By Susan Usher, Marla Gold, Mark Smilovitch
This case study was prepared by Health Innovation Forum with collaboration from Ms. Marla Gold and Dr. Mark Smilovitch from the McGill Cardiovascular Health Improvement Program. — Produced as part of the 2008 program of the MUHC-ISAI.
There is a reduction in mortality of up to 25% in patients who participate in cardiac rehabilitation programs focusing on modifiable risk factors following a heart attack or bypass surgery. However, only about 15% of post heart attack patients across Canada benefit from a structured program. Many patients leave the hospital after their acute care stay without a specific plan to address modifiable risk factors. Others may be “prescribed” an exercise plan, smoking cessation or nutritional counselling, but left to their own devices to put the plan into action. Some find that commercial fitness studios are not prepared to deal with people who have cardiovascular disease.
The McGill Cardiovascular Health Improvement Program (CHIP) is a nonprofit cardiac rehabilitation and prevention program affiliated, founded and staffed by a team of McGill University Health Centre (MUHC) physicians and allied health care professionals.
Six Montreal cardiologists started CHIP in 1996 because they saw that cardiac patients didn’t have programs to help them prevent recurrence. The group’s office is in the Atwater Club, a private sporting facility in downtown Montreal at which one of the founders was a member. CHIP’s aim is to help patients exercise safely during their recovery and establish lifestyle habits that will help prevent another event (eat well, stop smoking, exercise).
Patients are referred to the program upon discharge from the hospital and are assigned to one of the CHIP physicians, who follows them through the program. Each physician spends, on average, a half-day per week monitoring and conducting tests on program members to determine fitness levels and the heart’s response to exercise. Upon enrolment, new members see a physician specializing in cardiovascular prevention and rehabilitation. They then have a one-on-one private training session with an exercise physiologist who designs a fitness program based on individual ability. Members work out under supervision three times per week for a minimum of 12 –16 weeks, with regular check-ins with the physician. Dr. Steven Grover, CHIP medical director, believes it takes three to six months to “get over the hump” and make exercise part of a person’s routine.
The CHIP team is made up of cardiologists as well as internists, family practitioners, exercise physiologists, nurses, dieticians and psychologists. At any given time, the program has 120 participants: 30% for prevention and 70% in recovery.
Physicians involved in the program collect payment from Medicare on the fee-for-service model. Participant fees range from $760 to $965 for a complete CHIP program including 36 supervised sessions over 12 weeks. Private insurance plans often help patients with these costs. As well, financial assistance is available to those who require it. CHIP collects 50% of its funding from participant fees and the rest through fundraising and sponsors.
The ongoing challenge is to get more doctors to refer patients to the program. “We need to do a better job of letting physicians know we exist and what the benefits are to patients,” says CHIP Director Marla Gold, who recently partnered with cardiology wards at the MUHC to provide discharged patients with an information package about the program. Ideally, they should register with the program two to six weeks after they leave hospital.
Real-world data on the outcomes of cardiac rehabilitation may encourage more doctors to refer patients to them and promote the development of more and better programs across the country. CHIP has an academic mission, enabling researchers to study the benefits of structured exercise programs on a variety of conditions. Ontario, which initiated a major push in 2001 with pilot programs in cardiac rehabilitation, recently created a registry to track outcomes, monitor wait times and conduct research. Programs in Ontario range from the Ottawa Heart Institute’s fully equipped in-house facility to telephone management of self-directed exercise programs.
Potential for expansion
CHIP has recently enlarged the scope of its mission beyond adult programs for cardiac rehabilitation/prevention of diabetes and heart disease, notably with the launch of CHIP for Teens, an exercise program for young people suffering from obesity and at risk of premature cardiovascular disease or diabetes. Cancer rehabilitation has also been added to their list of programs.
Cardiac rehabilitation can reduce disability from and recurrence of heart attacks and other cardiovascular disease. Cardiac care units not equipped with in-house exercise facilities may benefit from partnership with exercise facilities, either public or private, in the community. A wide variety of funding formulas can be designed within the scope of each province’s fee structure for physicians and other patient supports.