There is a need to tackle issues around access and uptake for cardiac rehabilitation services.
Citatation: Armstrong-Klein S (2012) Modernising cardiac rehabilitation services. Nursing Times [online]; 108: 40, 20.
Author: Sarah Armstrong-Klein is National Improvement lead, NHS Improvement.
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The uptake of cardiac rehabilitation (CR) in England is 43% (National Audit for Cardiac Rehabilitation, 2011) meaning that the majority of eligible patients are either not offered or do not take up a programme. Across England, CR provision varies in availability, accessibility, quality and consistency and few services report any robust commissioning arrangements.
The cardiovascular disease outcomes strategy being developed by the Department of Health is likely to include rehabilitation across all clinical pathways. This should provide the impetus for CR teams to ensure their services are fit for purpose. Where services are already in place, teams should consider how they might use, share or adapt scarce resources more widely and in new ways to deliver better outcomes to all patients who might benefit from rehabilitation.
The improvement journey
New health policy priorities will bring new challenges to tackling issues around access and uptake to CR, so a good place to start planning service improvement is with the research and evidence available. We know that CR is cost-effective, reduces mortality by 26% and improves quality of life for many. It can also help to reduce unplanned admissions and yield significant savings (Heran et al, 2011; Lam et al, 2011; Davies et al, 2010).
The Department of Health CR commissioning pack, launched in 2010 (tinyurl.com/CR-resources), offers support to CR commissioners and providers, presenting an opportunity to make changes to deliver better quality and more consistent services. In a process led by NHS Improvement, the CR pack was tested in sites across England, bringing providers and commissioners together to develop robust local services with the aim of increasing access and uptake of high-quality CR services.
During testing, innovations such as the web-based CR service and early education models in Leicester were shared (Box 1); methods to improve access and uptake of services in south London, south of the Tyne and Wear and Addenbrooke’s Hospital in Cambridge were developed. A collaborative sub-project with the National Audit for Cardiac Rehabilitation team tested an adaption of the national dataset and produced a user-friendly report for commissioners/providers to help measure progress toward commissioning pack outcomes.
Box 1. Web-based cardiac rehabilitation
University Hospitals of Leicester Trust developed a unique interactive, password protected, web-based cardiac rehabilitation (CR) programme to increase access and choice for suitable patients. Web-based CR suits patients returning to work quickly, or those who prefer to do their rehab at home. Patients accepted on the programme can access CR more quickly, conveniently and at their own pace.
The Leicester CR team reports 65% of patients who completed a web-based CR programme would have declined a place on a conventional programme. The Leicester team has redesigned its education programme to start much earlier in the patient pathway. Separating it from the rest of the rehabilitation programme means that patients can access education within two weeks of discharge instead of waiting 4-6 weeks. These changes may have a positive impact on reducing anxiety while at the same time facilitating early patient engagement, potentially increasing the uptake of CR.
Improvement is not always easy. Motivating a team can be tough and letting go of traditional practice to embrace new ideas presents challenges for many. The resources in Box 2 help support service improvement by setting out the standards, providing knowledge and evidence and examples of innovation.
Box 2. Resources
Davies EJ et al (2010) Exercise based rehabilitation for heart failure. Cochrane Database of Systematic Reviews; Issue 4. Art No CD003331. tinyurl.com/Exercise-CR
Heran BS et al (2011) Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews; Issue 7. Art No CD001800.DOI:10.1002/14651858.CD001800.pub2. tinyurl.com/CR-heart-disease
Lam G et al (2011) The effect of a comprehensive cardiac rehabilitation program on 60-day hospital readmissions after an acute myocardial infarction. Journal of the American College of Cardiology; 57: 14s1, E597-E597.
National Audit of Cardiac Rehabilitation (2011) Annual Report. London: British Heart Foundation. tinyurl.com/NACR-report.