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1. RATIONALE

Chapter 2

Basic Principles

Ann-Dorthe Olsen Zwisler & Lone Schou


2.1 Introduction

The comprehensive cardiac rehabilitation programme offered by the Cardiac Rehabilitation Unit at Bispebjerg Hospital has been organized using several basic principles that are based on the current guidelines (1–3) and established by an interprofessional working group (4).

Basic principles of comprehensive cardiac rehabilitation
  • Broad concept of cardiac rehabilitation
  • Broad target group
  • Comprehensive cardiac rehabilitation services
  • Individually tailored programme
  • Involvement of family members
  • Performing tasks using an interprofessional approach
  • Patient-centred health communication
  • Systematic clinical assessment and referral

This chapter defines and explains the basic principles. The chapter concludes by outlining legislation and ethical aspects relevant to cardiac rehabilitation.


2.2 Basic Principles

2.2.1 Broad concept of cardiac rehabilitation

An international expert group appointed by the World Health Organization (5) defined cardiac rehabilitation as “the sum of activity required to ensure cardiac patients the best possible physical, mental and social conditions so that they may, by their own effort, regain as normal as possible a place in the community and lead an active life”. Efforts to prevent heart disease can be divided into primary, secondary and tertiary prevention. Primary prevention means preventing disease from arising at all. Secondary prevention means identifying patients at high risk of developing ischaemic heart disease and identifying symptoms and disease at early stages to reduce the course of disease and contribute to improving the prognosis. Tertiary prevention means preventing remission of disease and preventing chronic conditions, including reduced functioning as a result of disease (6).

Activities targeting patients with known heart disease therefore include secondary and tertiary prevention. The concept of tertiary prevention and WHO’s definition of cardiac rehabilitation are very similar.

Since both secondary and tertiary prevention are core services in cardiac rehabilitation, the comprehensive cardiac rehabilitation programme at Bispebjerg Hospital has aimed towards a concept of cardiac rehabilitation that covers both rehabilitation and disease prevention. We thus wanted to establish that the cardiac rehabilitation programme is a broadly founded rehabilitation programme that is considerably more extensive and comprehensive than previous cardiac rehabilitation programmes, which often concentrated on individual components such as physical rehabilitation (exercise training) and patient education.


2.2.2 Broad target group

The effects of cardiac rehabilitation have especially been documented among young men with myocardial infarction (7), but the results from recent studies show that these effects can be transferred to a broader target group:

Diagnostic groups
Ischaemic heart disease: Cardiac rehabilitation is recommended for all patients who have manifest ischaemic heart disease: patients with myocardial infarction, patients who have undergone percutaneous coronary intervention, patients who have undergone coronary artery bypass grafting and patients with stable ischaemic heart disease who have not yet been offered comprehensive rehabilitation (1;8–11).

Heart surgery: Patients who have undergone other heart surgery than coronary artery bypass grafting and percutaneous coronary intervention, such as the implantation of an implantable cardioverter defibrillator (12;13), heart valve surgery (14) and heart transplantation (15) also have documented benefits from cardiac rehabilitation organized based on the special conditions of the basic disease and intervention performed (11).

Congestive heart failure: Good evidence exists that physical exercise is a well-indicated treatment for patients with congestive heart failure whose symptoms are well controlled (16;17), and the clinical guidelines on cardiac rehabilitation recommend that patients with congestive heart failure be offered comprehensive cardiac rehabilitation based on the same principles as patients with ischaemic heart disease (10;11).

High-risk patients: Attention on the importance of preventing the development of heart disease among high-risk patients has increased in recent years. High-risk patients are considered a target group for cardiac rehabilitation emphasizing lifestyle intervention and risk factor management (10).

Groups unrelated to diagnosis
Women: Several studies (18–20) have shown that women obtain the same benefits from cardiac rehabilitation as men, and guidelines from Denmark (1) and elsewhere (8–10) emphasize that women should also participate in cardiac rehabilitation programmes. Despite these recommendations, studies (18;21–24) indicate that women participate half as often as men in cardiac rehabilitation programmes. One reason could be that fewer women are referred to cardiac rehabilitation (25;26) and another that women are more often older than men when they heart disease becomes manifest (27).

Elderly people: Evidence (28;29) indicates that elderly patients benefit as much as younger patients from cardiac rehabilitation. Despite the existing documentation for the effectiveness of cardiac rehabilitation, studies (25;26) show that fewer older than younger cardiac patients are referred to cardiac rehabilitation programmes, and elderly people are more likely to decline cardiac rehabilitation services (22;30). Some hospital departments in Denmark have a maximum age for participating in cardiac rehabilitation, typically 70 years (31).

Ethnic minorities: Knowledge is limited on the effectiveness of cardiac rehabilitation in Denmark among patients with an ethnic background other than Danish (32). Despite this lack of knowledge, this project could not investigate this important topic because money was lacking for simultaneous interpretation.

Based on the existing evidence and the clinical guidelines, the services offered by the Cardiac Rehabilitation Unit target men and women of all ages who speak Danish and have ischaemic heart disease, congestive heart failure or a high risk of developing ischaemic heart disease.

Target groups of the comprehensive cardiac rehabilitation programme
  • Patients with ischaemic heart disease
  • Patients with congestive heart failure
  • Patients with a high risk of developing ischaemic heart disease

Patients who cannot transport themselves are offered transport to and from the Cardiac Rehabilitation Unit.


2.2.3. Comprehensive cardiac rehabilitation services

The cardiac rehabilitation programme has three phases: during admission (phase I), hospital-based outpatient cardiac rehabilitation (phase II) and the late maintenance and follow-up phase (phase III) (33). 1 In recent years attention has increasingly focused on the fact that patients are especially vulnerable during the transitions between phases because coordination may be lacking between phases, actors and efforts, with the risk of losing the health benefits achieved (34).

The Cardiac Rehabilitation Unit offers a phase II hospital-based programme. According to current guidelines (1;35;36), outpatient cardiac rehabilitation includes comprehensive cardiac rehabilitation programmes involving exercise training, patient education, lifestyle intervention, risk factor management, psychosocial support and optimizing the pharmaceutical treatment of symptoms.Nevertheless, the recommendations do not prescribe how these elements should be weighted or composed in detail. A successful phase 2 cardiac rehabilitation programme requires optimum clinical assessment and acute treatment.

Based on current evidence, the Cardiac Rehabilitation Unit has seven components and a supplementary module for patients with type 2 diabetes.

Core components of the comprehensive cardiac rehabilitation programme
  • Individually tailored rehabilitation programme
  • Patient education
  • FExercise training
  • Support for changing diet
  • Support for smoking cessation
  • Psychosocial support, including a 24-hour helpline
  • Systematic risk factor management and clinical assessment
  • A supplementary module for patients with diabetes

Cardiac rehabilitation programme

Illustration of Cardiac rehabilitation programme

Knowledge is lacking on the relationship between the length of phase II cardiac rehabilitation and the resulting effects (10). The length of phase II programmes varies greatly in Europe: from 1 to 46 weeks (33;35); the length of the programmes included in a metaanalysis of the effects varied from 1 week to 30 months (7). Although this aspect has not been sufficiently studied, the most recent European position paper (10) indicates a minimum length of 8–12 weeks.

The comprehensive cardiac rehabilitation programme offered by the Cardiac Rehabilitation Unit lasts 12 months. The programme starts with a brief period in which the individual programme is tailored followed by intensive cardiac rehabilitation for 6 weeks. When the intensive programme ends, the patient attends planned clinical follow-up assessment at the Cardiac Rehabilitation Unit after 3, 6 and 12 months.Then the patients are referred to their general practitioners or continue under the supervision of a department of cardiology if the course of disease is complicated.

The individual components and the efforts of each group of professionals need to be coordinated for the comprehensive cardiac rehabilitation programme to succeed. The Cardiac Rehabilitation Unit ensures this by organizing clinical practice, communicating with patients and exchanging information between professions.


2.2.4 Individually tailored programme

The patient is the central actor in the cardiac rehabilitation programme, since involving patients is a prerequisite for success. The Cardiac Rehabilitation Unit tailors the programme to the needs and resources of each patient based on individual discussions between the patients and health professionals.


2.2.5 Involvement of family members

The patient’s family members (primarily spouses) play an important role in cardiac rehabilitation at Bispebjerg Hospital and are involved as resource people in the overall rehabilitation. Studies indicate that patients with good family support are more likely to maintain participation in cardiac rehabilitation and changes in lifestyle than patients without such support (36). In addition, family members often feel powerless and anxious in connection with the illness of close family and have an independent need for support in coping with the early phase of acute illness in their family (37–41).


2.2.6 The current guidelines

(18–10) unanimously emphasize that hospital-based cardiac rehabilitation efforts should be based on an interprofessional approach. In Europe, the practitioners involved are divided into a core team comprising the practitioners with whom the patient has daily contact and a peripheral team that can be involved under special circumstances. The clinical team in the Cardiac Rehabilitation Unit comprises the staff groups that already were part of the existing rehabilitation programme in the Department of Cardiology. The composition complies with the newest recommendations for Europe, which, however, do not indicate the form of cooperation and the responsibility and role of each team member in the cardiac rehabilitation programme.

Health professionals in the Cardiac Rehabilitation Unit
Core team

Physicians
Nurses
Physical therapists
Clinical dietitians
Secretaries

Peripheral team

Social workers
Liaison psychiatrists


2.2.7 Patient-centred health communication

Studies have shown that communication between patients and health personnel can influence satisfaction, quality of life and health (42;43) and compliance (44–47). In accordance with the most recent recommendations in Denmark for communication in the health care system (48), the Cardiac Rehabilitation Unit emphasizes a patient-centred form of communication. This means that the patient’s behaviour, thoughts, feelings and general well-being are taken into account along with biological and paraclinical aspects of illness and treatment.


2.2.8 Systematic clinical assessment and referral

Although services may be available in some areas, experience in many countries (33;35) indicates that few patients who need cardiac rehabilitation are referred. The Cardiac Rehabilitation Unit emphasizes that all individual patients should be assessed systematically to determine the need for cardiac rehabilitation. This assessment is based on information from the patient records on diagnoses and the results of tests and examinations, including risk factors, and counselling the patients on their needs and resources. The Unit emphasizes to the patient that cardiac rehabilitation is a service just like all other treatment and that cardiac rehabilitation is considered and recommended as part of overall treatment.

Because of the special requirements of carrying out a randomized clinical trial,2 a nurse within the Unit (which was a project with temporary status at that time) conducted the assessment and referral from the Department of Cardiology during the project period.


2.3 Legislation

In contrast to such places as Belgium (37), Denmark has no specific legislation on cardiac rehabilitation. The Hospitals Act of 1995, the general legislation on hospitals in Denmark, describes the obligations of hospitals in disease prevention, including cardiac rehabilitation (51). The Act on Patients’ Legal Rights of 1998 stipulates that health personnel must inform patients about their state of health and treatment opportunities, including rehabilitation opportunities. Information on rehabilitation opportunities must be provided even if the hospital providing the information does not offer rehabilitation. The Hospital System Act of 2001 strengthened the obligation of hospitals to prepare rehabilitation plans. Patients have the right to have an individual rehabilitation plan prepared in connection with discharge if the physician considers that the patient needs one. The ethical rules for doctors (§ 2 on physicians’ precision and conscientiousness) say that physicians are obligated to contribute to preventing disease and promoting health. In addition, the Hippocratic oath obligates physicians to seek new knowledge to benefit patients, including knowledge on preventing disease and rehabilitation.


2.3.1 Evidence-based treatment

The Cardiac Rehabilitation Unit strongly emphasizes monitoring the continually updated clinical guidelines on the treatment of patients with heart disease and a high risk of developing heart disease, including guidelines on cardiac rehabilitation (Chapter 4). Clinical guidelines are developed to support practitioners in composing the best possible evidence-based treatment for patients based on the existing knowledge in each field. The treatment recommendations in the clinical guidelines are not legally mandated but are increasingly included in legal assessments in connection with patient complaints (50).


2.4 Ethical Considerations

Medical ethics has four traditional principles: justice, respect for patients’ autonomy, beneficence and non-maleficence (51). Cardiac rehabilitation, like all other forms of treatment, includes these ethical considerations. This section outlines the significance and the weighting of these four principles, focusing on the complexity of the basic principles for cardiac rehabilitation activities.

The Cardiac Rehabilitation Unit maintains the basic principles of the Department of Cardiology for social justice in treatment: age, gender and social status do not influence treatment. The Unit also emphasizes tailoring the treatment to the needs and resources of each patient.

The patients’ motivation and own efforts are decisive in achieving the treatment goals, and respect for the patients’ self-determination is very important in cardiac rehabilitation. On the other hand, cardiac rehabilitation activities are based on the obligation of health professionals to disseminate and use knowledge on the relationships between disease, lifestyles, level of functioning and treatment opportunities. The programme strongly emphasizes the fact that patients are ultimately responsible for their own health.

Cardiac rehabilitation at Bispebjerg Hospital gives high priority to the safety of patients, similar to the rest of Denmark’s health care system. Nevertheless, in efforts to prevent disease, situations may arise in which health services inadvertently cause people to feel more ill than they are. This applies especially to high-risk patients, but patients who have been told that they are healthy after an invasive intervention may also experience an inadvertent feeling of being ill in connection with cardiac rehabilitation.


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