A Cardiac Rehabilitation Coalition measuring and improving practice

A Cardiac Rehabilitation Coalition: measuring and improving practice, ACRA 2018 Dr. Carolyn Astley RN, Dr. PH, Snr project lead, cardiac rehabilitation

What is the problem or gap? • Cardiac rehab (CR): effective in reducing risk factors and preventing death and readmission. 1 • Referral and completion are poor. 2 • Audit can measure service effectiveness. 3 • 2012 the SA Cardiac Clinical Network audit (N=13) showed a 12% completion rate. • Not all services were collecting data, data variables were not the same. • Our aim was to increase referral and completion. 1. Anderson et al. Exercise-based CR for coronary heart disease. JACC 2016; 67: 1 -12. 2. Clark AM et al. Factors influencing referral to CR and secondary prevention programs; a systematic review. Eur J Prev Cardiol. 2013. 20(4); 692 -700. 3. Ivers et al. Audit and feedback: effects on professionals practice and healthcare outcomes. Cochrane Database Systematic Reviews. 2012; 6: Cd 000259.

What did we do? 2015: i. CCnet centralised referral for country patients and external patients 2015: Built the CATCH database Web-based data entry 2012: Developed evidence – based minimum dataset Improving referral and completion for CR eligible patients 2013 -2016: i. CCnet/PHN a CR telephone service for country 2012: Coalition Clinicians Researchers i. CCnet Heart Foundation 2012: Agreed on standard data entry

What are the outcomes? Standardised, uniform data entry across 24 country and metropolitan CR services contributing to 3 audits. Audit years 2013 2014 2015 Referrals (n) 5, 031 4, 965 5, 138 • Telephone N/A 327 (16. 4%) 291 (54. 9%) • Face to face n(%) 100% 1, 628 (81. 6%) 2, 063 (86. 4%) Started n (%) 1, 134 (22. 5%) 1, 995 (40. 2%) 2, 387 (45. 1%) Completed n (%) 945 (83%) 1, 067(68. 8%) 1, 466 (77. 4%) Completion rate (% of referrals) 19% 21. 4% 28. 4%

Outcomes All cardiovascular readmission and by cardiovascular diagnosis 45 40 Adjust clinical and social factors: HR: 0. 68, 95% CI: 0. 57 -0. 80, P < 0. 001 35 % 30 25 20 15 10 5 0 All chest pain atrial fib AMI not referred Angina ACS Heart F referred/declined ICD-10 AM diagnosis Arryth attended CVA

Outcomes 35 30 25 Composite of death, new/re-MI, atrial fibrillation, heart failure & stroke by 12 months Adjust clinical and social factors; HR: 0. 80, 95% CI: 0. 60 -1. 08, p= 0. 156 20 % 15 10 5 0 inhospital 30 days not referred 70 days referred/declined Time 12 months attended

Lessons learned • Our Coalition provides a mechanism for clinician engagement • Audit is an effective tool to identify practice gaps • We need a structure to facilitate service improvements in the 70% who are referred but don’t attend CR • Ongoing data management and analysis costs

Acknowledgements The South Australian public metro and country cardiac rehabilitation service providers: SALHN: Sanchia Shute, Rhonda Naffin, Kerry Pasco CALHN: Amy Wilson, Renee Henthorn NALHN: Susan Sierp, Michelle Iadanza CATCH phone program: Teena Wilson, Claudine Clark CHSA leads: Ann Felder, Nicole Daws, Caroline Wilksch, Frank Circelli, Ceri Johns, Alyssia Smith, Trudy Baker, Cindy Whittlesea, Nikki Bock, Linda Marshall, Paul Whittaker, William Davies. SA Academic and Health Science CR Translation group

What are the outcomes? In 2018 we linked 2013 -2015 service level data with administrative data and found; N= 49, 909 ELIGIBLE for CR ATTENDED (n= 4, 286) vs REFERRED/DECLINE (n= 10, 803) Clinical and social factors adjustment (HR, 95% CI) P Value 1174/4286 (27. 3%) v 12034/34820 (43. 5%) 1174/4286 (27. 3%) vs 4478/10, 803 (41. 4%) HR: 0. 68 (95% CI: 0. 57 -0. 80) < 0. 001 Death, new/re 267/4286 (6. 2%) -MI, HF, AF, vs stroke 10, 400/34, 820 (29. 9%) n(%) 267/4286 (6. 2%) vs 1, 583/10, 803 (14. 6%) HR: 0. 80 (95% CI: 0. 60 -1. 08) 0. 156 Cardiovascular readmission n(%) ATTENDED (n=4, 286) vs NOT REFERRED ( n=34, 820) Referral rate across the 3 years was 15, 089/49, 909 or 30. 2%