Evolution of Cardiac Rehabilitation in Australia
The concept of cardiac rehabilitation (CR) was introduced into Australia by the National Heart Foundation (NHF) in 1961 when it began estab- lishing CR clinics in each of the major cities.
Medical Directors of the four pioneer CR clinics were Dr Alan Goble, Melbourne, Dr Tony Seldon, Sydney, Dr Graeme Neilson, Brisbane, and Dr Robert Cutforth, Hobart. By 1964 over 1000 patients were attending these clinics.
The success of these clinics, together with the establishment of coronary care units,led to a greater interest in the principles of CR among cardiologists, physicians, and general practitioners. Gradually the clinics were phased out in favor of structured exercise and education programs that were being established in hospital outpatient departments.
Multidisciplinary hospital- and community-based programs of group light–moderate exercise, combined with education and discussion, have become the predominant model throughout most of Australia.1 These programs incorporated the essential components of CR without reducing efficacy, thereby providing greater access for patients and improving cost-effectiveness.2
Factors Influencing Development of Cardiac Rehabilitation in Australia
Research
From 1980 to 1985 a landmark study, undertaken at the Austin Hospital, Melbourne, compared the
high-intensity exercise component of CR to a light–moderate exercise program. It was demon- strated that a light–moderate exercise program achieved the same benefits gained from high- intensity exercise.3,4This had important implica- tions for CR in Australia. The advantage of a light–moderate exercise program is that it can be conducted in community settings, as well as hos- pitals, because it needs no special equipment or medical supervision and is therefore much cheaper to run. It is also much more acceptable to older patients and females. As a result, high- intensity exercise programs typically recom- mended overseas are uncommon in Australia.
The important role that psychosocial factors play in the recovery and prognosis of patients with heart disease was recognized early in the development of CR in Australia.5The early NHF clinics included a social worker and psychiatrist as part of the rehabilitation team.
As evidence has emerged for the benefits of risk factor reduction and adherence to certain med- ications (secondary prevention), CR programs in Australia have increasingly incorporated the prin- ciples of identification and management of risk factors through lifestyle change and compliance with medical therapies.
Role of the National Heart Foundation (NHF)
In addition to establishing the NHF CR clinics during the early 1960s, the NHF maintained a National Cardiac Rehabilitation Committee re- sponsible for providing expert advice to the Foun- dation, as well as developing policies, guidelines,
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Cardiac Rehabilitation: Australia
Michael V. Jelinek and Stephen J. Bunker
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42 M.V. Jelinek and S.J. Bunker
and professional education resources. During the late 1980s and early 1990s, the growth and development of a decentralized network of hospital- and community-based programs throughout Australia was facilitated by NHF staff who had been employed to work with multi- disciplinary health professionals and assist with the planning and establishment of programs.
The NHF also encouraged and supported the establishment of state-based Cardiac Rehabilita- tion Associations, as well as the Australian Cardiac Rehabilitation Association, which provide forums and support for health professionals with an interest in, or working in, the field.
Funding Model
With the exception of the privately funded health sector, there has been no formal funding base for CR in Australia. Health professionals contribute their time to the program as part of their wider role and responsibilities within the hospital or primary care setting. Only in the case of larger centers are coordinators employed and then usually only on a part-time basis. This model has contributed to both the low cost of CR in Australia and its sustainability.
Current Status and Future Directions
Through its CR policy and guidelines6 the NHF promotes the routine referral of all patients with cardiovascular disease to an appropriate CR program. Patients are encouraged to attend as soon as possible after discharge. Currently, there are almost 300 structured post-discharge CR pro- grams throughout Australia, mainly in urban areas. Programs vary in length from a minimum of one session a week for 6 weeks through to more comprehensive programs.
Despite the abundant evidence supporting the benefits of CR, only a minority of patients attend a structured CR service in Australia.7–9CR is more likely to be performed by patients after coronary artery bypass surgery than after percutaneous coronary intervention. Reasons for poor attendance at CR include lack of available CR services10 as well patient under-referral and underutilization.8,11
To address issues such as the lack of CR services in rural and remote areas, the NHF has called for the development of alternative models of CR to reach a greater number of patients, particularly disadvantaged populations. For example, Aborig- inal and Torres Strait Islander people are known to die from cardiovascular disease at twice the rate of other population groups but they are under- represented in CR and there is a strong need to develop flexible methods of CR delivery.6
The delivery of home-based programs, which have been shown to be as safe and cost-effective as hospital-based CR programs, has been growing overseas, particularly in the UK. However, no such model is currently being evaluated in Australia.
The Coaching Patients on Achieving Cardiovas- cular Health (COACH) Program is a training program for patients with coronary heart disease.
Health professionals use the telephone to train patients to vigorously pursue the target levels for their particular coronary risk factors while working with their usual doctor(s). Coaching emphasizes both lifestyle measures and drug treatment. The COACH Program has been shown to be effective in achieving secondary preven- tion goals and targets12,13 and reducing hospital readmissions.14
Conclusion
CR in Australia is predominantly based on group light–moderate exercise and education programs.
As is true elsewhere, only a minority of patients with coronary heart disease attend CR. New models are being developed, particularly the COACH Program, which potentially can reach all patients in Australia by the telephone.
References
1. Hare DL, fitzgerald H, Darcy F, Race E, Goble AJ.
Cardiac rehabilitation based on group light exercise and discussion. An Australian hospital model.
J Cardiopulm Rehabil 1995;15(3):186–192.
2. Hare DL, Bunker SJ. Cardiac rehabilitation and sec- ondary prevention. Med J Aust 1999;171:433–439.
3. Goble AJ, Hare DL, Macdonald PS, Oliver RG, Reid MA, Worcester MC. Effect of early programmes of high and low intensity exercise on physical perfor-
8. Cardiac Rehabilitation: Australia 43
mance after transmural acute myocardial infarc- tion. Br Heart J 1991;65:126–131.
4. Worcester MC, Hare DL, Oliver RG, Reid MA, Goble AJ. Early programmes of high and low intensity exercise and quality of life after acute myocardial infarction. BMJ 1993;307:1244–1247.
5. Wynn A. Unwarranted emotional distress in men with ischaemic heart disease. Med J Aust 1967;2:
847.
6. National Heart Foundation of Australia. Recom- mended Framework for Cardiac Rehabilitation.
2004. (Available at: www.heartfoundation.com.au/
downloads/CR_04_Rec_final.pdf_)
7. Bunker S, McBurney H, Cox H, Jelinek M. Identify- ing participation rates at outpatient cardiac rehabilitation programs in Victoria, Australia.
J Cardiopulm Rehabil 1999;19(6):334–338.
8. Scott IA, Lindsay KA, Harden HE. Utilisation of out- patient cardiac rehabilitation in Queensland. Med J Aust 2003;179:341–345.
9. Sundararajan V, Bunker SJ, Begg S, Marshall R, McBurney H. Attendance rates and outcomes of cardiac rehabilitation in Victoria, 1998. Med J Aust 2004;180:268–271.
10. Dollard J, Smith JR, Thompson D, Stewart S. Broad- ening the reach of cardiac rehabilitation to rural
and remote Australia. Eur J Cardiovasc Nurs 2004;3:27–42.
11. Bunker SJ, Goble AJ. Cardiac rehabilitation: under- referral and underutilisation. Med J Aust 2003;179:
332–333.
12. Vale MJ, Jelinek MV, Best JD, Santamaria JD. Coach- ing patients with coronary heart disease to achieve the target cholesterol: a method to bridge the gap between evidence-based medicine and the
‘real world’. Randomized controlled trial. J Clin Epidemiol 2002;55:245–252.
13. Vale MJ, Jelinek MV, Best JD, et al. Coaching Patients on Achieving Cardiovascular Health (COACH); a multicenter randomized trial in patients with coro- nary heart disease. Arch Intern Med 2003;163:
2775–2783).
14. Vale MJ, Sundararajan V, Jelinek MV, Best JD.
Four-year follow-up of the multicenter RCT of Coaching Patients on Achieving Cardiovas- cular Health (The COACH Study) shows that The COACH Program keeps patients out of hospital. Oral presentation at the 77th Scien- tific Sessions of the American Heart Associa- tion, November 7–10, 2004, New Orleans, Louisiana, USA. Circulation 2004;110: Suppl: III- 801.
