Improving the Organisation and Delivery of Cardiac Rehabilitation

Cardiac rehabilitation can promote recovery, enable the achievement and maintenance of better health, and reduce the risk of death in people who have heart disease [1]. Various influential policy documents [2,3] and guidelines from across the world [4–8] have exhorted the need for rehabilitation, but have also made the point it should be integrated into the comprehensive care of cardiac patients. For example, the US Agency for Health Care Policy and Research (AHCPR) clinical practice guideline on cardiac rehabilitation [4] concluded that: ‘Cardiac rehabilitation services are essential components of the contemporary management of patients with multiple presentations of coronary heart disease and with heart failure. Cardiac rehabilitation is a multifactorial process that includes exercise training, education and counselling regarding risk reduction and lifestyle changes, and use of behavioural interventions: these services should be integrated into the comprehensive care of cardiac patients.’ However, in many parts of the world cardiac rehabilitation has become a Cinderella service because of the comparative lack of recognition, status, research and funding devoted to it. Thus, current service organization and delivery is often fragmented, mechanistic and haphazard. There is a paucity of research regarding the optimal frequency, duration and mode of delivery of cardiac rehabilitation programmes. Traditionally, service provision has focused on people with myocardial infarction or, to a lesser degree, who have undergone cardiac revascularization (angioplasty or coronary artery bypass surgery). Programmes have usually been organized on an outpatient, hospital basis, over a 6–12 week period, and generally run by a nurse and/or a physiotherapist. Although the multidisciplinary approach is acknowledged as important, in reality it is usually limited to other health professionals giving the occasional talk to groups of patients about lifestyle or stress [9]. Women, elderly people, ethnic minority groups and those living in rural areas are all under-represented in terms of access to and the uptake of cardiac rehabilitation services [10]. Much of this is due to services being delivered in a location (usually a hospital) and at a time (usually during the week between 09.00 and 17.00 h) of convenience to health care professionals rather than the patients to whom they are supposed to be serving. Little consideration is given to the inconvenience, distance and cost incurred by the individuals for whom the services are supposedly targeted. The obvious solution is to take the rehabilitation services to the person. Home and community-based programmes, often using self-help manuals and facilitated by a nurse, are becoming increasingly common [11]. Home-based programmes can start at hospital discharge or with patients managed in the community. The patient and family are involved in the process and contacted by the nurse to monitor adherence and offer encouragement. An obvious solution to overcoming the problems of distance is use of information technology and the electronic horizon. Distance-based interactive rehabilitation is already being used in Canada and Australia. The Internet presents an ideal opportunity, with disease-specific chat rooms having proved popular as a form of social support. A web-based route might offer real advantages for diagnostic patient groups, such as those with congenital heart disease or implanted cardiac defibrillators, who are widely dispersed between a few tertiary treatment centres. Guidelines recommend that cardiac rehabilitation should be a needs-led, menu-driven service [5]. This approach consists of individualised assessment, using validated measures, information and advice, early follow-up and specific treatments as determined by the assessment. Thus, for example, if the patient is a non-smoking, athletic, vegetarian with low blood pressure he or she is unlikely to require advice on smoking cessation, diet or exercise. The partner can be incorporated in rehabilitation with little additional effort or cost and his or her presence can improve confidence and morale in the patient. It is commonly the partner who has the most important role in the patient's adjustment during convalescence, and his or her behaviour is an important determinant of the rate and extent of the patient's recovery. Therefore, it is crucial that the partner is involved appropriately at all stages of the rehabilitation process [12]. Routine identification of specific treatment needs, monitoring of progress, follow-up and, where appropriate, referral to specialist services, should form the process of rehabilitation [13]. Audit and evaluation should be intrinsic to the organization and delivery of rehabilitation and this will permit benchmarking and indicate areas for quality improvement [14]. To meet the needs of all patients with heart disease, a more logical, flexible and integrated approach to the organization and delivery of cardiac rehabilitation is required. Much of the service provision could be shifted to the community. Primary and secondary care sectors should work together to provide a seamless service, minimize costs and maximize the efficient use of expertise and resources. There is a pressing need to improve quality of service provision and, in the first instance, this might best be done by enforcing national guidelines. New and more innovative means of organization and modes of delivery, especially using IT-based methods, should be considered. Whatever approach is used, feasibility, acceptability and effectiveness should be evaluated.