics covered, no. of sessions, co-ordinator hours spent in CR, CR staffing profile (regular and sessional). Patients: referral and attendance. Assessment / screening: what is done at entry and exit, who does it and and what instrument if any is used for depression, physical activity, functional capacity, sedentary behaviour, diet, sleep, anxiety, stress, quality of life, social support, other risk factors (eg history of anxiety and depression, living alone, self efficacy, medication adherence. Barriers to screening and assessment: personal factors (eg lack of knowledge about assessment tools) and structural barriers (eg no referral protocol in place if condition is assessed). Follow up: referral protocols for depression, anxiety, sleep disturbance, sedentary behaviour. Training in CR: what has the CR co-ordinator done, further training desired, ACRA membership.

9 Study sample 350 CR Programs 192 responses 4 refusals 12 Identified as HF coordinators 176 (50.3%) included

10 % Survey respondents (N=176) Service Type ACRA membership

11 Screening at CR program entry and exit ENTRY (n=165) EXIT (n=157) n % n % Median time spent per person = 60 minutes at entry 30 minutes at exit

12 Who does the screening at entry? (N=157) Staff % 1% 1% 1% 2% 7% Nurse Physiotherapist 8% Exerc Physiologist GP Dietician 54% Occup Therapist 26% AHA Other

13 Assessment of physical & behavioural factors % P h y s i c a l A c t i v i t y S m o k i n g F u n t i o n a l C a p a c i t y S e d e n t a r y B e h a v i o u r D i e t E n t r y ( n = ) E x i t ( n = )

14 Assessment of physical & behavioural factors Entry (n=157) Exit (n= 129) % Physical Activity Smoking Funtional Capacity Sedentary Behaviour Diet

15 Use of standardised measures in physical & behavioural assessment (n=157) % P h y s i c a l A c t i v i t y F u n t i o n a l C a p a c i t y S e d e n t a r y B e h a v i o u r D i e t I n s t r u m e n t u s e d F e w q ' s a s k e d o n l y

16 Assessment of psychological factors Entry (n=157) Exit (n= 129) % Depression Anxiety Stress Sleep

17 Use of standardised instruments in psychological factor assessment (n=157) % assess history of depression 80% assess history of anxiety I n s t r u m e n t u s e d F e w q 's a s k e d o n ly % D e p r e s s io n A n x i e t y S t r e s s S le e p

18 Example: depression assessment at entry (n=157) % PHQ HADS DASS K10 CDS BDI Ask few qs Do not assess

19 Example: sleep assessment at entry (n=157) % E p w o r t h S l e e p i n e s s S t a n f o r d L e e d s B e r l i n O t h e r i n s t r u m e n t A s k f e w q s D o n o t a s s e s s

20 Example: quality of life assessment at entry (n=157) Disease-specific (for cardiac patients) % S F M a c N e w H e a r t Q O L W H O Q O L S F O t h e r i n s t r u m e n t A s k f e w q s D o n o t a s s e s s

21 Other risk factors routinely assessed at CR program entry (n=157) Medical/Physical % Behavioural/Psychological % Social/ Functional Blood pressure 95 Smoking 96 Living alone 93 Family hx CVD 94 Hx anxiety 94 Return to work 85 Weight 90 Hx depression 88 Marital status 85 Cholesterol 76 Alcohol 87 Confidante 56 Waist girth 72 Medication adherence 87 Recent other loss (eg. Retrenchment) BMI 71 Substance abuse 54 Financial strain 50 Health literacy 41 Self-efficacy 50 Recent bereavement 42 Anger 19 Sexual dysfunction 24 % 50

22 Discussion Variability in screening practices in terms of what is screened for, and whether validated measures are used or simply questions asked. Depression generally well screened for, unlike sleep disturbance which is not well screened for. This is important as the estimated prevalence of OSA in cardiac patients ranges between 26% and 69%. Sleep disorders in these patients may severely impact upon secondary prevention efforts since they are associated with impaired exercise performance, functional limitation, depression and reduced health-related quality of life. In addition, poor sleep can double unplanned hospitalisations of heart failure patients. Possibly over-reporting of sedentary behaviour screening with some confusion with physical activity measurement. Health literacy and self efficacy screening seems high. This needs further exploration. Difficult to compare practices across services given the lack of standardised data collection tools and no national minimum data set requirement.

23 Conclusion The following papers are in preparation from this study: Jackson, A.C., Le Grande, M., Higgins, R.O., Beauchamp, A., Rogerson, M., Murphy, B.M. Screening, assessment, and referral practice within cardiac rehabilitation: A survey of cardiac rehabilitation coordinators in Australia, for European Journal of Preventive Cardiology Higgins, R.O., Beauchamp, A., Le Grande, M., Rogerson, M., Murphy, B.M., Jackson, A.C. A national benchmarking study of cardiac rehabilitation programs in Australia.