Effect of implementing a heart failure admission care bundle on hospital readmission and mortality rates: interrupted time series study.

This study aimed to evaluate the impact of developing and implementing a care bundle intervention to improve care for patients with acute heart failure admitted to a large London hospital. The intervention comprised three elements, targeted within 24 hours of admission: N-terminal pro-B-type natriuretic peptide (NT-proBNP) test, transthoracic Doppler two-dimensional echocardiography and specialist review by cardiology team. The SHIFT-Evidence approach to quality improvement was used. During implementation, July 2015-July 2017, 1169 patients received the intervention. An interrupted time series design was used to evaluate impact on patient outcomes, including 15 618 admissions for 8951 patients. Mixed-effects multiple Poisson and log-linear regression models were fitted for count and continuous outcomes, respectively. Effect sizes are slope change ratios pre-intervention and post-intervention. The intervention was associated with reductions in emergency readmissions between 7 and 90 days (0.98, 95% CI 0.97 to 1.00), although not readmissions between 0 and 7 days post-discharge. Improvements were seen in in-hospital mortality (0.96, 95% CI 0.95 to 0.98), and there was no change in trend for hospital length of stay. Care process changes were also evaluated. Compliance with NT-proBNP testing was already high in 2014/2015 (162 of 163, 99.4%) and decreased slightly, with increased numbers audited, to 2016/2017 (1082 of 1101, 98.2%). Over this period, rates of echocardiography (84.7-98.9%) and specialist input (51.6-90.4%) improved. Care quality and outcomes can be improved for patients with acute heart failure using a care bundle approach. A systematic approach to quality improvement, and robust evaluation design, can be beneficial in supporting successful improvement and learning.

Fitness predicts long-term survival after a cardiovascular event: a prospective cohort study.

OBJECTIVES: To identify the role of fitness, fitness change, body mass index and other factors in predicting long-term (>5 years) survival in patients with coronary heart disease. DESIGN: Cohort study of patients with coronary heart disease recruited from 1 January 1993 to 31 December 2002, followed up to March 2011 (1 day to 18 years 3 months, mean 10.7 years). SETTING: A community-based National Health Service (NHS) cardiac rehabilitation programme serving the Basingstoke and Alton area in Hampshire, UK. PARTICIPANTS: An unselected cohort of NHS patients, 2167 men and 547 women aged 28-88 years, who attended the rehabilitation programme following acute myocardial infarction, an episode of angina or revascularisation, and had a baseline fitness test. MAIN OUTCOME MEASURES: Cardiovascular mortality and all-cause mortality. RESULTS: A high level of fitness (VO2≥22 mL/kg/min for men, VO2≥19 mL/kg/min for women) at completion of the programme was associated with decreased all-cause death, as was a prescription for statins or aspirin, and female gender. Increase in all-cause mortality was associated with higher age and ACE inhibitors prescription. Higher risk of cardiovascular mortality was associated with increasing age, prescriptions for ACE inhibitor, and diagnosis of myocardial infarction or angina as compared with the other diagnoses. CONCLUSIONS: Prior fitness and fitness improvement are strong predictors of long-term survival in patients who have experienced a cardiac event or procedure. Some secondary prevention medications make a significant contribution to reducing all-cause mortality and cardiovascular mortality in these patients. This study supports public health messages promoting fitness for life.

Characteristics of patients entering cardiac rehabilitation in the United Kingdom 1993-2006: implications for the future.

PURPOSE: : To analyze changes in clinical characteristics of patients entering a cardiac rehabilitation program between 1993 and 2006 and to consider the implications on the delivery of cardiac rehabilitation programs in the future. METHODS: : Data were analyzed for 4692 coronary heart disease patients who joined the Phase II cardiac rehabilitation program between January 1993 and December 2006. RESULTS: : Over the study period mean age increased from 60.0 to 64.0 years (P < .001) and the proportion of participants aged 75 years or older increased from 4.4% to 17.1% (P < .001). In the first 8 years, the percentage of women increased from 17.8% to 23.7% but has changed little since. The most frequent index diagnosis throughout the study was acute myocardial infarction. The percentage of patients with percutaneous coronary intervention increased from 3.5% in 1993-1994 to 21.1% in 2005-2006, which contrasted with a recent decline in percentages of those with coronary artery bypass grafting in the United Kingdom. Prevalence of diagnosed diabetes almost doubled over the study period. The percentage of participants who were current smokers stayed constant at 6% to 9%. The percentage taking statins increased from 2.5% to 94.6% with a corresponding decrease of mean total blood cholesterol 6.00 to 4.07 mmol/L. Prescription of all cardiovascular secondary prevention medications increased significantly. CONCLUSION: : Overall, cardiac rehabilitation participants are becoming older with a consequent change in their abilities and needs. This may lead to changes in cardiac rehabilitation practice.

Outpatient cardiac rehabilitation attendance in England: variability by region and clinical characteristics.

PURPOSE: Cardiac rehabilitation is an effective but underprovided treatment for patients recovering from acute cardiac events. The geographical spread of provision has not been investigated recently in any country. This study aimed to investigate the level of participation in cardiac rehabilitation programs of patients following myocardial infarction or revascularization (eligible patients) and the geographical equity of attendance. METHODS: Questionnaire data were collected from all cardiac rehabilitation centers in England for the year 2003/2004. The number of patients attending rehabilitation was compared with eligible patients across the 9 Government Office Regions of England as indicated by Hospital Episode Statistics. RESULTS: Nationally, 29% of eligible patients attended rehabilitation, while within various regions, the proportion of eligible patients participating in rehabilitation ranged between 14% (95% CI, 13.2-14.3) and 37% (95% CI, 36.6-37.6). Participation also differed significantly by primary cardiac event: myocardial infarction, 25%; percutaneous coronary intervention, 24%; and coronary artery bypass surgery, 66% (P < .001). CONCLUSION: The participation rate of eligible patients in cardiac rehabilitation was low in all regions. There were large differences between regions with widely varying incidence of attendance in different parts of the country.

The rise and fall of cardiac rehabilitation in the United Kingdom since 1998.

BACKGROUND: Provision of cardiac rehabilitation is inadequate in all countries in which it has been measured. This study assesses the provision in the United Kingdom and the changes between 1998 and 2004. METHODS: All UK cardiac rehabilitation programmes were surveyed annually. Figures for each year were up-rated to account for missing data and compared with national data for acute myocardial infarction, coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). The total numbers and percentage of eligible patients included were charted for 7 years. RESULTS: For centres giving figures, the total number treated rose from 29,890 in 1998 to 37,129 in 2004. The up-rated figures show that the percentage of eligible patients enrolled rose from 25.0% in 1998 to 31.5% in 1999 and has changed little since, falling from 31.3% in 2002 to 28.5% in 2004. About 25% of myocardial infarction patients, 75% of CABG patients and 20% of PCI patients joined cardiac rehabilitation programmes. CONCLUSIONS: The National Service Framework for Coronary Heart Disease set a target for 85% of myocardial infarct and coronary revascularization patients to be enrolled in rehabilitation programmes. Only one-third of this number is currently being enrolled and the percentage is falling.

Cardiac rehabilitation in England: a detailed national survey.

AIMS: The purpose of this study is to conduct a detailed analysis of cardiac rehabilitation programmes in England to compare actual provision with the recommendations of the National Service Framework and Scottish Intercollegiate Guideline Network guidelines. METHODS: Questionnaires and interviews were conducted with key staff from one centre in each Strategic Health Authority in England to establish staffing levels, patient throughput, programme details, data collection and funding. RESULTS: There were major discrepancies between programmes and the national recommendations. Perceptions of the service were often at variance within key staff in the trust. Staffing levels, lack of facilities and space were identified as a weakness in many of the programmes. Inadequate exercise sessions, poor record keeping and a failure to tailor the sessions to the patients needs were common. Mean funding was pound288 per patient rehabilitated. CONCLUSIONS: For those 30% of eligible patients who enter cardiac rehabilitation in England, the service suffers from inadequate staffing, facilities and space, associated with gross underfunding. If the recommended 85% of eligible patients were included the situation would be much worse. The Department of Health recommendations for cardiac rehabilitation have not been translated into action, with most hospitals giving it low priority compared with other cardiology services. A treatment with demonstrable benefits should at least meet the standards recommended by national guidelines.

NSF for CHD: 3 years of 12-month follow-up audit after cardiac rehabilitation.

BACKGROUND: The coronary heart disease (CHD) National Service Framework (NSF) sets standards and milestones. For acute myocardial infarction (AMI) or coronary revascularization, 'Milestone 3, of Standard 12 requires that, by April 2002, every hospital should have clinical audit data no more than 12 months old showing 'total number and % of those recruited to cardiac rehabilitation who, one year after discharge, report: regular physical activity of at least 30 minutes duration on average five times a week, not smoking and a Body Mass Index (BMI) of <30 kg/m2'. This study looked at cost, method and practicalities of retrieving this data. METHODS: A postal questionnaire was used to follow-up coronary patients who started our cardiac rehabilitation programme between 1 April 2001 and 31 March 2004. The project was costed. RESULTS: Three hundred and seventy-five (33 per cent) AMI patients, 412 (36 per cent) coronary artery bypass grafting (CABG) patients and 343 (30 per cent) percutaneous coronary intervention (PCI) patients entered the cardiac rehabilitation programme over 3 years. Completed questionnaires were received from 903 (80 per cent). Post-AMI patients or those stratified as high risk for further cardiac events were least likely to respond. Of responders, 74 per cent were exercising regularly, 95 per cent were not smoking and 79 per cent had a BMI <30 kg/m2. CONCLUSION: Targets for smoking and BMI set by the NSF are too low and were achieved by most patients before the start of cardiac rehabilitation. Patients who are post-AMI or are stratified as high risk need to be targeted if a high level of follow-up is to be achieved.

Circulating levels of MCP-1 and eotaxin are not associated with presence of atherosclerosis or previous myocardial infarction.

The chemokines are a family of signalling proteins that participate in regulation of the immune system and have been implicated in the pathogenesis of vascular diseases. Deleting the gene encoding the chemokine MCP-1 in mouse models of atherosclerosis reduces lipid lesion formation and circulating chemokines are upregulated in man immediately following myocardial infarction (MI) or coronary angioplasty. We have therefore investigated whether circulating levels of two chemokines (MCP-1 and eotaxin) differ between subjects with and without atherosclerosis. We have used three different methods of measuring the presence and extent of atherosclerosis in human subjects: duplex ultrasonography of the carotid arteries and clinical diagnosis of coronary heart disease on individuals from the general population and coronary angiography on patients with suspected heart disease. There was no difference in the levels of circulating MCP-1 or eotaxin, measured by ELISA, between subjects with and without atherosclerosis. Furthermore, any increase in circulating MCP-1 following acute MI must be short-lived, since chemokine levels were not different in subjects who had had an MI previously compared to those who had not. We conclude that although there may be a transient increase in circulating chemokine levels following coronary angioplasty, there is no difference in the levels of circulating MCP-1 or eotaxin in subjects with and without atherosclerosis.

Results and cost of meeting the National Service Framework for Coronary Heart Disease requirement for 12 month follow-up after acute coronary events.

BACKGROUND: The National Service Framework (NSF) for Coronary Heart Disease (CHD) set standards, targets and milestones. In the case of acute myocardial infarction (AMI) or coronary revascularization, Milestone 3 of Standard 12 requires a 12 month audit of exercise and smoking habit and of body mass index (BMI) for patients who have attended cardiac rehabilitation (CR). The targets are that 50 per cent of patients should be exercising regularly, not smoking and have a BMI of <30 kg/m(2). The purpose of this study was to find out whether the targets are realistic and to measure the cost of retrieving the data. METHODS: A postal questionnaire was used to follow up all the patients who attended our CR programme over a 12 month period. The project was costed. RESULTS: Four hundred and three CHD patients who had attended the programme between April 2001 and March 2002 were sent questionnaires 12 months after their index event. Their diagnoses were AMI in 147 (36.5 per cent), coronary artery surgery in 157 (39 per cent) and angioplasty in 99 (24.5 per cent). Completed questionnaires were received from 358 (89 per cent). Of the responders, 69 per cent were exercising regularly, 91.6 per cent were not smoking (73 per cent had been non-smokers before their index cardiac event) and 79 per cent had a BMI of <30 kg/m(2)(the figure at the start of rehabilitation had been 79 per cent). The cost of performing the audit was pounds sterling 1204. CONCLUSION: This audit is inexpensive. The targets for smoking and BMI set by the NSF were achieved by a very large margin before either the index cardiac event or starting CR.

Psychological assessments for cardiac rehabilitation patients.

Psychological and quality of life measures are important in the assessment of cardiac rehabilitation (CR) patients and the outcome of treatment. This study aimed to assess the utility and sensitivity to change of three simple questionnaires in a CR setting. A total of 1403 patients who entered CR over 51 months were studied. Patients completed questionnaires before and after their phase 3 CR program-Hospital Anxiety and Depression (HAD) scale, WONCA/COOP charts and an analogue score of wellbeing. The three instruments took about 5.5 min in total to complete and 30 s to interpret. There were highly significant reductions in mean anxiety score-from 6.04 to 4.67 (P<0.001, 95% CI -1.52 to -1.16) and depression from 4.00 to 2.52 (P<0.001, 95% CI -1.62 to -1.29) The mean analogue of wellbeing score improved from 7.09 to 8.19 (P<0.001, 95% CI 0.97-1.22 ) There were highly significant improvements in five of the six WONCA domains. There were significant correlations between improvements in scores from all instruments. The sensitivity indices were in the 'good' range for changes in WONCA physical fitness domain and subjective well-being score and in the (moderate) range for changes in depression, well-being and WONCA overall health. Initial physical fitness was significantly correlated with the initial levels of all psychometric scores except anxiety and WONCA feelings, but improvements in fitness were not correlated with any changes in psychometric scores. The instruments described were quick to administer and to interpret and showed sensitivities to change superior to those which have been reported for other questionnaires. We believe them to be practical tools for use in CR units.

Rapid and noninvasive diagnosis of the presence and severity of coronary heart disease using 1H-NMR-based metabonomics.

Although a wide range of risk factors for coronary heart disease have been identified from population studies, these measures, singly or in combination, are insufficiently powerful to provide a reliable, noninvasive diagnosis of the presence of coronary heart disease. Here we show that pattern-recognition techniques applied to proton nuclear magnetic resonance (1H-NMR) spectra of human serum can correctly diagnose not only the presence, but also the severity, of coronary heart disease. Application of supervised partial least squares-discriminant analysis to orthogonal signal-corrected data sets allows >90% of subjects with stenosis of all three major coronary vessels to be distinguished from subjects with angiographically normal coronary arteries, with a specificity of >90%. Our studies show for the first time a technique capable of providing an accurate, noninvasive and rapid diagnosis of coronary heart disease that can be used clinically, either in population screening or to allow effective targeting of treatments such as statins.

Patient characteristics and outcomes of cardiac rehabilitation.

PURPOSE: To investigate changes in physical fitness and psychological characteristics of patients after cardiac rehabilitation, and to assess predictors of defaulting from the program. METHODS: A prospective study of 1902 consecutive patients admitted to a community-based, hospital-linked cardiac rehabilitation program was conducted over a period of 6 years and 7 months. The cardiac rehabilitation program centered on a 2-to 6-month circuit training course with education, stress management, relaxation, and risk factor monitoring. Before and after the program, measures of physical fitness and of hospital anxiety and depression were performed. RESULTS: The course was completed by 1443 patients (76%), with 240 patients (13%) defaulting. For those who completed the course, peak oxygen consumption per minute increased by 3.2 mL/min/kg (95% confidence interval [CI], 3.1-3.4) or 19% (95% CI, 17.7%-20.3%). According to the hospital anxiety and depression scores, anxiety fell by 1.1 (95% CI, -1.3 to -0.98) and depression by 1.3 (95% CI, -1.4 to -1.2). The main predictors of defaulting were depression (patients with depression were twice as likely to default as nondepressed patients) and diagnosis (patients who had experienced angina or percutaneous transluminal coronary angioplasty were twice as likely to default as those who had experienced infarct or coronary artery bypass graft). CONCLUSIONS: The identification of depressed coronary patients known to be at increased risk should be a priority for cardiac rehabilitation coordinators. Every effort should be made to keep them in the cardiac rehabilitation program.