Cardiac Rehabilitation Provision in Rural Wales: Demonstrating the benefits of a Service Gwenllian Parry Community Cardiac Rehabilitation Specialist Nurse Ceredigion and Mid Wales NHS Trust

Population- 78,000 NHS Trust catchment of 120,000 Geographical area of 696 square miles 1 DGH in Aberystwyth Demographics: Ceredigion

Project Team Denise Lewis- Cardiac Rehabilitation Coordinator, Ceredigion and Mid Wales NHS Trust Gwenllian Parry- Cardiac Rehabilitation Specialist Nurse, Ceredigion and Mid Wales NHS Trust Justyn Robbins- Specialist Fitness Instructor Ceredigion and Mid Wales NHS Trust Rachel Rahman- Research Assistant University of Wales Aberystwyth Professor Jonathon Doust- Head of Chelsea School University of Brighton

The Beginning Heart Manual Angina Plan Hospital Based Phase III - One class per week in Physiotherapy gym No Phase IV Provision

Collaborative Bidding- Physical Activities Forum Ceredigion and Mid Wales NHS Trust Ceredigion County Council University of Wales Aberystwyth CAVO Ceredigion Association of Voluntary Organisations Dyfed/Powys Health Promotion Unit

Result Big Lottery Fund Grant £ over 2½ years Working in Partnership with our Sister project “Ceredigion Exercise For Life Scheme” Research Assistant Commissioned

Aims of the Project Reduce inequalities for Cardiac Patients within Ceredigion. Improve quality of life for Cardiac Patients and their families in and around the county. Promote social integration Promote long term adherence to a healthy lifestyle

Aims of the Project Provide a non institutionalised approach to health promotion. To be inclusive for those who have acute or chronic cardiac disease, and their families To provide a Cardiac Rehabilitation Specialist Service that is accessible for all residents of Ceredigion

Project Structure Three Key Organisations Two Sister Schemes Management Board Operational Team Research Evaluation

Practicalities of the Project 3 Cardiac Rehabilitation Staff - Nurse /Exercise Instructor/Administrative Assistant Free Leisure Centre Based classes Gym and Circuit ( twice weekly X12 weeks) Education and Relaxation Sessions

Practicalities of the Project Health Walks Maintenance package Partner/Spouse/friend welcomed Numbers in accordance with Risk Stratification

Data and Results 577 participants referred in 30 months 71% referrals commenced classes 69% of those completed classes 80% (209) of those completing the program agreed to participate in the research

Measured Psychological Outcomes MeasureChange pre to post scheme Desired direction for change for improved Health Health Related Qol (Euro Qol)  Self-rated health (EQ VAS)  SF-36V2 Physical component summary  SF-36V2 mental component summary  Anxiety  Depression  Life satisfaction  Physical self-worth  Global self-worth  Habitual physical activity 

Measured Physiological Outcomes MeasureChange pre to post scheme Desired direction for change for improved health Hip Circumference  Waist Circumference  Weight  Skin fold measurements  Resting heart rate  Resting blood pressure  Heart rate post exercise  Blood pressure post exercise  Treadmill test time 

Adherence at 6 months follow up 136 randomly invited to 6 month follow up 86 (63%) responded to follow up questionnaires 71 participants were still exercising 15 reported they were not exercise

Sustainability of Psychological Outcomes: 6 months follow up MeasureChange from pre to post scheme Change from pre scheme to 6 months Health related QoL (EuroQol)  Self-rated health (EQ-VAS)  SF-36V2 Physical component summary  SF-36V2 Mental component summary  Anxiety  Depression  Life Satisfaction  Physical self-worth  Global self-worth  Habitual physical activity 

Sustainability of Physiological Outcomes: 6 months follow up MeasureChange from pre to post scheme Change from pre scheme to 6 months Hip circumference  Waist circumference  Weight  Skin fold measurements  Resting heart rate  Resting blood pressure  Heart rate post exercise  Blood pressure post exercise  Fitness test duration 

Participants feedback: At 6 months assessment Main Reasons for not exercising: ill health time lack of group support

Participants feedback at 6 months Changes suggested by patients to help maintain exercise: Regular check ups on progress Maintenance classes More help from staff during transition from group to individual session. Take home safety tips common problems, exercise tips and guidance. Taster sessions for other activities

Outcomes Statistically significant physical and psychological Improvements during the period of the scheme Provided Phase IV provision where none existed in Ceredigion Demonstrated need by recruiting 577 participants in 2½ years

Identified the importance of a local community- base and an emphasis on patient confidence and independence in achieving high participation and low attrition Demonstrated a sustained impact at 6-month follow-up once participants had left the scheme Demonstrated significant improvements in physical and psychological health Outcomes

Cost Analysis The scheme cost £722 per participant (NICE) National Institute of Clinical Excellence judges effective treatment as costing less than £20,000 per quality adjusted life year The cost of the scheme was £8,112 per quality adjusted life year, well within guidance issued by NICE

Discussion Provision in a rural area needs to be patient and not condition driven Importance of an inclusive service for all those with cardiac related disease Does a Cardiac Rehabilitation service need to have a huge multi-disciplinary team to achieve standards and significant outcomes? This is as stated in the recently released NSF and BACR recommendations

Changes following Project End Patient Driven Reduce to three Centres Participant Payment Maintenance Classes Maintenance Booklets Obesity-Body fat analyzer

What Now? Continued funding for our community based service for those in and around Ceredigion National CCAD database Measure benefits of continued inclusion of those with controlled arrhythmias into the service Continue to Improve cross boundary communications

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