California Pacific Currents 2000
The Cardiac Rehabilitation Program: Improving Patient Outcomes after a Cardiac Event
Gordon Fung, M.D., Merle Norman, M.S
The Cardiac Rehabilitation Program strives to improve clinical measures of health and help patients regain their functional status after a diagnosis of heart disease, heart attack, or post cardiac surgery. Even patients who are simply at high risk for developing heart disease are eligible to join the program.
“In the Cardiac Rehab Program patients receive care from a multidisciplinary team. Our curriculum is based on research that documents the benefits of completion of a comprehensive cardiac rehab program,” says Merle Norman, program manager. Studies in the medical literature report reduced cardiac symptoms, blood lipids, smoking, and mortality, in addition to improved ability to exercise, enhanced psychosocial well being and reduction of stress for patients who complete a rehabilitation program.
To track the effectiveness of the data-driven Cardiac Rehab Program, outcomes measurement began in June of 1998. The cardiac rehab staff, working in collaboration with the research institute's heath services research staff, developed strategies for measuring each important component of the program. “More and more, we're being asked to provide outcomes data,” reports Norman,“ and the research institute provided us with the expertise we needed to actually measure our results.”
Measuring Functional Status and Patient Satisfaction
Measurement of the success of the program is based on functional data collected with a widely used and well-accepted tool: the SF-36 questionnaire. This 36-question survey measures the degree to which one's level of health interferes with exercise, work, activities of daily living, social functioning, and emotional quality of life.
“To quantify and document health enhancement, program participants complete an SF-36 form at their initial visit. This provides us with our baseline data. At their final visit, they complete the questionnaire again, as well as at six and 12 months post-program completion.”
SF-36 data are available on the first two cycles of patients measured. “Scores of exercise capacity, ability to perform daily activities, and emotional well being, as measured by the questionnaire, indicate significant improvement,” says Merle Norman.
In addition, patients are asked to rate their experience of the Cardiac Rehab Program. A patient satisfaction survey is completed upon graduation. The highest scores given are on staff courtesy and staff role modeling. “Patients see that we enjoy working for them and that we live healthful life styles ourselves,” says Merle Norman.
Measuring Clinical Outcomes
Clinical data on these patients show a clinically significant decrease in resting heart rates after the program, as well as a significant increase in their overall level of fitness. Improved fitness translates into greater ability to engage in activities of daily living, better quality of life, and enhanced rates of survival.
Expanding the Program's Population
While there is reason to be encouraged by these data, staff feel that the program could be utilized by even more cardiac patients. The U.S. Department of Health and Human Services has issued a guideline that strongly urges optimal utilization of cardiac rehabilitation programs by eligible patients. Nationwide, referrals to these programs are not as robust as they should be.
“Our goal is to look a little more closely at the data, identify which patients are admitted into the hospital for cardiac events, and then determine what percentage of them become enrolled in our program. With timely and accurate identification of eligible participants, as well as a continued trend in improved outcomes, we will be able to obtain referrals for many more of the individuals who would truly benefit from cardiac rehab, get them into our program, and see even more impressive reductions in morbidity and mortality and improvements in quality of life for a greater number of cardiac patients,” says Merle Norman.
California Pacific Sets the Local Standard in Cardiac Rehabilitation
In 1968, William Armstrong, MD purchased the very first treadmill for cardiac patients at California Pacific Medical Center. At this time, exercise for cardiac patients was almost unheard of, as the established treatment was months of rest. Yet programs at both the University of Washington and San Diego Community College had patients exercising with various cardiac diagnoses and no history of negative consequences.
In February 1969, the first exercise program for California Pacific cardiac patients began with five patients. Despite a loud and sometimes highly critical response from the medical community, the program grew rapidly.
In the very early 70s, Dr. Armstrong became president of the San Francisco Heart Association (SFHA). This group performed a study of the needs of local patients after acute MI. “The results showed that there was an absolute lack of services other than routine medical care for patients after acute MI. The SFHA board started working with the hospitals in the city to develop immediate post-MI services that would follow the patient into the community,” says Dr. Armstrong.
As a result, most of the hospitals set up their own inpatient rehabilitation programs. While some of these cardiac rehab programs have recently fallen on hard times, the California Pacific program continues to thrive and remains a Bay Area leader in standards of practice for cardiac rehab.