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Aims of the British Association for Cardiovascular Prevention and Rehabilitation standards and core components
This second edition of the Standards and Core Components (SCC) for Cardiovascular Disease Prevention and Rehabilitation from the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) define cardiac rehabilitation (CR), operationally, through seven standards and seven core components for assuring a quality service of care using a multidisciplinary biopsychosocial approach.1 The seven standards aim to ensure that service commissioners, providers and health professionals are aware of the requirements for providing a multidisciplinary CR team that is competent and thus clinically effective, cost-effective and ultimately cost-saving as a result of preventing hospital readmissions. The seven core components (figure 1), delivered as a coordinated sum of activities aim to best influence uptake, adherence, quality of life and long-term healthier living.2 Details of the full version and related evidence base of the BACPR SCCs can be accessed from the following website: http://www.bacpr.com
Current challenges to implementing the evidence and achieving quality outcomes
Over the past three decades overwhelming evidence on comprehensive CR, which includes exercise, has reported reductions in morbidity and mortality; re-infarctions (47%), cardiac mortality (26–36%) and total mortality (13–26%).3 ,4 Secondary prevention, including blood pressure and cholesterol management and the prescription of cardioprotective medication, now also forms an integral part of an effective CR programme.5 The current evidence base included under the ‘umbrella’ of CR has reported many variations in the ‘dose’ of individual or collective interventions (medical, lifestyle and psychosocial), which may therefore explain the variations of outcomes found in the studies included in the key systematic reviews on CR.3 ,4 More recently published British evidence clearly shows that when the ‘dose’, at least of the exercise component, of CR is below those found in the more ideal research studies, the outcomes (functional capacity, quality of life and mortality) are poor.6 The emerging evidence base however demonstrates that when doses of CR are commensurate with the more ideal studies, morbidity and mortality are reduced and there is a 23–56% reduction in costly unplanned hospital readmissions.7 ,8 There is now increased emphasis on early CR commencing within 2 weeks of either discharge or diagnosis, with such a timeframe being safe, feasible, more clinically effective and with improved patient uptake and adherence.9 ,10 It is from this collection of evidence on the benefit of early CR that the BACPR has enhanced its emphasis on the central component of Health Behaviour Change and Education (figure 1) for achieving such goals as early commencement and reduced unplanned hospital readmissions. These goals fit well with the key aim of England's Department of Health of preventing readmissions within 30 days of an acute cardiac event. From a patient-centred focus, the BACPR's SCCs aim to ‘help people help themselves’ in the following ways: improving self-management skills; returning to a productive life in one's community; improving functional capacity and perceived quality of life; returning to work as early as possible; and supporting longer-term adherence to lifestyle and medical risk factor interventions.1 ,11
National and local factors for assuring quality
Quality assurance is achieved at local (eg, commissioners, service providers and service users) and national levels by combining participation in national audits with the measurement of performance against recognised standards.1 ,5 ,12
A seven-stage pathway of care for CR
The Department of Health Commissioning Pack for CR12 details a recommended seven-stage (0–6) pathway of care from patient presentation (eg, diagnosis or cardiac event), identification for eligibility, referral, and assessment through to long-term management. While intended for England, this pathway of care is relevant to all four UK nations. Each of these stages within this process is vital for programme uptake and adherence, the achievement of meaningful clinical outcomes and ensuring longer-term behaviour change and desired health outcomes. The assessed information must also be managed in a manner to fulfil the need for audit and evaluation. It is important to recognise that care across this seven-stage pathway may involve different healthcare settings and organisations.
Meeting quality assured guidelines towards excellence of care
CR has been identified in two of the indicators of the Quality and Outcomes Framework (QOF), which either currently exist or are part of the 2013/2014 planned guidelines from the National Institute for Health and Clinical Evidence (NICE; http://www.nice.org.uk). The two QOF indicators are the secondary prevention of coronary heart disease and the management of chronic congestive heart failure.
It is therefore vital that a contemporary and comprehensive set of SCCs for CR and other chronic conditions are available for health services to use as a quality guide in the procurement and in the delivery of front-line care. Although the QOF and NICE guidelines relate to services in England and Wales, the evidence base that underpins this guidance on CR can be applied to all four nations of the UK and even to other countries with state-run health services. A special focus of this planned 2013/2014 NICE guidance on coronary heart disease secondary prevention and heart failure is to improve early uptake and adherence to CR. The British Heart Foundation's National Audit for Cardiac Rehabilitation (http://www.cardiacrehabilitation.org.uk/nacr/) highlights two priority groups in which there is a need to improve uptake: those who have had percutaneous coronary interventions and those with heart failure, both of whom have the poorest uptakes of all eligible CR conditions.1
Cardiac rehabilitation as part of an integrated cardiology service
The position of CR as part of an integrated cardiology service and its national priority is acknowledged.13 It is the responsibility of every cardiologist, surgeon, rehabilitation physician or general practitioner to recommend CR to all eligible patients as part of their treatment plan. Within programmes, the benefit to patients and CR services from having committed cardiologist support is well recognised.13
The seven standards and seven core components of the BACPR
Box 1 and figure 1 summarise the seven standards and the seven core components of the BACPR, respectively. The delivery of the core components of CR should adopt a biopsychosocial evidence-based approach, which is culturally appropriate and sensitive to individual needs and preferences. The Lifestyle component for CR includes physical activity and exercise, diet and smoking cessation.
Seven service standards of the British Association for Cardiovascular Prevention and Rehabilitation1
The delivery of the seven core components employing an evidence-based approach
An integrated multidisciplinary team consisting of qualified and competent practitioners, led by a clinical coordinator
Identification, referral and recruitment of eligible patient populations
Early initial assessment of individual patient needs in each of the core components, ongoing assessment and reassessment upon programme completion
Early provision of a cardiac rehabilitation (CR) programme, with a defined pathway of care, which meets the core components and is aligned with patient preference and choice
Registration and submission of data to the National Audit for Cardiac Rehabilitation
Establishment of a business case including a CR budget which meets the full service costs
Future challenges for delivering CR
Although the provision of evidence-based CR is now moving into its fourth decade, the challenges ahead include: the determination of an appropriate costing for this multidisciplinary integrated medical, lifestyle and psychosocial intervention; filling the gaps of current service provisions; and meeting the needs of a changing healthcare landscape, where survival is increasing but in an era of an ageing and less able population who are living for many years with the burden of chronic diseases such as cardiovascular disease (CVD).
Cost of CR
The costing of CR should include the delivery of all seven core components across the seven stages of the patient care pathway. Published guidance and audit data have provided a recommended cost-per-patient for CR but greater detail is required in future modelling to show that all costs across the seven stages are included.1 Current cost models may prove to be insufficient for future service needs. With improved survival rates and accelerated discharge following acute events, prevention and rehabilitation programmes will need to be more equipped to help patients to better self-manage their condition and improve wellbeing; all of which is aimed at preventing subsequent cardiovascular events and unnecessary costly readmissions. The National Audit for Cardiac Rehabilitation has highlighted that there are gaps in provision that will need to be remedied in future costing models. These gaps include: a lack of psychologists involved in the health behaviour change and psychosocial wellbeing components; a need for enhanced provision of diet and smoking cessation specialists and for increased medical risk factor management either through specially trained healthcare prescribers or more dedicated input from cardiologists or specialist physicians. It is also important to recognise costs will vary considerably depending on the complexity of the patient caseload as well as the individual patient needs, requirements and choices.
Current gaps in service delivery
Making CR a core element of any cardiology service is gaining momentum but further work is required to achieve this. The British Cardiovascular Society is now beginning the inclusion of CR in its educational requirements for trainee cardiologists. It is paramount to include within CR programmes the direct involvement of cardiologists, specialist physicians or independent prescribers to deliver the medical risk factor management and cardioprotective therapies components.
Considerations for a changing landscape in healthcare provision
To date, there has been strong evidence supporting the contribution of CR to reduced mortality. Investment and innovation in all four UK nations over the last decade has led to major advances in cardiology practice and together with improvements in public health, these advances have contributed to considerably lower death rates following acute coronary syndromes.14 The continued important benefits of CR on influencing morbidity and patient wellbeing in light of the growing number of surviving individuals living longer with the burden of cardiovascular disease should therefore be emphasised. Improved survival coupled with an ageing population is leading to a growing number of people developing heart failure;15 a population known to benefit from CR.7 Simultaneously there are also increasing numbers of younger individuals identified at higher risk of developing cardiovascular disease and consequently a growing call for prevention-based strategies.14
In the implementation and delivery of the seven core components, underpinned by seven service standards, the BACPR has emphasised that CR must be integral to any modern cardiology service. CR has a strong evidence base for being clinically effective, cost-effective and cost-saving, together with patient-centred aims which support longer-term health, self-management and wellbeing. These outcomes are especially true when rehabilitation is commenced early following acute treatment, discharge and/or diagnosis, which lead to increased uptake, adherence and prevention of unnecessary hospital readmissions. These SCC can only be met if training is undertaken to create skilled and competent specialist practitioners for each of the core components. An overall aim of the BACPR is to be a resource for providing appropriate guidance and training on the knowledge, skills and competences required.
Full names and details of the 2007 and 2012 development and affiliated consultation groups are noted in the full free online version of the 2012 BACPR Standards and Core Components at: http://www.bacpr.com
Declaration The membership of the 2007 and 2012 BACPR Standards and Core Components’ development groups embody many professional associations working within CR services or allied professional organisations in the UK. The individual members of the development groups, working under the auspices of the BACPR, express no conflict of interests regarding the material contained in this publication.
Contributors All authors have made a substantial contribution to the following: conception and design, acquisition of data or analysis and interpretation of data, drafting the article or revising it critically for important intellectual content, and will be involved in the final approval of the version published. Each author has participated sufficiently in the work to take public responsibility for appropriate portions of the content.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.