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Current Issues - Overcoming barriers to better care

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Ian Jones, BSc (Hons), RN; Diane Jones, DipCot, SROT.

Ian-Lecturer in Cardiac Nursing, University of Salford; Diane-Senior Occupational Therapist, East Lancashire Hospitals NHS Trust (formerly Head Occupational Therapist, Cardiac Rehabilitation Service, Blackpool Victoria Hospital)

Despite a number of studies with positive findings (Oldridge et al, 1988; O'Connor et al, 1989; Carlson et al, 2000) a large percentage of people who are discharged from hospital with a diagnosis of coronary heart disease (CHD) are still not receiving adequate cardiac rehabilitation (NHS Centre for Reviews and Dissemination, 1998).
Despite a number of studies with positive findings (Oldridge et al, 1988; O'Connor et al, 1989; Carlson et al, 2000) a large percentage of people who are discharged from hospital with a diagnosis of coronary heart disease (CHD) are still not receiving adequate cardiac rehabilitation (NHS Centre for Reviews and Dissemination, 1998).


Several barriers to cardiac rehabilitation have been identified, including lack of flexibility of services, the distance patients have to travel to services (Oldridge, 1992) and inadequate provision for patients with co-morbidity (Ades et al, 1995). The continued reliance on exercise tolerance testing before commencement of phase three of cardiac rehabilitation means access to services is restricted to fitter individuals with less complex medical conditions (Thompson et al, 1997; Lewin et al, 1998).


Melville et al (1999) suggest that people from lower socio-economic groups find it difficult to access cardiac rehabilitation, in addition to which little is known about the needs and experiences of women, older people and people from ethnic minority groups (Thompson and DeBono, 1999), who are rarely offered rehabilitation or frequently fail to take up services. Depression has also been linked with non-attendance at cardiac rehabilitation, yet it is seldom assessed during a patient's hospital stay. Subsequently, such patients fail to attend their appointments and may be lost to follow-up.


Traditional cardiac rehabilitation programmes are neglecting the patients that need them most. The authors writing in this supplement have attempted, therefore, to identify and discuss a few of the many issues that cardiac rehabilitation co-ordinators should be addressing.


Coronary heart disease has many causative factors and is more complex than pure biology. The use of pharmacological agents has led to a reduction in cardiac mortality (Antiplatelet Trialist Collaboration, 1994; Yusuf et al, 1985; Furburg et al, 1994), but this forms only one aspect of rehabilitation. To reduce the risk of further coronary events and to sustain an adequate quality of life patients often need to adapt physically, psychologically and socially. To facilitate the changes the cardiac rehabilitation team will need a range of skills (Stokes and Thompson, 2002), which is beyond any single discipline.


The NHS Centre for Reviews and Dissemination (1998) concludes that the most effective form of cardiac rehabilitation combines exercise, psychological care and education. This recommendation appears to suggest the need for multidisciplinary working. However, the British Association for Cardiac Rehabilitation/British Heart Foundation review of cardiac rehabilitation services in the UK (Bethel et al, 2001) has identified that some disciplines are under-represented, indicating that very few cardiac rehabilitation programmes have adopted a truly multidisciplinary approach.


There is a need for cardiac rehabilitation co-ordinators and managers to develop a greater understanding of the specialist skills possessed by allied health professionals. These are often complementary to the skills possessed by nurses and taking a collaborative approach can have a much greater impact on the patient outcome. It is imperative that no single discipline has the monopoly on cardiac rehabilitation provision and a truly multidisciplinary approach is adopted both operationally and strategically.


If patients' interests are to come first primary/ secondary care barriers need to be dismantled. The majority of patients with CHD are cared for in the community. Therefore, it makes sense to provide cardiac rehabilitation for low-risk patients - as categorised by the American Association for Cardiovascular and Pulmonary Rehabilitation (1999) - in primary care.


A community-based programme may also be more accessible to older people and those who find hospital-based programmes unsuitable or inconvenient (Bowman et al, 1998). It would then allow specialist hospital staff to focus on the more high-risk groups that do not currently receive any form of cardiac rehabilitation and may require more time allocated to their treatment.


Introduction of an individualised programme would allow such patients to exercise in a safe hospital setting up to a point below their symptomatic threshold, thereby improving their level of fitness. This may not help them to run a marathon, but should be enough to improve their quality of life. Such interventions should be part of a menu of activities designed to facilitate rehabilitation. Patients who are genuinely unable to exercise should be offered other elements of the cardiac rehabilitation programme.


The timing of cardiac rehabilitation should also be reviewed. Since cardiac rehabilitation was introduced in the UK a number of technological and pharmacological developments have emerged. The most important is, arguably, the widespread use of thrombolytic therapy. The ability of these drugs to provide rapid reperfusion in acute myocardial infarction and limit the extent of myocardial damage could mean that there is no longer a need for all patients to wait in excess of four weeks before embarking on a cardiac rehabilitation programme. If a proposal to this effect was implemented, it could lead to a reduction in the phase two time frame, thereby cutting the need for specialist input at this point. The consequent cost saving could be used to improve the overall level of the service.


Cardiac rehabilitation in the UK is at a crossroads. Limited funding means that expensive outpatient programmes on offer only to reasonably fit and active people are no longer viable. It is time to move on. Most professionals would agree that the future of cardiac rehabilitation lies predominantly in primary care, employing all the skills of the multidisciplinary team. Hospital services have to be developed to cater for the needs of higher risk patients. This is the only way that a more equitable service can be achieved.

American Association for Cardiovascular and Pulmonary Rehabilitation. (1999) Guidelines for Cardiac Rehabilitation and Secondary Prevention. Champaign, Ill: Human Kinetics.

Ades, P.A., Waldman, M.L., Gillespie, C. (1995) A controlled trial of exercise training in older coronary patients. Journal of Gerontology 50A: 7-11.

Antiplatelet Trialist Collaboration. (1994) Collaborative overview of randomised trials of anti-platelet therapy-I: prevention of death, myocardial infarction and stroke by prolonged anti-platelet therapy in various categories of patients. British Medical Journal 308: 81.

Bethel, H.J.N., Turner, S., Evans, J.A., Rose, L. (2001) Cardiac rehabilitation in the United Kingdom: how complete is the provision? Journal of Cardiopulmonary Rehabilitation 21: 2, 111-115.

Bowman, G.S., Bryar, R.M., Thompson, D.R. (1998) Is the place for cardiac rehabilitation in the community? Social Sciences in Health 4: 243-254.

Carlson, J.J., Johnson, J.A., Franklin, B.A., VanderLaan, R.I. (2000) Program participation, exercise adherence cardiovascular outcomes and program cost of traditional versus modified cardiac rehabilitation. American Journal of Cardiology 86: 17-23.

Furburg, C.D., Byington, R.P., Crowse, J.R., Espeland, M.A. (1994) Pravastatin, lipids and major coronary events. American Journal of Cardiology 73: 1133.

Lewin, R.J.P., Ingleton, R., Newens, A., Thompson, D.R. (1998) Adherence to cardiac rehabilitation guidelines: a survey of rehabilitation programmes in the United Kingdom. British Medical Journal 316: 1354-1355.

Melville, M.R., Packham, C., Brown, N. et al. (1999) Cardiac rehabilitation: socially deprived patients are less likely to attend but patients ineligible for thrombolysis are less likely to be invited. Heart 82: 373-377.

NHS Centre for Reviews and Dissemination. (1998) Cardiac rehabilitation. Effective Health Care Bulletin 4: 1-11.

O'Connor, G.T., Buring, J.E., Yusuf, S. et al. (1989) An overview of randomised trials of rehabilitation with exercise after myocardial infarction. Circulation 80: 234-244.

Oldridge, N. (1992) Use of rehabilitation services: factors associated with attendance. Journal of Cardiopulmonary Rehabilitation 12: 25-31.

Oldridge, N.B., Guyatt, G.H., Fisher, M.E., Rimm, A.A. (1988) Cardiac rehabilitation after myocardial infarction. Combined experience of randomised clinical trials. Journal of the American Medical Association 260: 945-950.

Stokes, H., Thompson, D.R. (2002) Cardiac Rehabilitation in Cardiac Nursing: A comprehensive guide. Edinburgh: Churchill Livingstone.

Thompson, D.R., Bowman, G.S., Kitson, A.L. et al. (1997) Cardiac rehabilitation services in England and Wales: a national survey. International Journal of Cardiology 59: 299-304.

Thompson, D.R., DeBono, D.P. (1999) How valuable is cardiac rehabilitation and who should get it? Heart 82: 5, 545-546.

Yusuf, S., Peto, R., Lewis, J. et al. (1985)Beta blockade during and after myocardial infarction: an overview of the randomised trials. Progress in Cardiovascular Diseases 27: 5, 335.
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