Models of cardiac rehabilitation

Multidisciplinary rehabilitation is worthwhile, but how is it best delivered?

Papers p 1354

The survey by Lewin and colleagues of cardiac rehabilitation in the United Kingdom paints a picture of services predominantly provided by nurses and physiotherapists, with little formal input from physicians or psychologists, and a need both for more extensive use of validated methods of assessment and of formal audit (p 1354).1 Clinicians will bristle (I bristled) at the insinuation that they are not involved in rehabilitation. Cardiac and general medical outpatients clinics are full, we say, of patients being followed up after myocardial infarction or cardiac surgery. In theory (our theory) this should run parallel with and form part of the formal rehabilitation process. In practice, it often does not. Ten minutes of structured consultant time in the context of a rehabilitation process may be more valuable and more cost effective than an isolated 10 minutes in the middle of a busy outpatient clinic. Reorganisation to implement this would be feasible, but care would be needed to preserve valuable features such as continuity of care.

The issue of psychological input is more difficult. There is good evidence that psychological morbidity, particularly depressive illness, is common after infarction.2 However, intervention intended to counteract it has sometimes had paradoxical results and should certainly not be divorced from other rehabilitation measures.3 Given a relative shortage of clinical psychologists, the best strategy is probably to use a well validated assessment instrument to identify patients at risk and to concentrate resources on them.

An important issue which is not addressed in the survey is the extent to which cardiac rehabilitation should be hospital or community based. Rehabilitation guidelines rightly emphasise the need for a seamless rehabilitation service extending from acute hospital care into long term community follow up.4 However, few services have been successfully developed which actually provide this, and the idea sits uneasily with traditional ideas about the scope of secondary and primary care, or divisions between purchaser and provider. The concept of a rehabilitation cardiologist, from either a hospital or primary care background, who could provide a bridge between hospital and community rehabilitation is an attractive one, but is largely unproved. To what extent is it legitimate to separate cardiac rehabilitation from rehabilitation services in general? In many hospitals cardiac rehabilitation has evolved in isolation from rehabilitation linked to other specialist services, or from general rehabilitation aimed at the elderly. In our hospital the median age for cardiac surgery is now 65, and such traditional distinctions may need to be rethought.

The survey also mentions resources. Until relatively recently the inability of clinical trials of exercise based cardiac rehabilitation programmes to show benefit in terms of survival put them at a disadvantage in competing for resources in a cash limited health service. There is now recognition that cardiac rehabilitation in a wider sense—encompassing secondary prevention and other multdisciplinary interventions—is worthwhile. But the deferred and sometimes unspectacular nature of its benefits mean that it inevitably loses out to more urgent imperatives such as acute admissions and dealing with waiting lists—a problem not limited to cardiac rehabilitation.5 There is a temptation to set up token services whose inadequacies are cconcealed until they are properly audited.

The recognition in Our Healthier Nation of the importance of prevention and rehabilitation is welcome,6 but it remains to be seen whether this is backed up by resources. The shift of emphasis from general practitioner fundholding to community commissioning may provide a unique opportunity to set up integrated rehabilitation services. In addition, a greater emphasis on return to work should encourage links with occupational health services. Meanwhile, the onus is on the rehabilitation community to come up with clinically and economically effective models from which to deliver optimal rehabilitation.