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Cardiac Rehabilitation (CR) in General Practice Karen Kjær Larsen MD, PhD student Department of General Practice School of Public Health Aarhus University.

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Presentation on theme: "Cardiac Rehabilitation (CR) in General Practice Karen Kjær Larsen MD, PhD student Department of General Practice School of Public Health Aarhus University."— Presentation transcript:

1 Cardiac Rehabilitation (CR) in General Practice Karen Kjær Larsen MD, PhD student Department of General Practice School of Public Health Aarhus University Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Karen Kjær Larsen kkl@alm.au.dk

2 The effect of Cardiac Rehabilitation is very well documented. However, due to organisational and psychosocial issues, the uptake of CR is low. How can we improve attendance? Take on the role as main coordinator for patients with chronic diseases. Screen patients with chronic diseases for psychosocial vulnerability and offer them treatment and extra attention. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Karen Kjær Larsen kkl@alm.au.dk

3 Effect of Cardiac Rehabilitation Quality of life ↑ All-cause mortality ↓ OR=0.80 (0.68-0.93) Cardiac mortality ↓OR=0.74 (0.61-0.96) Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Taylor,R.S. et al. Am.J.Med.2004 Karen Kjær Larsen kkl@alm.au.dk

4 Cardiac Rehabilitation, is ”the sum of activities required to influence favourably the underlying cause of the disease, as well as to ensure the patients the best possible physical mental and social conditions, som that they may, by their own efforts, preserve, or resume when lost, a place as normal as possible in the life of the community” Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. WHO Regional Offices for Europe.1993 Karen Kjær Larsen kkl@alm.au.dk

5 The 5 components Psychosocial care Exercise training Diet changes Smoking cessation Medication Patient education Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Karen Kjær Larsen kkl@alm.au.dk

6 Post-AMI Major Depression: 20 % Depression and Anxiety: 50 % Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Thombs,BD. et al. J Gen Intern Med.2006 Karen Kjær Larsen kkl@alm.au.dk

7 Prognosis of post-AMI depression All-cause mortality ↑ OR=2.38 (1.76-3.22) Cardiac mortality ↑ OR=2.59 (1.77-3.22) Cardiovascular events ↑OR=1.95 (1.33-2.85) Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Van Melle JP. et al. Psychosom Med.2004 Karen Kjær Larsen kkl@alm.au.dk

8 Prognosis of post-AMI depression Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Van Melle JP. et al. Psychosom Med.2004 Karen Kjær Larsen kkl@alm.au.dk

9 Prognosis of post-AMI depression Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Van Melle JP. et al. Psychosom Med.2004 Karen Kjær Larsen kkl@alm.au.dk

10 Prognosis of post-AMI depression Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Van Melle JP. et al. Psychosom Med.2004 Karen Kjær Larsen kkl@alm.au.dk

11 Effect of Cardiac Rehabilitation Quality of life ↑ All-cause mortality ↓ OR=0.80 (0.68-0.93) Cardiac mortality ↓OR=0.74 (0.61-0.96) Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Taylor,R.S. et al. Am.J.Med.2004 Karen Kjær Larsen kkl@alm.au.dk

12 Attendance rates Only 10-47 % of eligible patients participate in comprehensive CR Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Ades, P.A et al. N.Engl.J.Med.2001 Karen Kjær Larsen kkl@alm.au.dk

13 Attendance rates 3 %in a full rehabilitation programme 47 %in parts of the rehabilitation programme 19 %no attendance at all Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Danish Heart Association. 2009 Karen Kjær Larsen kkl@alm.au.dk

14 OrganisationPatient Depression Anxiety Living alone Lower educational level Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Wyer,S. et al. Coronary Health Care. 2001 Factors associated with non-attendance Lack of support from GPs and cardiologists Lack of co-operation across the primary/secondary boundaries Karen Kjær Larsen kkl@alm.au.dk

15 Organisation Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Wyer,S. et al. Coronary Health Care. 2001 Meet the organisational challenges Lack of support from GPs and cardiologists Lack of co-operation across the primary/secondary boundaries Karen Kjær Larsen kkl@alm.au.dk

16 OrganisationMeet the challenge Encourage the patient Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Wyer,S. et al. Coronary Health Care. 2001 Meet the organisational challenges Lack of support from GPs and cardiologists Lack of co-operation across the primary/secondary boundaries Karen Kjær Larsen kkl@alm.au.dk

17 Encourage the patient CR participation by primary physician recommendation. The physician’s recommendation was graded from 1 (not mentioned) to 5 (strongly recommended). Score 1-3, entry rate: 1,8 % Score 4-5, entry rate: 66 % Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Ades,P. Arch Intern Med. 1992 Karen Kjær Larsen kkl@alm.au.dk

18 Encourage the patient CR participation by primary physician recommendation: No or weak recommendation, entry rate: 1,8 % Strong recommendation, entry rate: 66 % Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Ades,P. Arch Intern Med. 1992 Karen Kjær Larsen kkl@alm.au.dk

19 OrganisationMeet the challenge Take on the role as main coordinator Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Wyer,S. et al. Coronary Health Care. 2001 Meet the organizational challenges Lack of support from GPs and cardiologists Lack of co-operation across the primary/secondary boundaries Karen Kjær Larsen kkl@alm.au.dk

20 Take on the role as main coordinator The 2 sectors need to collaborate and communicate effectively to reduce treatment gaps and build on established models of integrated care with proved effectiveness Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Dalal,H. BMJ 2004 Collaborators in Cardiac Rehabilitation Phase I Acute admission Days Phase II Reconditioning Weeks – months Phase III Maintenance Months – years  Acute cardiac ward  Invasive cardiac centre  CR centre  Municipality  General Practitioner  Municipality  Local society Karen Kjær Larsen kkl@alm.au.dk

21 Patient Depression Anxiety Living alone Lower educational level Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Wyer,S. et al. Coronary Health Care. 2001 Meet the psychosocial challenges Karen Kjær Larsen kkl@alm.au.dk

22 Meet the challenge Screen for psychiatric illness and social vulnerability Patient Depression Anxiety Living alone Lower educational level Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Wyer,S. et al. Coronary Health Care. 2001 Meet the psychosocial challenges Karen Kjær Larsen kkl@alm.au.dk

23 Screening of psychosocial vulnerability Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Screening for depression and anxiety Screening for social vulnerability Depressive core symptoms? Living alone? Autonomic Symptoms?Level of education? Karen Kjær Larsen kkl@alm.au.dk

24 Meet the challenge Screen for psychiatric illness and social vulnerability Treat psychiatric illness Patient Depression Anxiety Living alone Lower educational level Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Meet the psychosocial challenges Karen Kjær Larsen kkl@alm.au.dk

25 Treat psychiatric illness Standard treatment of depression → effect on depressive symptoms → lower risk for subsequent cardiac events for responders Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Carney,RM et al. Psychsom Med. 2004 Karen Kjær Larsen kkl@alm.au.dk

26 Meet the challenge Screen for psychiatric illness and social vulnerability Treat psychiatric illness Offer extra attention to socially vulnerable patients Patient Depression Anxiety Living alone Lower educational level Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Meet the psychosocial challenges Karen Kjær Larsen kkl@alm.au.dk

27 Offer extra attention to socially vulnerable patients Extra attention to the socially vulnerable → social equality (attendance rates, adherence to medication and achieving treatment goals) Are patients with chronic diseases a new challenge togeneral practice? Cardiac Rehabilitation in general practice. Meillier,L. I gang igen efter blodprop i hjertet - socialt differentieret hjerterehabilitering. Region Midtjylland. 2007 Karen Kjær Larsen kkl@alm.au.dk

28 The effect of Cardiac Rehabilitation is very well documented. However, due to organizational and psychosocial issues, the uptake of CR is low. How can we improve attendance? Take on the role as main coordinator for patients with chronic diseases. Screen patients with chronic diseases for psychosocial vulnerability and offer them treatment and extra attention. Are patients with chronic diseases a new challenge to general practice? Cardiac Rehabilitation in general practice. Karen Kjær Larsen kkl@alm.au.dk

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