PRIMARY CARE PROVIDER RECEIPT OF CARDIAC REHABILITATION
DISCHARGE SUMMARIES: ARE THEY GETTING WHAT THEY WANT TO
PROMOTE LONG-TERM RISK REDUCTION?
PETER ANDREW POLYZOTIS
THESIS SUBMITTED TO THE FACULTY OF GRADUATE STUDIES IN PARTIAL
FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
MASTERS OF SCIENCE
GRADUATE PROGRAM IN KINESIOLOGY AND HEALTH SCIENCE
YORK UNIVERSITY
TORONTO, ONTARIO
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Communication between cardiac rehabilitation (CR) and primary care providers (PCP) is paramount to promoting long-term risk reduction. Many CR programs develop discharge summaries based on clinical experience and practice guidelines, but little is known about primary care provider's (PCPs) needs from these discharge summaries, and whether they are receiving them in a timely manner or even at all.
This study quantitatively assessed the transmission of CR discharge summaries to PCPs.
The receipt rate of discharge summaries received by PCPs was tracked from 8 CR programs in Ontario. Surveys were then mailed to PCPs that received a CR discharge summary. This survey assessed PCPs perceptions of the content and usefulness of informational elements of the CR discharge summary.
Approximately half of CR discharge summaries reached PCPs, revealing a large gap in continuity of patient care. This could lead to poorer outcomes for cardiac outpatients.
However, when discharge summaries were received, PCPs were quite satisfied with their content, and use it for care. Processes should be implemented to ensure consistent and timely high-quality discharge summary transmission. V Acknowledgements
I would first like to extend my sincere gratitude to my supervisor Dr. Sherry
Grace for supporting me throughout this project and giving me the opportunity to achieve
my academic goals. I feel very privileged to have had you as my mentor - Thank you! As
well I want to thank my committee members, Dr. Veronica Jamnik for her feedback and
suggestions on numerous revisions, and Dr. Liane Ginsburg for her participation. Thank
you to all of my lab mates and friends who I have worked with over the past two years:
Jonathan Yee, Lori Van Langen, Shamila Shanmugasegaram, Yongyao Tan, Tomasz
Kowal, Megan Cahill, Sanam Pourhabib, Mary Attia, Amanda Black, Nancy Ciccone,
Alina Coehn, Shazareen Khan, Gabriela Melo Ghisi, Candice Roy, Tiffany Tassopoulos and Michelle Schwarze. I am so fortunate to have met and worked with such amazing people. I would especially like to thank Yvonne Leung and Shannon Gravely for being
my stats guru's and being available to help me whenever I needed them. I would also like
to extend a special thank you to Sharmila Sriranjan for all of her help with this study. As
well, thank you to all of the study co-coordinators' who helped recruit the participants
and to the Canadian Institute for Health Research for supporting this research project. I
would also like to thank Kosta Poulos, a dear friend of mine for over a decade, who has
helped me to grow both mentally and physically over these past two years. And finally, to
my mother and father, you have been both my foundation for success and my inspiration.
Thank you for your love and support. To you I owe everything, and I only hope one day I
will be able to provide as much for my family as you have for me. Thank you to everyone
for helping me along the way and for making these past two years a great experience! vi Table of Contents
Copyright Page ii Certificate iii Abstract iv Acknowledgements v Introduction 1 Literature Review 3 Cardiovascular Diseases 3 Cardiac Rehabilitation 4 Continuity of Care 8 Inter-organizational Communication 11 Transmission and Content of CR Discharge Summaries 13 Objectives 17 Manuscript Preface 18 Certificate of Authentication 19 Manuscript 20 Abstract 21 Introduction 23 Methods 25 Results 28 Discussion 32 References 37 Tables and Figure 42 Extended Results and Discussion 46 Transmission Mode 46 Clinical Implications 47 Directions for Future Research 48 Conclusion 49 References 50 Figure 1: Conceptual Model of Inter-organization Communication 66 Appendix A: Study Design 67 Appendix B: Discharge Summary Receipt Confirmation 68 Appendix C: Primary Care Provider Summary Perceptions Survey 69 Appendix D: Cardiac Rehabilitation Site Survey 71 Appendix E: Consent Form Requesting Participation for Cardiac Patients 73 Appendix F: Consent Form Requesting Participation for Providers 76 Appendix G: Discharge Summary Templates for All Sites 79 1
Introduction
Cardiovascular disease (CVD) is the leading cause of mortality globally (World
Health Organization, 2011), and second in Canada(Statistics Canada, 2008). Primary care providers (PCPs) such as family physicians and nurse-practitioners customarily oversee patient care for those who require long-term disease management - such as those with
CVD. As per the American College of Cardiology /American Heart Association Practice
Guidelines( Kushner et al., 2009), among other organizations' recommendations (Goble
& Worcester, 1999; Piepoli et al., 2010; Stone et al., 2009; R. J. Thomas et al., 2010), cardiac rehabilitation (CR) is a Class I recommendation for patients post-cardiac event.
CR is a proven and effective program that typically lasts between 3 to 6 months in the province of Ontario and can promote and enhance secondary prevention through structured exercise, healthy lifestyle education, social support, and behavioral modification (A. M. Clark et al., 2010; Cohen et al., 1999; Lawler, Filion, & Eisenberg,
2011; Polyzotis et al., 2012; Rod S Taylor et al., 2004).
As patient's transition to and from CR programs, communication between CR health professionals and the patient's PCP is essential for continuity of care (Ahmed,
2003; M. A. Anderson & Helms, 1998; Haggerty et al., 2003; van Walraven, Oake,
Jennings, & Forster, 2010). This is especially important for patients with chronic diseases, because continuity of care has been shown to have beneficial effects on patient satisfaction (Fan, Burman, McDonnell, & Fihn, 2005; Urden, 1998), patient self- management, all while reducing the cost of care (Consorti, Lalle, Ricci, & Rossi-Mori,
2000; Tierney, McDonald, Martin, & Rogers, 1987), and ultimately improving patient 2 health outcomes (Ahmed et al., 2003; Cabana & Jee, 2004). While these studies were conducted on patients with any chronic disease, we infer that cardiac patients would derive similar benefits and it is essential that there is shared care and continuity between
CR and primary care to support long-term risk reduction and optimize patient health outcomes.
To facilitate shared care, CR discharge summaries are commonly generated by the
CR program and sent to the cardiac enrollee's PCP. CR discharge summaries are generated to communicate necessary information to the PCP such as the patient's clinical status at the end of the CR program, as well as identifying areas for continued risk reduction (Riley et al., 2009; van Walraven & Rokosh, 1999). Although these CR discharge summaries may be a key component in the continuity of care, previous research suggests that many PCPs are not receiving discharge summaries from CR(Riley et al.,
2009), and in a broader scope after any hospitalization for any condition (Kripalani et al.,
2007; van Walraven & Weinberg, 1995). In a study by Riley et al., 21/50 (42.0%) discharge summaries were received from 31 participating Ontario CR sites who all sent discharge summaries (Riley et al., 2009). Considering the positive effects of continuity of care and the lack of prior research, there is a need to explore the transmission of CR discharge summaries and to assess PCPs' receipt, use, and perceptions of discharge summary content.
For the purposes of this study, we did not examine patient outcomes, however this could be the focus of a future study. Our hopes are that the benefits of continuity of care shown in prior research that focused on all condition patients who transfer from hospital 3 care to PCPs will be applicable to cardiac patients who move from care within CR to their PCP. This prospective multicenter investigation assessed the transmission of CR discharge summaries to PCPs, and explored PCPs perceptions and use of CR discharge summary content in patient care. This was achieved through an observational and cross- sectional study design (Appendix A) involving consenting PCPs of CR enrollees from 8
CR sites across Ontario. CR discharge summaries were tracked through correspondence with all 8 CR sites and the patients' PCPs. A survey explored PCPs' perceptions of the
CR discharge summary (Appendix B) as it related to content quality and needs of the
PCP for patient care.
Literature Review
Cardiovascular Diseases
Globally, CVD is the leading cause of morbidity and mortality(World Health
Organization, 2011). In Canada, CVD is the second leading cause of death at
29%(Statistics Canada, 2008), as well as the leading cause of all hospitalizations at
16.9%(Public Health Agency of Canada, 2009). In 2008, approximately 70,000 deaths among Canadians were caused by CVD(Statistics Canada, 2008). Moreover, CVD is the second most costly contributor to total health costs in Canada with CAD$22 billion a year in health care and lost productivity(Public Health Agency of Canada, 2009). A conservative estimate is that 1.6 million Canadians currently have CVD(Public Health
Agency of Canada, 2009).
Over 50% of cardiovascular deaths can be attributed to coronary heart disease
(CHD), indicating that it is the most common form of CVD (Public Health Agency of 4
Canada, 2009). Evidence-based clinical care for acute coronary syndrome include pharmacotherapy, and in later stages of disease progression, intervention with adjunct pharmacotherapy^. L. Anderson et al., 2007; Hulten, Jackson, Douglas, George, &
Villines, 2006; Kushner et al., 2009). Revascularization procedures such as a coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) are common
(Kushner et al., 2009). However, interventional procedures are palliative, and do not treat underlying atherosclerosis and endothelial dysfunction.
Lifestyle interventions remain the cornerstone for the secondary prevention and management of CHD treating underlying atherosclerosis(MacNair & Bugden, 2007) and improving endothelial function(Walther, Gielen, & Hambrecht, 2004). A proven and effective multifaceted approach towards secondary prevention and management combines these lifestyle interventions through behavioral modification, exercise, and pharmacological management over the long-term(MacNair & Bugden, 2007; McPherson,
2000; Syed, Riaz, Ryan, & Reilly, 2010; Taylor et al., 2004; S. R. Wright et al., 2011).
This approach focuses on risk factors associated with CVD such as smoking, physical inactivity, obesity, poor diet, high cholesterol, hypertension, stress, and diabetes(Roger et al., 2011; Theriault, Stonebridge, & Browarski, 2010).
Cardiac Rehabilitation
The Canadian Association of Cardiac Rehabilitation (CACR) defines CR as the enhancement and maintenance of cardiovascular health through individualized programs designed to optimize physical, psychological, social, vocational, and emotional status.
This process includes the facilitation and delivery of secondary prevention through risk 5 factor identification and modification in an effort to prevent disease progression and the recurrence of cardiac events(J A Stone et al., 2009). While exercise training is the central component of CR, other comprehensive components of a CR program include patient assessment, nutritional counselling, weight management, blood pressure management, lipid management, diabetes management, tobacco cessation, psychosocial management, physical activity counselling, and the use of preventative medications(Balady et al., 2007;
J A Stone et al., 2009; N K Wenger, 2008).
CR is an evidence-based outpatient disease management program(Taylor et al.,
2004). In Ontario, patients usually participate in supervised exercise 1-2 times per week, over a mean of approximately 5 months (manuscript under review, JCRP) with most programs in Ontario lasting 6 months(Hamm & Kavanagh, 2000). Participation in CR programs is proven to result in multiple beneficial outcomes in cardiac patients. Most notably, a meta-analysis which synthesized 48 randomized trials found that compared to usual care (no cardiac rehabilitation, just pharmaceutical treatment and follow-up with physician), participation in CR was associated with a 20% reduction in all-cause mortality, and a 26% reduction in cardiac mortality(Taylor et al., 2004). This review also found that CR participation was associated with greater reductions in total cholesterol level, systolic blood pressure, and lower rates of self-reported smoking. Other benefits such as reduced morbidity, improved risk factor management, improved quality of life(Alter, Oh, & Chong, 2009; Boulay & Prud'homme, 2004; Digenio & Joughin, 1997;
J. A. Jolliffe et al., 2000; Lavie & Milani, 2004,2006; Rod S Taylor et al., 2004), improved exercise tolerance(P A Ades, 2001; Lavie & Milani, 1995), and a reduction in 6 depressive symptoms and psychosocial stress(R V Milani, Lavie, & Cassidy, 1996;
Richard V Milani & Lavie, 2009) have also been documented. Participation in CR also has beneficial effects on the healthcare system by decreasing the burden of rehospitalizations and procedures (Boulay & Prud'homme, 2004; Hedback, Perk,
Hornblad, & Ohlsson, 2001), and being more cost-effective when compared to usual care
(A Brown, Taylor, Noorani, Stone, & Skidmore, 2003; P Dendale, Hansen, Berger, &
Lamotte, 2008; Lee, Strickler, & Shepard, 2007; N Oldridge et al., 1993; Papadakis et al.,
2005).
While the benefits of CR are well-established, the need for longer-term risk reduction beyond the 6 month program is also needed (Ornish et al., 1990; Warburton,
Nicol, & Bredin, 2006). For example, Moore et al. found that 50% of women no longer exercised three months post-CR (Moore, Ruland, Pashkow, & Blackburn, 1998). In another study, Reid et al. found that the greatest rate of decline of physical activity occurred between 2 and 6 months post-CR (R. D. Reid et al., 2006). Additionally, Willich et al. found that blood pressure, body mass index, cholesterol, low-density lipids, and triglycerides worsened in the first three months post-CR and at 6 months returned to near baseline values pre-CR (Willich et al., 2001). However, interventions targeted at improving cardiac risk factors post-CR have been successful. Sniehotta et al. showed that patients who participated in a planning group and kept a diary had significantly higher exercise adherence 4 months post-CR (Sniehotta et al., 2005). Furthermore, by targeting inter-provider communication, Meis et al. showed that letters sent from the CR program medical director to the primary care provider (PCP) detailing their patient's lipid goals 7 and therapeutic options resulted in significantly higher attainment of target lipid levels
(Meis, Snow, Lalonde, Falko, & Caulin-Glaser, 2006). Additionally, other studies have shown that lipids and blood pressure can be significantly lowered post-CR by sending a reminder letter to the patient every 3 months informing them to see their PCP (Munoz et al., 2007), or by sending a letter every 6 months post-CR from the cardiac specialist to the PCP about risk factor targets (Farias-Godoy, Ignaszewski, & Lear, 2010). Thus, post-
CR care is critical to mitigating this decay in behavioural change and to ensure sustained chronic disease management. For these reasons, there is a need for behavioral reinforcement post-CR (R. D. Reid et al., 2006), and over the long-term to maintain behavioral changes(Sniehotta et al., 2005).
The CACR recommends CR maintenance programs, however not all sites have the capacity to offer this service (manuscript under review, JCRP). As a result, many CR programs offer linkages to community programs such as Heart Wise Exercise programs(University of Ottawa Heart Insitute, 2010), and the frequency of these linkages is currently being explored (manuscript under review, JCRP). While maintenance and community programs may be offered at CR sites, the patient is usually cared for by primary care providers (PCPs), generally family physicians or nurse-practitioners and they ensure appropriate long-term patient management for patient's post-CR. Thus, the continuity and shared care between CR and primary care may be important to support the patient in ongoing risk reduction. 8
Continuity of Care
Continuity of care refers to the delivery of ongoing healthcare from a variety of settings and occurs when a patient experiences coherent and integrated care from these services over time (Haggerty et al., 2003). In a multi-disciplinary review of the literature,
Haggerty et al. identified 3 types of continuity, namely relational, informational, and management(Haggerty et al., 2003). Relational continuity is the relationship between a patient and one or more health care providers over time. Informational continuity is the availability and use of data from prior events in patient care. For example, the test result from a patients visit with their specialist is available and used at a visit with their PCP.
Management continuity refers to the provision of coherent and timely services from different health care providers such as hospitalists and PCPs. Within the context of the
CR-primary care relationship, all of these types continuity are central to patient care. For example, informational continuity would ensure the provision of CR discharge summaries to primary care, and management continuity would ensure proper treatment of risk factors identified in the CR discharge summaries across the transition from CR to primary care.
The majority of studies focusing on continuity of care are not on cardiac specific patients, but for all conditions for patients discharged after hospital admission. In these studies focusing on all condition populations, continuity of care has been shown to have beneficial effects on patient satisfaction(Fan et al., 2005; Urden, 1998), reducing the cost of care(Consorti et al., 2000; Tierney et al., 1987), patient self-management, reducing hospital admissions, and ultimately improving patient health outcomes(Ahmed et al., 9
2003; Bell et al., 2009; Cabana & Jee, 2004; Coleman, Parry, Chalmers, & Min, 2006;
Jack et al., 2009; Villanueva, 2010; van Walraven et al., 2010; van Walraven, Seth,
Austin, & Laupacis, 2002). In a multidisciplinary review of the association between continuity of care and patient outcomes(van Walraven et al., 2010), van Walraven and colleagues identified eighteen studies that met their inclusion criteria, these studies addressed both clinical outcomes and the relative timing of the continuity of care plus outcome measures. The outcome measures were resource utilization (n=9), patient satisfaction (n=7), treatment plan compliance (n=l), and clinical markers (n=l). Overall, this review found that provider continuity of care resulted in increased patient satisfaction and decreased the utilization of health resources. The authors also found that intervention studies that increased informational continuity had a significant decrease in re-admission to hospital. Additionally, a study by Ahmed and colleagues showed that consultation, a form of increasing informational continuity, between general practitioners and cardiac specialists resulted in significantly greater left ventricular function evaluation, prescription rates for angiotensin-converting enzyme (ACE) inhibitors, and lower odds of
90-day readmission (OR=0.54) for heart failure patients when compared to patients treated by either type of physician alone(Ahmed et al., 2003).
Clearly communication among health care providers involved in the patients care is a priority, but other concerns are also present(R. Baker, 2011). In the chronic disease context, the patient requires ongoing multidisciplinary management and the number and types of community services utilized means that patient experiences are increasingly complex. As well, different physicians are responsible for care in different settings and who 'owns' the transition may be difficult to identify. With patients having shorter lengths of hospital stay, patients are discharged earlier and often prematurely resulting in a lack of care, increased hospital readmissions, and poorer health outcomes (Canadian
Institute for Health Information, 2012). Thus, there is a need for increased communication during patient handoff so that the chronic disease patient can be managed optimally (R. Baker, 2011).
In summary, the consequences of informational discontinuity or a lack of inter- provider communication results in medication discrepancies, pending tests, and unknown diagnostic treatment plans, all of which have an immediate impact on patients health outcomes(V. Snow et al., 2009). In recognition of the importance of the continuity of care transition from any setting, Snow and colleagues(V. Snow et al., 2009) provide recommendations for improving the continuity of care. The 2009 Transitions of Care
Consensus Policy Statement(V. Snow et al., 2009) recommends that there be clear and timely transition records sent to the patient and the patients' primary care provider at every transition to optimize continuity of care. The authors also posit that an updateable document be created that contains brief key informational elements that summarizes the patient's healthcare transitions so that communication is effective among providers.
However, currently these updateable summary forms are not standard practice and communication between care providers is established by other methods such as intake and discharge summaries. 11
Inter-organizational Communication
In Ontario, PCPs generally hold medical responsibility for patients with chronic conditions such as CVD, with the cardiac patient sharing the responsibility of self- management. Cardiac patients may be referred from primary care to cardiac specialists, admitted to hospital for a cardiac event or procedure, or referred to participate in CR. In each of these scenarios, both a detailed intake and discharge summary of information about the patient is sent to the PCP. Both of these summaries are central to the transmission of information, fostering inter-organizational communication(M. A.
Anderson & Helms, 1998) and informational continuity(van Walraven et al., 2010).
As conceptually shown in Figure 1, inter-organizational communication refers to the overall process of message-sending and message-receiving between two resource- dependent organizations, which can be divided into 6 components: sender (i.e., CR), message channel of transmission (e.g., fax, mail), the message (i.e., content), receiver
(i.e., PCP), feedback (i.e., receipt, evaluation of PCP information needs) and barriers
(e.g., CR site resources, mail delays, identification of PCP, correct contact information)(Krone K Putnam L., 1987). The model (Figure 1) further explains that factors that affect the strength of communication between organizations not only depend on the frequency of sender output to the receiver and the content of the message sent, but also requires feedback outputs from the receiver.
The outcomes of inter-organizational communication in healthcare continue to be
investigated(Kripalani et al., 2007), but current evidence suggests that it results in
improved delivery and quality of care, decreased fragmentation, promotion of long term behavioral change, and fewer hospital readmissions(J L Anderson et al., 2007; M. A.
Anderson & Helms, 1998; Epstein, 1995; Villanueva, 2010; van Walraven, Seth, Austin, et al., 2002). For example, in an Ontario study conducted by van Walraven and colleagues(van Walraven, Seth, Austin, et al., 2002), they tracked summaries for 888 patients after treatment of various acute medical conditions, such as pneumonia and stroke. Following 4,639 outpatient visits, there revealed a trend towards decreased risk of readmission for patients who were followed-up by a physician who had received a discharge summary from the hospital (RR=0.74). Additionally, disorganized inter- organizational communication may force PCPs at the next phase of patient care to spend time and resources compiling missing material and duplicating previously gathered patient-related information(M. A. Anderson & Helms, 1998; P. C. Smith et al., 2005).
For instance, a study by Smith and colleagues(P. C. Smith et al., 2005) reported that in
25.6% (n=413/1614) of primary care visits, the PCP spent 5-10 minutes unsuccessfully searching for missing clinical information, with 10.4% of visits resulting in 10 minutes or more of searching. As a result, hospitalists must be contacted to validate information, or must rely on patient recall. This lack of discharge summary receipt across the hospital to
PCP transition results in poor management and wasted resources. Actual transmission rates of these non-CR discharge summaries is suboptimal in areas of summary receipt, timeliness, and content(Bell et al., 2009; Chen, Brennan, & Magrabi, 2010; Kripalani et al., 2007; Mageean, 1986; van Walraven & Weinberg, 1995; van Walraven, Seth, &
Laupacis, 2002; van Walraven, Seth, Austin, et al., 2002). For example, Kripalani and colleagues found that only 12-34% of discharge summaries were received by PCPs for 13
patients discharged from hospitals(Kripalani et al., 2007). In an Ontario study by van
Walraven and colleagues, they found that 31.6% of discharge summaries were received
by the PCP, and only 8.2% were available for the patients first follow up visit (van
Walraven, Seth, & Laupacis, 2002). Possible reasons for low discharge summary receipt
included PCP misidentification, the discharge summary being sent to the wrong address,
and even the lack of producing a discharge summary at all.
From these studies regarding non-CR discharge summaries, it is clear that communication barriers exist and can have negative consequences on patient care. The discharge summary across any patient transition should not be undervalued. In most cases
the discharge summary is the only communication between health care providers(van
Walraven et al., 2010) and it is the only document that enables the transmission of key
information about the patients diagnosis, medications, laboratory tests and results along
with other information(van Walraven & Rokosh, 1999).. Discharge summaries across
any patient transition facilitates inter-organizational communication between providers
and the sharing of these reports fosters continuity of care and less duplication of health
care services(Riley et al., 2009). Therefore, as Gosbee states: "poor communication is not
only a waste of time; it can threaten patient care and is the chief culprit behind avoidable
errors in clinical practice, which can lead to injury and even death. We should therefore
push for more and better research into clinical communication..."(Gosbee, 1998).
Transmission and Content of CR Discharge Summaries
Just as hospitals use discharge summaries to communicate with PCPs, CR sites
also generate discharge summaries. CR discharge summaries usually compare baseline 14 and final patient data, inform PCPs that patients have finished the CR program, communicate clinical information at the end of the CR program, and identify areas for long-term risk reduction(M. A. Anderson & Helms, 1998; E M Antman et al., 2008).
Within the secondary prevention setting, health professionals agree that information transmission is essential however, information transmission is found to be poor(A. M.
Clark, Barbour, & Mclntyre, 2002; S L Grace et al., 2006). For example, in a non-CR study, a sample of 14 health professionals (eight primary and six secondary care professionals) in Scotland participated in focus groups to evaluate the dynamics of secondary prevention services for CHD. Qualitative analysis revealed that, although the transition between primary and secondary care was perceived as crucial for patient outcomes, information transmission was poor(A. M. Clark et al., 2002). Similarly, in a
Canadian CR-related study conducted by Grace and colleagues, an interview with key informants that represented the broad spectrum of the cardiac health system (e.g. cardiologists, family physicians) revealed that there was a need for inter-organizational communication, yet this was perceived as lacking (S L Grace et al., 2006). With respect to these findings, it is important to investigate communication around secondary prevention in order to determine where the information gap exists.
While many studies have looked at the flow of non-CR discharge summaries from hospital to primary care, only one study has looked at the flow of CR discharge summaries from cardiac rehabilitation to primary care(Riley et al., 2009). As well, there was one study that examined the transmission of CR intake summaries(Yee et al., 2011).
As a precursor to this study, Riley, Grace and colleagues examined the flow of CR discharge summaries to primary care, and PCP perception of summary content(Riley et al., 2009). Results showed that, although PCPs perceive discharge data as useful for facilitating patient care, only 42% (n=21/50) of PCPs received a CR discharge summary from 31 participating Ontario CR sites who all sent CR discharge summaries. Qualitative analysis of the reason why receipt may be low was that it was the cardiac specialist who received these CR discharge summaries and not the PCP. The cardiac specialist is generally less involved with long-term patient management, so it would be more important for the PCP to receive the CR discharge summary. Moreover, PCPs reported that the information received from CR programs was not consistent and in many cases diverged considerably from the information desired. The second study done by Yee et al., examined the flow and content of CR intake summaries and found that only 47.6% of
PCPs received a CR intake summary(Yee et al., 2011). However, when CR intake summaries were received, PCPs rated highly that they received all necessary information, and 86% found the summary useful in patient care. As well, many items were rated highly with respect to PCPs preferred summary content and PCPs preferred to receive these summaries by fax. Finally, on a 5-point Likert scale PCPs rated highly that receiving a CR intake summary makes them more likely to refer patients to the program
(mean=4.04±1.10).
Theoretically, a high-quality discharge summary across any patient transition, whether it is a CR or non-CR discharge summary, is defined as one which effectively communicates information necessary for ongoing care between secondary care and the
PCP(van Walraven & Rokosh, 1999). Thus, PCP needs should serve as a major criterion 16 for developing high-quality and content-rich discharge summaries with the end goal of creating effective and succinct standardized discharge summaries. Indeed, with regards to non-CR discharge summaries, standardized discharge summaries in particular are well- received by PCPs(J. E. Brazy, Langkamp, Brazy, & De Luna, 1993; Castleden, Stacey,
Norman, Lawrence-Brown, & Brooks, 1992; O'Leary et al., 2006) and employing standardized forms results in greater inter-organization communication and continuity(M.
A. Anderson & Helms, 1994; Kripalani et al., 2007; O'Leary et al., 2006; van Walraven,
Laupacis, Seth, & Wells, 1999).
While there has been some preliminary research examining the CR-PCP interface, clearly much is unknown about how this transition could and should be optimized and standardized. For instance, while Riley and colleagues'(Riley et al., 2009) retrospective, mixed-methods study examined the flow of CR discharge summaries and PCP perceptions of them, there is a need to replicate with a prospective design and to quantitatively explore PCP content needs for CR discharge summaries. As well, while
Yee and colleagues'(Yee et al., 2011) study quantitatively explored CR intake summary flow and content, they did not explore CR discharge summary transmission and content needs. Moreover, no study has explored whether PCPs use CR discharge summary content for patient care, and whether CR programs communicate patient dropout to PCPs for example. These gaps in the literature will be addressed through the objectives outlined below. 17
Objectives
The primary objectives of this study are to: (1) investigate the transmission of CR discharge summaries to PCPs, and (2) to evaluate physician use and perceptions of CR discharge summary content. Specifically, how useful PCPs find CR discharge summaries, how they use them, and if they use them in patient care. Secondary objectives include exploring identifying the reason for sent but un-received CR discharge summaries; and whether CR site practices regarding how patient dropout is communicated to PCPs.
The current novel study will inform clinical and scientific audiences on the ways in which CR discharge summaries are utilized in patient care post-CR, the ways in which
PCPs perceive CR discharge summaries could be improved to meet their needs, and their preferred mode of summary receipt. Moreover, by assessing PCP perceptions of CR discharge summaries, it is hoped that "best practice" in summary content can be identified. This could then be shared more broadly to hopefully improve PCP use of CR care plans in the future. The results of this study will not only be applicable to CR programs nationally and internationally, but will serve as a model for other forms of rehabilitation and chronic disease management and to inter-organizational healthcare communication more broadly. 18
Manuscript Preface
This thesis investigated: (1) The quality of transmission of information from CR programs to PCPs by examining the proportion of CR discharge summaries received by
PCPs, (2) PCP perceptions of CR discharge summaries received post-CR, and (3) CR site practices around CR discharge summary transmission. Participants were recruits from a larger study involving eight CR programs across Ontario, Canada. For the first objective, confirmation letters were mailed to the offices of PCPs (Appendix B). The second and third objectives were assessed using investigator-generated surveys that primarily consisted of closed ended questions (Appendix C and Appendix D). The results of this study are presented in the manuscript which follows. Certificate of Authentication
Re: Primary- Care Provider Receipt of Cardiac Rehabilitation Discharge Summaries: Are They
Getting What They Want to Promote Long-term Risk Reduction?
I hereby confirm that the first author of this manuscript, Peter Polyzotis, was responsible for all of the cleaning of data, statistical analysis, and for the write-up of the first iteration of the manuscript. As well, he was responsible for the latter data entry for the patient surveys, soliciting physician consent, administering primary care provider surveys, and responsible for drafting some ethics submissions. The co-authors are co-investigators on the larger grant who provided editorial feedback on the drafted manuscript.
Signature: Date: , Zo\L
Peter A. Polyztois
Signature: Date: y
Sherry L. Grace 20
Primary Care Provider Receipt of Cardiac Rehabilitation Discharge Summaries:
Are They Getting What They Want to Promote Long-Term Risk Reduction?
RUNNING HEAD: Cardiac Rehab Discharge Summaries
Peter A. Polyzotis, BSca
Neville Suskin, MDb,c
Karen Unsworth, MScb
Robert D. Reid, PhDd
Veronica Jamnik, PhDa
Cynthia Parsons, BScPT®
Sherry L. Grace, PhD3, f
"York University, bLondon Health Sciences Centre, cUniversity of Western Ontario,
dUniversity of Ottawa Heart Institute, eYork Central Hospital, fUniversity Health
Network 21
Abstract
Background: Communication between cardiac rehabilitation (CR) programs and primary care providers (PCPs) is paramount to promoting long-term risk reduction after the completion of CR. The objectives of this study were to investigate: (1) receipt of CR discharge summaries by PCPs, (2) timeliness of the CR discharge summary, and (3) satisfaction with, and perceptions of the CR discharge summaries.
Methods and Results: 577 eligible PCPs of consenting enrollees from 8 regional or urban
Ontario CR programs were invited to participate in this cross-sectional study. CR discharge summaries were tracked from the CR program to the PCPs office. PCPs who received a CR discharge summary were mailed a survey assessing their perceptions of the
CR discharge summary content.
Results: Of 139 (24.1%) consenting PCPs, 71 (51.1%) received a CR discharge summary, of which 64 (90.1%) PCPs completed a survey. All PCPs desired to receive CR discharge summaries, with most wanting it transmitted via fax (n=38,61.3%). Forty-seven (77.1%)
PCPs reported they had or will use information in the summary for patient care. PCPs who did not receive the CR discharge summary in advance of their patient's first post-CR visit (n=7,10.9%) were significantly less likely to use it in patient care (p<0.01). On a 5- point Likert scale, PCPs rated the following elements as most important to include in a
CR discharge summary: medication (4.65±0.74), patient care plan (4.43±0.87), and clinical status (4.33±0.94). These elements were not provided in 18.8% (n=12), 4.7%
(n=3) and 22.2% (n=14) of the CR summaries, respectively. 22
Conclusions: Approximately half of CR discharge summaries are reaching PCPs, revealing a large gap in continuity of patient care. This could result in poorer outcomes for cardiac outpatients.
Keywords: Cardiovascular Diseases, Rehabilitation, Continuity of care, Primary care, Interdisciplinary communication.
Correspondence Address: Sherry L. Grace, PhD, School of Kinesiology and Health Science, York University, 368 Bethune College, 4700 Keele Street Toronto, ON M3J 1P3. Phone: (416) 736-2100 x 22364, Fax: (416) 736-5774, E-mail: [email protected] 23
Introduction
Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in the world.1 While many patients survive their cardiac events due to advanced interventional procedures, there are many patients living chronically with CVD. This must be managed optimally to mitigate the high risk of recurrent events. Cardiac rehabilitation (CR) is an outpatient chronic disease management program that offers structured exercise, exercise testing, medical assessment, client and family education, as well as comprehensive risk factor identification and behavior modification that effectively manages these risks.2-5 (\ 7 Although the typical three-to-six month ' CR program model has been demonstrated to be efficacious in reducing morbidity and mortality, evidence suggests that CVD patients may require additional support post-CR to sustain and manage cardiac risk reduction.8 For example, Moore et al? found that 50% of women no longer exercised three months post-CR. Willich et al.10 found that blood pressure, body mass index, cholesterol, low-density lipids, and triglycerides worsened in the first three months post-
CR However, interventions targeted at improving cardiac risk factors post-CR have been successful. Sniehotta et al.11 showed that patients who participated in a planning group and kept a diary had significantly higher exercise adherence 4 months post-CR.
Furthermore, by targeting inter-provider communication, Meis et al}2 showed that letters sent from the CR program medical director to the primary care provider (PCP) detailing their patient's lipid goals and therapeutic options resulted in significantly higher attainment of target lipid levels. Additionally, other studies have shown that lipids and 24 blood pressure can be significantly lowered post-CR by sending a reminder letter to the patient every 3 months informing them to see their PCP,13 or by sending a letter every 6 months post-CR from the cardiac specialist to the PCP about risk factor targets.14
Indeed, communication between health care providers is recognized as a key aspect to effective patient care coordination and optimal continuity of care.15'16 CR discharge summaries enable coordination of patient care between practitioners, and provide the PCP with information about the principal diagnosis, medication list, test
|n results, and patients care plan. CR discharge summaries are also used by CR programs to communicate important patient information to the PCP at the completion of the CR program. A typical CR discharge summary contains information on exercise tolerance, a comparison of CR intake and discharge risk factors, and it identifies areas for long-term 9 18 risk factor management for the PCP to use in patient care. * In fact, CR Performance
Measures in Canada19 and the United States20 include CR communication to PCPs, and the most recent British Core Components21 recommendations also endorse the use of such communication practices.
Unfortunately however, the transmission of CR discharge summaries to PCPs has been demonstrated to be low. Riley et al. conducted a mixed-methods retrospective study that tracked the transmission of CR discharge summaries. Their results showed that although PCPs perceived discharge information as useful for facilitating patient care, only 42% received a CR discharge summary. Moreover, PCPs reported qualitatively that the information received from CR programs was not consistent, and in many cases, diverged considerably from the information they deemed useful and pertinent. 25
Prospective, quantitative study examining the transmission of CR discharge summaries across the CR-PCP interface is lacking. The objectives of this study were to examine:
(la) overall receipt of CR discharge summaries by PCPs, (b) whether they were received in time for patients' post-CR visit, and (c) whether they were used in patient care; (2a)
PCP satisfaction with and perceptions of CR discharge summaries, and (b) usefulness of specific information provided in the CR discharge summaries.
Methods
Design and Procedure
This study was observational and cross-sectional in design. Ethics approval was obtained from all participating institutions. The results herein follow from a cohort study analyzing
CR intake summary transmission,23 and present CR discharge summary transmission results based on pre-specified objectives.
In Ontario, CR services are supported through the provincial government. On average patients undergo supervised exercise 1-2 times per week, over a median of 5 months.4 Each of the 8 CR sites were chosen to represent a diversity of CR programs from large academic to smaller community sites. Sites were asked to describe their CR discharge processes. CR discharge summaries were created by each CR program individually at various time points prior to study inception as part of their program development. Usual practice was observed in this study.
Recruitment occurred between September 2008 and March 2011. Consecutive enrollees from each participating CR site were approached to solicit consent at their intake appointment by a staff member involved in the patient's care. Consenting 26 participants were asked to provide the name of their PCP, which could be a family physician or nurse-practitioner. Participant accrual was ended at each site when the pool of non-consenting PCPs was saturated.
The PCP's contact information and demographics were extracted from the
College of Physicians and Surgeons of Ontario directory (CPSO; http://www.cpso.on.ca/docsearch/) or the College of Nurses of Ontario directory (CNO; http://www.cno.org), which are publically-accessible online databases. This information was used to mail the PCP an information letter and consent form. PCPs were asked to rate their previous satisfaction with CR discharge summaries on a 5-point Likert scale.
Where the PCP provided consent, the research assistant tracked the patient's estimated CR discharge date, and confirmed with each site when a patient had graduated.
A form to verify receipt of the CR discharge summaries was mailed to PCP offices one month later. Administrative assistants were asked to check 'yes' or 'no' whether the CR discharge summary was in the patients' file. A modified version of Dillman's Tailored
Design Method24 to optimize response rate was applied, as follows: 1) replacement fax to non-responders 1 week later, and 2) telephone call to non-responders 2 weeks thereafter.
For those CR discharge summaries that were confirmed as sent by CR, but not received by the PCP, CR sites were contacted and asked to verify the contact information on the hardcopy CR discharge summary and to whom it was sent (i.e., PCP or cardiac specialist).
If the CR discharge summary was confirmed as received, a survey was mailed to these PCPs to investigate their perceptions of the content. The same approach of repeated 27 contacts to non-responders as outlined above was applied. To minimize bias, another member of the laboratory who was blind to study objective and CR site entered the verification and survey data.
Participants
PCPs were included in the study if their patient completed the CR program. The sole exclusion criterion was that the PCP had already consented to participate in the study based on consent of another one of their patients referred to CR. This was done so that there were no duplicate PCP responses
Measures
To describe the physician sample, the PCP's sex, year of graduation, and location of medical school was extracted from CPSO. In addition, PCPs were asked to rate their satisfaction with previous CR transition records received on a 5-point Likert scale (1
'very unsatisfied' to 5 'extremely satisfied'). The main outcome variable, receipt of a CR discharge summary, was recorded as 'yes' or 'no' by the PCP's administrative staff. 'No' was also recorded in the instance of non-response (1 PCP did not respond and was marked as having not received the discharge summary).
The investigator-generated PCP survey was developed based on the available literature,22 as well as input from the investigative team and participating CR programs.
The survey was primarily comprised of closed-ended (e.g., yes/no, or 5-point Likert type scale) questions that investigated summary transmission (timeliness, transmission mode preference), the usefulness of data elements, and perceptions (e.g., satisfaction, use of the 28 summary). Some questions included an additional open-ended response option for further description.
Analyses
All analyses were performed using SPSS version 19. A descriptive examination of
CR site discharge summary practices was performed. PCP demographics were compared based on participation status using one-way analysis of variance (ANOVA) and x2 as appropriate, with post-hoc tests of Least Significant Difference (LSD) where the former was significant.
To assess the first objective, the rate of CR discharge summaries received was calculated by dividing the number received (numerator) by the number of PCPs
(denominator). The rate received was also calculated counting only CR discharge summaries confirmed as sent by the CR program as the denominator. A descriptive examination was performed to describe timeliness and use of CR discharge summaries.
To assess the second objective, a descriptive examination was again performed.
Results
CR Program Practice
CR program practices in the transmission of CR discharge summaries are shown in Table 1. All 8 CR sites reported that they identified the patient's PCP, and sent CR discharge summaries to the PCP if the patient had one. Otherwise, they sent it to the referring physician. When asked if their site had a maintenance program, 3 (37.5%) indicated affirmatively. Of these, 2 (66.7%) indicated that they send CR discharge summaries at the end of the CR program provided the patient was enrolling in the maintenance program. The content of each CR sites' discharge summary is compared to recommended elements in Table 2.
Respondent Demographics
A study flow diagram illustrating the accrual of CR patients and their corresponding PCPs is shown in Figure 1. Of the 806 CR enrollees who consented to participate, 593 (74.8%) were male, and their mean age was 61.8±11.4 (standard deviation) years. Participants' cardiac history is reported elsewhere, but primarily patients had been referred following myocardial infarction and percutaneous coronary intervention.
One hundred and thirty-nine of the 577 (24.1%) eligible PCPs consented to participate. Consenting PCPs included 2 (1.4%) nurse practitioners, while all others were family physicians. As displayed in Table 3, participating PCPs were significantly more likely to be female and to have graduated from medical school more recently than declining PCPs.
The demographics of PCPs who received a CR discharge summary and completed the survey versus those who did not are shown in Table 3. There were no significant differences in measured variables between these PCPs, but there was a trend toward greater satisfaction with previous CR discharge summaries received among the 64 PCPs who completed the survey versus those that did not. Overall, PCPs were moderately satisfied with CR discharge summary content that they had received in the past. The median number of patients they reported seeing per week was 115. Twenty-six (41.9%)
PCPs worked within a Family Health Team. 30
PCP Receipt of CR Discharge Summaries
All 64 (100%) PCPs preferred to receive a CR discharge summary. Thirty-eight
(61.3%) of PCPs preferred to receive the CR discharge summaries by fax, 16 (25.8%) by mail, and 8 (12.9%) preferred electronic transmission. When asked in open-ended fashion why a specific mode of delivery was preferred,57.1 % (n=12/31) indicated that the fax was quickest, 23.8 % (n=5/31) indicated that the fax was compatible with importing into an electronic health record; surface mail was preferred by 22.6.1% (n=7/31) because of the consistency in transmission; and 22.6% (n=7/31) preferred the electronic transmission because it was easy to integrate into the patient's electronic health record.
The rate of CR discharge summary receipt is shown in Figure 1. A response was not received by 1 (0.7%) PCP office, and this was coded as non-receipt. As well, PCP receipt rate of CR discharge summaries sent by each site was significantly different
(p<0.01) where the site with the lowest receipt rate was 21.4% and the site with the highest was 100.0%. The number of PCPs with a patients enrolled in a CR program is shown in Table 4. Of the 139 discharged patients with consenting PCPs, CR discharge summaries were not generated by the CR program for 18 (13.0%) patients.
Given the high proportion of CR discharge summaries that were confirmed as being sent by CR site but not received by the PCP (i.e., 121-71=50 [41.3%]), a post-hoc investigation was performed. Three proximate CR sites were visited, representing 29
(58.0%) CR discharge summaries which were unaccounted for, to ascertain why. Seven
(24.1%) CR discharge summaries were addressed to a cardiac specialist and not the PCP, 31 and 22 (75.9%) were verified as having the correct PCP information but still did not reach the PCP for unknown reasons.
Timeliness and Use of CR Discharge Summary Content for Patient Care
Of the 64 PCPs who received CR discharge summaries, when asked if they received it in time for their patient's first post-CR visit, 57 (89.1%) responded affirmatively. PCPs who did not receive the CR discharge summary in time (n=7,10.9%) were significantly less likely to use it in patient care than those who did (p<0.01). When asked if they used the information found in the CR discharge summary for patient care,
47 (77.1%) PCPs reported they had or would be using it during an upcoming visit. Three
(4.9%) PCPs provided specific reasons why they did not use the CR discharge summary in patient care, specifically: that the patient was stable (n=l, 1.6%), the patient had already reached their rehabilitation goals therefore it was not necessary (n=l, 1.6%), and that a lipid profile and other tests were already performed on the patient (n=l, 1.6%).
Finally, when asked to rate their use of 3 main elements of the CR discharge summary to manage their patients (5-point Likert scale), PCPs most strongly agreed that they used information about exercise (3.48±0.98), followed by medication (3.41±0.97), and least strongly about weight (3.12±1.00).
PCP Perceptions of CR Discharge Summaries Received
PCPs' mean overall satisfaction with CR discharge summaries received was
4.01±1.40/5 on a Likert scale, and ranged from 3.00±1.89 to 5.0±0.0 across sites
(p=0.45). PCPs overall ratings of satisfaction (3.51±1.20) with CR discharge summaries received previous to the study were not significantly related to PCPs satisfaction with the 32
CR discharge summary under study (r=-0.06, p=0.70). Previous satisfaction was assessed for all 139 PCPs on the consent form (Appendix F), while current satisfaction data was only assessed for the 71 PCPs that received discharge summaries. PCP perceptions of CR discharge summaries received for their patients are presented in Table 5.
Table 6 lists key elements included in CR discharge summaries, and PCP report of whether or not they were provided in CR discharge summary received. Where provided, PCPs' ratings of the perceived usefulness of these data elements are also shown. Finally, PCPs were asked whether the CR discharge summaries were missing other desired elements (i.e., yes / no), and 7 (5.0%) indicated affirmatively. Open-ended responses from PCPs who specified what elements they desired were coded. Specifically,
PCPs wanted to know present medications (n=3), the amount of exercise the patient was able to do and any concerns with exercise (n=2), changes in medication made by a psychiatrist during CR (n=l), specific recommendations on return to work (n=l), and comorbidities (n=l).
Discussion
Clinical practice guidelines for CR promote communication of patient's medical condition at program entry and exit. Indeed, this communication is deemed an indicator of CR program quality in Canadian guidelines.19 This is based on evidence demonstrating that communication to primary care can result in improved risk factor control among patients.12'14 To our knowledge, this is the second study to investigate CR discharge summary transmission to primary care, however it is the first study to quantitatively assess PCP perceptions of CR discharge summary content and usefulness of specific data 33 elements. Despite being desired by all PCPs, only half of CR discharge summaries were received, which is consistent with Riley and colleagues' finding of 42% receipt. When received in time for the patient's first post-CR visit the CR discharge summaries were used in patient care, and were highly satisfactory.
CR Discharge Summary Transmission
Other than the low rate of receipt, 4 other findings related to transmission were particularly concerning. First, although patients were considered to have completed their
CR program, CR programs reported that many patients do not complete their post- program assessments. For example, program graduates are often asked to provide a blood sample, re-assess anthropometrics, undergo an exit stress test, and to complete psychometrically-validated surveys regarding nutrition and smoking behavior as well as quality of life for example. Where there is no exit data available, some CR sites do not generate a CR discharge summary, given that a complete update on a patient's health status since the CR intake summary would not be available to summarize and share. This problem should not be under-estimated as the gains patients achieve would then not be documented, any under-optimized elements of risk reduction would not be known, and
PCPs and patients would have no continuous care plan to promote continued risk management and reduction.
Second, there was significant variation in transmission rate by CR program. This suggests that there is a lack of standardized transmission practice across CR sites. Third, the problem of non-identification of the PCP also hampered CR discharge summary transmission. This is consistent with previous findings in the CR field22,23 and more 34 broadly25. With the growing implementation of systematic inpatient referral strategies,26 more CR referrals are being received from attending specialty physicians that will likely not see the patient in follow-up, decreasing the utility of generating a CR discharge summary for these referring specialty physicians. Clearly, PCPs need to be identified on the CR referral and subsequent CR discharge summaries.
Finally, despite post-hoc investigation, it is unknown why over 10% of CR discharge summaries never reached the PCP. Some potential explanations are offered below. First, some CR sites have a maintenance program and CR staff may have incorrectly reported sending a CR discharge summary when patients transitioned to this phase of care. Second, the PCPs may not be archiving patient information effectively
(which may be related to CR summary transmission mode). And third, administrative staff may have failed to locate the CR discharge summary.
CR Discharge Summary Content
Overall, PCPs were very satisfied with CR discharge summaries received, regardless of site. With regards to the format and usefulness of the CR discharge summary, PCPs were highly satisfied with the length, comprehensibility, organization, reading time required, and overall quality. PCPs found the CR discharge summary useful in managing patient risk factors. Information considered most important was medication, followed by the patient care plan, clinical status, and exercise test results. However, while the patient care plan was summarized in almost all CR discharge summaries received, one-fifth of the CR discharge summaries did not include medication information, and one-quarter did not include clinical status. These findings are congruent with other 35 studies examining CR22 and non-CR27'28discharge summaries, where physicians consider medication information the most important over other data elements. The least important information desired by PCPs was intake-discharge risk factor change, risk score, and psychological assessment data.
Limitations
There were limitations to our study. First, the low PCP response rate suggests volunteer bias, such that the representativeness of the sample is questioned. However, physician response rates are generally lower than observed in patient or other samples, and physicians as a group are more homogeneous regarding knowledge, training, attitudes, and behavior than the non-physician population.30 Second, female PCPs and those who graduated more recently from medical school were significantly more likely to participate in the study than male and longer practicing PCPs. Furthermore, we compared the sex of PCPs from our sample to the Canadian Medical Association master files
(available online at http://www.cma.ca/index.cfm/ci_id_16959/la_is.htm#l) and found no significant differences in the proportion of female PCPs in this study versus national data
(40.6% vs 36.5%; p=0.49). Third, CR sites were not blind to the study objectives. Rates of CR discharge summary transmission are likely over-estimates due to a Hawthorne effect,31 whereby CR sites may have optimized the content and flow of CR discharge summaries. Finally, no objective indicators of patient outcomes were assessed, so conclusions regarding the effect of CR discharge summary transmission on patient outcomes cannot be drawn. 36
In conclusion, despite published performance measures,19 only 50% of PCPs received a CR discharge summary for their patients, and receipt varied significantly by
CR site. When the CR discharge summary was received, PCPs were highly satisfied with the organization, clarity and utility of the CR discharge summaries, regardless of program. However, CR programs should more often provide patient's medication information and clinical status on their CR discharge summaries. While more clinical evidence supporting the impact of CR discharge summary transmission is needed, results suggest that more standardized strategies for CR discharge summary information gathering, generation and transmission are required.
Acknowledgments
We thank Peter Prior, Terry Fair, Jon Yee, Sue Evans, Freda Braeker, Debbie
Myketiak, Ashley Armstrong, Sharmila Sriranjan, Kelly Russell, Veola Caruso, Andrew
Lotto, Ellen Brisebois, and Ann Briggs for their contributions facilitating participation recruitment.
Funding Sources
Canadian Institutes of Health Research, grant # MOP-74431.
Disclosures
The authors declare no conflicts of interest. 37
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Table 1. Summary of CR Programs Discharge Communication Practices, N=8
CR Transmission Send to Send to Copy to Patient Lay Send Correspondence Site Mode PCP Both* Patient Version if Patient Drops Out
1 Mail Yes* No Yes Yes* No
2 Fax Yes Yes Yes Yes Yes
3 Mail Yes Yes No - Yes
4 Mail Yesn No Yes Yes* Yes
5 Mail Yes Yes No - Yes
6 Mail Yes Yes No - Yes
7 Mail Yes* Yes Yes Yes* Yes
8 Mail Yes Yes No - Yes
CR, cardiac rehabilitation; PCP, primary care provider. *Only if patient graduates and complete their post-program assessments. 1Send only to referring physician, which could be the PCP or cardiac specialist. 1"Both" denoting PCP & referring physician if they are different providers. 43
Table 2. Content of CR Discharge Summaries compared to Guideline Recommendations
CR Site
Element A B C D E F G H
Clinical status or risk score / / / / X / / •
Medication information / / / / • X X /
Exercise capacity / / / / • / • /
Stress test results / / / X / / / /
Exercise prescription / / / / X / / /
Blood pressure control / / / / / / / X
Lipid control / / / / X / / /
Anthropometric data / / / / X / / /
Diabetes control / / / / X / • /
Smoking cessation / / / / / / • /
Nutrition/weightmanagement / / / / X / • /
Psychological status / / / / X • / /
Recommended elements in this table are based on the 2009 Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention19 and were compared to sample discharge summaries that cardiac rehabilitation sites provided to us at the time of this study. 44
Table 3. Descriptive Characteristics of PCPs by Participation Status
Participants (%) Non-Participants (%)
Completed Did Not Surv ey Complete Survey Declined Characteristic N=64 N=75 p* N=438 p1
Sex. Male 38 (59.4) 44 (58.7) 0.93 311(71.0) <0.01
Location of Medical School 0.61 0.07 Ontario 49 (76.6) 56 (74.7) 291 (66.4) Canada. non-Ontario 8 (12.5) 7 (9.3) 48(11.0) Outside Canada 7(10.9) 12 (16.0) 99(22.6)
Year of Graduation from Medical School (Mean±SD) 1985±10.85 1984±10.20 0.65 1982±11.08 <0.01
Previous Satisfaction with 1 CR summaries (Mean±SD) 3.75±1.20 3,32±1,18 0.06 - -
Two PCPs were nurse-practitioners. The majority of ineligible PCPs were ineligible due to duplication, and therefore their characteristics are not shown. Student's T-test and y2 were used to compare groups. PCP. primary care provider: CR, cardiac rehabilitation. "Compares PCPs who completed a survey to those who did not complete a survey. fCompares participants to non-participants. :Scores range from 1-5. with higher scores denoting greater satisfaction. 45
Table 4. Consenting PCPs per CR site, N=139
PCPs CR Site N (%)
University of Ottawa Heart Institute 47(33.8)
York Central Hospital 28(20.1)
Southlake Regional Health Centre 16(11.5)
University Health Network 15(10.8)
Ross Memorial Hospital 14(10.1)
Grey Bruce Health Services 10(7.2)
London Health Sciences Center 5(3.6)
Alexandra Hospital 4 (2.9)
PCP, primary care provider; CR, cardiac rehabilitation Table 5. PCP Perceptions of CR Discharge Summaries, N=64
Rating (Mean±SD)
I was satisfied with the length of the discharge 4.07±0.71 summary
The discharge summary was easy to understand 4.00±0,76
I used information in the discharge summary to 3.90±0.81 manage my patients riskfactors
The discharge summary was of high quality 3.89±0.78
I was satisfied with the length of time required to 3,83±0.96 read the discharge summary
I was satisfied with the organization of the discharge 3.80±0,95 summary
The discharge summary contributed to my sense of 3.78±0,90 shared patient management with CR
The discharge summary met my needs 3.77±0,85
All necessary information was included in the 3.77±0.92 discharge summary
I was satisfied with the time from patient discharge to 3.77±0.98 summary receipt
Receiving a discharge summary from CR makes me 3.69±0.89 more likely to refer my patients
I will likely go back and refer to the info in the 3.58±0.96 discharge summary again at a later time
The discharge summary included non-useful 2,70±1.04 information
Ratings on a 5-point Likert scale, from 1 'strongly disagree' to 5 'strongly agree'. PCP, primary care provider; CR, cardiac rehabilitation. 47
Table 6. PCP Report of Data Element Presence In CR Discharge Summaries, and their Perceived Usefulness, N=64
Usefulness Not Reported Rating CR Discharge Summary Data Element N (%) (Mean±SD)
Clinical status (e.g., NYHA or CCS class) 14 (22.2) 4.33±0.94
Risk score 13(21.3) 4.08±1.09
Medication dose and frequency 12(18.8) 4.65±0.74
Psychological status 10(16.4) 4.02±1.14
Risk factors (actual) 10(16.1) 4.21±0.96
Risk factors (targets from recent guidelines) 9(14.5) 4.26±0.94
Exercise test results 6 (9.5) 4.32±0.93
Comparison of intake and discharge risk 5 (7.9) 4.12±1.14 factor measurements
Patient care plan 3 (4.7) 4.43±0.87
Ratings on a 5-point Likert scale, from 1 'not important at all' to 5 'very useful'. PCP, primary care provider; CR, cardiac rehabilitation; NYHA, New York Heart Association; CCS, Canadian Cardiovascular Society. 48
Figure 1. Diagram of Study Flow
806 Consenting CR patients from 8 CR sites 229/806 Ineligible Patients (median = 90 pts/site) (28.4%) Reasons: Duplicate PCP (n=143) Patient dropped out of CR (n=45) 139/577 Consenting PCPs PCP name not provided (n=14) (response rate =24.1%) PCP name not found (n=9) Inaccurate contact information (n=8) Other (n=10)
71/139 PCPs received discharge summaries (1 PCP did not respond) 51.1%
7/71 PCPs declined survey 9.9%
64/71 PCPs completed survey 90.1% 46
Extended Results and Discussion
Transmission Mode
Our results show that the majority of PCPs prefer to receive CR discharge summaries by fax, followed by mail, and lastly by electronic methods. Our findings suggest that the method a PCP archives their patient files is related to their transmission mode preference. This finding is congruent with the findings of Yee et al.(Yee et al.,
2011) where PCPs preferred method for CR communication was influenced by the way
PCPs archive patient medical records. For example, if the PCP did not use electronic health records (EHRs) in their office, than they did not wish to receive discharge communication via email. Whether changing the delivery mode of CR discharge summaries will improve communication across the CR-PCP interface is not yet known, however in a randomized control study conducted by Chen et al.,(Chen et al., 2010) they found that across the hospital-PCP interface, hospital discharge summaries delivered by fax (69.4% received) and email (73.9%) were significantly more effective at reaching the
PCP than those delivered by mail (43.8%) or patient delivery (24.2%) at seven days post- discharge. In our study, 7 of 8 CR sites transmitted CR discharge summaries via mail and with one by fax. However, if all CR programs transmitted CR discharge summaries via fax, this would be in accordance with our overall findings of PCP preference for CR discharge summary delivery mode. In addition, this may also increase the timeliness of transmission, ease of archiving patient records, and save CR sites time and money spent on the mailing of CR discharge summaries. While Chen et a/.(Chen et al., 2010) saw the 47 highest receipt with emailed summaries, standardizing CR summary delivery to email may be premature. Currently the majority of Canadian family physicians who actively provide patient care use paper charts only (45%), with the rest using a combination of paper and electronic (31%), or electronic only(24%).(Buske, 2011) Thus, the standardization of CR discharge summary transmission mode to fax may help improve receipt rate.
Clinical Implications
The Canadian Association for Cardiac Rehabilitation Guidelines(J A Stone et al.,
2009) (CACR) and the Transitions of Care Consensus Policy Statement(V. Snow et al.,
2009) (TOCC) provide guidelines for the standards for care transitions. These documents outline components that should be included in discharge summaries. While the ratings of data elements are high (as presented in Table 6), important elements like medication dose and frequency were sometimes not reported by PCPs as included in the CR discharge summary. Overall, the CACR guidelines and TOCC requirements were met, with a majority of data elements being included in most of the CR discharge summaries. In addition, the CR discharge summary content was rated highly and the transmission was deemed timely. Content omissions may be a result of the patient not attending their post-
CR assessment, or this data merely not being included in the summary. The low transmission rate found in the present study is of great concern, because not only may it have negative effects on present patient care, it may also affect future cardiac patient care via a lack of referral to CR. 48
Jackson et al.(L. Jackson, Leclerc, Erskine, & Linden, 2005) identified that the strength of physician endorsement and PCP attitudes towards the effectiveness of CR are the most powerful predictors of patient enrollment in CR. Our study identified that PCPs generally agreed that receiving a CR discharge summary makes them more likely to refer their patients (3.69±0.89 on a 5-point Likert scale ranging from 1 'strongly disagree' to 5
'strongly agree'). However, Grace et al.{S L Grace, Grewal, & Stewart, 2008), found that
PCPs generally disagreed that a lack of CR discharge summary communication from CR negatively impacted their referral practices (2.35±1.17). Whether receiving a CR discharge summary affects referral is currently not clear, but if physicians are not receiving communication from CR, this may foster negative opinions of CR and they may be less likely to refer patients in the future.
Directions for Future Research
Patient health outcomes should be assessed post-CR to determine whether the timely receipt of CR discharge summaries by PCPs results in better risk-factor management than those who do not receive CR discharge summaries. Indeed, the results of previous studies examining communication post-CR between CR and the PCP have shown to significantly increase the management of cardiac risk factors(Farias-Godoy et al., 2010; Meis et al., 2006; Munoz et al., 2007). Thus, it would be expected that a more comprehensive report of the patient's risk factors, as found in the CR discharge summary, would have similar positive effects on health outcomes. If true, this would support current best practice guidelines(J. Jones et al., 2012; Neville Suskin & Arthur, 2009; R. J. 49
Thomas et al., 2010; S. R. Wright et al., 2011) of CR discharge summary generation post-
CR for the PCP. A randomized control study with a larger patient sample would be needed to determine patient outcomes. More broadly, further research should examine current communications between the PCP and other rehabilitation programs, or chronic disease management programs to determine if similar findings regarding information transmission are present across these patient transitions.
Conclusion
In conclusion, to our knowledge this was the first study to quantitatively explore PCP needs for CR discharge summary content. When the CR summary was received PCPs were satisfied with the overall content and usefulness of the summary. Despite published performance measures,(Neville Suskin & Arthur, 2009) only 50% of PCPs received a CR discharge summary for their patients, and receipt varied significantly by CR site. Our study showed that PCPs consider all nine of the informational elements we explored as useful content. Although there were significant differences in receipt rate, PCPs were highly satisfied with the organization, clarity and utility of the CR discharge summaries, regardless of program. Timely, procedural, and evidence-based standardized summaries should be endorsed by all Ontario CR sites. This may improve CR discharge summary receipt rates, increase PCP satisfaction, and help to refine optimal CR discharge summary content. 50
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Walther, C., Gielen, S., & Hambrecht, R. (2004). The effect of exercise training on
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Warburton, D. E. R., Nicol, C. W., & Bredin, S. S. D. (2006). Health benefits of physical
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Wenger, N K. (2008). Current status of cardiac rehabilitation. J Am Coll Cardiol, 5/(17),
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Willich, S. N., Muller-Nordhorn, J., Kulig, M., Binting, S., Gohlke, H., Hahmann, H.,
Bestehorn, K., et al. (2001). Cardiac risk factors, medication, and recurrent clinical
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Wright, S. R., Anderson, J. L., Adams, C. D., Bridges, C. R., Casey, D. E., Ettinger, S.
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outpatient cardiac rehabilitation programs. BMC Health Serv Res, 17(1), 231. 66
Figure 1: Conceptual Model of Inter-organization Communication
Transmission Channel
SENDER (e.g. fax, mail) RECEIVER Primary Care Cardiac Rehab Provider MESSAGE |MRRIE^ (I BARRIERS \ 1 Summary Content
PCP FEEDBACK
Figure 1. The conceptual model of inter-organizational communication between the cardiac rehabilitation program and the primary care provider. PCP, primary care provider. 67
Appendix A: Study Design
Event
•Patient recruitment and consent CR Intake- •PCP consent and previous summary satisfaction •PCP characteristics 3-6
•Patient discharge verified with CR site CR Discharge • o> •Dischaige summary confirmed as sent to PCP
•PCP contacted to confirm receipt ^Transmission Assessment •If yes, PCP sent quantitative content survey
CR, cardiac rehabilitation PCP, primary care provider 68
Appendix B: Discharge Summary Receipt Confirmation
RE: Confirmation of Receipt of Discharge Summary
Date:
To the Office Staff of ,
We are writing to follow up on the CR2DoC study in which Dr. has consented to participate. This study examines the flow of information from cardiac rehabilitation to primary care physicians, and physicians' perceptions of this information.
One of Dr. patients, named has also consented to participated in this study. Dr. was sent a discharge summary from the cardiac rehabilitation program in the past month or so. Please answer the following 2 questions by checking one of the boxes below, and faxing back this sheet.
1. Did your office receive the discharge summary for the above patient? • Yes • No
2. Has the physician read the discharge summary? • Yes • No • I don't know
If you have any questions, please call the study coordinator at (416) 340-4800 ext.6593, or email [email protected].
THANK YOU
Please fax this completed form to (416) 340-4185 69
Appendix C: Primary Care Provider Summary Perceptions Survey ID#
CR2DoC Physician Survey University Health Network
1. How satisfied are you with the cardiac rehabilitation discharge summary? (please check one) • Very • Somewhat • Neither • Somewhat • Very satisfied unsatisfied unsatisfied satisfied
2. Did you receive the discharge summary in time for a post-cardiac rehabilitation patient visit? • Yes • No • I have not had a follow up visit with this patient since receiving the discharge summary
3. Did you use the information found in the discharge summary in patient care? • Yes • Please describe • No • No, but I will •
4. Was there any desired information that was not present in the discharge summary? • Yes- If YES, please describe: • No
5. Please rate your perception of the usefulness of the following aspects of the discharge summary (please B check 1 box per question): Not at Very Not all Useful Reported Useful a. clinical status (CCS and NYHA class) b. medication dose and frequency c. risk factors (actual) d. risk factors (targets from recent guidelines) e. intake and discharge risk factor measurements to show change f. exercise test results g. risk score h. patient care plan i. psychological status
6. If you had the choice, what would be your preferred mode of discharge summary receipt? (please check only one) • Fax WHY? • Regular Mail • Web • Email • I would rather not receive a discharge summary
PLEASE FAX THESE 2 PAGES TO (416) 340-4185 Version 2.0 April 16,2009 ID#
7. Please indicate the degree to which you agree or disagree with the following statements (please E check one box per question): Strongly Strongly Agree Disagree Disagree Neither Agree or Disagree Agree a. Receiving a discharge summary from cardiac rehabilitation makes me more likely to refer my patients. b. I was satisfied with the length of the discharge summary. c. I used information in the discharge summary to manage my patient's risk factors. d. All necessary information was included in the discharge summary. e. I was satisfied with the organization of the discharge summary. f. I was satisfied with the time from patient discharge to summary receipt. g. The discharge summary was of high quality.
h. I will likely go back and refer to the information in the discharge summary again at a later time. i. The discharge summary contained information I didn't need. j. The discharge summary met my needs. k. The discharge summary was easy to understand. 1.1 was satisfied with the length of time required to read the discharge summary. m. I used information in the discharge summary to manage my patient's medications. n. I used information in the discharge summary to manage my patient's weight. o. I used information in the discharge summary to manage my patient's exercise habits. p. The discharge summary contributed to my sense of shared patient management with cardiac rehab.
8. Are there any other comments you would like to make about discharge communication from cardiac rehabilitation?
9. How many patients do you see in an average week?
10. Do you work in a Family Health Team? • No • Yes
PLEASE FAX THESE 2 PAGES TO (416) 340.4185 Version 2.0April 16, 2009 71
Appendix D: Cardiac Rehabilitation Site Survey
RE: CR2DoC Study - Last Questions
Thank you for all of your help with the CR2DoC study. Dr. Sherry Grace and I were hoping you could help us clarify a few details to help us in writing up our findings.
1. What is the name of your CR site?
2. Do you identify every CR patient's family doctor / primary care physician? • Yes •No
3. Do you send a CR discharge summary to the patients' family doctor? I I Yes, if the patient has one • Yes, but only if family physician referred the patient • No
4. Do you send a CR discharge summary to the cardiac specialist? • Yes, if the patient has one • Yes, but only if the cardiac specialist referred the patient • No
5. If the referring provider is a professional other than the patients' primary care provider, do you send a CR discharge summary to the referring doctor and the patients' family doctor? • Yes • No
6. Does your site offer a maintenance program? • Yes •No
5b. If yes: If the patient joins your maintenance program, do you send a discharge summary to providers at the end of the formal CR program even though they will be starting your maintenance program? • Yes •No •N/A we do not offer maintenance •Other, please specify: 72
7 Do patients receive a CR discharge summary? • Yes, they all do • Yes, if they graduate and complete their post-program assessments • No lb. If yes, please provide an anonymized template to us lc. If yes, is it the same as the provider version or different? • Same • different 8 How does your program usually send the CR discharge summary to physicians? a. Mail b. Fax 9 Do you send correspondence to physicians if a patient drops out of CR? a. Yes, to the referring doc b. Yes, to the referring doc and the primary care doc (if GP wasn't the referring doc) c. No 3 b. If yes, please provide an anonymized template to us
Please contact me at the coordinates below with any questions or comments. Thanks in advance for your time.
Sincerely,
Peter Polyzotis Graduate Student, York University CR2DoC [email protected] 416 736-2100 ext. 20575 73
Appendix E: Consent Form Requesting Participation for Cardiac Patients
Cardiac Rehabilitation eSummarv Continuity: Patient Consent Form
You are being invited to participate in a research study looking at your family physician's satisfaction with cardiac rehabilitation intake and discharge summaries. This is a research study which includes patients and their family physicians who choose to take part. Please take your time to make a decision, and discuss this proposal with your personal doctor, family members and friends as you feel inclined. The purpose of this letter is to provide you with the information you require to make an informed decision on participating in this research. This letter contains information to help you decide whether or not to participate in this research study. It is important for you to understand why the study is being conducted and what it will involve. Please take the time to read this carefully and feel free to ask questions if anything is unclear, or there are words or phrases you do not understand. a) Purpose We are asking you to take part because you have enrolled in the cardiac rehabilitation program. Generally, the cardiac rehabilitation program sends an intake summary (when you enter the program) to your family physician, to provide them with an update on your progress and health. The purpose of this study is to send your family physician either a paper or an electronic summary, and to ask your physician for his / her opinions. The electronic summaries are kept in a secure server (i.e. The summaries are protected from being seen by anyone who is not authorized). We are asking your permission to contact your family physician to ask for his / her consent to participate in this study. We hope to enroll 150 family physicians caring for cardiac rehabilitation participants in the study. We hope to enroll 150 family doctors caring for cardiac rehabilitation participants in this study b) Methods If you choose to take part in this study, we would like you to complete a paper-and-pencil survey in the hospital, which involves 3 questionnaires and will require approximately 10 minutes to complete. The survey asks questions about your activities, health conditions, and general demographic information. You may skip any questions that you are not comfortable answering and still participate in the study. You can complete the survey and seal it, along with a signed copy of this consent form, in the envelope provided. The study coordinator will pick it up from you when you are finished.
Also, at the bottom of the consent form, you will find a space to enter the name of your family physician, to enable our research assistant to mail him / her an information letter and physician consent form. Your physician can decide whether or not they would like to participate. None of your current therapies or treatments are being altered or discontinued. 74
c) Risks & Benefits There is a possible risk of inadvertent release of personal health information due to transmission of information between sites. You may not benefit directly from participating in this study. d) Voluntary Participation and Withdrawal Your participation in this study is completely voluntary. You may choose not to take part, or refuse to answer any questions. If you decide to participate and later change your mind, you can withdraw at any time with no effect on your current or future care. If you choose not to participate, your family physician will be mailed the usual summaries that the cardiac rehabiliation program sends, and your care will not be affected in any way. You do not waive any legal rights by signing the consent form. e) Privacy & Confidentiality All information obtained during the study will be held in strict confidence. Your name will only be disclosed to your family physician, otherwise you will be identified with a study number only. Your physician's research records will be stored in a locked cabinet in a secure office. If the results of the study are published, your name will not be used and no information that discloses your identity will be released or published. Only the researchers involved in this study will have access to information that can identify you. f) Remuneration You will not be compensated for your participation. g) Contacts If you have any questions about the study, please contact the primary investigator, Peter Polyzotis, at (416) 340-4800 ext. 6593, or mail to Room 222A Bethune College, York University, 4700 Keele St., Toronto, ON, M3J 1P3. You can also call his supervisor, Dr. Sherry Grace at 416-340-4800 ext. 6455. Questions about your rights as a research participant should be directed to the Manager of Research Ethics for York University at the Office of Research Services, 214 York Lanes, phone 416-736-5055. You will receive a copy of this consent form.
Consent I have read the letter of information and consent, have had the nature of the study explained to me and I agree to participate. All questions have been answered to my satisfaction.
Name of Family Physician: Patient's Name (Please Print) Patient's Signature
Person responsible for obtaining informed consent 76
Appendix F: Consent Form Requesting Participation for Providers
Cardiac Rehabilitation eSummarv Continuity: Physician Consent Form You are being invited to participate in a research study investigating your opinions on electronic or paper-based cardiac rehabilitation summaries. This is a research study which includes patients and their family physicians who choose to take part. The purpose of this letter is to provide you with the information you require to make an informed decision on participating in this research. It is important for you to understand why the study is being conducted and what it will involve. Please take the time to read this carefully and feel free to ask questions if anything is unclear, or there are words or phrases you do not understand. a) Purpose We are asking you to take part because your patient has enrolled in the cardiac rehabilitation program, and has consented that we may approach you to solicit your participation. Generally, the cardiac rehabilitation program sends a discharge summary to you, to provide an update on your patient's progress and health. The purpose of this study is to send you either an electronic or paper-based summary, and to ask your opinions on its utility and how it can be improved. The electronic summaries are housed on a secure server. We hope to enroll 150 family physicians caring for cardiac rehabilitation participants in the study. b) Methods If you consent, you will be sent either an electronic or paper-based summary, depending on the CR program your patient is attending. If your patient is attending a CR program that is participating as an electronic program site, you would receive an email with a link to access your patient's electronic PDF discharge summary. We ask that you provide us with your email address so that we may be able to contact you accordingly. If you access the electronic summary online, this information will be recorded. In addition, if you are interested in participating in a brief telephone interview at your convenience regarding your opinions, you can check the box at the end of the consent form. The telephone interview would require approximately 15 minutes of your time, and will focus on your perceptions of either the electronic discharge summary sent to you. Interviews would be audiotaped with consent, and transcribed in a way that will preserve confidentiality. c) Risks & Benefits There are no known risks to your participation in this study. You may benefit from participating in this study if you find the electronic discharge summary more timely and useful to your ongoing patient care than the paper-based summary. d) Voluntary Participation & Withdrawal Your participation is entirely voluntary and refusal to participate and/or withdrawal from participation will not jeopardize current or future relationships with the researchers or any other group associated with this study. You may refuse to participate, refuse to answer 77 any questions, or withdraw from the study at any time. If you choose not to participate, you will receive usual summaries from the rehab program. You do not waive any legal rights by signing the consent form. e) Privacy & Confidentiality All information obtained during the study will be held in strict confidence. You will be identified with a study number only. Your electronic data will be stored anonymously and electronically, and your consent form will be locked in a cabinet in a secure office at Toronto General Hospital. If the results of the study are published, your name will not be used and no information that discloses your identity will be released or published. No information identifying you will be transferred outside the investigators in this study. Your confidentiality will be provided to the fullest extent by law. f) Remuneration You will not be compensated for your participation in this research study. g) Contacts If you have any questions about the study, please contact the primary investigator, Peter Polyzotis, at (416) 340-4800 ext. 6593, or mail to Room 222A Bethune College, York University, 4700 Keele St., Toronto, ON, M3J 1P3. You can also call his supervisor, Dr. Sherry Grace at 416-340-4800 ext. 6455. Questions about your rights as a research participant should be directed to the Manager of Research Ethics for York University at the Office of Research Services, 214 York Lanes, phone 416-736-5055. Consent I have read the letter of information, have had the nature of the study explained to me and I agree to participate. All questions have been answered to my satisfaction.
Physician's Name (Please Print) Physician's Signature Date
1. Your Email address: • I do not have an email address or access to the internet in my office
2.1 consent to being contacted for a brief telephone interview: • Yes • No
3. How satisfied are you with prior cardiac rehabilitation summaries you have received? (check one): •very unsatisfied •somewhat unsatisfied •neither unsatisfied or satisfied •somewhat satisfied 78
•very satisfied FAX TO: (416) 340-4185 Appendix G: Discharge Summary Templates for All Sites
Alexandra Hospital
Page 1 of3 Oxford County Cardiac Rehabilitation &. Secondary Prerontiipn 3 Program 29 Notdq Street IngenoK I, N5C3V6 Tel 519.485.1700 Fix 5! 9.485.9606
'dad 'dot d0' TNa nal review tun marizes 'patient' progress, outcome, current risk fecpr status and recommendations for ongoing' sacoi dary prevention strategies. Ret* at Event 'r»ferr»l event" CV Background *cardlobacksro Cum it Statu* CCS .nrfna Class •CCS' NYW Class *NYHA LVEF *LVEP Notk sdiac Mationt to exorciw Medit iMoos Medic ition Allergies [add TEXT] Heart tanutia __ • 8 dentary UfestvM: 'tadeotaryYN1 'Modttta physical nlMty< 30 mln, 3x*vk) • Ti aacco lias: tobacooYN1 D 'dtebatesVN' Jt periicideinla: 'hyperilpldemlaVN' 0 eattv: 'tonlYN^: VwisfYN' B*ff>30; WWW M>1QScmofW>04om) J+ aartenslon: 1hypertension VN1 J§ iily Hbfcyy of p ^mature CAD: 'farnUvtitotorvYN1 f degnta raittiv*) Pi ^-menopausal: ~ 'poetmenoYN' • Dl tress consbteni with anxiety or depression: 'dtetrossVN' i by HoapHal AnxMy end Dopn&akin Se»V) : Mean wnenla Related to Heart Hazards -1 Intake Dh charas Actual etual Tam* HRf«t (bpm) •HRrest0 1 Rrsef WA SBR«,(mmHa) •SBPrast* 'S JPrasf <136 DBPnai (mmHg) •DBPrwf 'D iPreet1 <75 WatoMftn) \ letaht' 'taroetwfelaht1 Waist (cm) •waist* vaisf M < 102 cm: F < 94 cm BMIfta/nrt •BMP BMP <25 RE:' patient0, 80 Page 2 of3 , ,,,r Mm uranMntaRslstid to Heart Hazards-2 i Bloc JWoifc Intake I HacharM t Actual Actual Taroat •UpMsdste0 1 pldsdsto' FBS •bloodsugu* '1 loodsugar* * 6.1 mrooML ; Total Cholesterol 'cholesterol0 'c hotestarot1 N/A j Triolvcwtdas •trtalYcerides* atvceridei' <1.8mmoW. HDL-C •HDL* 'HDL' >1-Ommolrt. LDL-C •LDL* 'LDL1 <2.Smmol/L 5 TC/HDL TC/HDL4 TC/HDL* <4.0 : i Entr Exorcise Teat "•xorcleodata0 "protocol* i \ SBP„«(mmHfl) •QBPresf SBI W(<"nHg) •SSPpoak* I DSPmt(mmHg) oDBPresf OB "OePpoaic0 \ 0 \ HR«,(bpm) "HRresf HR| •ak(bpm) •HRpeak I Peak METS •METs* RPI (Qorg Seal*) •BOTJ" ST depression (mm) •maxST Anj ina *ansinalndeK* Terminated due to •terminationReason* Com wntt t • Exit xwctae Tast 'exsrclsodate1 1protoool< 1 SBP,ut(mmHg) 'SBPrest" SBP ,wk 1 1 i 1 i i 1 i ! i RE; 'patient0/ 81 PBge3of 3 PA1 ENT PROGiRESS/CARE PLAN Car Oac: Exe visa: Lipi is/Nutrition : Diat b«m: Smc king: Pay* hosocfal: That k you for allowing us to participate in the care of this patient Please feel free to cont ct me if you have any questions or comments. Sine rely, M. H inoman, M.D., FRCP(C) Inter :al Medicine Oxfo d County Citrdiac Rehabilitation and Secondary Prevention Cfinic Copi Hospital chart to: Dr. M. H inoman Cardiac Rehab Clinic 1cc1 RE: patient0, 82 London Health Sciences Center & Grey Bruce Health Services April 16,2008 tat 519.607.6704 ft London Health Sciences Center tax: 519667.6532 An intervention plan was developed (or your patient to address cardiac risk factor management and promotion of life-tang adherence to lifestyle and pharmacological therapies. This final review summarizes patient progress, current risk factor status and recommendations fix ongoing secondary prevention strategies. Six-month outcomes were reviewed with your patient in all major areas. The dinlcal treatment goals and recommendations in this report conform to the Canadian Association ot Cardiac RehabHtetion Secondary PmvenOon Guidelines (2004) and recommendations established by the Canadian Cardiovascular Outcomes Research Team (2006). laaaa id: 12345678 date of birth: 21-09-65 referring health profesaional: Dr. Dennis Humen clinic dates: [1J Intake January-04-2008 [2] exit Jar>uary-04-2008 referral event: Ml CV background: none events since intake: none non-cardiac limitations to exercise: none summary status: TWa paflent was reviawad In the Cardiac RahabititaScfl clinfo on January 22,2007. Sha was admMtad to Bw hospital on December 12,200t. end dapweed as having en anterior Ml. She aut»equen«ir underwent a PCI/Start to Wilagonal artery. She haa lecently been complaining of Ightheadnesa and Dr-Huroan has ordered a 24hour hottar monitor to asaau her condition. I Make discharge CCS angina dass 0 P. NYHAdass ' _ ' j .... . ~ . LVEF normal (>= 50%) normal (>= 50%) dose Xdelly siMHRfeBmHnMnag doM X dally acetyfeakcyHc acid 81 1 atenolol 100 1 atorvastatin 40 1 ciopidogral 75 1 irbesartan 300 1 medication allergies none known MODIFIABLE RISK FACTORS Make dtacharg* Haa •; ^^^^^p?rwtSl»3^(seIf5eport)l sedentary active 1I moderate phya. ecftnty >30m)n. Stoaek stress test measures peak METS 7.0 9.0 72 SBPrest (mmHg) 124 150 SBPpesk (mmHg) 190 190 DBPrest (mmHg) . .. 80 80 DBPpeak (mmHg) 80 80 HRrest (bpm) 83 "77 HRpeak (bpm) 157 112 ST depression (mm) P 0 RPE (Borg Scale) 7-very, very light 7-very, very light Angina none none test data January 04.2008 January 04,2008 protocol Baike Balke termination reason fatigue/lag pain dyspnea status at dlacharge [positive stress leet (likely residual significant CAD) comments xxxxxxxxxx 83 OrBcommendation We recommend ongoing monitoring to ensure sustained blood pressure control. lipid control Mm lawzfa MOCKS, MScN 1 O status Your patient has achieved target blood lipid goals. o recommendation We recommend ongoing assessment of lipid control and use of llpld-iowering medications in order to maintain these goals. diabetes meliitus or Impaired fastinn glucose lorenzln RWCWS. MScN I o status Your patent has achieved optimal control of blood sugar. o recommendation We recommend ongoing assessment to maintain effective glycemic control. nutrition and weight management Carol M»»on-Twtar BO J. o nutrition status Your patient completed the nutrition counselling and weight management component of the cardiac rehabilitation program. O nutrition recommendation xxxxxxxxx Your patient win require ongoing support to achieve the recommended nutrition goals outlined below. O weight management status Your patient's body weight/composition measures are not at the recommended goals. o weight management recommendation An Intervention plan was presented to your patient that provided education about target goals and lifestyle modification, including healthy diet, behaviour change, and regular physical activity. Continued assessment and modification of interventions is required until your patient a weight loss goal is achieved and maintained. XXXXXXXXXXXX nutrition goals: A balance between caloric intake and physical activity: a Wet rich in vegetables and (Mt and whale grain high-fiber foods; Bsh consumption at least Mce per week; btake of saturated fat < 7% and trans fat < 1% of energy, and cholesterol < 200 mg/day; minimal or no intake of partially hydrogenoted fats, beverages and foods vMi added sugars; low sodium intake, <1,800 mg dally. physical activity habits and functional capacity u»R«u»pCK 1 O status Your patient completed the facility-based supervised exercise training program and has adopted aerobic exercise habits that conform to the recommended guidelines. She also received instruction In resistance and flexibility training. e functional capacity The results of your patient's 6-month follow-up exercise stress test reveal a 28.6% improvement in functional capacity compared with her entry assessment of Jan-04-2008. o recommendation Your patient is pleased with her progress and has been advised to continue to exercise at a prescribed training intensity of 95 to 98 bpm. psychological services judw.F^nct.PhO, c.p^»i O intake A screening questionnaire, the Hospital Anxiety & Depression Scale (HAOS), was given to your patient at intake and discharge. At Intake, your patient's scores were consistent with normal emotional status. At intake, your patient was referred to the following psychological service(s): individual counseling/psychotherapy (none attended) o discharge At discharge, your patient's scores on the Hospital Anxiety & Depression Scale were consistent with clinically significant emotional distress. o Your patient s psychologist has the following concerns/recommendations: xxxxxxxxx Thank you for allowing us to participate in the care of this patient Please feel free to contact me if you have any questions or comments. We wll now dose our chart on this Individual and except for re-referral, we wm no longer be involved in the care of this patient Therefore, kindly ensure that we are removed from your 'copy to* list concerning this person. Any documentation received about this patient will be forwarded to Medical Records. Sincerely, UWO & LHSC Cardiac Rehabilitation and Secondary Prevention Program Copy to: CRSP chart Dr. Anushl Mousa Dr. J.B. Horns Dr. Robert H. PameU Dr. Dennis Human Ross Memorial Hospital ROSS MEMORIAL HOSPITAL CARDIAC REHABILITATION PROGRAM DISCHARGE SUMMARY 10 ANGELINE STREET NORTH LINDSAY, ON K9V4M8 Dear Doctor. Date: Thank you for referring your patient to the Ross Memorial Cardiac Rehabilitation Program. Your patient with a diagnosis of has now completed the 12 week Program and has decided to continue/ not continue with the optional on going "Exercise Only" Program. If your patient has decided to continue exercising with us in the Phase III Program, please forward any new stress test or lipid profile results. For your information, I have included a summary of various test results. Cardiac Disease Questionnaire: PreProgram Score: Post Program Score: Depression Scale: Anthropometric Data: Admission Discharge Height: Weight: Admission Discharge Waist Measurement cm cm (Ideal <102cm for men, <8 8cm for women) %Fat (Measured by bioimpedance) Ideal: Other Comments: Cardiovascular Activity Score Determination of Overall Cardiovascular Risk of Future Adverse Events Table 7-6. The recurrent cardiac event risk score. Progression of Disease Score Disease Low Intermediate High Prognosis Score Risk Risk Risk High Intermediate High High Risk Risk Risk Intermediate Low Intermediate High Risk Risk Risk Low Low Low Intermediate Risk Risk Risk (Canadian Guidelines for Cardiac Rehab & Cardiovascular Disease Prevention, 2nd Ed. 2004) Thank you for your interest in our program. Should you have any suggestions or comments concerning the program please feel free to contact us at (705) 328-6094 or Fax #(705) 328-6093 Sincerely, Cardiac & Pulmonary Rehabilitation Program Ross Memorial Hospital MEMORIAL HOSPITAL U|Mi CONGRATULATIONS!! Date: Carole, Ruth, and Sue, along with our volunteers Frank, June, Tom, & Marg, would like to take this opportunity to wish you all the best and especially good heart health. Please remember that you now have the tools you need to continue improving your heart health on a daily basis. You have also been given an "Exercise Prescription" outlining your target heart rate for exercise and some goals that we hope you will strive to obtain if you have not already done so. If in the fiiture you have new information change in your medical status (ie. Surgery is performed) please feel free to touch base with us. Initial Discharge Height Weight Waist >102cm in men & > 88cm in women increases your risk of health problems Ideal Body Fat Body Fat Test Date Ratio (TC/HDL) (ideal <4) Triglycerides (ideal <1.7) LDL (ideal <2.0) Thank you again for participating in our program. We hope that you found itfun and educational Phone # (70S) 328-6094 /Fax# (705)328-6093 88 p. 0i NO>-2f -200B ll'*' CHRONIC DISEASE PREVENTION A MANAGEMENT PROGRAM -"ASSESSM iNT DATE: PHONE# FAX#. FAMILY I rlYSIClAN: PHONE# FAX# SPECIAL! T: CASE MA 1AGER: _ REASON "ORREFERRAL/DIAGNOSIS: MEDICAL I ISTORY: 0 Injury/Disability fl Renal Diseaae n Airythmla D DiabcM 0 Liver Diseaae • Seizure Disorder • Arthritis • DystipWemia • Lung Disease 0 Sleep Disorder U Aflhma CJ GERD 0 Mental Health D Pacemaker/1CD ri Blood Di» rden 0 Heart Failure • Neurological Diaorder • Stroke • Cancer • Heart Disease U Thyroid Disease a COPD • Hypertension • Pneumonia f l Tuberculosis a Dementi* U Immunocompromised U PVD Other COMME> RS: VACCINATI )NS: ENVIRONMENTAL ALLERGIES: VOCATION. 10BBIES: SPECIAL Dl rr: HOUSING: CARBGIVER; COMMVND t SERVICE: RISK FACT ORS: P Age n Caffeine U m 0 Exercise 0 Family Medic«] History _____ U Obesity D Smoking ___ • PYHX • Quit Date ______0 Substance/ Alcohol Abuse i! Stress COMMEN 'S: j Initial: Final: Height Weinht BMI %Bo Eorm 1202 89 P.kK NOU-21 2006 il:4fl CHRONIC DISEASE PREVENTION I MANAGEMENT PROGRAM (CDPM3 AIXKRGD i: INTOUXA ICES: 1 mr-TTM-""'Av«HiHP OYcsONo p*tkat'(C(NBi nalty Pli«ro*»y:_ viMMiil Cmttrw ___ PkoMNMbw ______— niBRENTMl |>K>TtnNS TAKING: O PBtwlWwmw • Fnily'Qntiw Indwtbif: 0 is'» »* OTO (ooum, drop., PRNs, spuys, «mples) U H«rb«li 0 ODBPnfib • Other MEDIC/ T10N* STRE 4CTR, ROLTX, COMMENTS: FKBQDEN'^V: («!• Stat Mm, h**Wn rrturiiixgpkftidm. mftmt. Use generic n*s>: of dn^ Recommend! hannacistCcunselling? n Yes u Not necessary —.ase Manage (please print Date"" D Set Over NOU-2&-2008 11 = 4" tetaMaUMn ' MEMORIAL HOSPITAL ly^iyj WAIST emOJMFERENCE -Alto gk.sx.ces sive. hody.M is. m&ealtiy^the. &sMhutL - perso is with, more fat 011 the trunk, (especially abdominal fat) are at increased risk of death, from cardiac causes when compa. ed to peisons who are equally fat, but have more of their fa: on the extremities. - measi rements above 102 cm for men and.88 cm for womer are cons idered to place you at significantly increm ed risk. ens 91 P. 04 N0U-2t -2008 11=4" table7-3e.£i)ki4 ioB(rf^Fnwi0^^r^5cws ferr^{od(^frwr! ilbal . JDLCholcitn al MENwithDoaroented CVD >_^hokateiol 030- .130- iiSS. >W Risk Points fevrlt nij/L oft m- itt- lil-'. Rukfoctor \A lJf: J34 MO ISP Age Group. yt <4,39 5 3 20-54 4.394.65 35-39 40-44 4.664.90 45-49 4.91-5.16 50-54 5.17-5.42 55-59 60-64 5.43-5.68 65-69 5.69-5.94 70-74 5.95420 >75 Age Scon 621-6.46 447-6.71 Tottl Riik Points » Age Score 4 Lipid Scote -f SB? Score + _j.72-6.97 fe.9S-7.23 724-7.49 7 6 Pidbihilttx • <• -St 7.50-7.75 7 7 (*) £ 7.76 Lipid Score '* Tff No 0 <110 0 Tfcs I 110-129 1 Smoker 130-149 2 Scoie 150-169 3 170-199 4 j 200-229 5 1 N; (1 2.23(1 ft j iy K i i SB!* •' ZJ.-r Diabetes! 92 Southlake Regional HealthCentre SOUTHLAKE •: «. ; C. \ i •• Cardiac Prevention & Rehabilitation Program Dear Dr. ( Dale ) He: Kicvlrvx. D.O.I). ^ Kxcrcixc Capacity and Symptoms: I Beginning of Program End ofl'rograin jKwrtisc Capacity: F.xercise Capacity: Able to walk miles with I break Able to walk miles w iih I break Total F.xcrcisc Time - minules Total F.xcrcisc Time r" • minutes , <;.vr = MF I'S GXT MI-IS •Peak I lean Rale: Peak Heart Kate: beats per minutes .beite per minute Sxnmioms: |S\ niplonis: iResliiig Blood Pressure: •Resting BIiKhI Pressure: mmtlg i mmHg L. Attendance. X per week lor >( weeks. The lull number of se.>sions was not attended due to A long with (lie exercise component of our program, there is a comprehensive education series w iih lectures on dietary modification. stress reduction, cardiac risk factors, exercise, and medication I liese sessions are taught by our multi-disciplined staff. 1:1 sessions were recommended with our: Registered Dietitian r. Social Worker Other: I: I sessions were attended wiih our' •. Registered Dietitian <. Social Worker -Other: Smoking cessation was also recommended/attended as part of the rehabilitation process. to* Comniciils: > iias been given a home-exercise prescription, and urged to continue exercising, but to be cautious during extreme v\cather. They have been instructed to visit the nearest hospital c r should ihere lie any discomfort. It was a great pleasure hai iitu 0 j.( in the program. c.c. Dr. v\v& c.c. Patient File 'Sfa.vC Kinesiulogisi lor Cardiac Rehab 93 University Health Network (Toronto Western Hospital) March 19 2010 Dear Dr. , Re: Last Name, First Name MRN:1234567 DOB: 09/06/1933 Your patient has successfully completed the cardiac rehabilitation portion of her treatment in the Peter Munk Cardiac Program Cardiac Rehabilitation and Secondary Prevention program. Mrs. XXX attended a graduation education class held on March 19.2010 that reiterated the importance of regular exercise and a heart healthy diet after the completion of cardiac rehabilitation. Topics covered included: Exercise Nutrition Your Stress Test Results Preventative Heart Healthy Nutrition Tips Exercise for Your Heart The Importance of Nutrients Monitoring Your Heart Rate Saturated and Trans Fats Exercise after Graduation Nutrition Label Reading Comparison of the results of your patient's pre and post rehabilitation stress tests and her lipid profile are shown below. The Bruce treadmill protocol was used. 'Pre' Stress Test Results 'Post' Stress Test Results Test Date: July 9,2009 Test Date: March 15,2010 Time completed: 4;00 minutes Time completed: 9:00minutes METs achieved: 6 METs achieved: 10 Based on the above results a target heart rate of 92-102 beats per minute was prescribed for Mrs. XXX. Before Cardiac Rehabilitation After Cardiac Rehabilitation Test Date: October 1,2009 Test Date: January 26,2010 Total Cholesterol:4.57 HDL: 1.01 Total Cholesterol: 3^0 HDL: 1.19 Triglycerides:^! LDL: 3.14 Triglycerides: Ml LDL: 1.58 T. Chol/HDL: 4.53 T. Chol/HDL: 2.69 HbAlC: n/a FBS:n/a HbAlC: 0.060 FBS: 5J5 94 A comparison of your patient's pre and post rehabilitation anthropometrics are shown below, including weight, body mass index (BMI), and waist circumference. The Canadian Guidelines for Body Weight Classification in Adults were used to determine level of health risk associated with body weight. 'Pre* Anthropometrics 'Post' Anthropometrics Date: October 14,2009 Date: January 26,2010 Weight 57.6kg Weight: 55.9kg BMI: 24 BMI: 23.6 Waist Circumference: 91cm Waist Circumference: 89cm Health Risk Classification: Increased Risk Health Ride Classification: Increased risk If you require any further information, please do not hesitate to contact us at 416-603 5268. Thank you for allowing the PMCP Cardiac Rehabilitation and Secondary Prevention program to participate in your patient's recovery, and we look forward to receiving future referrals. Tanya Holloway, M.Sc., RCEP Margaret Brum, RD, BaSc Registered Clinical Exercise Physiologist Registered Dietitian Peter Munk Cardiac Program Peter Munk Cardiac Program Cardiac Rehabilitation and Secondary Prevention Cardiac Rehabilitation and Secondary Prevention University Health Network University Health Network April 26,2010 RE: DOB: MRN: This letter is to inform you that Mr. commenced participation in the PMCC Cardiac Rehabilitation and Prevention home-based cardiac rehabilitation program at Toronto Western Hospital on , 2010. This home-based program begins with a general education class reinforcing risk factor modification strategies, which your patient has already attended, followed by four monthly follow-up group sessions that occur at the hospital and are led by an exercise specialist and dietitian. Additional follow-up by phone is conducted in between these monthly visits. A primary goal of the home-based cardiac rehabilitation program is for the patient to take an active role in adopting healthy dietary and exercise behaviours. With each consecutive class, the patient builds and strengthens self-regulation skills such as self-monitoring and realistic goal setting, while being educated on making appropriate dietary and exercise related decisions. Patients also leam through vicarious experience and receive social support while participating in the group-mediated sessions. Ait initial stress test was done on , 2010 using die Bruce treadmill protocol. The patient was able to complete minutes, achieving METS. Peak heart rate was bpm. [Indicate if negative/positive for ischemia and other changes noted.] Mr. has been given a target heart rate range of bpm and has been taught how to monitor his pulse properly. Identification of cardiac symptoms and the use of the Borg Scale (Rating of Perceived Exertion) to monitor his exercise intensity have also been taught He has also been instructed on the importance of a proper warm-up, cool-down, and stretching exercises. Mr. 's progress with his diet and exercise behaviour will be tracked using log sheets, and any further recommendations made will be documented tor die duration of the program. A final exercise stress test will be booked in 3 months and we will send a follow-up letter at that time. Thank you for the opportunity to participate in the care of your patient If there are any questions please call us at 416-603-2858. Sincerely, Kelly Russell, MSc,CK PMCC Cardiac Rehabilitation and Prevention University Health Network 96 April 26,2010 Dear Dr. Re: MRN: DOB: Your patient commenced participation in the PMCC Cardiac Rehabilitation and Prevention home-based cardiac rehab program at Toronto Western Hospital on . This letter is to inform you that he has successfully completed the program and attended the graduation class on Ova* the course of the program, Mr. has made positive changes related to his diet and exercise. [Comment on progress and current self-reported exercise habits, as well as any fiirther recommendations made to patient]. We plan to follow-up on Mr. 's exercise maintenance by phone in 3 months. Intake ^Gradpation~n Target Exercise Stress Test (Bruce Treadmill]^ j Insert Date . Heart rate, (rest)peak j BP, (rest)peak ! Y\-r)-J''-: • Minutes completed i PeakMETS ! >8 Max ST depression/Angina j None/None Prescribed target heart rate ! Fasting Lipid Profile i Insert Date U :\Ipsertpate, v'-; mmol/L Total cholesterol I <5.00 Triglycerides ! <1.70 HDL | •\ V- \ * "r -l/ '• >1.00 LDL : <2.00 TC/HDL ratio j '' <4.00 Fasting blood sugar •/ '"V '• V* •- .V":~ <6.00 '• t.v-. X >'.fc ' <£.• Glycosylated hemoglobin j -4 f h,l'-- ; • 0.040 - 0.070 jtattoopometrics j Insert Date - Insert Date. ^ Weight ; -.r >• ~. BMI " " : l~8J~-~24~9l&m2 Waist Circumference 1 V-, >y;i ^v-Y/ <102 cm If you require fiirther information, please do not hesitate to contact us at 416-603-5268. Thank you for the opportunity to participate in your patient's care, and we look forward to receiving future referrals. Kelly Russell, MSc.CK Nishta Saxena, MSc, RD PMCC Cardiac Rehabilitation and Prevention PMCC Cardiac Rehabilitation and Prevention University Health Network University Health Network 97 University of Ottawa Heart Institute GRADUATION HEART HEALTH RISK PROFILE Date printed:YYYY/MM/DD Name Address Birthdate: YYYY/MM/DD HospitalID: XXXXXXX X Your Score Grad Score Health Factor Desirable Level Notes YYYY/MWDD YYYY/MM/DO Smoking Mon-smoking t i i SystoSc = Systai)C< If diabetic: Blood ! mmHg 140 mmHg Systolic < 130 mm Hg Pressure Diastolic® Diastolic < Diastolic < 80 mm Hg mmHg 90 mmHg Exercise reguisrty at least 5 to 7»week for 30-60 Physical Minute s'week Minutes/week Inactivity mm ata time. Target 200-400 min/week. B,M): SMI: Body Mass index Overweight less than 25 Kg: Kg: <102 cm ma les cm cm Waist <88 cm females Healthy eating Nutrition habits Anxiety scone less Anxiety Scare: Anxiety Score: than 11 Depression score Psychosocial less than 8 Factors Depression Depression Score: Score: "successful coping 'absence of excessive stress <0 98 UNIVERSITY OF OTTAWA HEART INSTITUTE PREVENTION ft REHABILITATION INSTITUT DE CARDIOLOOIE DE I'UNIVERSrre D'OTTAWA PREVENTION ET (^ADAPTATION GRADUATION HEART HEALTH RISK PROFILE Name Birthdate: YYYY/MM/DD Hospital ID: Your Scon Grad Score H«atth Factor Desirable Level Notes YYYY/MM/DD YYYY/MM/DD Total Blood mmol/L ' mmol/L Cholesterol > 1.0 mmol/L males HDL mmol/L mmol/L >1.2 mmol/L females n/a Total Cholesterol to <4 HDL Cholesterol Ratio ALT: LDL mmol/L mmol/L < 2.0 mmol/L Triglycerides mmol/L mmol/L <1.7 mmol/L < 6.1 mmol/L non-diabetics Diabetes mmol/L mmol/L <7.0mmol/L diabetics <7% for HbA1C % diabetics General Notes 40, RUE RUSKIN STREET, OTTAWA, ON K1Y 4W7 T «13.761.5000 WWW.OTTAWAHEAIIT.CA 99 York Central Hospital York Central Hospital -Mum and Wellness Centre Cardiac Rehabilitation Centre York Central^^ 37 .tacob Keller Partawy, Maple, ON Cardiac Health Assessment Hospital ph. (905) 832-3070 tec. (905) 832-0720 for bailtr htuhh ear* 8sf~ for betttr ktalth Date of Report: MM/DD/YY A Patient (Last, First) Most Recent GXT: MM/DD/YY Specialist: Dr. X O.O.B.: MM/DD/YY FamBy Doctor. Dr.Y H.C.N.: 1234567890 Dfegnosfe: This is where you would enter the patients diagnosis ABeqjIes: Enter pafenftafcrgies Exercise Test Summary Target Heart Rate/MET Lew/ Protocol Bruce/Ramp HFW Target Heart Rate| Duration M0 HRpM* 128 MET level S 110 MET Level! RestECG: Stress ECG: Notes andfor Symptoms: This Is where you would enter resting ECG data This is where you would enter exercise ECG data This is where you would enter any exercise symptoms or other notes Exertlse Recommendations 'AS exercise should be 30-40 minutes in duration at your target heart rate, and should be done 4-5 times per week, or d&Ty if you have diabetes • Exercise is not to exceed 60 minutes in duration • 5 minute warm-up I cooktown si a comfortable pace •Combine aerobic exercises to make up your overall exercise time • Resistance exercise may be performed 2-3 x /wk iter class instruction Treadmill Outdoor Waft Exercise Cycle pace! speedF* Cholesterol/Blood Gkicose Tracking BlH Tracking Previous Current Target Previous Current Date MM/DD/YY MM/DD/YY - Date MM/DD/YY MM/DD/YY . Tot Choi. m$tm Height - HDL 2120 Weight •* ttVALUB LDL BMI #VALUE! WALUEI H Trig. £1.70 Abd. Meas. •* 102/89 Tot/HDL #VALUE! #VALUE! mmm Notes BMI recommendations and cholesterol recommendations FBS •* £6.00 HbA1C / 1 Progress Assessment Start exercise at recommended levels - start slowty and Increase intensity gradualy, Patlenfs short terra absolute risk for CV disease prognosis Is...* with the goal of optimizing functional capacity and decreasing risk factors for CV disease progression Patients long term absolute risk for CV disease progression is...* Law scores on the HADSsunrey Indicates that patient is not tending towards depression or amiaty WRNMtom&nndrtmiM Medication Special Considerations Current Mediation list This is where you would enter a special note to the dWcian, patient physician *** If any abnormaSties aitse during exercise... such as chest pain, nausea, dfcanees or abnormal shortness of breath, SLOW DOWN YOUR EXERCISE Afffi STOPt If your symptoms do notsubside, contact your physician. If you haw any ooncems regarding your exercise prescrtplon or arty exerdse questions please cat us at (905) 832-8070 ext 2233 ~ UN v * « : ' V of O *!•«* HMIt IN»»tTUT« INSTltUT Of CAItCHOtOGIi MtvtNTlOW t rt*Aft*ur*T«OK at SOI'SW RUIVTMTION IT R£AO.A?TAT.!QN