Introduction
The provision of multifactorial cardiac rehabilita- tion and secondary prevention strategies requires a range of skills and knowledge which, while understood by cardiologists, are delivered only in part by them. The role of the cardiologist in the initiation of cardiac rehabilitation programs is self-evident. As patient advisors, cardiologists are in an ideal position to recommend the benefits of cardiac rehabilitation to the individual patient.
They are also in a prime position within the health services and individual medical institutions to espouse the establishment and appropriate financial support of such services. However, most cardiologists today, while appreciating the value of secondary prevention as an essential follow-up to cardiovascular interventions including surgery, are not in a position to provide personally the advice and supervision of the individual patient’s activities that is required, due to the time demands of the greatly expanded application of new technologies in cardiovascular services.
There are thus a number of distinct challenges to ensuring the provision of cardiac rehabilitation services.1 Firstly, cardiologists must work at the policy and health service level to promote the establishment and ongoing provision of cardiac rehabilitation services. In tandem with this “top down” approach, cardiologists must ensure that as resources become available, they can ensure the provision of high quality cardiac rehabilitation programs for their patients. This needs to be achieved through the provision of appropriately trained cardiac rehabilitation staff. In this era of
rapid scientific development, cardiologists must start with their own training. Leading a cardiac rehabilitation team requires academic and team management skills. Alongside this there needs to be training for other health professionals who will work with the cardiologist to deliver the program for patients. This “bottom up” approach of pro- viding staff appropriately trained to deliver ser- vices is an essential counterpoint to the more “top down” activities necessary to deliver policy and resource change in the provision of cardiac reha- bilitation services. These three issues are dealt with in the next sections with illustrations of how that can be addressed.
Health Policy Changes to Promote Cardiac Rehabilitation
Service Delivery
It is essential that cardiac rehabilitation services are identified and supported in national strategic, policy and policy implementation documents if these services are to be established and main- tained and not subject to budgetary or other influences in the health or wider economic systems. Having clear commitments to service delivery is the most important protection that cardiac rehabilitation services can have. It allows individuals and centers or regions to look for the services that are committed and to resist efforts to dismantle services in the interests of other priorities, for example removing or reducing space or redeploying staffing already
55
Developing Cardiac Rehabilitation Services:
From Policy Development to Staff Training Programs
John H. Horgan
460
committed to cardiac rehabilitation services. Thus it is worth a lot of investment of time by individ- uals to this higher order aim, as when there is policy level protection, the debates can be about
“how” to provide services rather than about “will you” provide services.
A number of countries have developed explicit national policies on cardiac rehabilitation ser- vices. Two examples are the Republic of Ireland and the United Kingdom. The UK’s strategy – A National Service Framework for Coronary Heart Disease (2000) – has 12 sets of standards with one dedicated to cardiac rehabilitation.2The Republic of Ireland’s first national cardiovascular strategy – entitled Building Healthier Hearts (1999) – identified cardiac rehabilitation as a key aspect of services, devoted a whole chapter to it and pro- duced 10 specific recommendations.3 These rec- ommendations endorsed the need to expand cardiac rehabilitation services to all hospitals treating patients with heart disease; to have these programs supervised by a cardiologist/physician with a special interest in cardiology; to have pro- grams run by a specially trained cardiac rehabili- tation coordinator; to ensure a system of rehabilitation starting from phase I in hospital to phase IV in long-term community maintenance;
to ensure adequate funding for staff training, equipment and facilities; and to develop a national audit system for cardiac rehabilitation. The impact of a national strategy on cardiac rehabilitation service development has been significant.A review before the strategy commenced showed that only 29% of relevant hospitals had a cardiac rehabilita- tion program in 1998.4The first recommendation of the strategy in relation to cardiac rehabilitation was that “every hospital that treats patients with heart disease should provide a cardiac rehabilita- tion service.” Five years later, in 2003, a repeat survey showed that 77% had programs, with the remainder in advanced stages of planning.5
The benefits to cardiac rehabilitation service development are evident following a focused health service strategy in which cardiac rehabili- tation was prioritized. Thus collective efforts across centers to encourage the prioritization of cardiac rehabilitation in national health policy initiatives can be a very efficient method of sup- porting development. The next challenge in the Irish system, as in others, is to ensure optimum
levels of service uptake among cardiac patients. A recent study estimating the total number of patients referred to and completing cardiac reha- bilitation programs in the UK in 2000 found that only 45–67% of patients were referred while just 27–41% attended.6 On a more European-wide front, a 1996 survey found levels never exceeding 50% across 13 of the then 15 EU member states.7 Another “top down” recommendation of the Irish strategy was the development of a national audit system. This has been achieved and is currently being rolled out nationally. It is also forming a basis for European initiatives in this area. These have been developed with current European guidelines in mind.8 Only in this way can the real gap between service availability and universal service delivery be achieved.
The CARINEX project demonstrated that service uptake was a particular challenge across all of the EU states surveyed.7 While centers could produce numbers in terms of program throughput, particularly at phase III, very few could say what proportion of eligible patients were being serviced and why others were not invited or did not attend. These examples given here of the Irish system are to illustrate how individuals, centers, regions or national groups such as cardiac rehabilitation associations or professional bodies such as national cardiac soci- eties can use “top down” approaches. Documenta- tion may prove beneficial so that those interested in this approach do not have to undertake development de novo.
In terms of moving to “bottom up” approaches, specific training for professionals is considered next.
Professional Training for Cardiac Rehabilitation: Training for Cardiologists
Countries that have put in place policies to review the provision of cardiac rehabilitation services have uniformly recommended the involvement of a cardiologist or a cardiovascular physician as an essential requirement for the establishment of programs. At present, however, the training of most cardiologists does not include a mandatory
requirement to obtain experience in the areas of rehabilitation or secondary prevention although the acquisition of knowledge in this area is recommended. It can no longer be assumed that the knowledge required to impart appropriate advice in terms of secondary prevention strategies can be obtained during the clinical rotations which form part of most cardiology training pro- grams. Given the importance of national guide- lines, with their emphasis on primary and secondary prevention, it is essential that future cardiology training programs worldwide should obligate trainees to acquire experience of the broad area of secondary prevention and rehabili- tation, the value of which is becoming increasingly obvious and is supported by a growing literature as outlined in great detail elsewhere in this book.
The European Society of Cardiology has made significant developments in this field with a core curriculum now established. This will be an important mechanism to ensure cardiac rehabili- tation has effective leadership in the coming decades.
Professional Training for Cardiac Rehabilitation: Training for Other Health Professionals
The multifactorial nature of cardiac rehabilitation requires the expertise of a range of non-medical heath professionals including nurses, physiother- apists, occupational therapists, physical educa- tionalists, nutritionist, pharmacists, vocational counselors, and psychologists. The exact combi- nation in a team may differ from country to country depending on the resources available in terms of staffing and roles among different pro- fessional groups. While not every team will require the input of each of the above, many of the areas of special expertise peculiar to these profes- sional groups are of particular value in designing and/or delivering cardiac rehabilitation pro- grams. The education of these individuals, however, will have been confined to the core focus of their specialty and no in-depth training in car- diovascular disease is generally provided, even in the case of nurses. The rapid advances in
our understanding of cardiovascular pathology means that staff working in this area must have a basic familiarity with cardiovascular medicine and its treatments.
While it is unreasonable to expect all profes- sionals in these other disciplines who interact with cardiac patients to have an extensive knowl- edge of modern cardiovascular medicine and surgery, those entrusted with the coordination of rehabilitation programs should have a mechan- ism by which such an overall knowledge can be obtained. Such individuals can provide a valu- able link between the cardiologist, other mem- bers of the cardiac rehabilitation team, and the patient. To address this need for specialist educa- tion of those who will coordinate cardiac rehabilitation programs in the Irish context, an educational program was established with emphasis on the provision of a broad general training in cardiac rehabilitation program deliv- ery. It is characterized by its multidisciplinary approach to cardiac rehabilitation and the combi- nation of clinical and academic training. The aim is to produce cardiac rehabilitation coordinators who practice their profession in a way that com- bines attention to best practice from clinical and research evidence with sensitivity to the needs of individual patients. Such training can help promote cohesion among cardiac rehabilitation centers and promote acceptable standards of service to patients. In recognition of the course coverage and standard, the program now leads to a Masters in Cardiac Rehabilitation (MSc Cardiac Rehab) through the National University of Ireland and the Royal College of Surgeons in Ireland. The course outline has been published9and is briefly outlined here.
The aim of the course is to provide professional training for health professionals to qualify them to develop and coordinate cardiac rehabilitation programs within the healthcare services. The objective is to ensure that through the integration of theoretical and clinical training, graduates will be able to promote the delivery of multifactorial cardiac rehabilitation services. Trainees are pro- vided with the knowledge and skills to coordinate the activities of a multidisciplinary cardiac reha- bilitation team. The course is based on a scientist- practitioner model with the practice of cardiac
exercise and other components, report writing, referral letters, class planning, and coordination with other disciplines. Trainees are assigned to the various components of the cardiac rehabilita- tion setting to learn the skills and activities of the various team members. Trainees acquire practical experience with ECG technicians, psychologists, and a dietitian, pharmacist and vocational officer. Trainees are required to successfully run both psycho-educational and exercise classes. These classes are graded by the supervising professionals and contribute to course grades.
It has been an important principle of the course that students can be from any of the health professional disciplines (since the training is not in service delivery but in service coordina- tion and management). In practice, since in many situations the coordinator will fulfil this and other roles in a program, they have mostly been experienced cardiac nurses with some physiotherapists and physicians. The course has unseen written exams, a course planning project, grades for practical/clinical work, a research dissertation, and an oral examination, all overseen by an external examiner. For those who opt not to do the research dissertation component (since this may not be of interest to or a personal strength of the professional involved), a diploma is available on successful completion. To date, having started in 1992, 51 students have graduated with diplomas from the program with 11 undertaking research dissertations for MSc qualifications.
The development of this training program in the early 1990s was undertaken to bridge the gap between aspiration and action for busy cardiologists committed to the concept.
It has proven to be the enabler for national development of programs. Some cardiologists have been able to have selected staff released for training in order to run programs in the hospital which are cardiologist led but co- ordinator provided and managed. Training was supported by hospitals and also importantly by the national heart association – the Irish Heart Foundation. Staff training also meant that as soon as there was a national commitment to providing cardiac rehabilitation through rehabilitation grounded on scientific research.
The course has both an academic and skills-based component. It produces graduates who will prac- tice their profession in a way that combines atten- tion to best practice from clinical and research evidence with sensitivity to the needs of individ- ual patients. The course is run over an academic year. The first component is an intensive course of both formal lectures and practical sessions in physiology, exercise training, exercise stress testing, and psychological counseling The second component is an intensive course of both formal lectures and practical sessions in psychology, exercise training, and exercise stress testing.
This includes off-site visits to other cardiac reha- bilitation centers for further training. The final component comprises attendance at formal lec- tures on research methodology followed by indi- vidual completion of a course-related research thesis.
Trainees are assigned to the various compo- nents of a multidisciplinary cardiac rehabilitation service to learn the skills of various team members. Staff include cardiologists, nurses, medical staff, ECG technicians, exercise physiolo- gists, anatomists, psychologists and a dietician, pharmacist and vocational officer. All trainees must possess Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) certi- fication before completion of the program. Acade- mic content is summarized in Table 55-1.
The total number of contact teaching hours are 360, with a further 300 hours of directed learning.
The clinical training aims to ensure that trainees are competent in planning and supervis- ing multifactorial cardiac rehabilitation classes.
Training in planning and design of cardiac reha- bilitation programs is provided, for example choice of safe and appropriate locations for
TABLE55-1. MSc program: theory-based and competency-based components (allocated hours)
Theory-based Competency-based Total
Physiology 40 17 57
Clinical cardiology 40 – 40
Cardiac rehabilitation 88 155 243
Research methodology 20 – 20
References
1. Horgan JH, McGee HM. Cardiac rehabilitation:
future directions. In: Jones D, West R, eds. Cardiac Rehabilitation. London: BMJ Publishing; 1995.
2. Department of Health. A National Service Frame- work for Coronary Heart Disease. London: Depart- ment of Health; 2000.
3. Department of Health. Building Healthier Hearts.
The report of the Cardiovascular Health Strategy Group. Dublin: Government Publications; 1999.
4. McGee HM, Hevey D, Horgan JH. Cardiac rehabilita- tion service provision in Ireland. Ir J Med Sci 2001;170:159–162.
5. Lavin D, Hevey D, McGee HM, De la Harpe D, Kiernan M, Shelley E. Cardiac rehabilitation services in Ireland: the impact of a coordinated national development strategy. Ir J Med Sci 2005;174(4):
33–38.
6. Griebsch I, Brown J, Rees K, et al. Is provision and funding of cardiac rehabilitation appropriate for the achievement of national service framework goals?
Proceedings from the Society of Social Medicine 47th Annual Scientific Meeting, Edinburgh, 17–19th Sep 2003.
7. Vanhees L, McGee HM, Dugmore LD, Schepers D, Van Daele P. A representative Study of Cardiac Reha- bilitation Activities in European Union Member States. The Carinex Survey. J Cardiopulm Rehabil 2002;22:264–272.
8. Giannuzzi P, Saner H, Bjornstad H, et al. Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilita- tion and Exercise Physiology of the European Society of Cardiology. Eur Heart J 2003;24:
1273–1278.
9. Hevey D, McGee, Cahill A, Newton H, Horgan, JH.
Training cardiac rehabilitation co-ordinators. Coro- nary Health Care 2000;4:142–145.
the national strategy in 1999, there was a cadre of highly trained and motivated professionals to undertake this work. Some of the graduates also took up health service management positions to implement the cardiovascular strategy when it was launched and thus the message of the value of cardiac rehabilitation services was communicated to a much wider and different audience within the health system. This shows how bottom up and top down approaches can be very complementary in promoting cardiac rehabilitation development.
Conclusion
The rehabilitation system as it has evolved can be seen as the prototype of the concept of the cardiac care teams now utilized in the provision of acute chest pain and heart failure clinics. The establish- ment of such teams has already begun to mitigate to some extent problems arising from the interven- tional burden which has devolved on cardiologists.
The financial implication of the sharing of clinical responsibility between physicians and non-physi- cian members of cardiac teams may be seen by third party payers as a mechanism by which costs of care can be reduced and availability enhanced. It is critical, therefore, that outcomes are evaluated so that decisions concerning the sharing of specific responsibilities can be based on evidence that these changes have brought about improved outcomes.A trans-national agreed system would be of great importance in facilitating international compar- isons. The strategies outlined here can go a long way towards achieving the desired goal.
