Rehabilitation and Healthy Lifestyles: A Changing Landscape

in Northwestern Ontario

1

Dr. Ellen Melton Mr. Kyle Baysarowich

Presenter Disclosure

• Dr. Ellen Melton, FRCSP(C) • Assistant Professor, NOSM

• Physician Lead, Rehabilitation and Healthy Lifestyles Program

• Mr. Kyle Baysarowich, R. Kin, CES • Regional Manager, Rehabilitation and Healthy Lifestyles Program

• Relationships with commercial interests:

– We have no conflict of interest or affiliations that have influenced this presentation to disclose.

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Learning Objectives

At the end of this presentation, participants will be able to:

1. Identify how a quality improvement approach can be used to enhance therapy in an outpatient department.

2. Apply tools to support the provision of individualized aerobic exercise after a cardiovascular and stroke event.

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Introduction

• Participation in cardiac rehabilitation (CR) is an essential component of care for patients with coronary artery disease.

• Over the past decades the medical care of the patient with cardiovascular disease (CVD) has shown an impressive development, with marked positive consequences for mortality, morbidity, and the quality of life of coronary patients.

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Evolution of Cardiac Rehabilitation

• Simple monitoring and limitation of physical activity for several weeks

• Gradual introduction of more active approach, including a formal exercise prescription as a therapeutic aspect

• Multidisciplinary approach: – patient educational counselling

– psychosocial support

– individually tailored exercise training

– modification of the risk factors

– overall well-being of the cardiac patients.

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WHO definition

“The rehabilitation of cardiac patients is the

sum of activities required to influence

favourably the underlying cause of the

disease, as well as the best possible

physical, mental and social conditions, so

that they may by their own efforts,

preserve or resume when lost, as normal a

place as possible in the society.” (World Health

Organization. Needs and Action Priorities in Cardiac Rehabilitation and Secondary Prevention in Patients with Coronary Heart Disease. WHO Regional Office for Europe; Geneva: 1993)

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Spectrum of Patients

• Myocardial infarction survivors

• The younger patient from the 1970s with uncomplicated myocardial infarction without ventricular dysfunction

• The elderly were rarely enrolled in the early years of exercise-based training programs.

• Early 1990s: patients with advanced heart failure

• generation of patients who have been diagnosed and adequately treated early with minimal residual cardiovascular damage.

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• Post cardiac revascularization procedures patients

• Cardiac transplantation recipients

• Chronic heart failure patients, previously advised to avoid all forms of physical exertion, are now found to benefit from an aerobic, and in some cases, a resistance training program.

• Patients with pacemakers

• Implantable cardioverter defibrillators to prevent sudden death

• Patients with congestive heart failure.

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Spectrum of Patients

• Training benefits:

– improvement in self-confidence

– increased functional capacity

– enhanced quality of life

• With more cardiac patients surviving the

acute event, the numbers of elderly

patients have grown and the total need for comprehensive CR has not been reduced

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Spectrum of Patients

Benefits of Cardiac Rehabilitation

• Mortality reduction

• Symptom relief

• Reduction in smoking and improved

exercise tolerance

• Risk factors modification

• Overall psychosocial wellbeing

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Three Cochrane systematic reviews/meta-analyses have assessed the effectiveness of cardiac rehabilitation.

These reviews provide level I evidence that, when compared to usual care alone:

a) exercise-based cardiac rehabilitation reduces mortality and improves the risk factor profile of CHD patients;

b) psychology-based cardiac rehabilitation improves psychological well-being

and risk factor profile of CHD patients

c) exercise-based cardiac rehabilitation improves exercise tolerance and HRQoL of heart failure patients.

There is currently little evidence to support the belief that particular cardiac rehabilitation interventions are

more effective than others or that cardiac rehabilitation should be limited to any particular CHD or HF patient subgroups.

However, given the increasing resource and

financial limitations of providing cardiac rehabilitation to all patients, there is a need for additional

effectiveness and cost-effectiveness evidence on this issue.

4. Cardiac rehabilitation appears to have similar effects whether provided in a hospital-

(or centre-) based facility or at home. Therefore, where possible, patients should be offered

hospital- or home-based CR. However, more evidence is needed, particularly as to the

cost-effectiveness of CR provision in different settings.

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All-cause mortality forest plot. Four studies assessed the impact of multi-component CR on all-cause mortality, two of which provided an adjusted outcome effect which could be synthesised. CR was related to a decreased risk of death from AMI; unadjusted OR 0.25 (95% CI 0.16,0.40) I2 = 66% and adjusted OR 0.47 (95% CI 0.38,0.59) I2 = 0%. One further study, which could not be synthesised wit the adjusted ORs, reported an adjusted hazard ratio 0.08 (95% CI 0.01, 0.63) favouring CR [37].

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Cardiac-related mortality forest plot.

Two studies assessed the impact of multi-component CR on cardiac

related mortality, one of which provided an adjusted outcome effect. CR was

related to a decreased risk of cardiac-related death from AMI; unadjusted OR

0.21 (95% CI 0.12, 0.37) I2 = 0% and adjusted OR 0.43 (95% CI 0.23, 0.79).

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Hospital re-admission

Data could not be pooled from the two identified studies assessing the impact

multi-component CR on re-admission due to method of finding reporting. One study

reported an adjusted effect, finding no significant effect from CR 0.96 (95% CI 0.81,

1.13).

Re-occurrence of MI forest plot.

Three studies assessed the impact of multi-component CR on recurrent MI, one of which

provided an adjusted outcome effect. CR was related to a decreased risk of recurrent MI in unadjusted

analysis only; OR 0.31 (95% CI 0.13, 0.74) I2 = 61%. Adjusted analysis found no significant effect OR 0.72

(95% CI 0.43,1.21).

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Revascularisation forest plot.

Two studies assessed the impact of multi-component CR on re-

vascularisation following AMI, one of which provided an adjusted

outcome effect. CR was not significantly related to a reduction in

re-vascularisation in either unadjusted or adjusted effect

measures; OR 1.07 (95% CI 0.86, 1.38) I2 = 0% and OR 1.00 (95% CI

0.78, 1.28) respectively.

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• Referral problems

– enrollment

– alternate approaches: home-based, telehealth system and other means of monitoring and surveillance will help expand the utilization of cardiac rehabilitation.

• Altering factors:

– a worldwide pandemic of obesity is expected to again raise

– CVD will remain the main cause of premature death in the first half of this century.

– Preventive public health measures are required.

– Disturbances in the psychosocial sphere becoming more important.

– The focus of CR is changing from physical rehabilitation to lifestyle counselling.

– Prevention and rehabilitation are gradually becoming a united and intertwined multidisciplinary service.

• Furthermore, the theoretical basis for prevention and rehabilitation has been strengthened over past years and the medical, social and economic benefits have now been well established, contributing to their incorporation in standard cardiac care in many countries.

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Audience Poll

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Who Is CorHealth?

• CorHealth Ontario is an organization formed by the merger of the Cardiac Care Network of Ontario and the Ontario Stroke Network, with an expanded mandate spanning cardiac, stroke and vascular care.

• CorHealth Ontario advises the Ministry of Health and Long-Term Care, Local Health Integration Networks, hospitals, and care providers to improve the quality, efficiency, accessibility and equity of cardiac, stroke and vascular services for patients across Ontario.

• For more information, visit corhealthontario.ca.

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CorHealth Ontario Cardiac, Stroke and Vascular Rehabilitation Call-To-Action

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The Opportunity

• Recognition that Rehabilitation can improve health outcomes and quality of life, and reduce costs by shortening hospital stays

• Gaps in services related to Cardiac, Stroke, and Vascular Rehabilitation care in Ontario

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Approach & Scope

• CorHealth is committed to developing recommendations to the Ontario Ministry of Health and Long-Term Care (MOHLTC) that reflect common/integrated areas for improvement in cardiac, stroke and vascular rehabilitation in Ontario, by: – Analyzing the current state of cardiac, stroke and vascular

rehabilitation care in Ontario

– Identifying gaps/issues in each rehabilitation area and common/integrated features across all three

– Using the analysis of issues to develop cross-cutting priorities, with recommendations that are Reasonable, Achievable, Feasible & Sustainable

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CorHealth Process of Engagement

Specialized Cardiac, Stroke & Vascular Working Groups

Report to the Executive Steering Committee and include subject

matter experts. Each group reviewed available data, assessed

key gaps, and developed recommendations to improve the

rehabilitation care system.

Executive Steering Committee Reviewed deliberations of the

Working Groups, and consolidated, prioritized, and validated proposed recommendations; and guided the

development of final recommendations for

implementation.

Rehabilitation Symposium Brought together experts from

across the province to deliberate on work-to-date in three clinical domains; discussed and ranked

widespread identified opportunities affecting the most

people in Ontario. Provided feedback to guide and inform the

final recommendations.

Patient Rehab Panel Patients and families are engaged to provide their expertise, insights

and perspectives on identified widespread opportunities in rehab

care. Meaningful and valuable patient input will help guide the

development of final recommendations to the MOHLTC.

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Cross-Cutting Opportunities:

• The Working Groups identified a number of cross-cutting opportunities across all three clinical domains, recognizing the need and benefit of: – A provincial/regional rehab system

– Collaborative programs for self-management, risk factor reduction and well-being

– Best practice standards and guidelines

– A data/information system (with outcomes and accountabilities)

– Fair funding models to support the rehab system

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Next Steps

• A draft report of recommendations will be completed and submitted to the MOHLTC

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What is Cardiovascular Rehabilitation

• Individualized and personalized interventions that benefit participants with Heart Disease, Non-disabling Strokes, Transient Ischemic Attacks (TIAs), and Peripheral Vascular Disease (PVD)

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What is Cardiovascular Rehabilitation

• Cost effective Chronic Disease Management in the outpatient/community setting

• Essential component of the Continuum of Care using a multifaceted approach to: – Manage modifiable risk factors

– Use behaviour modification strategies to sustain a healthy lifestyle and promote pharmacological adherence

– Provide therapeutic exercise training

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What is Cardiovascular Rehabilitation

• Involves interprofessional teams, patients, and their families to deliver services, develop care plans, and facilitate successful lifestyle change

• Optimizes the individual’s functioning in terms of their recovery, and condition related to self management, risk factor reduction, wellbeing, living with their condition, and ongoing disease management.

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Impact on Cardiac Population • Reduce all-cause mortality by 12-24% and cardiac

mortality by 26-31% (Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, Taylor RS,

2016; Sagar VA, Davies EJ, Briscoe S, Coats AJS, Dalal HM, Lough F, Rees K, Singh S, Taylor RS, 2015)

• Prevent unplanned cardiac readmissions by 28-56% and reduce heart failure hospitalizations by 39% (Anderson L,

Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, Taylor RS, 2016; Sagar VA, Davies EJ, Briscoe S, Coats AJS, Dalal HM, Lough F, Rees K, Singh S, Taylor RS, 2015

• Managing modifiable risk factors including reducing blood pressure, cholesterol, smoking

• Increased physical activity • Improved mood, anxiety and quality of life (QoL) • Safe return to work

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Impact on TIA and Non-Disabling Stroke Population

• Managing risk factors (lower cholesterol and blood pressure)

• Improved fitness level, mood, and QoL,

• favorable effects on balance, muscular strength, mobility, and cognition

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Impact on Peripheral Vascular Disease Population (PVD)

• Manage modifiable risk factors, including support with smoking cessation and blood sugar control

• Improved functional performance and QoL

• Assisting with pain management

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Self-Reflection

• Is there an opportunity for collaboration in your Practice?

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Northwestern Ontario

• Geographical Size:460,000km²

• Represents 47% of province

• Population – 235,666

– Age >65: 17%

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Northwestern Ontario • Indigenous population represents 18.3% of the total

population (Health in the North – Health Quality Ontario 2017)

• Majority of the Indigenous population reside outside the City of Thunder Bay Sub Region

• Many remote communities that are not accessible by road year-round

• Indigenous people have a reduced life expectancy and poorer health status (Health in the North – Health Quality Ontario 2017)

• 24.5% of the population report as having 2 or more Chronic conditions such as Heart disease, diabetes, anxiety, and depression (Health in the North – Health Quality Ontario 2017)

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Percent of Population by Risk

Risk Factor Northwest LHIN Ontario

Overweight or Obese (BMI >30) 62.1% 52.6%

Diabetes 7.6% 6.6%

Hypertension 21.1% 17.6%

Smoking (Daily or occasional) 22.9% 17.3%

Alcohol use (Heavy) 20.9% 16.9%

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Statistics Canada Health Profile, December 2013 Northwest LHIN

Rehabilitation and Healthy Lifestyles Program

• Recognized the need for Cardiovascular Rehabilitation prior to the call to action

– Started to expand services in 2015

• Worked with the Regional Stroke Network, Regional Stroke Unit, St. Joseph’s Care Group, Dr. McDonald, etc. to establish referral processes/stream for Stroke/TIA and Vascular Patients

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Rehabilitation and Healthy Lifestyles Program

• Participants exercise within the same group and are not differentiated by referral type

• Participants receive individualized care plans and are followed by a case manager

• Participants receive individualized care for dietary and psychosocial needs

• Group education sessions offered to all participants and their families

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Utilization of Technology

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1 Program 12 Sites • Atikokan General Hospital • Dryden Regional Health Centre • La Verendrye General Hospital (Fort Frances) • Geraldton District Hospital • Mary Berglund Health Centre (Ignace) • Lake of the Woods District Hospital (Kenora) • Manitouwadge General Hospital • Wilson Memorial General Hospital (Marathon) • Nipigon District Memorial Hospital • Red Lake Margaret Cochenour Memorial Hospital (Red Lake) • Sioux Lookout Meno Ya Win Health Centre • Thunder Bay Regional Health Sciences Centre

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Referral per year

863 913 935

1123

1350

1752

2013 2014 2015 2016 2017 2018*

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* Projected using Q1 data

Program Improvements

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Client Navigator

• Triage Referrals in a timely manner to decrease wait to contact and service

• Inpatient education to bridge the gap between inpatient and outpatient care

• Follow up on client medical needs prior to Intake into program

• Referral to more appropriate programs for participants who need more specialized care

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Nurse Practitioner

• Help support Dr. Melton to increase participant intake numbers per month

• Acts as a resource to the interdisciplinary team for concerns with program participants

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Moving Forward

• Curriculum Based Programming

– Core Education Sessions

– Core Counseling Sessions

– Optional Education Sessions

• Current Research

• Seasonal needs

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Moving Forward

• Increased Program Stream Options

– Education Only

– Education and Exercise

• Return to work

• 3 Month

• 6 Month

• Home Program

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Questions

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References

• Alter DA, Oh PI, Chong A. Relationship between cardiac rehabilitation and survival after acute cardiac hospitalization within a universal health care system. Eur J Cardiovasc Prev Rehabil. 2009; 16(1):102-113

• Alter,D., Bing Yu,B., Bajaj,R., OH,P., Relationship Between Cardiac Rehabilitation Participation and Health Service Expenditures Within a Universal Health Care System, Mayo Clin Proc. 2017;92(4):500-511

• Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, Taylor RS Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis. J Am Coll Cardiol. 2016 Jan 5;67(1):1-12.

• Balady GJ, Ades PA, Bittner VA, Franklin BA, Gordon NF, Thomas RJ, Tomaselli GF, Yancy CW. Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centres and beyond: a presidential advisory from the American Heart Association. Circulation. 2011;124:2951-2960

• Dalal HM, Doherty P, Taylor RS. Cardiac rehabilitation. BMJ. 2015;351

• Dhamoon MS, Sciacca RR, Rundek T, Sacco RL and Elkind MS. Recurrent stroke and cardiac risks

after first ischemic stroke: the Northern Manhattan Study. Neurology. 2006;66:641-646.

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References

• Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis Lindsey Anderson PhD, Neil Oldbridge PhD, David R. Thompson PhD, Ann-Dorthe Zwisler MD, Karen Rees PhD, Rod S. Taylor PhD

• Fakhry F, Rouwet EV, den Hoed PT, Hunink MG, Spronk S.. Long‐term clinical effectiveness of supervised exercise therapy versus endovascular revascularization for intermittent claudication from a randomized clinical trial. BJS, 2013

• Hamm LF, Kavanagh T, Campbell RB, et al. Timeline for peak improvements during 52 weeks of outpatient cardiac rehabilitation. J Cardiopulm Rehabil 2004;24:374–382.

• Health in the North A report on geography and the health of people in Ontario’s two northern regions - http://www.hqontario.ca/portals/0/Documents/system-performance/health-in-the-north-en.pdf

• Humen D, Higgins G, Unsworth K, Prior P, Massel D, Suskin N. A Cost Analysis of Event Reduction Provided by a Comprehensive Cardiac Rehabilitation Program. Can J Cardiol 2013;29(10),S156

• Kamke W, Dovifat C, Schranz M, et al. Cardiac rehabilitation in patients with implantable defibrillators: Feasibility and complications. Z Kardiol 2003;92(10): 869–875.

• Kavanagh T, Mertens DJ, Hamm LF, et al. Prediction of long-term prognosis in 12,169 men referred for cardiac rehabilitation. Circulation 2002;106:666–671.

• Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J. 2011 Oct;162(4):571-584.

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References

• Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J. 2011 Oct;162(4):571-584.

• Macko RF, Ivey FM, Forrester LW, Hanley D, Sorkin JD, Katzel LI, Silver KH and Goldberg AP. Treadmill exercise rehabilitation improves ambulatory function and cardiovascular fitness in patients with chronic stroke: a randomized, controlled trial. Stroke. 2005;36:2206-2211.

• Marzolini S, Oh PI, McIlroy W and Brooks D. The effects of an aerobic and resistance exercise training program on cognition following stroke. Neurorehabil Neural Repair. 2013;27:392-402.

• North West LHIN 2016/2017 QIP Snapshot Report - http://www.hqontario.ca/Portals/0/documents/qi/qip/nw-lhin-report-en.pdf

• Prior PL, Hachinski V, Unsworth K, Chan R, Mytka S, O'Callaghan C, Suskin N. Comprehensive Cardiac Rehabilitation for Secondary Prevention After Transient Ischemic Attack or Mild Stroke. Stroke, 2011

• Sagar VA, Davies EJ, Briscoe S, Coats AJS, Dalal HM, Lough F, Rees K, Singh S, Taylor RS. Exercise-based rehabilitation for heart failure: systematic review and meta-analysis. Open Heart. 2015;2(1)

• Shah ND, Dunlay SM, Ting HH, et al. Long-term medication adherence after myocardial infarction: experience of a community. Am J Med. 2009 Oct;122(10):961.e7-13

• Stahle A, Mattsson E, Ryden I, et al. Improved physical fitness and quality of life following training of elderly patients after acute coronary events. Eur heart J. 1999;20:1475-1484

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References

• Standards for the Provision of Cardiovascular Rehabilitation in Ontario, www.ccn.on.ca/ccn_public/.../files/CCN_Cardiovascular_Rehab_Standards_2014.pdf

• Statistics Canada Health Profile, December 2013 Northwest LHIN- http://www12.statcan.gc.ca/health-sante/8228/details/page.cfm?Lang=E&Tab=1&Geo1=HR&Code1=3514&Geo2=PR&Code2=35&Data=Rate&SearchText=North%20West&SearchType=Contains&SearchPR=01&B1=All&Custom=&B2=All&B3=All

• Stone JA, ed. Canadian Association of Cardiac Rehabilitation Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention. Winnipeg: Canadian Association of Cardiac Rehabilitation; 2004.

• Suskin, N, MacDonald S, Swabey T, et al. Cardiac rehabilitation and secondary prevention services in Ontario: Recommendations from a consensus panel. Can J Cardiol 2003;19(7):833–838.

• Taylor RS, Sagar VA, Davies EJ, Briscoe S, Coats AJ, Dalal H, Lough F, Rees K, Singh S. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev. 2014 Apr 27;(4):CD003331.

• The CLEVER study. J Am Coll Cardiol. 2015;65(10):999-1009. • The Ontario Cardiac Rehabilitation Pilot Project: Final Report and Recommendations.

www.ontla.on.ca/library/repository/mon/5000/10309581.pdf • World Health Organization. Needs and Action Priorities in Cardiac Rehabilitation and Secondary

Prevention in Patients with Coronary Heart Disease. WHO Regional Office for Europe; Geneva: 1993

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