Transcript Outcomes from a Multi-disciplinary Cardiac Rehabilitation

Outcomes from a Multi-disciplinary
Cardiac Rehabilitation
Programme:
Are Angioplasty Patients
Addressing Lifestyle Changes?
Eve Scarle,
Mark Giles, Maggie Gallacher, Julian Bath, Julia Harrison, Alison Anderson
Gloucestershire Cardiac Rehabilitation Service
Gloucestershire Hospitals NHS Foundation Trust
Background
 Death rates from CHD have fallen by 44% in those under
65 years old (1)
 2.6 million people in the UK living with CHD
(1)
 Growth of RACPC and interventional cardiology
 6,000 PTCA in 1982 increased to 54,000 in 2003
 NSF for CHD (2000)
(1)
(2)
“Once Trusts have an effective system recruiting
people who have survived an MI or undergone surgery
to a high quality cardiac rehabilitation, they should
then extend their rehabilitation services to people
admitted to hospital with other manifestations of CHD”.
(Chapter 7:4)
PTCA
CABG
MI
Intervention
Normally planned
Normally planned
Sudden an unexpected/
can be life-threatening
Length of
stay
1-2 days
At least 5 days
At least 5 days
Recovery
Immediate relief of
symptoms
Post-operative pain
and discomfort
Gradual ambulation
Intervention
Local anaesthetic
Open-heart surgery
Possible intervention
History of MI
No
Possibly
Possibly
Driving
1 week off
4-6 weeks off
4 weeks off
Work
1-2 weeks
6-12 weeks
6-12 weeks
Activity
Restrictions
Little restriction on
activity
Physical restrictions
e.g. lifting
Physical restrictions e.g.
lifting
Time for
education
Little time for inhospital education
Seen by CR team
Seen by CR team
Rationale
 Limited studies on first time PTCA patients with
no history of MI
 May feel cured by the procedure or less sick
than other CHD patients- motivation to change
 Evidence suggests 30-40% of individuals
experience recurrent angina or a cardiac event
by 2 years (4) (5)
 Less compliance to behaviour changes when
compared to CABG patients (3)
 Low levels of CR participation (0-10%) (6) and
twice as likely to drop out (7)
Method- Comparative Study
Initial sample- baseline data
n=1387
MI n=936
CABG n=285 PTCA n=166
CR programme
Accepted and attended
n=590
Completed initial questionnaire
and attended 7 weeks rehab
MeasuresIPQ, SF-12, HADS,
Self-efficacy, Risk factor profile
Dropped out of CR
Programme
13%
Follow-up of patients at 6 months
post cardiac event
completed second questionnaire
Cardiac Rehab Programme
 Seven sessions for two hours
 Multi-disciplinary
– nurse, physiotherapist, psychologist, dietitian
 Exercise and education component
 Based around cognitive behavioural model
 Two follow-ups at six months and one year
post cardiac event
Results
 Attendance
 Quality of Life (SF-12)- physical and
mental
 Anxiety and Depression (HADS)
 Illness Perceptions (IPQ)
 Risk behaviours
 Self-efficacy
Results
 HADS
– Reductions in anxiety
and depression
scores
– Greater improvement
in those who had
clinically meaningful
scores
60
55
50
MI
CABG
45
PTCA
40
35
30
Before CR
Mean anxiety score (0-21)
– Mental health
improved in all 3
groups
– Physical health better
for PTCA at baseline
– Improvements in
physical health in MI
and CABG group
Mean physical health score (0-100)
 SF-12
8 weeks after CR
8
6
MI
CABG
PTCA
4
2
0
Before CR
8 weeks after CR
Results
 Illness Perception (IPQ)
– Increased timeline scores
Patients who accepted their condition to be long-term
(timeline) had better diet and exercise self-efficacy scores (8).
Perceiving CHD as chronic may be instrumental in engaging
individuals in making long-term changes.
– MI thought consequences of illness were
more serious
– Following rehab PTCA patients had increased
consequences scores
CR may facilitate a raising of awareness of the
consequences of CHD and enhance motivation to make
behavioural changes
Results
 Self-efficacy
– No group differences
Increased SE for stress reduction and dietary changes
High SE scores for stopping smoking and increasing fitness
 Risk Factor Modification
– No group differences
80.4% abstinence from smoking at 6 months
Significant increases in fruit and vegetable and oily consumption,
and frequency of exercise
No significant improvements in BMI
Study Limitations
 Lack of control group
– No assessment on individuals who refuse CR
– Threats to internal validity
 Data collection difficult with lengthy
questionnaire
– Need all answers for each measure at each time
point
 Data only available up to six months post
event
Conclusion
 No significant differences between three groups
in success at CR
 CR a worthwhile venture for PTCA patients
 PTCA motivated to attend CR and make
favourable lifestyle changes
 Evidence suggests only 5-10% of PTCA
patients are offered the chance to attend CR (6)
Future Directions
 Long-term follow-up period beyond one year
 Investigate individuals that refuse CR
 Investigate patient activity levels outside CR
 Explore alternative tools for CR
– Home programme
– Videos/dvds
– Evening classes
Any
Questions?
References
1. Heart Stats Website
http://www.heartstats.org/ (2005) accessed on the 25th July 2005.
2. Department of Health (2000) The National Service Framework for Coronary Heart Disease, London:
HMSO.
3. Crouse, J. and Hagaman, A. (1991) Smoking Cessation in relation to Cardiac Procedures, Amercian
Journal of Epidemiology, 134 (7), pp. 699-703.
4. Hlatky, M. Charles, E. Norbrega, F. Gelmen, K. Johnstome, I. & Melvin, J. (1995) Comparison of
Coronary Bypass Surgery with Angioplasty in Patients with Multi-Vessel Disease (BARI) , New
England Medical Journal, 335, pp. 217-25.
5. Tuniz, D. Bernardi, G. Molinis, G. Valente, M. D’Odorico, N. Mirolo, R. Morocuttl, G. Spedicato, L. &
Fioretti, P. (2004) Ambulatory Cardiac Rehabilitation with Individualised Care after Elective
Coronary Angioplasty: One Year Outcome, European Heart Journal Supplements, 6 (A), A1-10.
6. Bethell, H. Turner, S. Evans, M. & Rose, L. (2001) Cardiac Rehabilitation in the United Kingdom.
How Complete is the Provision?, Cardiopulmonary Rehabilitation, 21 (2), pp. 111-15.
7. Turner, S. Bethell, H. Evans, J. Goddard, J. & Mullee, M. (2002) Patient Characteristics and
Outcomes of Cardiac Rehabilitation, Journal of Cardiopulmonary Rehabilitation, 22, pp. 253-260.
8. Lau-Walker, M. (2004) Relationship between Illness Representation and Self-Efficacy, Journal of
Advanced Nursing, 48 (3), pp. 216-225.
Contact details for further information:
[email protected]
[email protected]