Health authorities should purchase cardiac rehabilitation for all those who may benefit and provide good quality discharge care Audit Commission. Dear to our hearts? Commissioning services for the treatment and prevention of coronary heart disease. London: HMSO. 1995.,East riding project - the impetus,East riding project - the brief,provide equitable and universal CR for all MI patients in the health authority area be evidence based and guideline compliant* be acceptable to clinicians and patients build on existing local provision implicit - cost neutral! create potential model for others to adopt *Thompson DR, Bowman GS, De Bono DP, et al. Cardiac Rehabilitation: Guidelines and Audit Standards. London: Royal College of Physicians, 1997.,literature review 316:1354-5.,East riding project - the method,Equity not universally provided (50,000 of 150,000 survivors) patchy geographical provision many patients fall through net, e.g. transport problems, MI identified to late for admission, early discharges, general physician discharge elderly, female, ethnic & rural populations particularly under represented in CR programmes attendees are volunteers - often the well motivated & most likely to be OK anyway (smokers, the depressed, manual workers all underrepresented),East riding project - the national picture,Quality most programmes fail to meeting UK guidelines* little - individual assessment of needs, setting of goals, checking their attainment * limited attention to secondary prevention through medical care, (eg. 30% of MI patients not on asprin or Beta-Blockers)* * Lewin RJ, Ingleton R, Newens AJ, et al. Adherence to cardiac rehabilitation guidelines: a survey of cardiac rehabilitation programmes in the United Kingdom. BMJ 1998;316:1354-5. *ASPIRE Steering Group. A British Cardiac Society survey of the potential for the secondary prevention of coronary heart disease: ASPIRE principal results. Heart 1996;75:334-42.,East riding project - the national picture,Other problems often no help for the first 6 weeks (when many going to work) patients receive conflicting advice (hospital / GP) little or no follow-up after discharge, no acute/community dialogue no training for CR and poor knowledge amongst staff no identifiable budget for CR lack of support from cardiology Thompson DR, Bowman GS, Kitson AL. Cardiac rehabilitation services in England and Wales: a national survey. Int J Cardiol 1997;59:299-304. Campbell NC, Grimshaw JM, Ritchie LD, et al. Outpatient cardiac rehabilitation: are the potential benefits being realised? J R Coll Physicians Lond 1996;30:514-9.,East Riding Project - the national picture,East riding project - the area,East riding project - key solutions,identify and follow patients - hospital information systems too slow and inaccurate - central MI register updated daily transport - too far for many patients to travel, some unwilling/unable to come back to hospital - home based programme cost effectiveness - provide appropriate level of help - 30% of patients 12 weeks after MI report “life as good or better than before” without rehab - provide only the care required long term compliance and secondary prevention - traditionally poor - improve acute/community dialogue, annual audit, use sports centres and self help groups,The Heart Manual,150 NHS locations 110 Hospitals 6 health authority wide schemes 9 health districts 5 PCGs 20 single handed GPs 5,000 patients & families pa. 1,650 trained facilitators in UK available across USA, RCTs underway in Holland & Italy,Information from Heart Manual Project, Edinburgh. 0131 537 9127,Confirmed MI Hospital based facilitator introduces patient and partner to HM,East riding project - system,Community based Facilitator guides patient through 6 week HM programme. Home visits week 1,3,6. Final visit gathers assessment data.,Triage meeting,Discharge to support group and gym,Annual GP checks,Refer to GP / specialist (psychologist, dietician etc),Refer to hospital based programme,Community facilitator visit at 6 months to reassess,East riding project - database,Measure week 1 week 6 6 months BP BMI Smoking Medication Anx / Dep (HAD) Diet / Exercise (DINE) QOL / symptoms (CLASP),East riding project - assessments,East riding project - system,East riding project - costs,Costs in first year cont. Heart Manuals 700 pa. 7,000 14,000 Training facilitators 3,000 1,000 Admin costs 3,000 2,000 Community facilitators 38,540 40,000 Admin & clerical 10,346 12,000 Total 61,886 69,000 approx 100.00 per patient,East riding project - results,April 1st 1999 - March 13th 2000 798 confirmed MIs Hospital based facilitator introduced 82% patients discharged with HM,95% completed 6 week assessment after HM Programme (22 died 12 withdrawn from HM for variety of reasons),443 patient have been triaged,78% discharged to support group 23% assessed for gym,15% referred to GP,15% referred to hospital based programme 9% to rehab nurse 2% hospital dietician,