Cardiac Rehabilitation (CR) in General Practice Karen Kjær Larsen MD, PhD student Department of...

Cardiac Rehabilitation (CR) in General Practice

Karen Kjær LarsenMD, PhD student

Department of General PracticeSchool of Public Health

Aarhus University

Are patients with chronic diseases a new challenge to general practice?

Cardiac Rehabilitation in general practice.

Karen Kjær [email protected]

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.




Effect of Cardiac Rehabilitation

Quality of life ↑All-cause mortality ↓ OR=0.80 (0.68-

0.93)Cardiac mortality ↓ OR=0.74 (0.61-

0.96)



Taylor,R.S. et al. Am.J.Med.2004


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


The 5 components

Psychosocial care

Exercise training

Diet changesSmokingcessation

Medication




Post-AMIMajor Depression: 20 %Depression and Anxiety: 50 %



Thombs,BD. et al. J Gen Intern Med.2006


Prognosis of post-AMI depression

All-cause mortality ↑ OR=2.38 (1.76-3.22)

Cardiac mortality ↑ OR=2.59 (1.77-3.22)

Cardiovascular events ↑ OR=1.95 (1.33-2.85)



Van Melle JP. et al. Psychosom Med.2004


Effect of Cardiac Rehabilitation

Quality of life ↑All-cause mortality ↓ OR=0.80 (0.68-

0.93)Cardiac mortality ↓ OR=0.74 (0.61-

0.96)



Taylor,R.S. et al. Am.J.Med.2004


Attendance rates

Only 10-47 % of eligible patients participate in comprehensive CR



Ades, P.A et al. N.Engl.J.Med.2001


Attendance rates

3 % in a full rehabilitation programme47 % in parts of the rehabilitation programme19 % no attendance at all



Danish Heart Association. 2009


Organisation Patient

DepressionAnxietyLiving aloneLower educational level



Wyer,S. et al. Coronary Health Care. 2001

Factors associated with non-attendance

Lack of support from GPs and cardiologists

Lack of co-operation across the primary/secondary boundaries


Organisation




Meet the organisational challenges




Organisation Meet the challenge

Encourage the patient




Meet the organisational challenges




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


Organisation Meet the challenge

Take on the role as main coordinator




Meet the organizational challenges




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

Collaborators in Cardiac Rehabilitation

Phase IAcute admission

Days

Phase IIReconditioning

Weeks – months

Phase IIIMaintenance

Months – years

Acute cardiac ward

Invasive cardiac centre

CR centre

Municipality

General Practitioner

General Practitioner

Municipality

Local society


Patient





Meet the psychosocial challenges


Meet the challenge

Screen for psychiatric illness and social vulnerability

Patient







Screening of psychosocial vulnerability



Screening for depression and anxiety

Screening for social vulnerability

Depressive core symptoms?

Living alone?

Autonomic Symptoms? Level of education?


Meet the challenge


Treat psychiatric illness

Patient






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


Meet the challenge


Treat psychiatric illnessOffer extra attention to

socially vulnerable patients

Patient






Offer extra attention to socially vulnerable patients

Extra attention to the socially vulnerable → social equality (attendance rates, adherence to medication and achieving treatment goals)

Are patients with chronic diseases a new challenge togeneral practice?


Meillier,L. I gang igen efter blodprop i hjertet - socialt differentieret hjerterehabilitering. Region Midtjylland. 2007


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.




Cardiac Rehabilitation (CR) in General Practice Karen Kjær Larsen MD, PhD student Department of...

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