The BACPR

Standards and Core Components for Cardiovascular Prevention and Rehabilitation

Promoting Excellence in Cardiovascular Disease Prevention and Rehabilitation

Aim of the BACPR Standards and Core Components

Background and evidence Introducing to the 2012 update of the

BACPR Standards and Core Components

Shaping future service delivery

Overview

This second edition of the BACPR Standards and Core Components aims to ensure programmes are

clinically-effective, cost-effective and achieve sustainable health outcomes

for patients.

7 core standards and 7 core components are set out which aim to improve uptake and quality

of rehabilitation programmes nationwide

Aim

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Cardiac Rehabilitation defined by the WHO (1993)

“The sum of activities required to influence favourably the underlying cause of the disease so that (people) may, by their own efforts preserve or resume when lost, as normal a place in the community…

…it must be integrated within 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.

Modern cardiovascular prevention and rehabilitation

Sharing cardiac rehabilitation information (education) and long-term management strategy with the patient

Patient presentation

Manage referral and recruit patient

1

Identify and refer patient

0Deliver

comprehensive *CR programme

4

*CR = cardiac rehabilitation

Assess patient

2

Develop patient care plan

3

Patient discharged

Conduct final CR assessment

Discharge and transition to long

term management

6

5

*From DH Commissioning Pack: Service specification for cardiac rehabilitation 2010

Modern CR is menu-based and patient centred, and provides a pathway across the 7 stages from diagnosis to long term management.

Reduces: All cause mortality by 11- 26% 1,2,3

Cardiac mortality by 26 – 36% 1,2,3

Morbidity 3,4

Unplanned admissions by 28 -56% 5,6

Improves: Quality of life 7

Functional capacity 7

Supports: Early return to work 7 The development of self-management skills 7

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The benefits of cardiac rehabilitation

Cardiac Rehab is Cost Effective

Cost to achieve adding 1 year to a patients life

– PPCI £6,054 – 12,057– PCI £3,845 – 5,889– CABG £3239 – 4,601– Cardiac Rehab £1,957– Aspirin/B-block <£1,000Fidan et al 2007

CR is one of the most clinically and cost-effective therapeutic interventions in

cardiovascular disease management More living and surviving with CVD or

heightened risk of CVD Increased survival from CHD events means

greater numbers with heart failure in future CR shifting from a “survival of the fittest” goal

(reduced mortality) to one of prevention, chronic disease management and morbidity reduction

The future for CR Summary 1

UK Standards for CR – a brief history

Number of cardiac rehabilitation programmes expanded rapidly during 1980s and 90s

BACR formed in 1992 and recognised the importance of establishing guidelines for good practice – 1995 publication of BACR Guidelines for CR.

BACR Standards 2007Core components:Lifestyle:

Physical activity and exercise

Diet and weight management

Smoking cessation

EducationRisk factor managementPsychosocialCardio protective drug therapy and implantable devices

Long-term management strategy

Date of Preparation: September 2009OMA624

British Association for Cardiac Rehabilitation (BACR), Standards and Core Components for Cardiac Rehabilitation (2007).

The NHS for the future

Has to save money, not just be more cost effective

Our goals for Cardiac rehab must includePreventing hospital re-admissionsPreventing unnecessary appointments in

primary careEducated patients knowing who to contact if

symptoms or condition changesA focus on managing chronic disease linked

with or causing CVD

Changes to the Standards and Core

Components Emphasis on:

– Patient-centred approach– Biopsychosocial focus– Multidisciplinary team work– Health behaviour change and Education

at core of all components– Recognition of the importance of audit

and evaluation– Matched to DH Commissioning pack for

CR

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

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

3. Identification, referral and recruitment of eligible patient populations.

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

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.

6. Registration and submission of data to the National Audit for Cardiac Rehabilitation.

7. Establishment of a business case including a cardiac rehabilitation budget which meets the full service cost.

BACPR Standards 2012Patients, healthcare professionals and commissioners should expect

the following from high quality cardiac rehabilitation services

Seven Core Components

1. Health behaviour change and education

2. Lifestyle risk factor management– Physical activity and exercise– Diet– Smoking cessation

3. Psychosocial health4. Medical risk factor management5. Cardioprotective therapies6. Long-term management7. Audit and evaluation

The future for CR

Summary 2Ensuring referral of all eligible patients by cardiologists and/or specialist cardiovascular health care physicians to a prevention and rehabilitation programme as a standard (not optional) policy that is held in the same regard as the prescribing of cardioprotective medications.

Tighter control of service audit (e.g. through NACR), not only to ensure these standards and core components are being met but to demonstrate that improved practice, clinical effectiveness and health outcomes have been achieved

The continuing of a national campaign that raises the profile and need for comprehensive integrated cardiovascular prevention and rehabilitation programmes to be properly funded as a cost-effective means and obligatory element to any modern cardiology or vascular health care service.

BACPR’s next steps Develop a set of performance indicators for the

standards. Provide resources for service development e.g. tool-kits

for business case development, exemplary assessment frameworks and mechanisms for effective knowledge transfer and training.

Developing competency frameworks that are fully supported by high quality education and training programmes and research where required.

• Support the uptake of CR in groups that are currently not represented or are under-represented

• Edit a book from BACPR giving more detail on the “how to” of providing modern CR programmes.

References from slide 4

1. Heran et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No: CD001800. DOI: 10.1002/14651858.CD001800.pub2.

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

3. Lawler et al. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: A systematic review and meta-analysis of randomized controlled trials. Am Heart J Oct 2011; 162: 571-584.

4. Clark et al. Meta-Analysis: Secondary Prevention Programs for Patients with Coronary Artery Disease. Ann Intern Med 2005; 143(9): 659-672.

5. Lam et al. The effect of a comprehensive cardiac rehabilitation program on 60-day hospital readmissions after an acute myocardial infarction. J Am Coll Cardiol 2011; 57:597, doi:10.1016/S0735-1097(11)60597-4.

6. Davies et al. Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis. Eur J Heart Fail 2010; 12(7): 706-715.

7. Yohannes et al.. The long-term benefits of cardiac rehabilitation on depression, anxiety, physical activity and quality of life. Journal of Clinical Nursing 2010; 19(19-20):2806-2813.