A comparison of outpatient cardiac and pulmonary rehabilitation patients

Nurse-Led Cardiac Rehabilitation Care Coordination Program: Improving Functional Outcomes for Patients Through Automatic Referral and Effective Care Coordination

PURPOSE

The aim of this investigation was to evaluate the impact of automated cardiac rehabilitation (CR) referral and nurse care coordination on patient and program outcomes. Specifically, the aim was to identify whether differences exist in physical and psychological function at CR Phase 2 enrollment and completion and CR Phase 2 participation and completion for hospitalized patients who receive in-person CR nurse visits versus phone consultation. Using a retrospective pre-/post-intervention descriptive design, a purposive sampling technique was used to select groups with matching clinical attributes. Dates were selected to mitigate the impact of COVID-19 on CR program enrollment and completion.

METHODS

Data were abstracted from the patient electronic medical record, telemetry documentation, and CR referral tracking tool. Patient descriptors included age, sex, cardiac diagnosis/procedure (post-coronary artery bypass graft surgery, myocardial infarction, percutaneous coronary intervention, heart failure, and aortic valve repair and replacement) and cardiac risk stratification category. Patient functional outcomes included the 6-min walk test and metabolic equivalents of task levels for functional capacity; psychological function was measured by the Patient Health Questionnaire assessment. Program outcomes included discharge to CR Phase 2 enrollment, CR sessions, and completion.

RESULTS

Each group had 52 patients. Age was 64 ± 12 yr, 68% were male. Perhaps indications for CR included coronary artery bypass graft surgery (44%), myocardial infarction (19%), percutaneous coronary intervention (20%), heart failure (10%), aortic valve repair and replacement (8%). Cardiac risk was low in 30%, intermediate in 65%, and high in 5%. The post-intervention group compared with the pre-intervention group had a shorter discharge to CR Phase 2 enrollment (35 ± 18 d vs 41 ± 28 d, P = .078) and significantly fewer sessions required for CR completion.

CONCLUSION

Automated CR referral and nurse care coordination visits for hospitalized patients decreased the transition period between CR Phase 1 and 2. Patients were physically and psychologically prepared for earlier CR Phase 2 enrollment and successfully completed the program in fewer days than the pre-intervention group.

Protocol for a feasibility trial to inform the development of a breathlessness rehabilitation programme for chronic obstructive pulmonary disease and chronic heart failure (the COHERE trial)

INTRODUCTION

Adults with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) commonly suffer from exertional dyspnoea and fatigue. Exercise training is recommended in the management of both diseases, yet many of the outcome measures traditionally reported are disease specific and may not fully acknowledge the multimorbid older adult. Based on our previous research, a breathlessness rehabilitation programme for patients with COPD/CHF or combined disease has been introduced as a service improvement within University Hospital Leicester National Health Service Trust and has amalgamated aspects of cardiac and pulmonary rehabilitation. This has created an opportunity to expand the outcome measures assessed and introduce a holistic approach in a population that share common symptoms. Therefore, this multisite trial will explore the feasibility of collecting novel outcome markers as part of a comprehensive assessment prior to enrolment in a breathlessness rehabilitation programme for participants with COPD and/or CHF.

METHODS AND ANALYSIS

The rehabilitation programme consists of 12 sessions, twice weekly, over a 6-week period. In addition to usual rehabilitation outcome measures, the trial will collect measures of future cardiometabolic risk including arterial stiffness, body composition, physical activity/sedentary time, frailty and symptom burden in a comprehensive rehabilitation assessment. The primary outcome measures will centre around feasibility (eg, acceptability of the comprehensive rehabilitation assessment, intervention delivery and the experiences and attitudes of healthcare professionals and participants). Focus groups and interviews will be conducted to further explore barriers and facilitators to the operation and participation in a breathlessness rehabilitation programme and the trial. Thematic analysis will be used for the interpretation of all qualitative data.

ETHICS AND DISSEMINATION

The research ethics committee East Midlands Leicester-Central has provided ethical approval for the conduct of this trial. The results of the trial will be disseminated through appropriate conference proceedings and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN11636308.

Rehabilitation of Patients with Coexisting COPD and Heart Failure

Chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) frequently coexist, significantly reducing the patient's quality of life (QoL) and increasing morbidity, disability and mortality. For both diseases, a multidisciplinary disease-management approach offers the best outcomes and reduces hospital readmissions. In both conditions, muscle dysfunction may dramatically influence symptoms, exercise tolerance/performance, health status and healthcare costs. The present review describes muscular abnormalities and mechanisms underlying these alterations. This review also discusses studies on training programs for patients with COPD, CHF and, where available, combined COPD-CHF diagnosis. Dyspnea, peripheral muscles and activities of daily living (ADL) represent a potential starting point for improving patients' functioning level and quality of life in COPD and CHF. A synergy of the combined diagnostic, pharmacological and rehabilitation treatment interventions is also essential. Integration between exercise training, drug therapy and nutritional care could be a valid, synergic and tailored approach for patients presenting with both diseases, and may have a positive impact on the exercise performance.

Developing the model of pulmonary rehabilitation for chronic heart failure

Patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) commonly suffer from exertional symptoms of breathlessness and fatigue. The similar systemic manifestations of the conditions, including skeletal muscle dysfunction, are a major contributing factor to the limitation in exercise capacity. A period of exercise training has been shown to improve exercise performance and health-related quality of life for both conditions. Exercise training is a key component of pulmonary rehabilitation (PR) which is now a standard of care for patients with COPD and is symptom based. Although it may be assumed that patients with CHF could be incorporated into cardiac rehabilitation, this is predominantly a secondary prevention programme for patients who are largely asymptomatic. It has been shown that patients with CHF can be successfully trained together with patients with COPD by the same therapists within PR. There are comparable outcome measures that can be used for both COPD and CHF. Many patients with CHF still do not have access to an exercise rehabilitation programme and incorporating them into the PR model of care could be one solution. This article reviews the (1) similar symptoms, mechanisms and consequences between COPD and CHF, (2) rationale and evidence for exercise training in CHF, (3) model of PR, (4) safety of exercise training in CHF, (5) evidence for combined exercise rehabilitation for CHF and COPD, (6) adaptations necessary to include patients with CHF into PR, (7) the chronic care model and (8) summary.

Generic, symptom based, exercise rehabilitation; integrating patients with COPD and heart failure

BACKGROUND

Patients with Chronic Heart Failure (CHF) develop similar symptoms of exertional breathlessness and fatigue as patients with COPD. Although pulmonary (exercise based) rehabilitation (PR) is an integral part of the management of COPD, the potential for exercise rehabilitation (ER) to assist patients with CHF may not be as readily appreciated. We investigated whether combined ER for patients with CHF and COPD was feasible and effective using the model of PR.

METHODS

57 patients with CHF were randomized 2:1 to 7 weeks ER (CHF-ER) or 7 weeks of usual care (CHF-UC). As a comparator 55 patients with COPD were simultaneously recruited to the same ER program (COPD-ER). The primary outcome measure was the Incremental Shuttle Walk Test (ISWT) and the secondary outcome measures were the Endurance Shuttle Walk Test (ESWT), isometric quadriceps strength and health status.

RESULTS

27 CHF and 44 COPD patients completed ER and 17 patients with CHF completed UC. The CHF-ER group made significant improvements, compared to CHF-UC, in the mean (95%CI) ISWT distance; 62(35-89)m vs -6(-11 to 33)m p < 0.001. The CHF-ER group also made statistically significant improvements in health status. The improvements in exercise performance and health status were similar between patients with CHF and COPD, treated with ER.

CONCLUSION

Patients with CHF who undergo ER improve similarly in their exercise performance and health status to COPD. Combined training programs for COPD and CHF are effective and feasible, such that service provision could be targeted around common disability rather than the primary organ disease.