Cardiac rehabilitation (CR) is recommended as part of integrated cardiac care in Denmark to improve the health-related quality of life, slow disease progression and reduce mortality among the large group of patients suffering from ischaemic heart disease.
This PhD dissertation assesses the implementation of hospital-based CR at hospitals in Denmark and presents a local model of comprehensive CR that complies with Denmark’s current guidelines. The dissertation is based on two articles, five book chapters and a home page (www.hjerterehabilitering.dk). The dissertation outlines the current recommendations for CR, reviews the evidence for CR and summarizes the results of a survey on the implementation of CR at hospitals in Denmark. Further, a local model of outpatient comprehensive CR is presented.
According to Denmark’s current guidelines and statements from professionals, politicians and health planners, comprehensive CR should be implemented throughout Denmark’s health care system for patients with ischaemic heart disease. In the future, these services might also be aimed at patients with heart failure and patients at high risk of developing ischaemic heart disease. CR is a comprehensive intervention including: individual tailoring, patient education, exercise training, dietary guidance, smoking cessation, psychosocial support and systematic risk factor management and clinical assessment.
The international scientific literature on CR has been growing steadily since the late 1960s, and the number of publications has more than doubled within the last 10 years. Systematic meta-analysis has documented that exercise-based CR reduces overall mortality by 20% and cardiac mortality by 26%. Further, CR has been documented to reduce important risk factors. Studies have indicated that CR positively influences the health-related quality of life. The positive influence on the health-related quality of life still remains to be proven, and standardized validated disease-specific instruments for measuring the health-related quality of life are needed.
The evidence for CR has primarily been documented among men younger than 65 years of age who have experienced myocardial infarction. A subgroup analysis indicates that these results can be applied to a broader group of patients. The intervention trials on comprehensive CR vary markedly, and the quality of the trials has been questioned due to lack of allocation concealment, lack of blinding and poor or missing description of intervention.
A postal questionnaire survey showed that most hospitals in Denmark offer one or more of the CR components. However, not all hospitals offer comprehensive CR that complies with the current guidelines. The survey in 1999 found that 36% of hospitals in Denmark offer comprehensive CR according to Denmark’s current guidelines but our survey might overestimate the coverage. Differences in health care systems and the organization of services do not allow the coverage of CR to be directly compared between countries, but Denmark seems to be lagging 5 years or more behind compared to England and Germany. Several CR activities have been initiated in Denmark since the survey in 1999 and may have positively influenced the coverage of CR at hospitals in Denmark.
H:S Bispebjerg Hospital received Denmark’s guidelines on CR in 1997 and initiated implementation of comprehensive CR the same year. Since Denmark’s guidelines do not describe comprehensive CR in detail, a local programme was developed. The Cardiac Rehabilitation Unit was founded in 1999, and a 3-year study was conducted on implementing a local model of comprehensive CR. The study showed that outpatient comprehensive CR that complies with Denmark’s existing guidelines could be organized and implemented at a large urban hospital. Experience from the study indicated some key areas that need special attention in implementing hospital-based comprehensive CR locally: individual tailoring and coordination must be systematically assessed; the quality of each core component must be systematically monitored; continual development of an interprofessional approach and culture must be given priority; profession-specific as well as CR-specific education are cornerstones in ensuring high-quality CR services. A coherent CR programme across sectors and CR phases must be ensured.
The DANREHAB Trial, a large-scale randomized clinical trial, was designed to clarify whether the local model of comprehensive CR is superior to usual care. The Trial included 770 patients and is the largest single-centre trial conducted so far worldwide on comprehensive CR aimed at a broad target group. The results of the DANREHAB Trial will be prepared for publication within the coming year and will contribute to knowledge on CR in a hospital setting in Denmark. Further, the evaluation will contribute to knowledge on the cost–effectiveness, organizational issues and patients’ perspectives.
This dissertation shows that Denmark’s health care system made marked progress in implementing CR services in the 1990s; nevertheless, the quantity and quality of services vary widely, and the coverage of services still needs to be expanded considerably. The local implementation study showed that outpatient comprehensive CR services that comply with Denmark’s current guidelines can be organized and implemented at a full scale. The local study can contribute to the development and implementation of CR in Denmark. Further results from evaluation of the local programme will bring knowledge on hospital-based CR in Denmark.
The overall challenge is to provide high-quality CR services to everyone who can benefit and at a level appropriate to their needs. Several reports and statements have been published in Denmark since 1997; the time has come to prepare practical action plans nationally, regionally and locally. These plans must consider the continuum of care, the quality of CR services, educational needs and future research and development.