Cardiac Rehabilitation Review (April 2010-March 2011 data ... of... · SWCN Cardiac Rehabilitation Review (April 2010 – March 2011) and Recommendations Page 2 of 20 Author Jackie

Cardiac Rehabilitation Review (April 2010-March 2011 data)

and Recommendations Referenced against the British Association

Cardiovascular Disease Prevention and Rehabilitation Standards and Core Components 2012

SWCN Cardiac Rehabilitation Review (April 2010 – March 2011) and Recommendations

Page 2 of 20 Author Jackie Austin Lead Cardiovascular Nurse March 2013

Contents

1. Executive summary p. 3

2. Aim of the review 4

2.1. Objectives 4

3. Background Fig 1 4

4. Method 6

5.1 Standard 1 Table 1 7

5. 2 Standard 2 Tables 2,3, Fig 2 8-9

5.3 Standard 3 Tables 4, 5, 6, 7, Fig 3 10-11-12

5.4 Standard 4 Tables 8,9 Fig 4 13-14


5.6 Standard 6 16


6. Conclusion 18

References 18

List of Recommendations 19



1. Executive summary An inaugural review of Cardiac Rehabilitation (CR) services across South Wales was

undertaken in 2008/9 by the then South East Wales and the Mid and South West Wales Cardiac Networks. With reference against the Quality Requirements (supporting the updated

NSF 2009) the report highlighted inequity in service provision and made specific recommendations on how services could be improved. Recommendations requiring no additional resource such as a designated cardiologist for each centre and robust referral

criteria for the region have been actioned.

With mounting concerns of withdrawal of CR services due to cost pressures particularly in Mid and West Wales the South Wales CR Group requested a further review for 2010/11; the initial purpose of which would be to act as a service comparator over time. Although the supplied

information is referenced against the Quality Requirements the group decided to take a contemporary approach and model the review against the publication of the national British

Association for Cardiovascular Prevention and Rehabilitation (BACPR) Standards and Core Components 2012 (1). The aim of this second edition is to ensure programmes are clinically-effective, cost-effective and achieve sustainable health outcomes for patients.

The seminal definition of CR is ‘The co-ordinated sum of activities required to influence

favourably the underlying cause of cardiovascular disease as well as to provide the best possible physical, mental and social conditions, so that patients may by their own efforts

preserve or resume optimal functioning in their community and through improved health behaviour slow or reverse disease progression…………..it must be integrated with secondary prevention services of which it forms one facet’

(The World Health Organisation (WHO). Cardiac rehabilitation and secondary prevention long

term care for patients with ischaemic heart disease. Briefing letter. Regional office for Europe: Copenhagen, Denmark; 1993)

Irrespective of where CR is delivered it is said to have occurred only when a patient has been assessed and completed an agreed programme of care using evidence based guidelines; it is

not a case of patients being in receipt of lifestyle information leaflets and attending a community exercise class or receiving ad hoc advice on exercises to do at home. NICE acknowledges the evidence base for CR is at the highest Level 1 (2) it is a clinically cost

effective therapeutic intervention. But as in 2008/9 this review continues to identify inequities and variations in: service models, patient groups offered CR (e.g. heart failure), staffing

levels and skill mix - more specifically patients may not have access to a full multidisciplinary team. These differences in service delivery are inherently related to a lack of adequate funding as a result of earlier poor commissioning activity. It is questionable as to how under

resourced programmes can possibly achieve published benefits such as a reduction in premature cardiac mortality (26-36%) or a reduction in non elective hospital admissions (28-

56%) (2,3,4). The data in this review predominately reflects service performance as opposed to clinical

outcomes and patient experience and satisfaction. To raise the profile of CR in Wales it is important that future reporting will take account of outcomes representing good value both

for patients, service providers and commissioners. The subsequent twenty-three recommendations for service delivery and future service

evaluation are aligned with current national guidelines. Using the National Association of Cardiac Rehabilitation (NACR) data base as a reference it is anticipated there will be

agreement by the South Wales CR community to report on the following four main outcomes on a six-monthly basis.



The number of patients offered (invited to) CR The percentage of patients who started CR

The percentage of patients completing CR The number of patients in whom experience/satisfaction was measured

Regularly comparing the results against the number of patients who should be offered CR and the target completion % will give an indication of how well referral mechanisms are

working and patients’ willingness/ ability to attend and complete CR. Aligning national audit data and guidelines with local delivery will ensure services are doing the job they are

meant to.



2. Aim of the Review The aim of this exercise is to assist in a contemporary approach for future reviews

and act as a precursor for service improvement initiatives

2.1 Objectives

To evaluate CR in South Wales against the Standards and Core Components for

Cardiovascular Disease Prevention and Rehabilitation 2012 using audit data submitted 2010-11

With reference to each Standard and the National Association of Cardiac Rehabilitation Audit make recommendations for future reporting to inform both service providers and commissioners

3. Background As one of the best researched examples of long term conditions management CR is a clinically

and cost effective intervention that results in improved outcomes and quality of life for the patient with heart disease (2,3,4). The following section clarifies the process of CR, lists the

new standards, gives an overview of the patient pathway, and identifies the recommended four key service outcomes and the patient groups to be included in CR.

The definition of the PROCESS of CR is when the patient (6);

Has been assessed using valid measures that address the core components of rehabilitation and secondary prevention

Has had a discussion with appropriate members of the CR team and agreed (appropriate programme goals according to baseline assessment and patient needs)

Has undertaken and completed a clear rehabilitation delivery plan (based on patient

choice and preference) and in accordance with BACPR core components Has completed a final assessment (post delivery of the core components) using valid

measures Has facilitated and agreed a long term management plan for ongoing rehab’ upon being

discharged from a ‘formal’ CR

Has completed and sent a discharge letter to the GP outlining progress and ongoing management

Has been sent and completed a measure of patient satisfaction

The Standards – it is expected that CR services meet seven standards covering all aspects of service delivery from programme content to audit and evaluation

1. Delivery of seven core components inclusive of the following patient management strategies: Health behaviour change and education/ Lifestyle risk factor management/

Psychosocial health/ Medical risk factor management/ Cardio protective therapies/ Long term management/ Audit and evaluation)

2. An integrated multidisciplinary team consisting of qualified and competent practitioners, led by a clinical co-ordinator

3. Identification, referral and recruitment of eligible patient populations

4. Early initial assessment of individual patient needs in each of the core components, on-going assessment and reassessment upon programme completion

5. Early provision of a cardiac rehabilitation programme, with a defined pathway of care, which means the core components are aligned with patient preference and choice



6. Registration and submission of data to the National Audit for Cardiac Rehabilitation (NACR) (3)

7. Establishment of a business case including a cardiac rehabilitation budget which meets

the full service costs

To be responsive to the dynamic nature of cardiac care, where patients may only be in hospital for two to three days CR has moved away from the previous distinct Phases 1-4 (where Phase 1 was In-patient management; Phase 2 the support period prior to Phase III

(exercise/ education programme/ psychosocial support) and Phase IV long-term exercise)

The new Stages of CR are demonstrated in Figure 1 where the strategy focuses on sharing information and education along a continuum from patient identification to discharge and transition to long term management.

FIG 1 Patient pathway of care 0-6 (British Association for Cardiovascular Prevention and Rehabilitation 2012))

The National Audit of Cardiac Rehabilitation (NACR) produces an annual report at the

Strategic Health Authority (England) and Cardiac Network (Wales) level. In South Wales

there is 100% compliance on data entry (n=19 programmes) on those patients who decide to

take part in CR. The next NACR report will align data collection against the following key

outcomes as set out in the Department of Health Cardiac Rehabilitation Commissioning Pack

(5).

The number of patients offered (invited to) CR

The percentage of patients who started CR*

The percentage of patients completing CR

The number of patients in whom experience/satisfaction was measured

It is impossible, however, (a note that is transferable from the South Wales CR Review, 2008) to make comparisons across all Cardiac Rehabilitation centres in terms of staffing, skill mix

and funding. Service variance is largely dependent on the funding and location, type of centre and the population it serves. District General Hospitals (DGH), for example, may not provide

early rehabilitation for patients who require surgical interventions at Tertiary Centres; however, they will continue the rehabilitation pathway of some of these patients. Not all

centres are funded to provide rehabilitation for all groups of patients e.g. heart failure.

0 Identify and

refer patient

1 Manage referral

and recruit patient

2. Assess patient

3. Develop patient

care plan

4. Deliver comprehensive

CR programme

5. Conduct final CR

assessment

6. Discharge and transition to

long term management



In regards to diagnostic groups to be included in CR the DH CR Commissioning Pack (2010) advises high priority should be given to patients with;

A primary diagnosis of Acute Coronary Syndrome (ACS) which includes STEM, STEMI

and unstable angina (NICE CG48; NICE CG 94); and all patients undergoing reperfusion e.g. CABG, PCI, or PPCI.

Chronic heart failure (CHF) of new diagnosis or CHF with a step change in clinical

presentation (NICE CG5)

It is suggested that once services are successful with the high priority patients they should be extended to include for example patients who have undergone valve surgery for reasons other that ACS or heat failure and those with a confirmed diagnosis of exertional angina.

4. Method To enable this review two meetings took place in May and August 2012 between representatives from the South Wales Network and senior CR personnel. To update the

review the data submitted for the period 2010-11 was rationalised and it was decided to employ a data analyst to configure the data from Excel into table format. The Lead

Cardiovascular Nurse for the Network agreed to produce the first draft of the review by end 2012.



5. This section gives a brief overview of each Standard (1-7). The South Wales CR data is presented with recommendations

5.1 STANDARD 1. The delivery of the seven core components employing an evidence-based approach

A key aim of CR, through the core components, is not only to improve physical health and quality of life but also to equip and support people to develop the necessary skills to

successfully self-manage. The delivery of CR should adopt a bio psychosocial evidence-based approach, which is culturally appropriate and sensitive to individual needs and

preferences. With reference to the NACR; the annual outcome report uses data submitted by each

centre from the patient assessment records and demonstrates change between Assessment 1 and 2 (start and completion of the CR programme) and change between

assessment 1 and 3 (@12 months) using the following measures;

BMI <30

Exercise: 5+30 sessions per week

Smokers

HADS Anxiety and Depression

Blood pressure <systolic 140 <diastolic 90

Total Cholesterol <4, Cholesterol LDL <2 Waist <102cm (men) or <88cm (women)

Dartmouth COOP – Quality of Life (inc’ - physical fitness, feelings, activities,

pain, overall health, social support, quality of life) NEW 2013 Minnesota Living with Heart Failure questionnaire

NEW 2013 6 minute Walk Test

This standard also advises patients to have a self management ‘patient held record’ and a discharge letter on completion of Stage 4 is sent to the patients GP and referring

clinician.

RECOMMENDATIONS: 1. Each centre collects and reports on % change in outcome measures 2. There is South West Wales agreement on the use of the same ‘Patient Held

Record’



5.2 STANDARD 2. An integrated multidisciplinary team consisting of qualified and

competent practitioners, led by a clinical co-ordinator This standard also refers to the importance of engagement with the wider team (e.g.

community, primary tertiary and social services)

Table 1 - Staffing WTE - clinical leadership

AB

M B

rid

gen

d

AB

M N

PT

AB

M W

est

C&

V

RC

T N

ort

h

RC

T So

uth

PTH

B

AB

HB

Bla

enau

/Mo

n

AB

HB

To

rfae

n

AB

HB

New

po

rt

AB

HB

Cae

rph

ily

HD

d C

arm

s

HD

d C

ere

dig

ion

HD

d P

emb

s

Population 504, 457 466,036 290,008 131,313 561,420 374,741

Total WTE by LHB 19.1 6.27 14.52 3.3 22.6 15.9

1.0 WTE per

100/1000

26 74 20 40 25 24

Total WTE by Locality 5.3 3.6 10.2 6.27 4.66 9.86 3.3 9.75 4.45 5.0 3.4 10.5 2.6 2.8

A designated team

leader ensuring:

NSF Quality

Requirements

Development of CR

services

Coordination of CR

services

0 20 40 60 80

ABM

C&V

RCT

PTHB

ABHB

HDd

1.0 WTE per100/1000

Total WTE

In regards to the number of WTE per 100/1000 of population, C&V have the least

number with 1.0 WTE per 74.3 (100/1000), RCT the highest with 1.0 WTE per 19.9 (100/1000). The remaining LHBs range between 39.7 and 23.5. When considering the

staffing level for each LHB account needs to be taken of the demography profile. CTHB and ABHB have some of the most deprived areas and the highest levels of CHD in the UK – Blaenau Gwent, Merthyr Tydfil and Rhondda Cynon Taff. It is encouraging to note

that all centres comply to the QR’s.



Table 2 - Staffing – specialist support

Does the cardiac

rehabilitation

service have

access to the

following specialist

services A

BM

Brid

gen

d

AB

M N

PT

AB

M W

est

C&

V

RC

T N

ort

h

RC

T S

ou

th

PTH

B

AB

HB

NH

H

AB

HB

To

rfa

en

AB

HB

New

po

rt

AB

HB

Caerp

hil

ly

HD

d C

arm

s

HD

d C

ered

igio

n

HD

d P

em

bs

a) Smoking cessation

services?

b) Specialist dietary

advice?

c) Designated

Clinical Psychology

service?

d) Counselling and

psychological

support?

Table 3 - Staffing – cover arrangements

The Cover

arrangements for

each member of the

Cardiac Rehabilitation

Team should be

identified: AB

M

Brid

gen

d

NP

T

AB

M W

est

C&

V

RC

T N

ort

h

RC

T S

ou

th

PTH

B

AB

HB

NH

H

AB

HB

To

rfa

en

AB

HB

New

po

rt

AB

HB

Caerp

hil

ly

HD

d C

arm

s

HD

d

Cere

dig

ion

HD

d P

em

bs

Cardiologist or Lead

Physician

Secretary/Administrator

/Team Coordinator

BACR Trainer Instructor

Cardiac Nursing

Physiotherapy

OT

Dietetics

Pharmacy

Psychological Support

As identified in Tables 2-3, all centres have a clinical co-ordinator responsible for the MDT. Access to specialist smoking cessation support is excellent whereas psychological and

dietary support for patients is absent in two areas – C&V and RCT South. Cover arrangements are generally poor apart from Bridgend where all disciplines have cover

apart from a Cardiologist and fitness instructor. Nursing appears to fare better than other disciplines, OT cover is particularly poor. ABHB is the only service that benefits from another Cardiologist taking the lead if required.

RECOMMENDATIONS:

3. To meet Standard 1 ‘ensuring patients receive cardio protective drug therapies’, the team should include at least one independent prescriber. Thereby giving the opportunity to be responsive if patients present who are

not maximally medicated within current guidelines. 4. Centres keep a record of staff changes i.e. <> WTE and professional status

5. The South Wales Cardiac Network is kept informed of cuts to services / staff



5.3 STANDARD 3. Identification, referral and recruitment of eligible patient

populations

For patients to be assessed and recruited to Stage 4 of CR programme within 3 weeks of

the initiating event an agreed and co-ordinated patient referral and recruitment process should be in place for all ‘in scope’ patients (those patients with a confirmed diagnosis as they appear in Table 4). Evidence from the American Heart Association (2011) suggests

that any longer than this, and the memory of the event is diminished and the urgency to attend becomes less.

The eligible patient population are listed in the tables’ priority diagnosis in bold. Identification and referral of patients usually starts following admission to hospital.

Several centres provide in-patient CR and immediate referral into the service; others rely on external referral processes.

Table 4 - Centres in which a member of the team is available to review in- patients and directly take referrals

AB

M B

rid

gen

d

AB

M N

PT

A

BM

West

C

&V

R

CT

No

rth

R

CT

Sou

th

P

TH

B

A

BH

B N

HH

A

BH

B T

orfa

en

A

BH

B N

ew

po

rt

A

BH

B C

aerp

hil

ly

H

Dd

Carm

s

H

Dd

Cered

igio

n

H

Dd

Pem

bs

ACS –

NSTEMI,

STEMI

NA NA

PPCI/PCI NA NA

Exert Angina NA NA

Heart Failure NA NA N/A N/A

Device therapy NA NA N/A N/A

Valve/ CABG NA NA

GUCH NA NA N/A

Transplantation NA NA N/A N/A

Apart from three centres all patients presenting with ACS have the potential to be reviewed by a member of the CR team whilst an in-patient. Although heart failure

accounts for the majority of cardiac re-admissions only one centre (Nevill Hall) sees HF in patients. Patients are more likely to be seen as an in-patient if they live within the catchment area of NH and least likely if they live in HDd Pembrokeshire.



Table 5 - The number of patients referred to CR by hospital

A

BM

Bri

dge

nd

Pri

nce

ss o

f W

ale

s

AB

M N

PT

Ne

ath

Po

rt T

alb

ot

AB

M_W

est

Mo

rris

ton

Sin

gle

ton

C&

V

RC

T P

rin

ce C

har

les

RC

T R

oya

l

Gla

mo

rgan

PTH

B B

reco

n

WM

NA

AB

HB

Nev

ill H

all

AB

HB

To

rfae

n

AB

HB

New

po

rt

Ro

yal G

we

nt

AB

HB

Cae

rph

iilly

YY

F H

D d

Car

ms

HD

d_C

ere

dig

ion

Bro

ngl

ais

HD

d P

emb

s

Wit

hyb

ush

TOTA

L

In-patients

reviewed

(n=)

183 128 2141 1696 337 266 N/A 547 N/A 108 12 485 127 N/A

5865

Depending on the location of the CR department to the referring hospital, the size and nature of the hospital (DGH or Tertiary) and resource there is a vast difference in this

aspect of service provision. At the upper end of the scale the tertiary centres ABM West and C&V with 2141 and 1696 patients respectively and at the lower end Torfaen and

Caerphilly. Of inpatients an unknown percentage are seen by CR Specialist Nurses Band 6/7; one area uses Band 5 nurses (HDd Carm).

Improving the in-patient referral pathway results in a higher level of recruitment for example; patients admitted to NH have a 70% chance of being seen by a member of the

CR team and recruitment is >80%. Whereas RGH (Gwent) patients are rarely seen and uptake is 60%. Whether this is the same for other LHBs remains to be seen.

Table 6 - Services available to in-patients under the umbrella of CR

Table 6 lists other specialist services available to in-patients. Only five centres offer full specialist in-patient support. i.e. CR Nurse Specialist plus OT/ Physiotherapy/ Counselling/ Social Work/ Dietetics/ Pharmacist. The majority of patients benefit from

pharmacological and dietary advice very few receive counselling and psychological support.

Service OT Physiotherapy

(functional/exercise

advice)

Counselling/

psychological

support

Social

Work

Dietary

advice

Pharmacy

ABM Bridgend

ABM NPT

ABM West

C&V

RCT North

RCT South

PTHB

ABHB NHH

ABHB Torfaen

ABHB Newport

ABHB

Caerphilly

HDd Carms

HDd

Ceredigion

HDd Pembs



Table 7 - Following referral the total number and category of patients

contacted and offered support by their local centre once they leave hospital

A

BM

Bri

dge

nd

A

BM

NP

T

A

BM

We

st

C

AV

C

THB

No

rth

C

THB

So

uth

P

THB

A

BH

B N

HH

A

BH

B T

orf

aen

A

BH

B N

ewp

ort

A

BH

B C

aerp

hill

y

H

Dd

Car

ms

H

Dd

Ce

red

igio

n

H

Dd

Pem

bs

TO

TAL

Patients n= 299 287 631 421 398 654 224 500 360 609 315 530 300 349

6095

ACS NSTEMI/STEMI

PPCI/PCI

Exert Angina

Heart Failure

Device therapy

Valve/CABG

GUCH na na na na na na na na na

Transplantation na na na na na na

ABHB

ABM

RCT

C&V

PTHB

HDd

When patients with ACS, following re-vascularisation or valve surgery leave hospital (with a referral into CR) they are all contacted by their respective teams. Patients with heart failure

fare the worst in terms of this element of support. Na depicts where no referrals for transplanted or GUCH patients within this time period. For all teams apart from the Tertiary

Centres there is an increase in patient numbers for this aspect of care when compared to in-patient review.

RECOMMENDATIONS

6. To assess the number of missed referrals’ - compare the % number of in-patients reviewed against the number of in scope admissions.

7. To assess the difference in uptake to a comprehensive CR between those patients who have in-patient CR and those who do not.

Fig 3; Number of patients

contacted by respective HB on

referral



5.4 STANDARD 4. Early initial assessment of individual patient needs in each of the core components, on-going assessment and reassessment upon programme completion.

There are two operational time frames attached to this standard;

Patients should be contacted within 3 operational days of receipt of referral

To attend an assessment ideally within 2 calendar weeks of discharge or diagnosis

This standard also includes monitoring the number of patients attending for assessment (Stage 2) and whether they are in receipt of a copy of a care plan and arrangements for long term management.

All centres use validated assessment tools for quality of life, functional and psychosocial

assessment these are required in delivery of the seven core components

Table 8 - Number and category of patients enrolled in a comprehensive

CR programme per centre

AB

M

Bri

dge

nd

AB

M N

PT

AB

M W

est

C&

V

RC

T N

ort

h

RC

T So

uth

PTH

B

AB

HB

NH

H

AB

HB

Torf

aen

AB

HB

New

po

rt

AB

HB

Cae

rph

illy

HD

d C

arm

s

HD

d

Cer

edig

ion

HD

d P

emb

s

Tota

l

Patients n= 246 279 365 335 187 575 96 389 278 270 114 200 288 228 4231

ACS NSTEMI/STM

PPCI/PCI

Exert Angina

Heart Failure

Device therapy

Valve/CABG

GUCH

Transplant



0

200

400

600

800

1000

1200

1400

1600

1800

ABM C&V CT PT ABHB HDd

All centres deliver comprehensive CR to patients with ACS and following revascularisation whether PPCI/ PCI or surgery. Only 8 out of 14 centres offer patients with heart failure CR despite the strong evidence base (5). Although numbers are small

– it appears that 4 centres don’t take patients with heart transplant (which is difficult to understand) and although a discrete group no patients with GUCH were referred to CR

within the time frame. The total number of patients enrolling in CR = 4231, this is 69% of the number

contacted and offered CR by teams once they receive the referral.

The number of referrals, however, does not reflect the total number of ‘in scope’ patients - the number of patients in specific diagnostic categories who may have been eligible for CR. Encouragingly it appears there was an improvement in the percentage of

patients with MI enrolling in CR (44%) 2010/11 compared with (37%) in 2009/10 (NACR Audit 2010/11).

The percentage of patients enrolling across Wales (69%) appears to be higher than that reported in the results of a recent collaborative project between NHS Improvement and the NACR (2012) of 49% (2)

There is evidence that all centres offer the core components referred to in Standard 1

and patient information is supported by written material and a patient held record. It is unclear if patients are routinely offered a copy of their care plan.

Fig 4. The number of

patients referred to HBs

Compared to those enrolling

in CR



Table 9 - Centres offering long-term community exercise classes, independent of the National Exercise Referral Scheme (NERS)

Brid

gen

d

NP

T

AB

M W

est

C&

V

RC

T N

ort

h

RC

T S

ou

th

HD

d P

em

bs

PTH

B

AB

HB

_N

HH

AB

HB

To

rfa

en

AB

HB

New

po

rt

AB

HB

Caerp

hil

ly

HD

d C

arm

s

HD

d C

ere

dig

ion

ACS NSTEMI/STEMI

Re Vasc eg PCI

Exert Angina

Heart Failure

Device therapy

Valve/CABG

GUCH

Transplantation

Only two centres offer long term exercise classes for patients independent of the National

Exercise Referral Scheme for all patient groups. The National Exercise Referral Scheme (NERS) is a Welsh Assembly Government (WAG) funded scheme which has been developed

over the last 4 years to standardise exercise referral opportunities across all Local Authorities and Local health Boards in Wales. The scheme targets clients who have a chronic disease or

are at risk of developing chronic disease. The scheme has secured funding until March 2014.

RECOMMENDATIONS:

8. Using identified codes the Cardiac Network will assess whether it is possible to

acquire and make available the annual number of in scope or eligible patients for each centre.

9. Each centre reports on how many patients are contacted within 2 operational days of receipt of referral

10. Each centre reports on how many patients attend an assessment to agree a

care plan ideally within 2 weeks of discharge or diagnosis 11. As a main outcome measure each centre reports on the number of patients

offered (invited to) CR (1) 12. As a main outcome measure each centre reports on the percentage of

patients who started CR (1)



5.5 Standard 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

This standard links to the operational time frame of Stages 2, 3 and 4 (Assessment,

developing the care plan and commencing CR). It also recommends a menu based approach in a venue based on patient’s choice.

Table 10 - The number of programmes per centre, where they are based, the number of sessions per week and the duration, along with

the average waiting time

Venue provision is generally based on historical arrangements and funding and despite the welcome move to provide CR in the community this transition may add to the overall

cost in regard to venue hire. There is no correlation between the size of the population and the number of programmes for each HB it appears to be based more on rurality. For

example C&V offer 4 programmes whereas HDd offer 7. Out of 54 programmes 31 are community based. ABM West, CTHB North, ABHB Newport offer no community

programmes whereas HDd Ceredigion’s are all based in the community.

Duration of the programmes vary between 6 and 12 weeks and sessions per week 1-2

the clinical evidence base needs reviewing and agreement reached by the network on standardisation.

RECOMMENDATIONS:

13. With the drive to provide more services in the community a record is kept of venue changes

14. As a main outcome measure each centre reports on the percentage of patients completing CR (1)

15. As a main outcome measure each centre reports on the number of patients

in whom experience/satisfaction was measured (1) 16. There is an agreement on an All Wales measure of patient experience /

satisfaction 17. Review variations (duration and sessions) and compare with national guidance

to reach agreement on standardisation

AB

M

Brid

gen

d

AB

M N

PT

AB

M W

est

C&

V

RC

T N

ort

h

RC

T S

ou

th

PTH

B

AB

HB

NH

H

AB

HB

To

rfa

en

AB

HB

New

po

rt

AB

HB

Caerp

hil

ly

HD

d C

arm

s

HD

d

Cere

dig

ion

HD

d P

em

bs

Number of programmes 3 3 5 4 2 3 6 3 3 2 2 7 5 6

Number hospital-based 0 1 5 3 2 1 2 1 2 2 0 3 0 1

Number community-based

3 2 0 1 0 2 4 2 1 0 2 4 5 5

Number of sessions per week.

1 1 1 or 2 2 2 1 2 2 2 2 2 2 2 1

Duration of programme (weeks)

7 7 6 or 12

6 6 6-12 6-8 8 6 5 6 8 8-12

8-10

Average wait (week)s 2 3 0 0 2-3 9 0 2-8 3-4 4 0 2 0 2-4



5.6 Standard 6. Registration and submission of data to the National Audit for Cardiac Rehabilitation (NACR)

The requirement for commissioners and service providers to make the most of national audits to report service outcomes has recently been reinforced by NICE (CMG 39 and

CMG 40) and NICE Commissioning Outcomes Framework (COF). And WG – ref The ability to use audit methodology effectively, however, requires adequate resource.

Table 11 All centres submit data in South Wales

ABM Princess of Wales, Neath Port Talbot, Morriston, Singleton

C&V UHW, Llandough

CTHB Prince Charles (Merthyr), Royal Glamorgan

PTHB Brecon

ABHB Nevill Hall (Blaenau Gwent/ North Monmouthshire), County (Torfaen), St Woolos (Newport), YAB (Caerphilly),

HDd Glangwilli, Bronglais, Withybush, Prince Phillip Hospital

RECOMMENDATIONS:

18. Resources required to fully comply with the NACR are built into service

specifications 19. Annual audit and evaluation includes data on clinical outcomes, patient

experience and satisfaction as well as service performance

20. Produce annual comparative audit data aiming to present at national audit day

5.7 Standard 7. Establishment of a business case including a cardiac rehabilitation

budget that meets the full service costs

In essence this standard advocates funding for each CR service is based on a robust

model of care that meets local population needs and performs against agreed service outcomes. Funding needs to take account of staff costs, non-pay costs (such as venue

hire, transport, patient educational material and team training and capital development projects).

There is wide variation in funding and delivery across South Wales and this in part affects the level of intervention for example; incorporated with ABHB’s budget are nurse

led clinics and the specialist nurse heart failure service. Some centres are able to provide all aspects of a comprehensive CR programme to all ‘in scope’ patients others are restricted to patients with ACS and post revascularisation. For this aspect of the

review some centres failed to submit data and due to the complexity regarding service costs this aspect has not been reported.

RECOMMENDATIONS:

21. The CR co-ordinator leads on/ is consulted on financial management and

resource planning 22. Local managerial support is required to identify savings attributable to the

service from reduced hospital readmissions

23. The Cardiac Network is advised of cuts to funding



6. Conclusion This review has broadly met its objectives in aligning CR service specification data submitted

two years ago with the most recent standards. The main issues of differences in CR programme in terms of staffing and exclusion of specific patient groups continues to be a post

code lottery. As the BACPR purport ensuring that all eligible patients are referred to CR as a standard not an optional therapy remains a challenge in a resource limited health service. Regular service audit against national standards will show if clinical effectiveness and health

outcomes are being realised. It is hoped the subsequent 21 recommendations will, with the support of the South Wales Cardiac Network, act as a vehicle for progressing this invaluable

aspect of patient care.

7. References

1. The BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 2012 (2nd Edition. British Cardiovascular Society

2. NICE CMG40 – Cardiac Rehabilitation Services (Oct 2011)

3. Taylor et al. Exercise-based rehabilitation for patients with coronary heart disease systematic review and meta analysis of randomised controlled trials. Am J Med 2004; 116(10):682-697

4. Clark et al. Meta-Analysis: Secondary prevention programmes for patients with coronary

heart disease. Ann intern Med 2005; 143(9):659-672 5. The National Audit of Cardiac Rehabilitation Annual Statistical Report 2012. NACR Team,

University of York

6. Measuring outcomes in the Department of Health Commissioning Pack for Cardiac Rehabilitation. Final evaluation report (June 2012). A collaborative project between NHS

Improvement and the National Audit of Cardiac Rehabilitation (NACR)



LIST OF RECOMMENDATIONS

1 Each centre collects and reports on % change in outcome measures

2 There is South Wales agreement on the use of the same ‘Patient Held Record’

3 To meet Standard 1 the team should include at least one independent prescriber

4 Centres keep a record of staff changes i.e. <> WTE and professional status

5 The South Wales Cardiac Network is kept informed of cuts to services

6 To assess the number of missed referrals’ - compare the % number of in-patients

reviewed against the number of in scope admissions.

7 To assess the difference in uptake to a comprehensive CR between those patients who

have in-patient CR and those who don’t

8 Using identified codes the Cardiac Network will assess whether it is possible to acquire

and make available the annual number of in scope or eligible patients for each centre.

9 Each centre reports on how many patients are contacted within 3 operational days of

receipt of referral

10 Each centre reports on how many patients attend an assessment within 2 weeks of

discharge or diagnosis

11 As a main outcome measure each centre reports on the number of patients offered

(invited to) CR (1)

12 As a main outcome measure each centre reports on the percentage of patients who

started CR (1)

13 With the drive to provide more services in the community a record is kept of venue

changes

14 As a main outcome measure each centre reports on the percentage of patients

completing CR (1)

15 As a main outcome measure each centre reports on the number of patients in whom

experience/satisfaction was measured (1)

16 There is an agreement on an All Wales measure of patient experience/satisfaction

17 Review variations (duration and sessions) and compare with national guidance to reach

agreement on standardisation

18 Resources required to fully comply with the NACR are built into service specifications

19 Annual audit and evaluation includes data on clinical outcomes, patient experience and

satisfaction as well as service performance

20 Produce annual comparative audit data aiming to present at national audit day

21 The CR co-ordinator leads on/ is consulted on financial management and resource

planning

22 Local managerial support is required to identify savings attributable to the service from

reduced hospital readmissions

23 The Cardiac Network is advised of cuts to funding

Documents

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