Cardiac Rehabilitation CR in General Practice

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Cardiac Rehabilitation (CR) in General Practice
Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Karen Kjær Larsen
• MD, PhD student
• Department of General Practice
• School of Public Health
• Aarhus University

2
Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• The effect of Cardiac Rehabilitation is very well
  documented. However, due to organisational and
  psychosocial issues, the uptake of CR is low. How
  can we improve attendance?
• Take on the role as main coordinator for patients
  with chronic diseases.
• Screen patients with chronic diseases for
  psychosocial vulnerability and offer them
  treatment and extra attention.

3
Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Effect of Cardiac Rehabilitation
• Quality of life ?
• All-cause mortality ? OR0.80 (0.68-0.93)
• Cardiac mortality ? OR0.74 (0.61-0.96)

Taylor,R.S. et al. Am.J.Med.2004
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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Cardiac Rehabilitation, is
• the sum of activities required to influence
  favourably the underlying cause of the disease,
  as well as to ensure the patients the best
  possible physical mental and social conditions,
  som that they may, by their own efforts,
  preserve, or resume when lost, a place as normal
  as possible in the life of the community

WHO Regional Offices for Europe.1993
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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• The 5 components

Exercise training
Patient education
Psychosocial care
Smoking cessation
Diet changes
Medication
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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Post-AMI
• Major Depression 20
• Depression and Anxiety 50

Thombs,BD. et al. J Gen Intern Med.2006
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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Prognosis of post-AMI depression
• All-cause mortality ? OR2.38 (1.76-3.22)
• Cardiac mortality ? OR2.59 (1.77-3.22)
• Cardiovascular events ? OR1.95 (1.33-2.85)

Van Melle JP. et al. Psychosom Med.2004
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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Prognosis of post-AMI depression

Van Melle JP. et al. Psychosom Med.2004
9
Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Prognosis of post-AMI depression

Van Melle JP. et al. Psychosom Med.2004
10
Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Prognosis of post-AMI depression

Van Melle JP. et al. Psychosom Med.2004
11
Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Effect of Cardiac Rehabilitation
• Quality of life ?
• All-cause mortality ? OR0.80 (0.68-0.93)
• Cardiac mortality ? OR0.74 (0.61-0.96)

Taylor,R.S. et al. Am.J.Med.2004
12
Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Attendance rates
• Only 10-47 of eligible patients
  participate in comprehensive CR

Ades, P.A et al. N.Engl.J.Med.2001
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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Attendance rates
• 3 in a full rehabilitation programme
• 47 in parts of the rehabilitation programme
• 19 no attendance at all

Danish Heart Association. 2009
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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.
Factors associated with non-attendance

• Organisation

• Patient

• Depression
• Anxiety
• Living alone
• Lower educational level

Lack of support from GPs and cardiologists Lack
of co-operation across the primary/secondary
boundaries
Wyer,S. et al. Coronary Health Care. 2001
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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.
Meet the organisational challenges

• Organisation

Lack of support from GPs and cardiologists Lack
of co-operation across the primary/secondary
boundaries
Wyer,S. et al. Coronary Health Care. 2001
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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.
Meet the organisational challenges

• Organisation

• Meet the challenge

• Encourage the patient

Lack of support from GPs and cardiologists Lack
of co-operation across the primary/secondary
boundaries
Wyer,S. et al. Coronary Health Care. 2001
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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Encourage the patient
• CR participation by primary physician
• recommendation.
• The physicians recommendation was
• graded from 1 (not mentioned) to
• 5 (strongly recommended).
• Score 1-3, entry rate 1,8
• Score 4-5, entry rate 66

Ades,P. Arch Intern Med. 1992
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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Encourage the patient
• CR participation by primary physician
  recommendation
• No or weak recommendation, entry rate 1,8
• Strong recommendation, entry rate 66

Ades,P. Arch Intern Med. 1992
19
Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.
Meet the organizational challenges

• Organisation

• Meet the challenge

• Take on the role as main coordinator

Lack of support from GPs and cardiologists Lack
of co-operation across the primary/secondary
boundaries
Wyer,S. et al. Coronary Health Care. 2001
20
Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Take on the role as main coordinator
• The 2 sectors need to collaborate and communicate
  effectively to reduce treatment gaps and build on
  established models of integrated care with proved
  effectiveness

Dalal,H. BMJ 2004
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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.
Meet the psychosocial challenges

• Patient

• Depression
• Anxiety
• Living alone
• Lower educational level

Wyer,S. et al. Coronary Health Care. 2001
22
Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.
Meet the psychosocial challenges

• Meet the challenge

• Patient

• Screen for psychiatric illness and social
  vulnerability

• Depression
• Anxiety
• Living alone
• Lower educational level

Wyer,S. et al. Coronary Health Care. 2001
23
Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Screening of psychosocial vulnerability

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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.
Meet the psychosocial challenges

• Meet the challenge

• Patient

• Screen for psychiatric illness and social
  vulnerability
• Treat psychiatric illness

• Depression
• Anxiety
• Living alone
• Lower educational level

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Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• Treat psychiatric illness
• Standard treatment of depression
• ? effect on depressive symptoms
• ? lower risk for subsequent cardiac events for
  responders

Carney,RM et al. Psychsom Med. 2004
26
Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.
Meet the psychosocial challenges

• Meet the challenge

• Patient

• Screen for psychiatric illness and social
  vulnerability
• Treat psychiatric illness
• Offer extra attention to socially vulnerable
  patients

• Depression
• Anxiety
• Living alone
• Lower educational level

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Are patients with chronic diseases a new
challenge togeneral practice? Cardiac
Rehabilitation in general practice.

• Offer extra attention to socially vulnerable
  patients
• Extra attention to the socially vulnerable
• ? social equality
• (attendance rates, adherence to medication and
  achieving treatment goals)

Meillier,L. I gang igen efter blodprop i hjertet
- socialt differentieret hjerterehabilitering.
Region Midtjylland. 2007
28
Are patients with chronic diseases a new
challenge to general practice? Cardiac
Rehabilitation in general practice.

• The effect of Cardiac Rehabilitation is very well
  documented. However, due to organizational and
  psychosocial issues, the uptake of CR is low. How
  can we improve attendance?
• Take on the role as main coordinator for patients
  with chronic diseases.
• Screen patients with chronic diseases for
  psychosocial vulnerability and offer them
  treatment and extra attention.