The New BACPR Standards and Core Components

Driving Forward more Effective Cardiovascular Prevention and Rehabilitation for Improved Outcomes

Jennifer JonesBACPR President

Cheshire and Merseyside Clinical Networks

Cardiac Rehab Practitioners Forum

Wed 12th September 2012

Promoting Excellence in Cardiovascular Disease Prevention and Rehabilitation

Driving forward more effective cardiovascular prevention and

rehabilitation in light of the new BACPR Standards and Core

Components

7 core standards and 7 core components are set out which aim to improve uptake and quality of

rehabilitation programmes nationwide

Aim

www.bacpr.com

With special thanks to: BHF, BSC, NHS Improvement, NACR, BANCC, BSH, HCP (UK), UK Heart Health and Thoracic Dietitians Group, the original 2007 and 2012 development groups as well as health care professionals from our consultation event and BACPR council members past and present.

Meet our case Background and evidence NACR 2011 findings Introducing to the 2012 update of the BACPR

Standards and Core Components Shaping future service delivery Promoting excellence in cardiovascular disease

prevention and rehabilitation

Overview

Case Scenario Mr BC is a 51-year-old male from Pakistan

residing in London. Recent anterior STEMI with primary PCI (drug eluding stent).

He is currently sedentary, has recently quit smoking and has a family history of premature atherosclerotic cardiovascular disease (father died aged 54-years following an acute MI).

Will taking up a cardiovascular prevention and rehabilitation programme offer benefit?

Cardiac Rehabilitation Saves Lives

There is overwhelming evidence that comprehensive cardiac rehabilitation is associated with a

reduction in both cardiac mortality (26-36%) and total mortality (13-26%).

Heran BS, Chen JMH, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No: CD001800. DOI: 10.1002/14651858.CD001800.pub2.

Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med 2004; 116(10):682-697.

Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: A systematic review and meta-analysis of randomized controlled trials. Am Heart J Oct 2011; 162: 571-584.

Recent

Directly Standardised Mortality Rate per 100,000 – All Ages - Ischaemic Heart Disease/CHD - England & Three

EU Comparators 1993 - 2008

0

50

100

150

200

250

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Dire

ctly

Sta

ndar

dise

d M

orta

lity

Rat

e pe

r 10

0,00

0

England

EU

EU members before May 2004

EU members since 2004 or 2007

Country

Average Annual Reductionin DSR 1993-2006 – 3.8%

Average Annual Reductionin DSR 1993-2006 – 5.6%

Cardiac Rehabilitation Reduces Morbidity

There is emerging evidence that cardiac rehabilitation is also

associated with a reduction in morbidity, namely recurrent

myocardial reinfarction

Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: A systematic review and meta-analysis of randomized controlled trials. Am Heart J Oct 2011; 162: 571-584.

Clark AM, Hartling L, Vandermeer B, McAlister, F. Meta-Analysis: Secondary Prevention Programs for Patients with Coronary Artery Disease. Ann Intern Med 2010; 143(9): 659-672.

1940 2010

British Heart Foundation “heart stats” 2010 www.bhf.org.ukSmolina et al. 2012 BMJ 2012;344doi: 10.1136/bmj.d8059(Published 25 January 2012)

1970

CHD Mortality

CHD Morbidity

Cardiac Rehabilitation Reduces Hospital

Readmissions

Lam G, Snow R, Shaffer L, La Londe M, Spencer K, Caulin-Glaser T. The effect of a comprehensive cardiac rehabilitation program on 60-day hospital readmissions after an acute myocardial infarction. J Am Coll Cardiol 2011; 57:597, doi:10.1016/S0735-1097(11)60597-4.

Heran BS, Chen JMH, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No: CD001800. DOI: 10.1002/14651858.CD001800.pub2.

28-56% reduction in costly unplanned

readmissions.

Chronic Disease Management

Cardiac rehabilitation improves functional capacity and perceived quality of life whilst also supporting early return to work and the development of self-management skills.

Yohannes AM, Doherty P, Bundy C, Yalfani A. The long-term benefits of cardiac rehabilitation on depression, anxiety, physical activity and quality of life. Journal of Clinical Nursing 2010; 19(19-20):2806-2813.

Cardiac Rehab is Cost Effective

Cost to achieve adding 1 year to a patients life

PPCI £6,054 – 12,057 PCI £3,845 – 5,889 CABG £3239 – 4,601 Cardiac Rehab £1,957 Aspirin/B-block <£1,000Fidan et al 2007

CR is one of the most clinically and cost-effective therapeutic interventions in

cardiovascular disease management More living and surviving with CVD or

heightened risk of CVD Increased survival from CHD events means

greater numbers with heart failure in future CR shifting from a “survival of the fittest” goal

(reduced mortality) to one of prevention, chronic disease management and morbidity reduction

The future for CR Summary 1

Cardiovascular Prevention and Rehabilitation

Mr BC is a 51-year-old male from Pakistan residing in London. Recent anterior STEMI with primary PCI (drug eluding stent).

He is currently sedentary, has recently quit smoking and has a family history of premature atherosclerotic cardiovascular disease (father died aged 54-years following an acute MI).

Mediterranean Diet Score = 5 (fruit and veg 3 portions/day; no fish; savoury snacks+)

Pedometer: ~5,000 steps per day; Aerobic capacity ~ 7 METs BMI = 33; Waist circumference = 116cm HAD: Anxiety=9 Depression = 5 BP: 140/83; Cholesterol: TC 5.0 mmol/l, LDL 3.3 mmol/l, HDL 1.2 mmol/l,

Triglycerides 1.1mmol/l, Glucose: FBG 5.8 mmol/l Bisoprolol 2.5mg; Simvastatin 40 mg; Aspirin 75mg; Clopidogrel 75mg;

Ramipril 1.25mg

Offers detailed comprehensive and integrated assessment of lifestyle, psychosocial health, medical risk factor management and

cardioprotective therapies

SO..... how well are we doing?

Number of Programmes Submitting and Data Collected

Years 06/07 07/08 08/09 09/10 10/11* 11/12*

Initiating Events 45,900 71,300 93,200 101,700 101,900 63,600

Baseline assessment

30,300 46,100 56,600 57,100 52,800 25,600

12 week assessment

15,800 22,700 25,700 25,200 22,400 6,900

12 month assessment

8,000 8,300 10,000 9,000 4,000 -

*Data still being collected/enteredOver 8,000 new patient records entered every month

213 rehab programmes in the UK uploaded some level of patient data in 10/11

Who actually gets cardiac rehabilitation?

Stable angina? Heart failure?

Other opportunities e.g. PAD, TIA, high multifactorial risk?

www.cardiacrehabilitation.org.uk/nacr/

SmokingDietPhysical activity and exercise

Smoking 10-11

0

2000

4000

6000

8000

10000

12000

14000

16000

Non-smoker

Smoker

11.4% 6.4% *

n

11.6% 6.3% *

11.7% 6.3% *

* p< 0.001IA EOP IA EOP IA EOP

ALL Male

Female

IA = Initial assessment

EOP = End of programme

BMI (kg/m2) 10-11 n= 12905

27.8 28.7

72.2

27.8 28.3

72.7

0

10

20

30

40

50

60

70

80

Mean % with BMI<25 % with BMI<30

IA

EOP

p>0.05 for all

BMI >=30 (at assessment 1)Mean Weight assess 1 = 97.92kg (se=0.269) at assessment 2 = 97.04kg (se=0.276): Change = -0.883kg (95% CI = -1.100 to-0.665)

Waist 10-11 n = 5532

98.791.25

33.9

96.4*88.4*

36.3

0

20

40

60

80

100

120

Mean cm (male) Mean cm (female) % at target waist

IA

EOP

p < 0.001 p= 0.08 p < 0.001

% with Target Waist (< 94cm men, <80cm women)

Physical Activity (5x30mins moderate)

10-11

32%56%

68%44%

0

2000

4000

6000

8000

10000

12000

14000

Initial assessment End of programme

No

Yes

* p<0.001

n

How much benefit?

1 serving/day increase in intake of fruits or vegetables is associated with a ?% lower risk of CHD

A 2-point increase in the Mediterranean diet score is associated with a ?% reduction in mortality.

Every 1 cm increase in waist circumference is associated with a ?% increase in risk of future CVD events including fatal and non-fatal CHD and stroke.

Every MET gain in physical fitness is associated with a ?% reduction in mortality.

How much benefit?

1 serving/day increase in intake of fruits or vegetables is associated with a 4% lower risk of CHD (Joshipura et al., 2001, Ann Int Med)

A 2-point increase in the Mediterranean diet score is associated with a 9% reduction in mortality (Sofi et al., 2008, BMJ) .

Every1 cm increase in waist circumference is associated with a 5% increase in risk of future CVD events including fatal and non-fatal CHD and stroke (de Konning et al., 2007 EHJ).

Every MET gain in physical fitness is associated with a 12% reduction in mortality (Myers et al., 2004, Am J Med).

Blood pressureCholesterolMedications

Blood Pressure 10-11n=7310

23% 24%

77% 76%

010002000300040005000600070008000

Initial assessment End of programme

No

Yes

p=0.2

n

Blood Pressure

BP diastolic >=80 (at assessment 1) Mean diastolic BP assess 1 = 87.08mmHg (se=0.123)

at assessment 2 = 81.56mmHg (se=0.138): Change = -5.518mmHg (95% CI = -5.818 to-5.219) BP systolic >=130 (at assessment 1) Mean systolic BP assess 1 = 146.63mmHg (se=0.200)

at assessment 2 = 137.71 mmHg (se=0.247): Change = -8.923mmHg (95% CI = -9.422 to-8.424)

Cholesterol at Target 10-11

TC : n= 5252 LDL : n= 1987

30.9 31.2

54.9*49.9*

0

10

20

30

40

50

60

% at TC Target % at LDL Target

IA

EOP

* p<0.001

Medications 10-11Aspirin: n= 15095 Statins: n= 14985 Ace: n= 14604 BB n= 14815

0

20

40

60

80

100

% taking Aspirin

% taking Statins % taking Ace inhibitor

% taking Beta blockers

IA

EOP

p=0.33 p=0.57 p=0.948

*p=0.001

Outcomes for impact!

Mr X’s reduction of -7/4 mm Hg Law et al., (2009) (meta-analysis) would

suggest this is linked to ~ a 20% reduction in risk of CHD and 35% reduction in the risk of stroke (BMJ)

An LDL-C reduction of 0.6 mmol/L would be expected to reduce

cardiovascular events by 14% (Baigent et al., 2005, Lancet).

Anxiety and Depression: HAD-A

* p<0.001

n

Anxiety and Depression: HAD-D

* p<0.001

n

A challenging environment

16% access to psychologists in 2009/10 compared with 34% in 2007/08.

55% of programmes included access to a physiotherapist in 2009/10 compared with 75% in 2007/08,

<50% included access to a dietitian

Current UK Service Delivery: Is there really an asymmetry?

Taylor, R., Bethell, H. & Jolly, K. 2003

Cochrane Review British Heart Foundation Stats

Age mean 54.3 62.6

Overall duration months

4.4 1.9

Frequency of supervised sessions

2.80 1.66

Exercise intensity (%HRmax)

75% Unknown

The future for CR Summary 2

CORE COMPONENT

1 Lifestyle risk factor management

Physical Act and Ex Diet Smoking cessation

√In part√

2 Psychosocial health √

3 Medical risk factor management In part

4 Cardioprotective therapies In part

5 Long-term management In part

6 Audit and evaluation In partShaping future cardiovascular prevention and rehabilitation

services

Key Alliances Assuring Quality

NICE guidelines (Post-MI, Heart Failure)

DH Commissioning Pack for CR

NICE commissioning guides for cardiac rehabilitation and heart failure services

BACPR Standards and Core Components

NACR NHS Improvement CR

Resource

+ for England Post-discharge Tariff – uptake + completion + outcomes

Quality, innovation and value in cardiac rehabilitation: commissioning for

improvement”

http://www.improvement.nhs.uk

1. The delivery of seven core components employing an evidence-based approach.

2. An integrated multidisciplinary team consisting of qualified and competent practitioners, led by a clinical coordinator.

3. Identification, referral and recruitment of eligible patient populations.

4. Early initial assessment of individual patient needs in each of the core components, ongoing assessment and reassessment upon programme completion.

5. Early provision of a cardiac rehabilitation programme, with a defined pathway of care, which meets the core components and is aligned with patient preference and choice.

6. Registration and submission of data to the National Audit for Cardiac Rehabilitation.

7. Establishment of a business case including a cardiac rehabilitation budget which meets the full service cost.

BACPR Standards 2012Patients, healthcare professionals and commissioners should expect

the following from high quality cardiac rehabilitation services

CriteriaStandard Criteria

An integrated multidisciplinary team consisting of qualified and competent practitioners, led by a clinical coordinator.

The team must include a senior clinician who has responsibility for coordinating, managing and evaluating the service.

Identification, referral and recruitment of eligible patient populations.

The initial assessment should be from a member of the cardiac rehabilitation team as part of in-patient care for those admitted to hospital.

Early initial assessment of individual patient needs in each of the core components, ongoing assessment and reassessment upon programme completion.

Within 2 weeksCompletion definition

Anxiety and depression, untreated leads to poor uptake, adherence and outcomes

Education is key for those with ACS rapidly discharged following PPCI – do they know they’re not fixed and their disease still exists?!

Exercise commenced within one-week post MI (stable) is safe – every week delay potentially requires 1 month more training to +ve affect ventricular remodelling

Rationale for early commencement

Cognitive behavioural approaches

Early goal setting is key

Criteria (continued)

Standard Criteria

Early provision of a cardiac rehabilitation programme, with a defined pathway of care, which meets the core components and is aligned with patient preference and choice.

Within 2 weeksA menu-based approach, easily accessible venues, choice in terms of venue (including home) and time (e.g. early mornings and evenings)

Registration and submission of data to the National Audit for Cardiac Rehabilitation.

Individual data on clinical outcomes and patient experience and satisfaction as well as data on service performance.Funded administrative time

Establishment of a business case including a cardiac rehabilitation budget which meets the full service cost.

Appropriately funded and adequately resourced to meet and deliver these standards and core components. Resource and financial management

What if................

Mr BC is a 51-year-old male found to be at high multifactorial risk who is currently sedentary, has recently quit smoking and has a family history of premature atherosclerotic cardiovascular disease?

Mr BC is a 51-year-old male with stable angina who is currently sedentary, has recently quit smoking and has a family history of premature atherosclerotic cardiovascular disease?

Mr BC is a 51-year-old male with intermittent claudication who is currently sedentary, has recently quit smoking and has a family history of premature atherosclerotic cardiovascular disease?

The future for CR Summary 3

Ensuring referral of all eligible patients by cardiologists and/or specialist cardiovascular health care physicians to a prevention and rehabilitation programme as a standard (not optional) policy that is held in the same regard as the prescribing of cardioprotective medications.

Tighter control of service audit (e.g. through NACR), not only to ensure these standards and core components are being met but to demonstrate that improved practice, clinical effectiveness and health outcomes have been achieved

The continuing of a national campaign that raises the profile and need for comprehensive integrated cardiovascular prevention and rehabilitation programmes to be properly funded as a cost-effective means and obligatory element to any modern cardiology or vascular health care service.

BACPR supporting implementation

Performance Indicators’ Tool Providing resources for service development

e.g. tool-kits for business case development, exemplary assessment frameworks and mechanisms for effective knowledge transfer and training.

Developing competency frameworks that are fully supported by high quality education and training programmes and research where required.

BACPRPromoting Excellence in Cardiovascular Prevention and Rehabilitation

BACPR Annual Conference in collaboration with CRIGS Thursday 4 & Friday 5th October, 2012, Edinburgh University Pollock Halls Campus

Setting the Standard – Challenges and Achievements

Coming soon…..

The BACPR Standards and Core Components

Continue to strive for our ultimate goal, namely to ensure that all eligible patients receive high quality

care in cardiovascular disease prevention and rehabilitation

Consolidating, Collaborating & Championing for High Quality Care

THANKYOU

Promoting Excellence in Cardiovascular Disease Prevention and Rehabilitation