Træningsbaseret hjerterehabilitering - mangler vi alternative modeller til patienterne?

Transkript

1 Træningsbaseret hjerterehabilitering - mangler vi alternative modeller til patienterne? Hjerteforeningens Sundhedskonference Postdoc Lars Hermann Tang Ph.d., cand.scient.san, fysioterapeut Lars Hermann Tang

2 Min pointe Effektive rehabiliteringsprogrammer men nuværende tilbud er ikke tilstrækkelige

3 Hjerterehabilitering er ikke kun fysisk træning

4 Retningslinjerne for fysisk træning Individuel tilrettelagt træningsprogram baseret på initial vurdering af arbejdskapacitet med anvendelse af anerkendt test 12 ugers superviseret træning minimum 2 x ugtl. Træningsniveau/form og varighed tilpasses individuelt Gradueret udholdenhedstræning Styrketræning Opvarmning og nedvarmning Vurdering af effekt med anvendelse af anerkendt test Nationale kliniske retningslinjer for hjerterehabilitering. 2013

5 Landsdækkende tilbud Traditionel placering Placering efter 2007 Fase 1: - Special genoptræning Fase 2 og (3) - Almen genoptræning Vejledning om kommunal rehabilitering. Indenrigs- og Sundhedsministeriet 2011 Fase Almen genoptræning

6 Nationale standard i dansk hjerterehabilitering

7 Bjarnason-Wehrens et al Turk-Adawi et al <50%

8 Mortality rates are 21% to 34% lower in CR users than nonusers (Suaya, 2009)

9 Jolly K et al, 2007 Barrierer

10 Table 1: Barriers to uptake and adherence may be summarised as follows. Patient factors: Service factors: Professional factors: Lack of interest Cost and reimbursement Knowledge and attitudes Reluctance to change lifestyle ECG monitoring requirement Referral Depression Location and accessibility Prejudice (age, race, gender). Dislike of classes/hospitals Car parking Work or domestic commitments Lack of family support Rural residence. Sociodemographic (older, women) Financial or occupational constraints Fewer comorbidities Lacking knowledge of CR-programmes Negative views of services Perceptions of heart disease Patient identity Belief and knowledge Table 1 has been published by Beswick and colleagues in Summer et al. (2016), Clark et al. (2011), Neubeck et al. (2016)

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12 Citat: Kim Høgh administrerende direktør for Hjerteforeningen

13 Skræddersyet interventioner - The new black Local healthcare systems should strive to integrate alternative models of cardiac rehabilitation, such as brief telehealth interventions tailored to individual s risk factor profiles as well as community- or home-based programmes, in order to ensure there are choices available for patients that best fit their needs, risk factor profile, and preferences.

14 Home-based is defined as CR which is delivered either in the patients home or in a local, nonhospital location (Blair et al.2011). Alternativt tilbud

15 Patienternes præference for træningslokation RCT choice uptake preferences King et al. 2007

16 27 % - 57 % ville vælge at træne hjemme (Doherty, 2013, Dalal, 2007, Oerkild, 2012, Tang, 2017)

17 Kende tegn for hospital præference - Ønsker supervisor - Mangler disciplin - Kammeratskab Kende tegn for hjemme præference - Passer ind i dagligdagen - Ønsker ikke gruppetræning - Transportproblematisk

18 Valg af træningslokation Other elements; Patient type Employment status Income Ethnic background (Grace, 2005, Tang, 2017) Patients who choose a home-based setting had better physical health: - Maximum watt level - (mean difference 15.9 (95 % CI ; p=0.011) - SF-36 physical component score - (mean difference 5.0 (95 % CI ; p=0.001)).

19 Sikkerhed From a total of patients the event rate was 1 per 8484 exercise stress tests and 1 per patient-hours of exercise training; the cardiac arrest rate was 1.3 per million patient hours of exercise.

20 Supervision i hjemmet Telehealth interventions can include: Feedback, face-to-face consultations,education, psychosocial support and/or behaviour change components delivered via fixedline telephone, SMS-service, , website, online tutorial or online chat Conclusion: Telehealth exercise-based CR appears to be at least as effective as centre-based rehabilitering Telehealth exercise-based CR utilisation by providing additional options for patients who cannot attend centre-based rehabilitation

21 91 % jævnligt på internet (76 % dagligt). 97 % ejer en mobiltelefon (64 % en smartphone(særligt yngre)) 77 % var positive overfor internet-baseret rehabilitering

22 Accordingly, there is a need to design, evaluate, and implement evidence-based alternative approaches to traditional cardiac rehabilitation that help provide all appropriate patients affordable access to clinically effective secondary prevention interventions. Such alternative approaches should not replace traditional modes of delivery but should be used to engage the many patients who currently do not participate and to provide ongoing intervention after completion of traditional rehabilitation.

23 Factors to increase adherence Successful interventions included: Self monitoring of activity Action planning Tailored counselling by staff Practice recommendations for increasing adherence to cardiac rehabilitation cannot be made. Interventions targeting patient-identified barriers may increase the likelihood of success.

24 Effekten af systematisk henvisning Tilbudt rehabilitering Fysisk træning (61,5 %), Individuel samtale om medicin (52,6 %) Rådgivning om kost (50,7 %) Undervisning i deres sygdom og behandling (35,4 %) Psykisk støtte (18,8 %) Rådgivning om sex- og samliv (15,6 %) Rygestop (ca. 25 %) Christiansen et al. 2014

25 Mit Budskab 1. Nye individuelle skræddersyede løsninger er nødvendige, for at øge deltagelsen i dansk hjerterehabilitering. 2. Nye individuelle skræddersyede løsninger skal kun være et alternativ til nuværende løsninger 3. Som behandler er man en kraftigfuld prædiktor for, hvorvidt en person vælger at deltage i rehabilitering.

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