LAUSR

A man with no previous medical history has survived his first heart attack and is now all of a sudden a patient with a chronic disease. Apart from painkillers and antibiotics, he never took any medicine before, but is now presented with a list of several pills to be taken every day. Before the event he lived his life as he liked without thinking about a healthy lifestyle. He ate the food that he preferred, enjoyed his remote control and smoked. Ischaemic heart disease is an illness with a heavy social inequality, so he is likely to belong to a low social stratum, and he will probably have a low level of education. Naturally, he wants to make a full recovery, but he will have marked difficulties in talking about how to cope with his new situation, about goals of rehabilitation or even about his expectations. The solution for him and for many other patients with cardiological diseases is the cardiac rehabilitation programme. The study by Tea and colleagues focused on quality in rehabilitation programmes. Contemporary cardiac rehabilitation is focused on optimal outcome and the reduction of possible complications after acute coronary events and primary or elective percutaneous coronary interventions. The main components of cardiac rehabilitation are pharmacological treatment, non-pharmacological counselling (lifestyle changes), physical exercise, smoking cessation programmes and information on return to work, social welfare and psychological reactions. The education is presented to the patient in a pedagogical setting that considers his educational level. This is a pedagogical method based on the learning method that was used in his time as an apprentice. He will listen to other patients that explain how they coped with, for example, exercise and diet, and he will tell other patients how he coped with some of the lifestyle factors. The comprehensive rehabilitation programme has been shown to reduce the number of admissions to hospitals and even deaths due to ischaemic heart disease. But what happens if cardiac rehabilitation fails on one or more of the components? Then the patient will not benefit from the rehabilitation programme to an optimal degree. The work by Tea and colleagues demonstrates that many patients do not receive the medicine recommended by guidelines. The authors use the medications from national guidelines as indicators of a correct guideline-driven pharmacological rehabilitation. We do not know whether there were side-effects or contraindications to the medicine, and we do not know about possible local differences in the rehabilitation programmes. Some staff members may not hold consistent views regarding goal orientation in the rehabilitation clinic. Problems in goal-setting are also related to staff, their interaction as well as the general framework or the organisational processes within rehabilitation. The authors also document that the gap between the social groups is bigger after rehabilitation because the groups with low social status were prescribed less medicine than the groups with high social status. Some countries have national obligatory quality databases to cover quality problems in the rehabilitation centres. These databases have indicators in areas of pharmacological treatment, all risk-factor modulations, psychological assessment and return to work. A quality database is a drive for centres and nations to improve quality in treatment, because the centres compete and strive to improve from year to year. If a country has no quality database, they should use some other quality improvement method to ensure that the treatment that is recommended in the guidelines is given to the patients.