A new approach to cardiac rehabilitation and secondary prevention

Cardiac rehabilitation and secondary prevention (CRSP) is a specialized component of chronic vascular disease care. By integrating structured behaviour change interventions like diet, exercise, and smoking cessation, with medical and case management, these components can decrease cardiac mortality by 20-25 per cent. Over the past decade, the CRSP Program at London Health Sciences Centre (LHSC) has united a number of health-care professionals to optimize a chronic vascular disease management program. Today, Lawson Health Research Institute’s Karen Unsworth, Dr. Neville Suskin, and Dr. Dennis Humen continue to lead this innovative inter-professional, team-based approach to cardiac care.

Transitioning from inpatient care to outpatient care to the home environment can be overwhelming for many patients. “Patients need support to improve their confidence to perform usual activities, to independently adopt healthy lifestyle behaviours, and to realize that they do not need constant medical supervision in order to resume their lives” explains Dr. Suskin. To empower patients, the CRSP Program deploys the Chronic Care Model, a patient-centered system of integrated information-sharing that ensures safe, high-quality care. This system is highly efficient and effective, providing patients the support they need to confidently self-manage. “The patient is essentially the centre of the care team,” explains Unsworth. “Our purpose is to help them reduce their risk factors, adhere to evidence-based therapies, and overall, to become effective self-managers of their vascular and heart health.”

While the CRSP Program is an outpatient program, it strives for integration at every point along the continuum of cardiac care. For example, the Guidelines Applied in Practice (GAP) initiative incorporates a set of recognized quality indicators structured into a discharge checklist. Items include appropriate prescription medications, standardized education on diet, exercise, and smoking cessation, and a referral to the CRSP Program.When patients leave the hospital, these items are uploaded into the CRSP Program’s electronic patient management system for quick and accurate evaluation. The GAP initiative also uses a unique automated Interactive Voice Response (IVR) system, which calls patients at regular intervals to confirm they are following best practice guidelines. A nurse reviews responses generated from an interactive voice algorithm and, when necessary, helps patients to get back on track. This level of universal teamwork is crucial to the success of the CRSP platform; however, it would not be possible without the program’s advanced technological system.

Unlike traditional methods of data warehousing and retrospective reporting, the CRSP Program provides immediate, integrated information sharing. The Cardiovascular Information System (CVIS-CRSP) is an advanced web-based clinical management system offering cutting-edge functionality and comprehensive patient management. Through electronic charting, automated clinical reporting to primary care, program evaluation, reporting of aggregate data across multiple sites or institutions, and research capabilities, CVIS-CRSP can interact with hospital information systems, as well as population-oriented or administrative networks such as Ontario’s Cardiac Care Network. The system also offers “symbiotic registry” capability, which enables a comprehensive multi-site registry that emerges directly and seamlessly from ongoing clinical management in real time. This state-of-the-art system continues to support the program’s success.

To date, the outcomes of the GAP initiative have been very promising. In just over one year, 75 per cent of LHSC patients with Acute Coronary Syndrome have been assigned a GAP best-practice discharge contract. Six-month smoking cessation rates have increased from 25 per cent to 47 per cent, and referral to the CRSP Program has increased by 22 per cent. Patients in cardiac rehabilitation continue to experience increased exercise capacity and show improvements in anxiety, depression and quality of life scores. “Many of our patients are running on the cusp of performance where it makes a difference for them to be able to carry groceries in from the car, climb a flight of stairs to get where they’re going, or be able to go shopping and not feel miserable in the process,” Dr. Humen explains.

“Optimal and efficacious chronic disease management requires an overall system redesign,” Unsworth explains. “We believe that CRSP cannot function in isolation, apart from the continuum of cardiac care. Conversely, the continuum of cardiac care must include cardiac rehabilitation.” By integrating all components of patient care, the team believes they can improve both the quality and quantity of patient care. “You may not actually save the hospital money, but you would allow them to process more patients,” Dr. Suskin says. “You would create a virtual increase in the number of beds.”

The CRSP program is funded by the Ministry of Health and Long-Term Care.