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Promoting Excellence in Cardiovascular Disease Prevention and Rehabilitation
The New BACPR Standards and
Core Components
Driving Forward more Effective Cardiovascular
Prevention and Rehabilitation for Improved
Outcomes
Jennifer Jones
BACPR President
Cheshire and Merseyside Clinical Networks
Cardiac Rehab Practitioners Forum
Wed 12th September 2012
Aim
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
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.
Overview
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
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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%).
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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 metaanalysis 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
Age Group All ages Source (All) Disease (All)
Directly Standardised Mortality Rate per 100,000
250
200
Average Annual Reduction
in DSR 1993-2006 – 5.6%
150
100
Country
Average Annual Reduction
in DSR 1993-2006 – 3.8%
50
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Data
England
EU
EU members before May 2004
EU members since 2004 or 2007
Cardiac Rehabilitation Reduces Morbidity
There is emerging evidence that cardiac
rehabilitation is also associated with a
reduction in morbidity, namely recurrent
myocardial reinfarction
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Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation postmyocardial 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.
British Heart Foundation “heart stats” 2010 www.bhf.org.uk
Smolina et al. 2012 BMJ 2012;344doi: 10.1136/bmj.d8059(Published 25 January 2012)
CHD Morbidity
CHD Mortality
1940
1970
2010
Cardiac Rehabilitation Reduces
Hospital Readmissions
28-56% reduction in costly
unplanned 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.
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
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PPCI
PCI
CABG
Cardiac Rehab
Aspirin/B-block
£6,054 – 12,057
£3,845 – 5,889
£3239 – 4,601
£1,957
<£1,000
Fidan et al 2007
The future for CR
Summary 1
 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
Cardiovascular Prevention and Rehabilitation
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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
213 rehab programmes in the UK uploaded some level of patient data in 10/11
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/entered
Over 8,000 new patient records entered every month
Who actually gets cardiac rehabilitation?
www.cardiacrehabilitation.org.uk/nacr/
Stable angina? Heart failure?
Other opportunities e.g. PAD, TIA, high multifactorial risk?
Smoking
Diet
Physical activity and
exercise
IA = Initial assessment
Smoking 10-11
16000
EOP = End of programme
11.6% 6.3% *
14000
11.7%
12000
n
6.3% *
10000
Non-smoker
8000
Smoker
6000
4000
11.4% 6.4% *
2000
0
* p< 0.001
IA
ALL
EOP
IA
EOP
Male
IA
EOP
Female
BMI (kg/m2) 10-11 n=
12905
p>0.05 for all
80
72.2 72.7
70
60
50
40
30
27.8 27.8
28.7 28.3
Mean
% with BMI<25
IA
EOP
20
10
0
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)
% with BMI<30
Waist 10-11
n = 5532
% with Target Waist
(< 94cm men, <80cm women)
120
100
98.7 96.4*
91.2588.4*
80
60
IA
33.9 36.3
40
20
0
Mean cm (male) Mean cm (female) % at target waist
p < 0.001
p < 0.001
p= 0.08
EOP
Physical Activity (5x30mins moderate)
10-11
14000
12000
10000
n
8000
44%
68%
No
6000
Yes
4000
2000
56%
32%
0
Initial assessment
* p<0.001
End of programme
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 pressure
Cholesterol
Medications
Blood Pressure 10-11
n=7310
n
8000
7000
6000
5000
4000
3000
2000
1000
0
76%
77%
No
Yes
23%
24%
Initial assessment
End of programme
p=0.2
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
60
LDL : n= 1987
54.9*
49.9*
50
40
30
30.9
31.2
IA
EOP
20
10
0
% at TC Target
* p<0.001
% at LDL Target
Medications 10-11
Aspirin: n= 15095 Statins: n= 14985 Ace: n= 14604
BB n= 14815
100
80
60
IA
40
EOP
20
0
% taking
Aspirin
p=0.33
% taking Statins % taking Ace
inhibitor
p=0.57
*p=0.001
% taking Beta
blockers
p=0.948
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
n
* p<0.001
Anxiety and Depression: HAD-D
n
* p<0.001
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 part
Shaping 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
BACPR Standards 2012
Patients, healthcare professionals and commissioners should expect the following from
high quality cardiac rehabilitation services
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.
Criteria
Standard
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 weeks
Completion definition
Rationale for early commencement
 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
Early goal setting is key
Cognitive
behavioural
approaches
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 weeks
A 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
Appropriately funded and adequately
cardiac rehabilitation budget which meets the resourced to meet and deliver these
full service cost.
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. toolkits 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.
BACPR
Promoting 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