Research Project: Coronary Heart Disease

Chapter 1. Introduction

Coronary Heart Disease (CHD) is a quite serious illness that leads to a variety of negative consequences in the patients. Among its major risks cardiovascular events, such as myocardial infarction or stroke, can be distinguished. In such cases, the peculiarities of the body as well as the accompanying factors may cause not only inconveniences or pain, but even death. With regard to this outcome, each person who suffers from the disease or has ill relatives has to realize the seriousness of this condition and adjust the lifestyle according to the recommendations represented by the existing preventive programs. The major recommendations include establishing desirable levels physical activity, adopting various diets aimed to ensure the normal weight of the patient, excluding smoking and leading a healthy lifestyle. In addition, there also exist effective drug therapies. They are strongly dependent on the patient’s symptoms and can be accompanied by a diet and physical therapy. Drug therapy is based on aspirin, statins, beta blockers and angiotensin converting enzyme inhibitors or angiotensin receptor blockers intake.

The statistics of the Coronary Heart Disease in the UK has led to the foundation of multiple related rehabilitation and secondary prevention programs. However, not all of them offer equally effective treatment to all patients. The aim of the current research is to assess the quality, state and number of existing CHD rehabilitation plans and secondary prevention programs as well as their correspondence to the World Health Organization’s recommendations.

Chapter 2. Literature Review

Coronary Heart Disease (CHD) refers to a disease that occurs as a result of an accumulation of fatty deposits in the vessels that supply the heart with oxygen, which leads to the narrowing or blockage of the vessel and limits blood flow. According to the World Health Organization (2010), in the third world countries, this disease is among the major causes of death accounting for over 25% of the total number. In 2010, coronary heart disease was responsible for over 10 million deaths globally, and more than one-third of total mortality in developed states. It has been estimated that over 101000 of deaths in the UK were caused by CHD in the beginning of the 21^st century (Clark et al. 2005). 30% of this number was a result of the secondary or subsequent occurrence of the disease (Clark et al. 2005). In 2008, the number of deaths decreased, but remained quite high and reached 88236 (Scarborough, Bhatnagar & Rayner 2010). Primarily, these statistics have predetermined the importance of searching for the most effective approaches to treat the patients, reduce the number of disease occurrences and determine its secondary prevention.

A study by Lawler, Filion & Eisenberg (2011) focused on development of new techniques and facilities, such as angioplasty and bypass graft surgery. This approach has improved the methods of diagnosis and treatment of the disease and has led to an increase in diagnosed, treated, and discharged alive patients. As a result of improved treatment techniques, the number of deaths due to CHD has reduced during the previous years. However, even though the mortality levels have been reduced, there is still a growing prevalence of CHD in the contemporary world.

The program of CHD originated in the USA in the 1940s as a result of increased reduction in workforce due to cardiac related diseases. When it was identified that many people who had prematurely retired as a result of CHD were capable of work, the first centre for work evaluation was opened in New York. After the review and assessment, several CHD patients were found to be capable of work, which triggered the establishment of other evaluation units in many parts of the country. The initial primary aim of these rehabilitation centres was to evaluate the capability of those previously diagnosed with CHD to go back to work. Later, the program was proven to help many CHD patients and was improved to incorporate a psychological recovery program on top of the physical plan. During this time, the program was run by interested and willing health professionals who offered advice and education to the patients. All CHD Rehabilitation and Secondary Prevention Programs were to provide suitable and low-cost services as well as be conducted by well-trained and competent health experts. This structure was meant to facilitate and enable all the coronary heart disease patients to access the beneficial and useful service.

The recommendations for the CHD primary and secondary treatment were offered by the World Health Organization (WHO) and were to be followed worldwide. Among such recommendations, one can find that the human resources that participate in the programs have to be doctors, trained nurses or other non-physician health care workers, who have corresponding experience (World Health Organization 2007). In addition, such obligatory resources as stethoscope, weighing scale, blood pressure measuring device, appliances for urine glucose and albumin check, assay of blood cholesterol and glucose and appropriate drugs must be at disposal (World Health Organization 2007). Professionals have to be proficient in such objectives as helping by quitting smoking, learning to choose healthy foods, decreasing BMI, increasing physical activity, reducing cholesterol and blood pressure, controlling glycaemia and undergoing antiplatelet therapy in case of necessity (World Health Organization 2007). In order to estimate the cardiovascular risks, healthcare workers have to rely on a special chart that is based on such data as diabetes presence, gender, smoking, age, blood pressure and cholesterol level. Appropriate devices are used to measure triglyceride, cholesterol, C-reactive protein, homocysteine levels, glucose tolerance and some other indicators that predetermine the peculiarities of preventive program design (World Health Organization 2007). When it comes to dealing with finances, the recommendations of the WHO include grant funding and governmental support.

Several countries around the world have established CHD rehabilitation programs to help those recovering from CHD and to prevent further development of the disease by offering relevant education. Some of these countries conform to the WHO recommendations, while others do not. Most Asian states such as Malaysia, Indonesia, Thailand, Hong Kong, Philippines, and Pakistan have established CHD rehabilitation programs that follow WHO’s recommendations. Most of these programs have been facilitated by World Heart Federation (WHF). According to Goble & Worcester (1999), the majority of CHD rehabilitation programs in Europe have been transformed to become regional centres offering services to only CHD patients from particular hospitals. Rehabilitation programs have recently gained momentum in Europe, which means that little is known about the compliance of these programs with the WHO’s requirements.

According to Kotseva et al. (2013), cardiovascular prevention and rehabilitation in the UK is still not excellent. While the British Association for CPR recommends Cardiac Rehabilitation, it is based on seven appropriate standards and components that assure high-quality service. Biological and psychosocial approaches are effective as they assure proper rehabilitation. However, the issue of CHD’s secondary prevention faces some challenges. The ASPIRE-2-PREVENT has led to poor lifestyle and inappropriate risk factor management (Kotseva et al. 2013).

Chapter 3. Methodology

The research was longitudinal. The data was collected from different sources over one and a half months. The literature analysis allowed to choose the main CHD programs that were used in the UK and analyse them according to the WHO’s recommendations, cost effectiveness, technological support and professionalism. Quantitative data about cost and training that the health personnel in the various rehabilitation program centres gets in relation to the recommendations provided by World Health Organization was gathered.

The study has adopted a descriptive research design focused on survey and comparison. The survey was conducted on the existing coronary heart disease rehabilitation programs offered by the London Cardiac Institute, Heart Rehabilitation Organization of Berkshire, Cardiac Rehabilitation at Papworth Hospital, Chartered Society of Physiotherapy, British Association for Cardiovascular Prevention and Rehabilitation, Gill Heart Institute, Grampian Cardiac Rehabilitation, Cardiac Rehabilitation Department at Hillingdon Hospital, Poole Hospital Cardiac Rehabilitation and Portsmouth Cardiac Associates. The main emphasis was on the cost, technology, and the level of training of the health care providers of these rehabilitation organizations. The research design also involved a meta-analysis of the status of the existing rehabilitation organizations about the recommendations of the WHO, especially concerning cost and training of the personnel.

Random sampling technique was adopted in order to select the samples from which data was collected. On the other hand, focusing on all the rehabilitation program centres across the UK would be tedious, time-consuming, and costly. The study used both secondary and primary information. Secondary data was collected from the London Cardiac Institute, Heart Rehabilitation Organization of Berkshire, Cardiac Rehabilitation at Papworth Hospital, Chartered Society of Physiotherapy, British Association for Cardiovascular Prevention and Rehabilitation, Gill Heart Institute, Grampian Cardiac Rehabilitation, Cardiac Rehabilitation Department at Hillingdon Hospital, Poole Hospital Cardiac Rehabilitation and Portsmouth Cardiac Associates. This information included the number of currently registered rehabilitation programs. Additionally, more data was collected from WHO to determine and confirm its recommendations about the CHD rehabilitation program. It was gathered from the organization’s website and publications.

Primary data was collected from some of the existing CHD rehabilitation centres through the interviewing technique. To reduce the time and cost of completing this research, the interviews were conducted through the reliable media, including Skype.

Chapter 4. Results and Analysis

The collected data was analysed by determining whether the rehabilitation programs complied with the recommendations of WHO or not. The variables were evaluated with regard to WHO recommendations. According to World Health Organization, the practitioners offering healthcare to the CHD patients should:

• Demonstrate that they possess appropriate qualifications, training, skills, competencies, and professional development in the fields they handle within the centre;
• The centre should have a senior clinician who has training necessary for managing, coordinating, and assessing the services undertaken by the centre;
• The rehabilitation facilitating team should link and actively engage the general health professionals such as cardiovascular disease specialists, general practitioners, educationists and pharmacists, leisure and sports instructors, and other relevant specialists.

London Cardiac Institute is characterised by highly qualified staff with major specialities of general cardiology, cardiac arrhythmias, echocardiography, cardiac rehabilitation, respirology and internal medicine. The information about them is available not only through personal communication, but also online on their official website. The centre has been established by a group of clinicians and lacks one senior coordinator at the moment. All health professionals are mostly cardiovascular specialists skilled in cardiovascular treatment. However, the centre does not offer leisure and sport instructors to the patients.

Chartered Society of Physiotherapy represents the group of physiotherapists, physiotherapy students and support workers. Hence, not all members have the appropriate education. The Chair of the organization Professor Patrick Doherty has education in the cardiovascular health and manages his workers effectively. As for the specialist, who work for the organization, they are mostly physiotherapists with not considerably diversified specialities and responsibilities.

Cardiac Rehabilitation at Papworth Hospital provides support of qualified anaesthetists, cardiologists, consultant physicians, hystopathologists, radiologists, surgeons and other specialists. It is also guided by Dr. Nick West, Consultant Cardiologist as the Clinical Lead, who possesses competencies and training necessary for managing, coordinating, and assessing the services undertaken by the centre. The facilitating team consists of a number of relevant specialists.

The Heart Rehabilitation Organization of Berkshire comprises of socially active people who have no medical education, but struggle with the Coronary Heart Disease together with well-qualified nurses. Senior clinical qualification is not mentioned. Hence, one cannot be completely sure about the competencies of the coordinating personnel. The organization is focused solely on phase 4 of the CHD, which includes exercising and active lifestyle.

The British Association for Cardiovascular Prevention and Rehabilitation provides support of qualified anaesthetists, cardiologists, consultant physicians, and also includes simply socially active people without any medical education. The association is managed by the qualified director and coordinator who have medical specializations. The professional group consists of instructors, nurses and other experts.

Gill Heart Institute has qualified anaesthetists, cardiologists, consultant physicians, radiologists and other specialists. The institute was founded and run by expert cardiovascular specialists Linda and Jack Gill. It offers a number of specialized services.

Grampian Cardiac Rehabilitation has cardiologists, consultant physicians and other specialists. The name of the senior manager is not provided. The centre does not offer leisure and sport activities to the patients. Hence, it does not have a wide variety of specialists.

Cardiac Rehabilitation Department at Hillingdon Hospital provides support of qualified experts, too. It is managed by Lynne Colling, a Cardiac Rehabilitation Administrator, who is skilful and qualified enough to administer the department. Mostly nurses are responsible for wok with patients there.

Poole Hospital Cardiac Rehabilitation has qualified anaesthetists, cardiologists and other specialists. The main manger is not named. However, it has a number of qualified professionals for all relevant tasks.

Portsmouth Cardiac Associates comprises of the socially active people who have no medical education, but struggle against the Coronary Heart Disease together with well-qualified nurses. The organization is led by Julianne Page, who is a highly qualified business manager. As for the variety of staff, the organisation has mostly qualified rehabilitation nurses.

To sum up, three variables show that the cardiac rehabilitation in the UK does not completely correspond to the WHO recommendations. With regard to 10 organizations that were analysed, 70% of them have obvious correspondence of qualifications, training, skills, competencies, and professional development of the specialists. In 60% of organizations, the presence of the competent senior clinician in the position of a manager was proven. Only 40% of organizations have skilled teams consisting of all possible professionals, including cardiovascular disease specialists, general practitioners, educationists, pharmacists, leisure and sports instructors, and other relevant specialists. In such a way, the qualification of the variable staff professionals reached the highest correspondence of 70 %, while the multiple professional variable characterizing a number of specialists had the lowest correspondence level of 40 % (See Appendix A). The overall efficiency of the CHD rehabilitation and prevention programs estimated with reference to World Health Organization is 57% in correspondence to healthcare personnel proficiency demands.

Cost Assessment

The cost of accessing the services depends on the country and the frequency with which the education sessions are undertaken as well as the duration and the level of the exercise. However, WHO recommends to make the cost feasible by reducing certain expenditures, such as the adoption of technology, which is cost-efficient, and avoiding overpayments for the staff. Therefore, the organization estimates that mean cost incurred by one patient to be about $60 per session. WHO recommends the following strategies to reduce costs:

• Adopt low-intensity services;
• Avoid overpayments to the staff;
• Encourage on continued employment to avoid reduction of retirement, social security, and pension benefits.

London Cardiac Institute adopts no low-intensity services, pays decent salaries to the workers and encourages continued employment to avoid reduction of retirement, social security, and pension benefits and cover. Heart Rehabilitation Organization of Berkshire adopts low-intensity services but does not avoid overpayment to the staff and encourages continued employment. Cardiac Rehabilitation at Papworth Hospital is supported by £5million external research grant funding, avoids overpayment of the staff and encourages continued employment. Chartered Society of Physiotherapy adopts charity funding and support of the exterior organizations, avoids overpayment of staff and encourages continued employment. The British Association for Cardiovascular Prevention and Rehabilitation adopts low-intensity services, pays decent salaries to the workers and encourages continued employment to avoid the reduction of retirement, social security, and pension benefits.

On the other hand, Gill Heart Institute adopts no low-intensity services, pays decent salaries to the workers and encourages continued employment. Grampian Cardiac Rehabilitation is supported by the external research grant funding, it avoids overpayment for the staff and encourages continued employment. Cardiac Rehabilitation Department at Hillingdon Hospital is supported by the external research grant funding as well, and it does not avoid overpayment for the staff but encourages continued employment.

Poole Hospital Cardiac Rehabilitation is supported by £5million external research grant funding, they avoid overpayment for the staff and encourage continued employment. Portsmouth Cardiac Associates adopts charity funding and support of the exterior organizations, avoids overpayment of staff, but does not encourage continued employment.

These variables were used to assess the measures taken by the centres to reduce costs. In addition, the average cost per session for a single patient was used to determine the level of cost of service in the existing rehabilitation centres. With regard to the sample of 10 organizations, it has demonstrated that the Cardiac Rehabilitation organizations correspond to WHO’s recommendations to a different extent depending on the variables. 80% of the organizations adopt low-intensity services, 50% of them avoid overpayments for the staff, and 90% encourage continued employment to avoid reduction of retirement, social security, and pension benefits (See Appendix B). Hence, the overall efficiency of the CHD rehabilitation and prevention programs was estimated with reference to World Health Organization’s 73% correspondence to cost efficacy demands.

Chapter 5. Discussion

CHD rehabilitation and programs that prevent secondary development of the disease have been recommended by several organizations and health professionals, because they have to assist CHD patients with leading a normal life. They also help to prevent the secondary development of the disease. Therefore, this research is important for assessing the status of the existing CHD rehabilitation programs and secondary prevention programs in the UK based on WHO’s recommendations.

Overall, it has been proven that the Cardiac Disease Rehabilitation organizations are widely spread all over the UK. They mostly correspond to the treatment recommendations of WHO and promote active lifestyle, special diets, exercises and refusal from smoking. The organizations also use essential technological appliances. In addition, there is a number of charity foundations and governmental grant support, such as Attendance Allowance, Disability Living Allowance or Statutory Sick Pay, all of which ensure funding help (NHS 2014). However, the listed organisations are not totally correspondent to the WHO’s recommendations, especially regarding the variety of professionals and overpayment for the staff. Such research enables the health organizations and health professionals to enforce these recommendations to be applied to assist CHD patients to improve their lives.