The exercise debate

Following publication of recent National Institute for Health and Clinical Excellence (NICE) guidance for the management of chronic heart failure (CHF), which includes heart failure rehabilitation incorporating exercise, there has been a substantial amount of rhetoric and debate on how to deliver this specific intervention.¹ In theory, amelioration of heart failure patients into existing cardiac rehabilitation (CR) exercise programmes appears the most feasible option in practice, however, this may prove to be somewhat problematic.

Historically, CR programmes have been under funded and under resourced; this has resulted predominantly from the absence of a CR specific tariff resulting in the inclusion of the service into the broader cardiology tariff or service level agreements between commissioners and providers. This could be about to change with the proposed introduction of payment by results recognising CR programmes as cost-effective interventions that produce substantial health benefits.²

Resources

Resources, at the most basic level, are defined as appropriately qualified staff to deliver exercise programmes within suitable venues. Current recommendations for exercise programmes in cardiac populations include “a minimum of one appropriately qualified exercise professional at all supervised exercise sessions. In the early post event or intervention stage there should be a minimum of two appropriately trained CR professionals who meet the criteria identified by the BACR-EPG (1:5). The ratio of staff to patients should be dependent on the risk stratification of the patients and level of supervision required by the individuals within the group. The number of staff should be increased for more complex patient presentations.”³

Risk assessments for design and delivery of exercise programmes in both hospital and community environments should prioritise safety of participants by identifying the level of staff expertise and staff–patient ratios required. Risk assessments are central to vicarious liability arrangements within service level agreements with leisure or community centres for delivery of exercise in specific population groups. As a result, population groups such as those with a diagnosis of heart failure are deemed as high risk in relation to exercise, and are excluded from participation in exercise programmes outside the hospital environment. Heart failure patients have traditionally fallen into the high-risk category as a result of complex management needs and/or multiple comorbidities. These factors make patients with heart failure a challenging group to exercise. In CR programmes high-risk individuals do access exercise programmes, the hospital environment being the initial venue of choice. The anticipated outcome is progression to specialised phase IV community exercise programmes. CR programmes are time-limited interventions; it is anticipated that individuals will, on completion, access main-stream exercise programmes within the wider communities. With continued specialist nursing support, the transition from hospital to community is a robust and seamless pathway.

As a result, generally speaking, the exercise and health education component of CR programmes are continuous rolling programmes.

Changing population

Heart failure has a number of aetiologies many of which are non-ischaemic, however, the challenges in relation to exercise remain the same, if not greater. These challenges include delivery of appropriate patient-focused exercise and lifestyle interventions. With an increasing incidence of non-ischaemic cardiomyopathy in the young adult population, services need to be able to offer contemporary exercise options to high-risk patients alongside more traditional programmes for those with the functional capacity that is a feature of a myriad of symptoms associated with a New York Heart Association (NYHA) grade 3 classification.

Current staffing levels in a large majority of CR services would not meet the recommended patient–staff ratio for exercise in high-risk groups or for the anticipated increase in numbers participating in the exercise component of CR programmes. Pathways for onward referral to community exercise facilities need to be in place in order to meet capacity concerns within phase III programmes.

With the projected increase in the numbers of individuals being diagnosed with heart failure there will be a substantial increase in numbers of possible participants referred to already over-subscribed exercise programmes in CR services. The waiting time to access the exercise component of CR programmes has risen dramatically. With improved referral processes and a greater buy-in from stakeholders involved in both delivery and commissioning we can expect to see an increase in participation with subsequent increase in waiting times unless additional resources are available.²

Future planning

In future planning strategies, stakeholders from commissioning organisations and those involved in the delivering of the intervention need to agree care pathways and interventions that are not one dimensional but realistic and sustainable.

Benefits from participation in exercise or activity are multi-faceted with improvements in functional capacity, quality of life or, anecdotally, through participation in inclusive supportive environments.⁴ These can be achieved by breaking down existing barriers and fears related to exercising patients with heart failure in the wider community. Within current economic constraints and with increasing evidence on the benefits of exercise in cardiac and other chronic disease populations the challenge is to deliver effective health interventions in an environment where resources are limited. Clear identified care pathways, population specific interventions that appeal to the targeted groups, use of specialist knowledge and building on existing structures are the key to achieving this. Care pathways cannot be one dimensional; in order to achieve maximum benefit, interventions must be realistic and sustainable.

Exercise or activity participation is a key factor in improving health outcomes, however, this is only one intervention within a substantial repertoire of expert measures currently provided by cardiac and heart failure rehabilitation services.

Conflict of interest

None declared.

References

1. National Institute for Health and Clinical Excellence (NICE). Chronic heart failure. Management of chronic heart failure in adults in primary and secondary care. London: NICE, August 2010. Available at: www.nice.org.uk/guidance/CG108
2. British Heart Foundation. The National Audit of Cardiac Rehabilitation. Annual statistical report. 2010. Available at: www.cardiacrehabilitation.org.uk/nacr/docs/2010.pdf
3. Association of Chartered Physiotherapists in Cardiac Rehabilitation. Standards for physical activity and exercise in the cardiac population 2009. Available at: www.acpicr.com/publications
4. Conn VS, Hafdahl AR, Brown LM. Meta-analysis of quality-of-life outcomes from physical activity interventions. Nurs Res 2009;58:175–83. http://dx.doi.org/10.1097/NNR.0b013e318199b53a