| Project Objectives / Summary:
This study sought to evaluate the health care outcomes of a primary health care model of cardiac rehabilitation against conventional facility-based group rehabilitation and against usual care. The Northern Queensland Rural Division had developed a primary care model of cardiac rehabilitation called Outreach CR. Within this model, the patient's rehabilitation is managed by their GP, and includes a home-based walking / exercise program, with patient education delivered in modules supported by the cardiac rehabilitation coordinator.
The primary care model contrasts with the conventional model of cardiac rehabilitation, which is conducted as a group program in a hospital outpatient or community based setting and includes a structured education and physical activity component. However, facility based group programs are generally not accessible to people in rural and remote Australia, and have low uptake.
This project sought to determine whether patient outcomes (measured in terms of clinical risk factor modification, return to normal daily activities and re-admission to hospital) are improved for patients undertaking rehabilitation in the primary health care program, or facility- based program again compared with usual care.
Project Collaboration:
- Townsville General Hospital (TGH)
- Mater Misericordiae Private Hospital in Townsville
- Collaboration with the Cairns and Townsville Divisions of General Practice
- Centre for General Practice Integration Studies UNSW
- Mt Isa Centre for Rural and Remote Health
Project Outcomes:
- Participation in cardiac rehabilitation does not appear to be associated with patients' risk factor status; rather accessibility and availability appear to be the most important predictors of cardiac rehabilitation attendance in North Queensland.
- Facility-based and Outreach cardiac rehabilitation programs encouraged few additional CVD risk factor benefits above usual care.
- All patients made significant improvements in CVD risk factor behaviour by 2 months after cardiac intervention, and maintained these changes up to 12 months.
- There are a number of possible explanations at the program or GP level and patient level for the apparent ineffectiveness of the facility-based and Outreach cardiac rehabilitation programs.
- The results of the GP and patient focus groups highlighted the need to address CVD risk factor management at an individual, community, GP and patient level.
- The establishment and annual running costs of the Outreach program were lower than those of the facility based programs.
Recommendations:
- There is a need for alternative approaches to the management of cardiac rehabilitation other than hospital-based cardiac rehabilitation, in rural and remote areas of North Queensland.
- Patients benefit most if support in making appropriate CVD risk factor changes is available as soon as possible following cardiac intervention and if this support continues.
- Education sessions should include significant family members or friend, patients should be exposed to CVD risk factor messages repeatedly, patients should be given ample opportunity for problem solving and decision making, and CVD risk factor messages should be both general and specific to the patient.
- GP-based programs should use a variety of instructional, motivational and behavioural techniques in which the doctors' advice and guidance can be supplemented by printed or audiovisual materials.
- Health professionals need to examine a number of determinants of patient behaviour including: patients' specific intentions regarding CHD risk factors, environmental, social and demographic factors, patient perceptions of the threat of disease, patients beliefs in the value of the treatment, and the relationship with a therapist.
- CVD risk factors would be best managed with an understanding of the principles of health promotion. That is, developing the patients' personal skills, strengthening community action, creating supportive environments, building health public policy, and reorienting health services.
- There is a need for more research on the cost effectiveness of cardiac rehabilitation before any definitive statement is made about reimbursement. The establishment and annual running costs of the Outreach program were lower than those of the facility-based program.
Disseminating Project Information:
- The Project Officer presented a plenary session at the 2001 ACRA (Australian Cardiac Rehabilitation Association) conference.
- The Project Officer developed a GP CME event for management of cardiology patients.
- Cardiac Rehabilitation Strategic Planning Meeting, Cairns Qld, November 21-23. Cairns area health professionals expressed an interest in the Outreach Cardiac Rehabilitation Program.
- Development and Distribution to participants of the project of the following resources: Healthy Heart Guide to Medications for the Heart, Healthy Heart Guide to Exercise and Activity and Healthy Heart Guide - What do I do now I have left the Hospital.
Lessons / Assessment:
- Patient response at follow-up for the Outreach Cardiac Rehabilitation was initially poor due to confusion with forms meant for their GP. A separate envelope was provided and marked "for your doctor" and patient response improved.
- Patient responses more likely to increase if given a friendly reminder call and / or letter.
- The GP focus groups provided very useful information for the Division for planning for future chronic disease risk factor management programs. A key finding was that each community had different needs.
- During 2000, there were a number of changes within the Division including in management. The Division combined the Diabetes, CVD and Mental Health programs to form a Chronic Disease Program. The steering committee for this new group took over the direction of the CVD project.
- Overall, the project met its original aims, despite the initial Project Officer recruitment difficulties. These highlight the different practical issues faced by rural Divisions compared with their urban counterparts.
- The project outcomes will assist the Division in its current and future activities relating to broader Chronic Disease initiatives.
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