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1、Cardiac rehabilitation in Germany and Europe德国及欧洲的心脏康复-指导方针,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,德国的心脏康复,Cardiac Rehabilitation in Germany 德国心脏康复,To provide comprehensive cardiac care,a rehabilitation-road“for treatment subseque
2、nt to myocardial infarct,heart surgery or other severe cardiovascular diseases was developed in Germany.为提供全面心脏护理，德国针对心肌梗死、心脏手术或其他严重心血管疾病，发展了后续的“康复之路”治疗。,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,Cardiac Rehabilitation in Germany 德国心
3、脏康复,The rehabilitation starts at hospital stage(Phase I)and is continued immediately after the release from the hospital as an inpatient or outpatient rehabilitation in specialized rehab clinics(Phase II).康复始于住院阶段（阶段I），出院后立即在康复诊所以门诊或住院形式（阶段II）继续开展。Rehabilitation phase III serves lifelong after-care
4、at the patients residence.康复阶段III需要患者在家做长期康复治疗。Here,the patient gets the chance to ensure the success of the Phase II rehabilitation in a heart-group.此时，患者尝试在心脏小组中维持康复阶段II所取得的成效。,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,In hospital
5、stage 住院阶段,Phase II cardiac rehabilitation阶段II 心脏康复,Residential 住院(in-Patient),Ambulatory 门诊(out-Patient),Intensive after-rehab-care 出院后加强康复护理,IRENA出院后强化康复,INA出院后强化,Heart group 心脏小组,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,KARENA 出院
6、后心脏康复,Cardiac Rehabilitation in Germany 德国心脏康复,Phase II of cardiac rehabilitation in Germany德国心脏康复阶段II,160 rehab clinics currently provide Phase II rehabilitation in Germany德国现有160多家康复诊所提供阶段II康复服务。,Residential 住院ambulatory 门诊residential and 住院兼门诊 ambulatory,Prof.Dr.Birna Bjarnason-Wehrens,Institute
7、for Cardiology and Sports Medicine,German Sport University Cologne,According to German health law,patients have the right to in-or outpatient phase II rehabilitation subsequent to myocardial infarct,PCI,heart surgery,or other severe cardiovascular diseases.根据德国卫生法规，患者在心肌梗塞、经皮冠状动脉介入治疗（PCI）、心脏手术或其他严重心
8、血管疾病后，有权选择后续阶段II住院或门诊康复治疗。Necessary measures are paid for by either retirement insurance or health insurance provider,or by social aid if no other provider happens to be responsible.必要治疗由养老保险或医疗保险承保人支付费用，如没有其他承保人则由社会救助支付。,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,G
9、erman Sport University Cologne,Phase II of cardiac rehabilitation in Germany德国心脏康复阶段II,Bjarnason-Wehrens et al.Cardiac Rehabilitation in EuropeEur J Cardiovasc Prev Rehabil.2010;17:410-8.),In 13 countries(46%),national legislations or laws regarding phase II cardiac rehabilitation are existent.针对心脏康
10、复阶段II，13个国家（46%）有国家法律或法规。,National legislation/law(s)regarding phase II cardiac rehabilitation in Europe欧洲关于心脏康复阶段II的国家级法律/法规,Health insurance providers 医疗保险承保人 The aim of phase II rehabilitation is to prevent impending disability or need for nursing,to extinguish them after occurrence,to improve th
11、e condition,or to merely prevent it from getting worse secondary prevention.康复阶段II的目标是防止出现残疾或丧失独立能力，防患于未然，改善身体状况，或防止状况恶化 二级预防。From an economic perspective,the resulting costs of a disease or disability can especially be reduced by cutting the costs of outpatient clinical treatment.从经济角度看，疾病或残疾的花费可通过
12、削减门诊临床治疗而大幅降低。,Bundesarbeitsgemeinschaft fr Rehabilitation(BAR):Rahmenempfehlungen zur ambulanten kardiologischen Rehabilitation vom 20.Oktober 2000.Frankfurt am Main,2001,Phase II of cardiac rehabilitation in Germanycosts of phase II rehabilitation program德国心脏康复阶段II 康复方案阶段II 费用,Prof.Dr.Birna Bjarna
13、son-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,Retirement insurance provider 养老保险承保人“rehab before an early retirement”提前退休之前做康复“The aim of Phase II rehabilitation is to counteract or overcome the diseases consequences for the patients ability to work.康复阶段II的
14、目标是消除疾病的影响，如患者丧失工作能力等。The retirement insurance provider grants medical rehabilitation measures before they start paying pension due to reduced working capacity.因工作能力下降，养老保险承保人支付退休金之前，也认可医学康复措施。Bundesarbeitsgemeinschaft fr Rehabilitation(BAR):Rahmenempfehlungen zur ambulanten kardiologischen Rehabili
15、tation vom 20.Oktober 2000.Frankfurt am Main,2001 联邦康复工会：于2000年10月20日在法兰克福,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,Phase II of cardiac rehabilitation in Germanycosts of phase II rehabilitation program德国心脏康复阶段II 康复方案阶段II 费用,Economic
16、 perspective:Rehab is a profitable business for the retirement insurance companies经济角度：康复对养老保险公司是可盈利的生意,Costs花费,Income收益,Savings储蓄(not prematurely paid retirement pension 并非提前支付的退休金),Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,Cardiac
17、rehabilitation in Germany guidelines,position papers and more 德国心脏康复指南、意见书等,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,Recommendations推荐:Cardiac rehabilitation after coronary bypass surgery.(I,A).冠状动脉搭桥手术后的心脏康复。(I,A).Cardiac rehabilit
18、ation after myocardial infarction(STEMI or NSTEMI)and/or interventional therapy.(I,A).心肌梗塞(STEMI急性心肌梗死 or NSTEMI非ST段抬高心肌梗死)后的心脏康复和/或介入治疗。(I,A).,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,Effect of early short-term cardiac rehabilitati
19、on after acute ST-elevation and non-ST-elevation myocardial infarction on 1-year mortality.急性ST段抬高的心梗和非ST段抬高的心梗之后，早期短期心脏康复对1年死亡率的影响。Junger et al.Curr Med Res Opin 2010 Apr;26(4):803-11,ACOS-Register(“observational,prospective Acute COronary Syndromes”)ACOS-登记（“观察，预期急性冠脉综合征”）Retrospective randomized
20、Cohort-Study in Germany,data from ACOS Register,n=4547(STEMI n=2432;NSTEMI n=2115),collected in 155 German hospitals in 2000 to 2002,follow up 1 Year德国回顾随机队列研究，ACOS登记数据，n=4547（ST段抬高心梗 n=2432；非ST段抬高心梗 n=2115），2000年至2002年间收集的155家德国医院数据，跟踪期1年Objective of the Study 研究目标:to analyze the effect of 3 week p
21、hase II cardiac rehabilitation on clinical development in the first year after STEMI or NSTEMI.ST段抬高心梗或非ST段抬高心梗后的第一年，分析3周心脏康复阶段II对临床发展的影响。,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,CAD-patients with STEMI(67.8%)more often attend card
22、iac rehabilitation compared to NSTEMI-Patients(52.3%)患ST段抬高心梗（67.8%）的心脏病患者，比非ST段抬高的心梗患者（52.3%）更常做心脏康复,STEMI ST-evaluation-myokardial-infarction;NSTEMI non-ST-evaluation-myokardial-infarction;MACCE:major adverse cardiac and cerebrovascular events(death,re-infaction,stroke);OR odds ratio,Retrospective
23、 randomised Cohort-Study in Germany,德国回顾随机队列研究，data from ACOS Register,n=4547 collected 155 German hospitals in 2000 to 2002数据来自ACOS登记，n=4547,2000年至2002年间收集的155家德国医院数据。,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,Effect of early short-
24、term cardiac rehabilitation after acute ST-elevation and non-ST-elevation myocardial infarction on 1-year mortality.急性ST段抬高的心梗和非ST段抬高的心梗之后，早期短期心脏康复对1年死亡率的影响。Junger et al.Curr Med Res Opin 2010 Apr;26(4):803-11,Results 结果:age(70 years)and a history of earlier myocardial infarction were independent pr
25、edictors for not attending phase II cardiac rehabilitation年龄（70岁）有早期心梗史，是不参与心脏康复阶段II的独立预测因素early revascularization(48 hours after admission to hospital)was a predictor for attending phase II cardiac rehabilitation早期血运重建（入院48小时，是参与心脏康复阶段II的预测因素）,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiolog
26、y and Sports Medicine,German Sport University Cologne,Effect of early short-term cardiac rehabilitation after acute ST-elevation and non-ST-elevation myocardial infarction on 1-year mortality.急性ST段抬高的心梗和非ST段抬高的心梗之后，早期短期心脏康复对1年死亡率的影响。Junger et al.Curr Med Res Opin 2010 Apr;26(4):803-11,Main objective
27、s of phase II cardiac rehabilitation心脏康复阶段II的主要目标,Improve overall quality of life 提升整体生活品质:reduce cardiac pain/disorders 减少心脏疼痛/心脏疾患 improve functional and physical capacity 改善功能和体质improve psychological well-being(coping with the disease)改善心理健康(应对疾病）improve social and occupational re-integration 促进社
28、会和职业重组Improve prognosis 改善预后:prevention und risk reduction预防并减少风险 reduce morbidity 减少发病率 reduce mortality 减少死亡率Reduce Costs 减少花费:improve patients compliance 提高患者依从 reduce/avoide hospitalisation 减少/避免住院治疗 avoide premature retire and/or need for home care 避免过早退休及/或需要家庭看护,Prof.Dr.Birna Bjarnason-Wehren
29、s,Institute for Cardiology and Sports Medicine,German Sport University Cologne,The comprehensive rehabilitation program includes somatic,educative,psychological,and social medical elements that are ensured by an interdisciplinary rehabilitation team.全面康复方案包括身体的、教育的、心理的及社会医学因素，由跨学科康复团队提供保证。The interd
30、isciplinary rehabilitation team 跨学科康复团队:The rehab is supervised by cardiologists 心脏病专家指导康复additional physicians 更多医生nursing staff 护理人员physiotherapist and exercise therapist 物理治疗师及运动治疗师Psychologist 心理学家Dietician 营养学家occupational therapist 职业治疗师social services expert 社会服务专家consultant professionals 专业咨
31、询(i.e.internist,neurologist,diabetologist,cardiac surgeon)（比如内科医生、神经学家、糖尿病专科医生、心脏手术）,.,Phase II cardiac rehabilitation in Germany德国心脏康复阶段II,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,Cardiac rehabilitation a comprehensive care,medical
32、 diagnostic,therapy and care医疗诊断、治疗和护理Physiotherapy 理疗physical therapy 物理治疗exercise therapy 运动疗法,Information 信息Motivation 积极性education and training 教育和培训,Psychotherapy 心理疗法stress management training 压力管理训练relaxation training 放松训练critical incident stress debriefing 危机事件紧急晤谈coping with the disease 应对疾
33、病depression,Anxiety抑郁、焦虑,occupational therapy 职业疗法social therapy 社会疗法functional therapy功能性疗法,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,心脏康复是综合性护理,身体 教育 心理 社会医疗,Special indications such as long-term work incapacity may require employe
34、d patients to attend intensified after-care programs at home for a limited amount of time.特殊适应症，比如长期没有工作能力，需要受雇患者一段时间内，在家做出院后的强化康复。,Phase III 阶段III maintenance therapy 维持疗法life-long after-care at the patients residence患者出院后，在家终身坚持,IRENA8 weeks 8周1-2 units 90-120 minutesper week1-2单元，每周90-120分钟,Heart
35、-Group 心脏小组12-24 months including 90 units 60-90 minutes(Lifelong)12-24个月包括90个单元，60-90分钟（终身）,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,All costs are carried by the patients retirement/health insurance.所有费用都可由患者的退休/医疗保险支付。,IRENA8 week
36、s 8周1-2 units 90-120 minutes per week1-2单元，90-120分钟/周,Aerobic exercise training 有氧运动训练resistance exercise training 抗阻训练physical therapy 物理治疗problem-oriented group work(for instance non-smokers training,overweight groups,stress management groups)以问题为导向的小组作业（比如，非吸烟者的训练、肥胖组、压力管理组）information,motivation
37、,and education(dietetic consulting,cooking lessons(if necessary),fostering of motivation)信息、积极性和教育（饮食咨询、烹饪课程（如有必要）、培养积极性）,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,Retirement/health insurance providers退休/医疗保险承保人-intensified rehab-aft
38、ercare-programs to secure/stabilize job-related rehabilitation success and the reintegration into working life/social life immediately(at latest 3 months)after phase II rehabilitation-出院后的强化康复项目，可以确保/稳定与工作相关的康复成果，康复阶段II之后，让患者立刻重回工作生活/社会生活（最迟三个月）。,Phase III 阶段IIIMaintenance therapy 维持疗法life-long afte
39、r-care at the patients residence 患者出院后在家长期坚持,Heart-Group心脏小组 6000 Groups in Germany德国 6000组,Organization and administration 组织和管理:regular sport clubs,health-oriented sport clubs,rehab institution etc.一般体育俱乐部、健康为导向的运动俱乐部、康复机构等。Institutions have to get licensed to bill insurance companies for their se
40、rvices.机构需要获得认证，就自己的服务为保险公司提供账单。Rehab team:sport therapist,physician,(nutritionists,psychologists,social workers)康复团队：运动治疗师、医生（营养学家、心理学家、社会工作者）Finances 财务:health insurance or/and retirement insurance providers subsidized participation(a minimum 90 units;7 Euro for each patient/units).医疗保险或/和养老保险承保人补
41、贴（最少90个单元；每位患者7欧元/单元）。patient himself 患者自己,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,Development heart groups in Germany德国心脏小组的发展,Grafik:P.Ritter,DGPR,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,Germa
42、n Sport University Cologne,Long term results of maintenance therapy in heart groups-Case-Control Study心脏小组案例对照研究，维持疗法的长期效果,(Buchwalsky et al.Z Kardiol 91(2002),139-46),In summary the results show:总的结果显示：-significantly improved exercise tolerance in the heart group 心脏小组可显著提高运动耐力heart group members ha
43、d significantly lesser cardiac pain/discomfort,心脏小组成员明显较少出现心脏疼痛/不舒服significantly lesser moderate to severe stress induced angina pectoris,明显较少出现压力导致的中度至重度心绞痛-lower need for cardiac medication.对心脏药物需求较少-cardiac morbidity was reduced by 54%.心脏发病率减少了54%the costs for medical care were lowered by 47%in t
44、he heart group.心脏小组里医疗护理费用减少了47%。,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,Cardiac Rehabilitation in Europe欧洲心脏康复,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,26,Eur J
45、Cardiovasc Prev Rehabil.2010;17:410-8,European Cardiac Rehabilitation Inventory Survey(ECRIS)欧洲心脏康复现况调查,Prof.Dr.Birna Bjarnason-Wehrens,Institute for Cardiology and Sports Medicine,German Sport University Cologne,欧洲心脏康复：欧洲心脏康复现况调查结果,-Austria 奥地利-Belarus 白俄罗斯-Belgium 比利时-Croatia 克罗地亚-Cyprus 塞浦路斯-Czec
46、h Republic捷克共和国-Denmark 丹麦-France 法国-Finland 芬兰-Germany 德国-Hungary 匈牙利-Iceland 冰岛-Ireland 爱尔兰-Italy 意大利-Lithuania 立陶宛-Luxembourg 卢森堡-Netherlands 荷兰,-Norway 挪威-Poland 波兰-Portugal 葡萄牙-Romania 罗马尼亚-Russian Fed.俄罗斯-Serbia 塞尔维亚-Slovak Republic 斯洛伐克共和国-Spain 西班牙-Sweden 瑞典-Switzerland 瑞士-United _ _ Kingdom
47、 英国,Countries participating 参与国家,Responder rate 72%响应率 72%39 countriesinvited to participate39个国家受邀加入28 countriescompleted the questionnaire28个国家完成了问卷,Bjarnason-Wehrens et al.Cardiac Rehabilitation in EuropeEur J Cardiovasc Prev Rehabil.2010;17:410-8.),Countries participating 参与国家,Representing 72%of
48、 all the European country members of the ESC代表72%的欧洲经济社会委员会成员国Including 600 million inhabitants 80%of the total population包括 6亿居民 总人口的80%,Bjarnason-Wehrens et al.Cardiac Rehabilitation in EuropeEur J Cardiovasc Prev Rehabil.2010;17:410-8.),-Austria 奥地利-Belarus 白俄罗斯-Belgium 比利时-Croatia 克罗地亚-Cyprus 塞浦
49、路斯-Czech Republic捷克共和国-Denmark 丹麦-France 法国-Finland 芬兰-Germany 德国-Hungary 匈牙利-Iceland 冰岛-Ireland 爱尔兰-Italy 意大利-Lithuania 立陶宛-Luxembourg 卢森堡-Netherlands 荷兰,-Norway 挪威-Poland 波兰-Portugal 葡萄牙-Romania 罗马尼亚-Russian Fed.俄罗斯-Serbia 塞尔维亚-Slovak Republic 斯洛伐克共和国-Spain 西班牙-Sweden 瑞典-Switzerland 瑞士-United _ _
50、Kingdom 英国,Phase II cardiac rehabilitation currently offered现行心脏康复阶段II提供,29,Bjarnason-Wehrens et al.Cardiac Rehabilitation in EuropeEur J Cardiovasc Prev Rehabil.2010;17:410-8.),阶段II（早期出院后方案）,阶段II（门诊方案）,阶段II（住院方案）,阶段II（居家方案）,是 否,64%,25%,11%,Only out-patient programme-仅门诊方案 Only out-patient and home-
