Comprehensive cardiac rehabilitation (CR) is defined as: “The sum of activities required to ensure the best possible physical, mental and social conditions, so that the cardiac patient may resume as normal a place as possible in the life of the community.”1This implies the use of an indi- vidually tailored combination of physiological, clinical, psychological and social methods. Mea- suring the outcome of a multifaceted intervention is a methodological and logistical challenge.
At present quality assurance of CR is relatively uncommon even though guidelines recommend that data are routinely collected and presented.2 Thus, as CR programs must compete for resources with other healthcare modalities, caregivers will increasingly demand auditing of the service.
When measuring outcome by means of an audit, three different levels are used: clinical outcome of the individual patient, health service outcome of the program, health economic and health management data. Recently a standardized cardiac rehabilitation system for Europe (Euro- CardioRehab) has been proposed under the aus- pices of the former ESC Working Group on Cardiac Rehabilitation and Exercise Physiology (now: the European Association for Cardiovascu- lar Prevention and Rehabilitation (EACPR)).3This system forms the basis of the chapter.
Data Required for the Audit
As not all centers have the means to perform a major audit, we present the following options for quality control: a basic outcome report, the stan-
dard EuroCardioRehab audit and an extended version including health economic data. In all three alternatives, data on program content, referral, baseline program entry data, and outcome at the end of the program are needed.
For the extended version a cost-analysis is mandatory.
Define Program Content (Table 59-1)
This includes the design of the program, that is, inclusion criteria for participation, description of the different interventions (physical training, psychological support, dietary counseling, smoking cessation, vocational guidance), dura- tion, number of sessions. It should contain a description of the structure of the cardiac reha- bilitation staff, facilities (training halls, equip- ment), and safety precautions. Financial issues should be addressed: costs of the program, costs for the participant, resources available from healthcare providers.
Referral to CR (Table 59-2)
Here an estimate of the annual total patient population eligible for CR from the referral area of the center should be given. For the individual patient, the initiating cardiac event and the demographic data are required as well as information on relevant co-morbidity. Date of referral, referring physician, and reasons for non- referral or not agreeing to attend should be recorded.
59
Outcome Measurement and Audit
Joep Perk
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Pre-Cardiac Rehabilitation Data (Table 59-3)
Upon commencing the program, work status and risk behavior prior to the event, the present risk factor status, relevant biometric data and bio- chemistry, ongoing medication, physical work capacity, and mental health status should be entered.
TABLE59-1. Content of the cardiac rehabilitation program Criteria for participation: initiating event
All age groups or age limits?
Contraindications:
Unstable angina pectoris Severe cardiac failure Hazardous arrhythmia Others
Options (duration, number of sessions) Exercise training
Group exercise
Individual exercise program Home exercise plan Lifestyle education
Written
Group discussion, video etc.
Dietary advice
Group class (practical sessions) Individual
Psychological intervention Stress management Psychological advice in group Individual psychological session Vocational assessment
Occupational therapist: group session Occupational therapist: individual session
Other methods, e.g. Heart Manual, Angina Plan, home visits etc.
Medication advice Staff
Structure: cardiologist, cardiac nurse, physiotherapist, dietitian, occupation therapist, psychologist, others
Level of competence: targeted education, postgraduate education, research
Facilities, safety
Training halls, meeting rooms, equipment
Safety precautions, resuscitation material, emergency medication Costs
Total CR program budget Staff costs Other program costs Patient fees Main care provider
TABLE59-2. Referral to cardiac rehabilitation
Expected annual size of the population eligible for the program: n= . . .
Referral Reason for non-inclusion
• Referring physician or clinic • Exclusion criteria
• Date of referral • Lack of resources
• If no referral: reason? • Ongoing investigations
• Age • Other
• Gender
• Marital status Reasons for non-acceptance
• Educational level • Not interested
• Too far to travel
• Returned to work
• Mental disorder
• Others
Initiating event Previous cardiac events (as left)
• STEMI/LBBB MI
• NSTEMI Relevant co-morbidity
• Unstable angina • Angina
• Stable angina • Stroke
• Percutaneous coronary • Diabetes mellitus intervention
• Coronary artery bypass surgery • Hypertension
• Other cardiac surgery • Claudication
• Chronic heart failure • Musculoskeletal disorders
• Pacemaker • Chronic obstructive pulmonary
• ICD disease
• Cardiac transplant • Malignancy
• Congenital heart disease • Other
• Other
TABLE59-3. Pre-cardiac rehabilitation data
Work status Risk factor status
• Full-time • Smoking
• Part-time Current
• Unemployed Former
• Permanent sick leave Never
• Retired • Hypertension
• Housework • Hyperlipidemia
• Student • Physical inactivity
• Overweight Biometric data and biochemistry
• Height Mental health status
• Weight • History of depression
• Waist circumference • Anxiety score on HAD chart
• Systolic blood pressure • Depression score on HAD
• Diastolic blood pressure chart
• Blood lipids
Total cholesterol Medication HDL cholesterol • Antiplatelet LDL cholesterol • Anticoagulant
Triglycerides • Beta-blocker
• Fasting plasma glucose • ACE inhibitor
• Physical work capacity • Angiotensin II receptor blocker Exercise stress test • Lipid-lowering drugs
METs • Antidiabetic drugs
Number of shuttles • Others Distance walked
such as the costs of medical care (including drugs and admissions) during the duration of CR and the indirect costs for the patient (absence from work). (See Chapter 60.)
Basic Outcome Report
The basic report consists of an individual patient assessment form and an annual service assess- ment form. The patient document can act both as direct outcome feedback to the participant and as a base for onward referral after completion of the program. This form should contain a progress report, a summary of the patient’s risk factor status, ongoing treatment, and recommendations for a heart-healthy lifestyle.
The basic demands of an annual service assess- ment form are:
• number of participants entering the CR program as part of the total eligible population
• number of patients completing the program
• percentage of patients reaching the target goals for preventive cardiology4
䊊 total cholesterol <5mmol/L, LDL cholesterol
<3mmol/L
䊊 Blood pressure <140/90mmHg
䊊 BMI ≤25, waist circumference <102cm for men, 88 cm for women
䊊 non-smoking
䊊 regular physical activity 30 min/day at least 3–5 times weekly
• percentage of patients returning to work
• a summary of adverse events related to the program.
The basic outcome report will give patients, referring physicians, and the recipients of onward referral the key patient data of the program. It may also satisfy the need for annual quality assurance of CR centers in most countries as the main data on production, effects, and side-effects are included.
Standard EuroCardioRehab Audit
This audit provides an in-depth analysis of the program. Detailed data on the population using the service are available: demographic data, the
Post-Cardiac Rehabilitation Data (Table 59-4)
When the patient has completed program work the actual risk factor status (physically active, non-smoker, adequate food habits etc.), relevant biometric data and biochemistry, ongoing med- ication, physical work capacity, mental health status, and the resumption of work should be recorded. Has the patient complied with the program, discontinued, or was there poor compli- ance? Any adverse events in the course of the program? Which type of onward referral has been chosen?
Health Economic Data
In the extended version of the audit, the total direct costs of the program and the program costs per patient are required, as are the direct costs for the patient (fees, transport etc.). For a more advanced analysis, other costs must be included, TABLE59-4. Post-cardiac rehabilitation data
Program Compliance
Which options were offered: Participation rate:
• Exercise training • 90% of all sessions
• Lifestyle education attended
• Dietary advice • 75–90% attended
• Psychological intervention • 50–75% attended
• Vocational assessment • <50% attended
• Other methods
• Medication advice
Reasons for drop-out:
Adverse events: • Poor motivation
• Cardiac events • Distance
• Orthopedic injuries • Returned to work
• Psychological complaints • Intercurrent disease
• Other • Others
Return to work Onward referral
• Yes • General practitioner
• No • Cardiologist
• Part-time • Primary care CHD nurse
• Sick leave retirement • Phase IV maintenance program
• Other community program
Physical activity • Patient support group
• Number of times per week • Smoking clinic
• Duration of the activity • Other
Food habits
• Unchanged
• Partially changed
• Completely changed
different indications for referral, time lag between initial event and entry in the program, and the reasons for not being or not willing to be enrolled.
There are the necessary data at the start of CR to be compared with the outcome after completing the program: metabolic parameters, blood lipid levels, blood pressure, weight, and exercise capacity. Risk behavior is documented regarding physical activity, smoking and food habits, but even psychological outcomes are all measured.
The EuroCardioRehab model includes an analysis of compliance in which participation in the different CR options can be monitored and related to age, gender, and the initial cardiac event, thus enabling in-program adaptations.
Here, the individual patient assessment form may contain the same elements as in the basic format but the annual service assessment form can be further tailored to the needs of the CR team (e.g. detailed report on adherence and outcome of different interventions).
Health authorities will find data regarding access for the eligible population, the size and structure of CR, adherence to guidelines and health policy data.
On an international level, it facilitates a comparison between different national models which may well contribute to improved services.
In this respect it should be noted that the dataset in EuroCardioRehab is based upon existing experience from Italy, Ireland, the United Kingdom, and Switzerland. It has been prepared after consultation with 30 European countries.
The format of the annual service assessment form may differ between users and centers:
obviously a service manager will need a different type of report than the team dietitian, who will be more interested in the specific nutritional parts of the program. Therefore it is beyond the scope of the textbook to propose detailed audit models. Yet we recommend that the core components of the annual assessment contain:
• demographic data on the participants entering the CR program as part of the total eligible pop- ulation: age, gender, diagnosis, risk factor levels at entry, work status.
• reasons for non-referral or non-attendance
• numbers of patients attending the options of the program, drop-out rates per option, and reasons for drop-out
• percentage of patients reaching the target goals for preventive cardiology
䊊 total cholesterol <5mmol/L, LDL cholesterol
<3mmol/L
䊊 blood pressure <140/90mmHg
䊊 BMI ≤25kg/m2, waist circumference <102cm for men, 88 cm for women
䊊 non-smoking
䊊 regular physical activity of 30 min/day, at least 3–5 times weekly
• basic statistics of the biometric and biochem- istry data
• percentage of patients returning to work
• data on quality of life
• an overview of adverse events related to the program
• morbidity data
• actions taken to improve the program during the year
• educational activities for the staff, scientific projects.
Extended Audit Version
Beyond the core components of the audit, extensions can be made for research purposes, for scientific comparison between models, but even for health economic studies. It has been shown that cardiac rehabilitation is an effective use of available means although the competition from other sectors of healthcare is fierce. CR programs vary widely and the dif- ferences in health economic results between programs have been insufficiently documented.
Only a small proportion of the patients who would benefit are at present invited to participate, which might be explained by a lack of knowledge on the efficiency of the programs. Therefore, the extended annual assessment should include data on the cost of participation per patient and the cost related to the outcomes on risk factors, medication, return to work, and quality of life.
The choice of method of outcome measurement and auditing remains evidently in the hands of the
2. Giannuzzi P, Saner H, Bjornstad H, Fioretti P, et al.
Secondary prevention through cardiac rehabilita- tion: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. Eur Heart J 2003;24:1273–1278.
3. McGee H, Fioretti P, Saner H, Perk J. EuroCardio- Rehab: a standardised cardiac rehabilitation infor- mation system for Europe. Eur J Cardiovasc Prev Rehabil 2005;12:299.
4. Third Joint Task Force of European and other Soci- eties. European guidelines on cardiovascular disease prevention in clinical practice. Eur J Cardiovasc Prev Rehabil 2003;10(suppl 1):S1–S78.
CR staff, its management and policy makers, but in the light of increasing demands for healthcare, comprehensive cardiac rehabilitation will face difficulties in the near future if no regular quality control, especially an annual service assessment, can be provided.
References
1. WHO. The rehabilitation of patients with card- iovascular diseases. Report on a seminar. EURO 0381. WHO, regional office for Europe, Copenhagen;
1969.
