I want to start off with a bit about Cardiac Rehabilitation. The speciality is where people who have suffered a cardiac event are managed and supported by specialist healthcare practitioners in a variety of settings and ways.
Coronary heart disease (CHD) affects millions of people in the UK and is the cause of around 100,000 deaths every year. Even though mortality rates have halved since the 1980s, cost of treatment by the NHS exceed £2 billion yearly but mortality rates still remain relatively high. Internationally, CHD is the main cause of death.
Cardiac Rehabilitation is a professionally supervised programme run by specialist registered healthcare professionals. A Cardiac Rehabilitation programme consists of a clinical assessment to determine if there are any symptoms, review of the patients’ needs and limitations, and in partnership with the patient develop a programme covering several main components:
· lifestyle and risk factor management
· cardio-protective drug therapy
· psychosocial status and quality of life
· long-term management
Who can benefit from Cardiac Rehabilitation
Those with a primary diagnosis of acute coronary syndrome (ACS) which includes STEMI, NSTEMI and Unstable Angina (UA) should engage in Cardiac Rehabilitation. It can also include all patients undergoing revascularisation (e.g. CABG, PCI or PPCI) and those with heart failure, both acute and chronic. These are considered as high priority groups, but the benefits of Cardiac Rehabilitation extend beyond these.
Cardiac Rehabilitation services can also include those who require:
· heart transplant
· ventricular assist devices (VADs)
· surgery for ICD or Cardiac Rehabilitation, this is not just for HF or ACS
· valve replacement, that is not just associated with HF or ACS
· treatment with a confirmed diagnosis of angina,
and even branching to those without CHD but are still affected by a condition that comes under the CVD diagnosis such as stroke and peripheral vascular disease, of which there is good evidence of benefits to these groups.
But, with national uptake to Cardiac Rehabilitation at around 50% of the priority groups if we were to attain 100% uptake there would not be the resources to deliver a service to them. So trying to include these other groups is currently unattainable.
Maybe the governing bodies should promote support only to those with CHD? Is it too much to ask for a Cardiac Rehabilitation service to take on ALL of the CVD burden? Should other associations focus on development of programmes to support their patient groups?
The evidence base for Cardiac Rehabilitation
The strongest evidence for Cardiac Rehabilitation is where it reduces morbidity, reduces hospital re-admissions and also, potentially the need for follow-up consultation. It can also support a swift return to work, both from a physical and psychological point, improves and increases functional capacity, physical activity levels and quality of life. This is all well and good but one of the main issues with Cardiac Rehabilitation is that it only lasts for a certain length of time, mostly due to resources. But even if there were unlimited resources, allowing a patient to continue being managed by a Cardiac Rehabilitation team will not do well for them. The current (and pre-covid) model of Cardiac Rehabilitation needs to adapt and focus more on the development of self-management skills.
The need for Cardiac Rehabilitation-an essential service!
The evidence shows that cardiac rehabilitation is second, only to aspirin and beta-blockers, in terms of cost effectiveness costing £1,100 per life year gained compared with £1,957 respectively. The term “cardiac rehab needs rehab” has been used widely recently. This is based on the fact that over the last decade Cardiac Rehabilitation uptake has only risen by about 10%. With a national target set to increase uptake to 85% based on current rates this will take decades. So it is evident that a new system is needed to meet this target, before even starting to introduce the other conditions into the priority groups.
Human beings naturally continue doing things they like, and they don't continue what they don't like."
One of the main things I have learned as a nurse is that humans don't like being told what to do! Now this can potentially cause a problem in health care, as we want what's best for our patients, and so will try and 'advise' them as to what is best for their health. Health Coaching in Cardiac Rehab predominantly will mean changes to their lifestyle.
If you were to look at behaviour change theory then when a patient will enter CR they are bypassing many behaviour change stages. Patients come in at the action stage but are not ready to take action. So we need to support the rapid acquisition/transitioning of the previous stages. This can be hard and potentially is a reason behind the low uptake levels of CR. If you were to look at other lifestyle change facilitators such as public health centres then you would see a thriving industry. This can be attributed to the fact that those who enter a gym would have already gone through contemplative and preparation stages that are essential to ensure a successfully transition to any action and then more importantly a maintenance stage.
So it is essential that we work with patients in an equal relationship following and andragogic education principles.