Giuliano Catherine, Parmenter Belinda J, Baker Michael K, Mitchell Braden L, Williams Andrew D, Lyndon Katie, Mair Tarryn, Maiorana Andrew, Smart Neil A, Levinger Itamar
Institute of Sport, Exercise and Active Living (ISEAL), Victoria University, Melbourne, VIC, Australia.
Department of Exercise Physiology, School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.
Clin Med Insights Cardiol. 2017 Jun 12;11:1179546817710028. doi: 10.1177/1179546817710028. eCollection 2017.
Coronary artery disease (CAD) is a leading cause of disease burden worldwide. Referral to cardiac rehabilitation (CR) is a class I recommendation for all patients with CAD based on findings that participation can reduce cardiovascular and all-cause mortality, as well as improve functional capacity and quality of life. However, programme uptake remains low, systematic progression through the traditional CR phases is often lacking, and communication between health care providers is frequently suboptimal, resulting in fragmented care. Only 30% to 50% of eligible patients are typically referred to outpatient CR and fewer still complete the programme. In contemporary models of CR, patients are no longer treated by a single practitioner, but rather by an array of health professionals, across multiples specialities and health care settings. The risk of fragmented care in CR may be great, and a concerted approach is required to achieve continuity and optimise patient outcomes. 'Continuity of care' has been described as the delivery of services in a coherent, logical, and timely fashion and which entails 3 specific domains: informational, management, and relational continuity. This is examined in the context of CR.
冠状动脉疾病（CAD）是全球疾病负担的主要原因。基于参与心脏康复（CR）可降低心血管疾病和全因死亡率、改善功能能力和生活质量的研究结果，推荐所有CAD患者接受CR治疗是I类推荐。然而，项目参与率仍然很低，通常缺乏在传统CR阶段的系统进展，医疗服务提供者之间的沟通也常常不尽人意，导致护理碎片化。通常只有30%至50%符合条件的患者被转诊至门诊CR，完成该项目的患者更少。在当代CR模式中，患者不再由单一从业者治疗，而是由一系列跨多个专业和医疗环境的健康专业人员治疗。CR中护理碎片化的风险可能很大，需要采取协调一致的方法来实现连续性并优化患者结局。“护理连续性”被描述为以连贯、合乎逻辑和及时的方式提供服务，它包括三个特定领域：信息连续性、管理连续性和关系连续性。本文将在CR的背景下对此进行探讨。
