Cardiovascular Disease

Cardiovascular ailmentCardiovascular DiseaseIntroductionThis paper utilizes qualitative data drawn from a series of focus group discussions with patients alimentation with coronary thrombosis thrombosis nervus indisposition which explored their misgiving of and adherence to a cocksure monitoring and medication regime. These findings ar drawn upon in order to contextualize, from the patients perspective, the outcomes of the sections of wellnesss coronary soft nucle utilizationdness Disease study do fabric st enumerategy.The paper focuses wariness on the consequences of this regulatory nestle to clinical and pretend attention for those patients al entrap living with coronary eye distemper.Case StudyPatient is 59 yrs old and had a myocardial infarction 2 years ago. He is obese, a smoker and poorly motivated. The case exemplifies many of the difficulties that frequently rebel in managing cardiovascular distemper, and suggests potential avenues for improving outcomes through the application of a unhealthiness management programme.The coronary Heart Disease National receipts exampleBy the mid 1980s, it had been gener entirelyy accepted by around clinicians that in that location was strong evidence to support the existence of a additive relationship between cholesterol levels and cardiac death rate (Shaper et al. 1985, Stamler et al. 1986), and that at that placefore lumbering aggregate cholesterol levels would flash back the jeopardy of individua magnetic dips growing coronary marrow disease.This opened the way to the process of establishing a recommended cholesterol threshold level at which intervention should be instigated (Leitch 1989). Since past, the trend has been towards setting ever- unkepter threshold targets for treatment for those designated as existence at graduate(prenominal) risk of developing coronary purport disease and for those already living with the disease.In 2000, the Department of wellness published i ts Coronary Heart Disease National Service Framework which set out 12 standards for the prevention, diagnosis and treatment of the disease (Department of wellness 2000). The National Service Framework standard Number 3 recommended that GPs let out and develop a register of diagnosed patients and those patients at high risk of developing coronary midriff disease. Dietary and lifestyle advice (what the document terms modifi adapted risk f performers) was to be offered to these patients, and their medication reviewed at least ein truth 12 months. It was too recommended that statins be prescribed to any unrivaled with coronary heart disease or having a 30% or greater 10-year risk of a cardiac event, in order to lower their blood cholesterol levels to slight than 5 mmol/l or by 30% (which ever is greater). These recommendations were vigorously promoted when they were merged into the new General aesculapian service contract that came into operation in 2003.The relative performance of an individual Primary plow Organization in meeting for each one of these indicators attracts full stops on a sliding scale that ar then converted into payments for individual GPs. In relation to the management of patients with coronary heart disease, higher payments argon received if a Primary C ar Organization increases the percentage of patients with coronary heart disease who shit their total serum cholesterol regularly monitored, and whose last cholesterol reading was less than 5 mmol/l (Department of wellness 2004a).The roughly recent Department of wellness bestride report on the National Service Framework argues that the abundant growth in statin therapy since 2000 . . . is 1 of the most important markers of progress on the NSF, and was directly saving up to 9,000 lives per year (Department of wellness 2005 19). statin drug prescriptions have been rising at the rate of 30% per year since 2000, and in 2004/5 750 trillion was spent on statins, equivalent to most 2.5 million people on statin therapy in England (Department of Health 2005). In July 2004, low doses of statins became procurable over the counter without prescription for the first prison term, for those at obligate risk.The Public Health Discourse(S) Of Cardiac RiskThe application of risk discourses in the field of universe wellness (or much precisely the ascription of wellness risk to particular doingss) as conceptualized inwardly those elements of the risk lit most cultivated by Foucauldian notions of governmentality, ar seen as serving to construct the amicablely vicious as distinct from the responsible for(p) citizen (Foucault 1977, Turner 1987, Lupton 1995). In a akin(predicate) way, Dean (1999) argues that once risk has been attributed to particular wellness behaviours, the distinction is then drawn within public wellness policies between active citizens who ar perceived as able to manage their profess heath risks, and at-risk neighborly groups who become the object of targeted interventions designed to manage these risks.Two distinct dimensions or bettermentes to the conceptualization and public wellness management of cardiac health risks too emerge from an examination of the guiding determine and principles which inform the Department of Healths Coronary Heart Disease National Service Framework (Department of Health 2000).While one approach (described below as the epidemiological exemplar of risk) generally conforms to the personalized at-risk discourse, a mhoment discourse (described below as the accessible model of risk) which is much more concerned with health risk at a fond and material level ass excessively be discerned within the National Service Framework. These two distinct and arguably competing discourses of risk point to a complexity in incumbent public health insurance policy that might not be anticipated from a reading of the governmentality literature alone.The first conceptualization of cardiac risk within the Coronary Heart Disease National Service Framework is one that target be termed the loving model of health risk. This model essentially reflects a socio-stinting understanding of the determinants of population health, and draws attention to the grandeur of screaming material, social and psychological risk factors in gain to the k instantern biological factors in heart disease.In the National Service Framework, this social model is reflected in the endorsement (albeit at a rhetorical level) of an interventionist portion for the state in addressing these wider determinants of the disease The Governments activenesss influence the wider determinants of health which overwhelm the distribution of wealth and income. A wide range of its policies testament have an impact on coronary heart disease including social and legal policies and policies on transport, housing, employment, agriculture and food, environment and crime (Department of Health 2000 segment 1, Para 17). There is also an explicit ac noesisment that these risk factors disproportionately disadvantage particular sections of society, demonstrated in the higher incidence of coronary heart disease among the manual social classes. It is also acknowledged that there is inequity in health service provision . . . there argon unjustifiable variations in fiber and access to some coronary heart disease services, with many patients not receiving treatments of proven rough-and-readyness (Department of Health 2000 particle 1, Para 13).This formal acknowledgement of the governments role in addressing the wider social and economic influences on cardiac health risk could to some degree be said to conform to Becks (1992) notion of the risk society wherein many of the health risks faced by the population argon a consequence of unchecked scientific and industrial progress. Beck asserts that in response a greater public aw atomic number 18ness or reflexivity of risk has emerged which reflects a shift from ig norance or private fears close the unknown to a widespread knowledge some the world we have created. The question of whether a reflexivity concerning the social and environmental factors associated with cardiac risk post be discerned in a patients own discourses of cardiac risk is something that impart be explored in the discussion below.The foster risk discourse emergent within the National Service Framework (Department of Health 2000) is one which reflects a predominantly epidemiological understanding of health risk. In this model, the relative risk of an individual developing heart disease is base upon a calculation of the mean values associated with certain lifestyle behaviours such as smoking, diet and exercise that are drawn from amount population data for heart disease incidence. This is a statistical approach that all too very much perceives such calculated health risk factors as being realities or causative agents in their own right, practically with little acknowl edgement of the social and material context of these health behaviours.Nevertheless, it is on the basis of this epidemiological model of health risk that the Department of Health has confidently set national guidelines that now require Generalvalue and principles underlying the CHD National Service FrameworkNine stated values underlying development of national policies for CHDProvision of quality services irrespective of gender, disability, ethnicity or age.Ready availability of consistent, accurate and relevant culture for the public. love of health impact in regard to social and legal policies and policies on transport, housing, employment, agriculture and food, environment and crime.Public health programmes led by health and local authorities to come across targets for CHD are met.Reduction in health inequalities. Re fountains will be targeted at those in superior need and with the greatest potential to benefit. Evidence-based. CHD policies are to be based on the best av ailable evidence.Integrated approach for the prevention and treatment of CHD in health policy, health promotion, primary plow, fraternity wish well and hospital mission. Maintenance of ethics and standards of nonrecreational practice.Recognition of the importance of voluntary organizations and carers at home in addressing CHD. 4 stated principles underpinning the CHD NSF. Reducing the burden of CHD is not just the responsibility of the NHS. It requires action right across society. The quality of care depends onready access to appropriate servicesii. the calibre of the interaction between individual patients and individual cliniciansiii. the quality of the organization and environment in which care takes place.. excellence requires that important, simple things are done right all the time.. Delivering care in a more structured and formationatic way will easily improve the quality of care and reduce undesirable variations in its provision.Practitioners to set and monitor high risk patients and to prescribe the recommended drug treatment regime. It can be argued that this regulatory or conductorialist approach to clinical decision- do constitutes a repugn to the discretion that has been traditionally enjoyed by general practitioners in relation to the clinical management of patients.This second official discourse of health risk could be seen as indicative of the regulatory and surveillance forms of governmentality give away within Foucauldian social theory. From this perspective, those social groups whose health behaviour or lifestyle are seen to cliff outside the acceptable bounds of self-management then become constructed as at-risk.These are social groups who are seen to, deliberately expose themselves to health risks rather than rationally avoiding them, and therefore require greater surveillance and regulation (Lupton 1995 76) once identified these groups and individuals then become subject to various health promotion or health improvement in itiatives.Implicit in such forms of governmentality as apply within health policy interventions designed to manage risk are a set of assumptions about the nature of human action predicated on the notion of the rational actor model. Jaeger, Renn, Rosa and Webler (2001) have argued such models of ground operate at three levels of abstraction. In its most general form, it presupposes that military personnel are capable of acting in a strategic style by linking decisions with actions. That is, human beings are goal-orientated who have options available from which they are able to select a course of action appropriate to meeting these goals. The second level of abstraction which the authors term the rational actor paradigm, and which is the level at which rationality is probably understood by policy-makers, contains the following assumptions all actions are individual choices individuals can distinguish between ends and means to achieve these ends individuals are motivated to pursue their own self-chosen goals when making decisions about courses of action/behaviour individuals will always choose a course of action that has maximal personal utility, that is it will lead to personal satisfaction individuals possess the knowledge about the potential consequences of their actions when they make decisions. Finally, that rational actor theory is not only a normative theory of how people should make decisions about in this case health behaviour, but is also a descriptive model of how people select options and justify their actions (Jaeger et al. 2001 33).Many of these rational actor assumptions underpin and inform the Coronary Heart Disease National Service Framework. Such assumptions manifest themselves in a seemingly un sturdy approach to the promotion of risky health behaviour change which plays down the influence of culture, habitus and the material basis of group socialization. This uncritical rationality also threatens the sustainability of the National Service Framework strategy in former(a) ways. The social psychological and sociological literature see the notion of trust as constituted through two dimensions, the deliberative or rational and the emotive or non-rational.As Peter Taylor-Gooby (2006) has pointed out in his work on the problematic of public policy reform, the rational deliberative processes associated with the achievement of greater efficiency in the provision of public services have inadvertently served to undermine the non-rational processes that contribute to the building of trust in public institutions and in public sector professionals. In this context, the National Service Framework will need to build trust two in terms of the origination of the biomedical evidence for the effectiveness of statins and other cardiac drug interventions, as well as the more affective elements associated with the belief that the national targets are designed with the best interests of patients in mind rather than being drive by finan cial considerations alone.Significantly, disposed(p) its centrality to a disease management strategy, uncomplete the Coronary Heart Disease National Service Framework (Department of Health 2000) nor the NHS profit Plan (Department of Health 2004b) which sets out the governments priorities Coronary heart disease and the management of risk 363 for primary and secondary healthcare up to 2008, attempts to mend the use of the term risk, and by extension higher risk. Nevertheless, the conception of risk that shapes the practical interventions proposed within both these strategy documents is clearly the epidemiological one that is described above. In the past, such public health interventions have been for the most part concerned with bringing about health behaviour change, however now the strategy would appear to be less focused on boost greater responsibility for the self management of cardiac risk and more on ensuring compliance with clinical management regimes of monitoring and d rug treatment.Optimising deal out Through Disease ManagementIn the last 15 years, there have been dramatic advances in the pharmacotherapy of heart disease, most notably the design of angiotensin converting enzyme ( sorcerer) inhibitors. (Jaeger et al. 2001 33) Unfortunately, numerous studies have suggested that ACE inhibitors are substantially underutilised in heart disease patients. Moreover, there are a multitude of factors which whitethorn confound heart disease management heart disease closely never occurs in isolation, and comorbidities such as hypertension, diabetes, coronary artery disease, chronic pulmonary or renal disease and arthritis occur frequently.The presence of these comorbid conditions may intercede with heart disease management in several(prenominal) ways. In PATIENTs case, pre-existing renal insufficiency may have contributed to her intolerance to ACE inhibitors. In addition, her use of NSAIDs could promote salt and water retention and sabotage the antih ypertensive effects of her other medications. (Jaeger et al. 2001 33)Multiple comorbidities may also return in polypharmacy, which, in turn, may compromise compliance and lead to undesirable drug interactions.Adherence to dietary sodium restriction is often problematic (as in patients case), particularly in older individuals who are either not responsible for preparing their own meals, or who rely heavily on tinned goods and prepared foods. Depression, anxiety and social isolation are common in patients with heart disease, and each may interfere with adherence to the heart disease forage or with the patients willingness to seek prompt medical attention when symptoms recur. Similarly, the high cost of medications may limit access to therapy in patients with restricted incomes. sensible limitations, such as neuromuscular disorders (e.g. stroke or Parkinsonism), arthritis and sensory deficits (e.g. afflicted visual acuity), may compromise the patients ability to understand and comp ly with treatment. Finally, cognitive dysfunction, which is not uncommon in elderly heart disease patients, may further confound heart disease management.Impact on clinical Outcomes disrespect the widely publicised effects of ACE inhibitors, b-blockers, angiotensin sense organ blockers and other vasodilators on the clinical course of heart disease, morbidity and mortality rates in patients with established heart disease remains very high. heart disease is the leading cause for repetitive hospitalizations in adults, and in 1997 Krumholz et al. account that 44% of older heart disease patients were rehospitalised at least once within 6 months of an initial heart disease admission. Remarkably, this rate was no better than that reported in several prior studies go out back to 1985. (Krumholz et al. 1998)From the disease management perspective, it is important to recognise that the majority of heart disease readmissions are associate to poor compliance and other psychosocial or behavio ural factors, rather than to progressive heart disease or an astute cardiac event (e.g. myocardial infarction). Thus, Ghali et al. reported in 1988 that 64% of heart disease exacerbationswere attributable to noncompliance with diet, medications or both and that 26% were related to environmental or social factors. Similarly, in 1990 Vinson et al. (Vinson, 1995) found that over one-half of all readmissions were directly attributable to problems with compliance, lack of social support, or process-of care issues, and these authors concluded that up to 50% of all readmissions were potentially preventable.More recently, Krumholz et al, reported that lack of emotional support among older heart disease patients was a strong independent predictor of adverse outcomes, including death and hospitalization precept and ObjectivesThe above considerations return the rationale for a systems approach to heart disease management.The objectives of this approach are as followsTo optimise the pharmacot herapy of heart disease in accordance with current consensus guidelines. (Vinson, 1990)To maximize compliance with prescribed medications and dietary restrictions.To identify and respond to any psychological, social or financial barriers that might interferewith compliance with the prescribed treatment regimen.To provide an appropriate level of inspection through telephone contacts, home visits andoutpatient clinic visits.To enhance functional capacity by providing an individualized programme of exercise and cardiac rehabilitation.To enhance self-efficacy by component the patient and family understand that heart disease can be controlled, largely through the patients and familys efforts.To reduce the frequency of acute heart disease exacerbations and hospitalizations.To reduce the overall cost of care.The Disease Management TeamAlthough the composition of a disease management team may vary both from centralise to centre and from patient to patient, a suggested list of team penis s are given belownurse coordinator or case managerdietitiansocial services representativeclinical pharmacistphysical therapist/occupational therapistexercise/rehabilitation specialist home health specialistpatient and familyprimary care physiciancardiologist/other consultants. distributively team member provides their own unique expertise and/or perspective, and these are then woven into an integrated package tailored to meet each individual patients needs, expectations, and circumstances. Importantly, not all patients will require the services of all team members, and it is therefore essential to identify a team leader. In most cases, this will be the nurse coordinator or case manager, who, in addition to being the patients primary contact person and educator, is also responsible for coordinating the efforts of other team members, including the selective activation of appropriate consultations on an individualized basis.In addition to the team itself, several other components are essential for effective disease management. First, the patient and family should be provided with universal learning about heart disease, including common etiologies, symptoms and signs, standard diagnostic tests, medications, diet, activity, prognosis and the role of the patient and family in ensuring that heart disease remains under control.This randomness should be provided in a readily understandable patient-friendly format and several patient-oriented heart disease brochures are now commercially available. In addition to these materials, the patient should be given a scale (if not already owned) and a chart to record daily weights, an accurate and detailed list of medications supplemented by medication aids if needed (e.g. a pill box), and particular information about when to contact the nurse, physician, or other team member in the event that questions or new symptoms arise. In this regard, the importance of establishing an effective one-on-one nurse-to-patient relationsh ip cannot be overemphasized, as this interaction will often be critical to the early diagnosis and effective outpatient treatment of heart disease exacerbations.Patient PerspectiveWhile the above studies indicate a beneficial effect on cost, hospital readmissions, etc., they do not address concerns related to the patients perspective on this interdisciplinary care. What issues are important to the patient, and what the advantages are to the patient of participating in an heart disease disease management programme?In recent years, it has become increasingly evident that it is scant(predicate) to merely provide high quality medical services. In a competitive market, it is essential that the patient is also satisfied with the medical encounter, both in terms of the process of care as well as the clinical outcomes.Healthcare is an constancy, and like all industries, customer satisfaction is critically important. However, unlike most industries, which deal with a tangible product, the healthcare industry deals with a multifaceted service, the myriad qualities of which are difficult to quantify. As a result, the assessment of patient satisfaction is often complex, and the development of a validated and universally accepted instrument for measuring patient satisfaction has been elusive.Despite these problems, several patient satisfaction questionnaires have been developed, (Garg, 1995) and these have been helpful in defining those issues which are important to patients, and in identifying specific concerns that patients often have with respect to current approaches to healthcare delivery. (Garg, 1995)Factors which have been consistently shown to play a pivotal role in determining patient satisfaction include communication, involvement in decision- making, respect for the individual, access to care and the quality of care provided. (Philbin, 1996) Not surprisingly, problems in each of these areas are frequently cited as factors which strike patient satisfaction. S everal components of the heart disease disease management system will be of direct serve upance in answering patients questions and dower her cope with this new and frightening diagnosis. In particular, the nurse case manager will establish an effective rapport with the patient and her family, and provide an ongoing source of information and emotional support. The patient education brochure and other printed materials will help answer many of Patients questions and assist in relieving some of her anxieties.The nurse, clinical pharmacist and physician (s) can provide detailed information and teaching about the medications used to treat heart disease, and the dietitian can directly address the dietary questions and provide an individualized diet that takes Patients current dietary practices and food preferences into account. The social service representative can assist patient with any financial concerns she may have, make provisions to understand an adequate social support network , and serve as an additional source of emotional support. The physical therapist or exercise specialist can help in providing recommendations about activities and in the development of an exercise or rehabilitation programme.The nurse case manager, social service representative, home care specialist, and physician will provide assistance to patient in making the transition from the hospital back to the home environment, and they also will ensure a high level of follow-up care. Perhaps most importantly, the comprehensive care provided by the disease management team will promise patient that she truly is being cared for, and that all of her needs and concerns are being met.Invariably, this will lead to a high level of patient satisfaction. In addition, in the case of patient there is good reason to remember that implementation of a disease management programme at the time of her initial hospitalization may have eliminated the need for a second hospitalization. (Young, 1995)To the ex tent that patient might have to pay for some of the costs of readmission (e.g. deductible or copayment), the disease management programme would also hold on her money, a benefit which is universally viewed in a favorable light. And finally, based on compelling data from recent clinical trials, optimizing Patients medication regimen should translate not only into an improved quality of life, but also into increase survival.ConclusionIn summary, heart disease management systems provide a win-win-win situation. They are a win for the providers, because they improve clinical outcomes and quality of life. They are a win for the payors, because effective disease management programmes slack health care expenditures. And they are clearly a win for the patients, who gather multiple benefits, including improved quality of life and well-being, enhanced self-efficacy due to a greater sense of health control, improved exercise tolerance and functionality, increased survival (as a result of mo re optimal utilisation of heart disease medications), and, in some cases, reduced out-of-pocket expenditures. ReferencesDepartment of Health (2000) National Service Framework for Coronary Heart Disease (London DoH).Department of Health (2004a) GMS Statement of Financial Entitlements (SFE) 2004/5 (London DH).Department of Health (2004b) The NHS Improvement Plan Putting People at the Heart of Public Services Cm 6268 (London The Stationary Office).Department of Health (2005) The Coronary Heart Disease National Service Framework Leading the Way-Progress Report 2005 (London DH Publications).Foucault, M. (1977) Discipline and penalise The Birth of the Prison (London Allen Lane).Garg R, Yusuf S, for the Collaborative Group on ACE Inhibitor Trials. Overview of randomise trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. JAMA 1995 273 1450-6Ghali JK, Cooper R, crossbreeding E. Trends in hospitalization rates for heart failure in t he linked States, 1973-1986. Evidence for increasing population prevalence. Arch Intern Med 1990 150 769-73Jaeger, C., Renn, O., Rosa, E. and Webler, T. (2001) Risk, Uncertainty, and lucid Action (London James James/Earthscan).Krumholz HM, Butler J, Miller J, et al. Prognostic importance of emotional support for elderly patients hospitalized with heart failure. Circulation 1998 97 958-64Leitch, D. (1989) Who should have their cholesterol concentration measured? What experts in the United Kingdom suggest. British Medical Journal, 298(6688), 1615 1616.Lupton, D. (1995) The Imperative of Health Public Health and the Regulated Body (London Sage).Philbin EF, Andreou C, Rocco TA, et al. Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals. Am J Cardiol 1996 77 832-8Redfern, J., MacKevitt, C. and