Rehabilitation and follow-up monitoring of patients who have experienced acute coronary syndrome in Perm krai

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Introduction

In recent years, the Russian Federation (RF) has been paying special attention to increasing life expectancy and extending the working life of its citizens. However, despite these efforts, coronary heart disease (CHD) remain the leading cause of death among the older age groups. Among CHD, the most common causes of death are coronary heart disease (CHD), cerebrovascular disease (CVD), myocardial infarction (MI), and acute cerebrovascular accidents (ACVA) [1–3]. In 2023, the Perm Krai region recorded higher than average mortality rates from cardiovascular disease in Russia, although there was a positive trend in the form of a 2.1 % decrease in these rates. Nevertheless, the problem requires further study and the development of new measures to improve the situation [4], in accordance with Resolution No. 1319-p of October 3, 2013, “On the Approval of the Perm Region State Program ‘Quality Healthcare’” (taking into account changes until November 21, 2024).

The aim of the study is to analyze the organization of medical care for patients who have suffered acute coronary syndrome (ACS) as part of rehabilitation and dispensary observation in the Perm Krai.

Materials and Methods

In 2024, specialists from the Perm Region Ministry of Health and employees of Perm State Medical University (PSMU) conducted an audit of the organization of the rehabilitation and dispensary observation process for patients who had undergone ACS, using the Perm Krai as an example. An analysis of indicators from the following sources of information was performed: the automated medical statistics monitoring system of the Federal State Budgetary Institution “Central Research Institute for Health Care Organization and Informatization” (CRIHCI) (http:// asmms.mednet.ru), including data on monitoring the reduction in mortality from CHD, monitoring the reduction in mortality from CVD, and signal indicators from the federal project “Combating Cardiovascular Diseases”; compilations and reports on medical statistics provided by the medical information and analysis center on the CRIHCI portal.

Results and Discussion

In 2023, the overall mortality rate per 100,000 population in the Perm Krai was higher than the Russian average (1,333.8 vs. 1,206.2). However, there was a 4.1 % decrease in mortality compared to 2022, which is a positive trend. CVD mortality structure: chronic forms of CHD account for a significant proportion of CVD mortality – 46.5 %, acute MI – 4.3 %, ACVA – 3.0 %. The ratio of fatalities from ACVA to deaths from MI is 3.0 to 1.0, which indicates the high prevalence of ACVA among causes of death. The high proportion of chronic forms and CVD emphasizes the need for further development of secondary prevention programs for cardiovascular diseases in the Perm Krai to improve the health situation of the population.

Important reserves in the region are concentrated in the area of primary and secondary prevention of cardiovascular diseases. Thus, primary prevention programs are not sufficiently effective, as there is a high percentage of people aged 40 to 65 who have not undergone preventive medical examinations (PME) and dispensary observation of certain groups of the adult population (DOCGAP) in the last two years (47.7 %). In addition, the proportion of patients with a newly diagnosed CVD among patients who underwent PME and the first stage of DOCGAP is low (2.6 % against a target of 3.5 %). At the same time, according to statistical observation form No. 131, there is a high prevalence of risk factors—obesity, perlipidemia, arterial hypertension, diabetes mellitus, and excess body weight (indicators higher than in the Russian Federation). At the same time, among those who underwent medical examinations, CHD (3.8 % vs. 4.9 % in the Russian Federation) and CVD (3.5 % vs. 5.0% in the Russian Federation) are not sufficiently detected. Despite the high rate of referral for medical observation of patients with CVD – 79 % (target – 70 %), there is a potential for improvement in the quality of medical observation. This is due to both the high frequency of emergency medical service calls due to exacerbations of diseases (9.2 % against the target of 10.0 % by the end of the year) and the high proportion of people hospitalized with exacerbations of CVD among those under dispensary observation (2.17 % against the target of 3% by the end of the year), which indicates insufficiently effective management of patients at high risk of adverse events. Thus, with a high percentage of patients registered with dispensaries, dispensary observation itself can be implemented more effectively.

Medical rehabilitation of adult patients in the Perm Krai is regulated by two main documents: Order of the Ministry of Health of the Russian Federation No. 788n of July 3, 2020, “On the Procedure for Organizing Medical Rehabilitation of Adults,” and Order of the Ministry of Health of the Perm Krai No. 34-01-05-1234 of November 16, 2021, “On the Approval of the Regulations for the Provision of Medical Care to Adults in the Field of Medical Rehabilitation in the Perm Krai.” Currently, the region provides continuity of medical care at different stages of medical rehabilitation. This means that patients can sequentially undergo various stages of recovery without interrupting the treatment process. The routing of patients to stages of medical rehabilitation is determined using the indicators of the rehabilitation routing scale, which is set out in the Regulations and agreed with Resolution No. 1319-p of October 3, 2013, “On the Approval of the Perm Krai State Program ‘Quality Healthcare’” (taking into account changes until November 21, 2024).

To date, a network of early medical rehabilitation departments (first stage) has been established in the Perm Krai for patients with neurological and cardiological diseases, which operate on the basis of four regional vascular centers and 23 primary vascular departments. The main goal is to provide patients with access to specialized care immediately after the acute phase of the disease in order to restore their functions as much as possible and improve their quality of life as part of the Perm Region's “Quality Healthcare” program.

Medical rehabilitation for adults in the second stage is carried out by seven medical organizations (MOs). The total number of beds for this stage is 323 for patients with various types of disorders of the central and peripheral nervous systems, as well as somatic diseases such as myocardial infarction and pneumonia. In order to increase the availability of rehabilitation beds for the population of the Perm Krai, the Ministry of Health has developed a roadmap that provides for a phased increase in the number of beds for medical rehabilitation. This plan is part of a regional program called “Optimal Medical Rehabilitation for Health Recovery.” The program aims to improve the availability and quality of medical services in the field of rehabilitation, which will enable residents of the region to recover more quickly from various illnesses and injuries. The introduction of additional beds will contribute to raising the level of medical care and improving the overall health of the population of the Perm Krai.

As part of the day hospital program, medical rehabilitation services are provided at 12 medical organizations (MOs) in the region. The total number of beds is 167. Outpatient rehabilitation services are also available at 14 MOs in the region. Services are provided by members of multidisciplinary teams consisting of medical rehabilitation department staff, which emphasizes the importance of a comprehensive approach to rehabilitation and the accessibility of services for residents of the Perm Krai.

Perm State Medical University offers professional retraining in the specialty of “Physical and Rehabilitation Medicine Physician.” Currently, 77 specialists have undergone retraining, and all of them work in the Perm Krai Ministry of Health. Thus, the medical rehabilitation system in our region is organized in accordance with federal and regional regulations, ensuring effective interaction between the various stages of restorative treatment for adult patients.

Table 1 presents data on dispensary observation and rehabilitation of patients with CHD, carried out as part of the action plan to reduce mortality from CHD.

 

Table 1. Indicators of dispensary observation of patients with CHD in the Perm Kraiin 2018–2023

Indicator	2018	2019	2020	2021	2022	2023
Number of patients under dispensary observation for CHD (ICD-10: I20–I25), number of people	69 850	68 752	67 002	59 848	61 122	65 322
Total number of registered patients with CHD (ICD-10: I20–I25), number of people	76 870	93 856	93 671	78 448	79 793	80 867
Number of patients under dispensary observation for CHD who have undergone training in patient schools (ICD-10: I20-I25), number of people	6 321	6 137	2 889	3 239	4 408	3 317
Number of patients who have had ACS (ICD-10: I20.0; I21; I22; I24) and are under dispensary observation for this disease, number of people	6 859	7 202	7 375	6 595	6 592	5 948
Number of registered patients who have had ACS (ICD-10: I20.0; I21; I22; I24), number of people	10 552	10 591	9 219	8 244	8 227	7 436
Percentage of patients who have had ACS and are under dispensary observation, %	65.0	68.0	79.9	79.9	80.1	79.9
Number of patients who suffered ACS (ICD-10: I20.0; I21; I22; I24) and received rehabilitation care at the first stage of medical cardiac rehabilitation, number of people	9 224	8 803	5 836	4 053	5 409	2 687
Percentage of patients who had ACS (ICD-10: I20.0; I21; I22; I24) and got rehabilitation help in the first stage of medical cardiac rehabilitation, %	87.4	83.1	63.3	49.2	65.7	36.1
– of these, number of patients of working age, absolute	2 124	2 640	2 356	1 096	2 371	1 348
Number of patients who suffered ACS (ICD-10: I20.0; I21; I22; I24) and received rehabilitation care during the second stage of medical cardiac rehabilitation, number of people	235	407	45	0	0	401
Percentage of patients who had suffered ACS (ICD-10: I20.0; I21; I22; I24) and received rehabilitation care during the second stage of medical cardiac rehabilitation, %	2.2	3.8	0.4	0	0	5.4
– of these, the number of patients of working age, abs.	96	122	9	0	0	100
Number of patients who had suffered ACS (ICD-10: I20.0; I21; I22; I24) and received rehabilitation care at the third stage of medical cardiac rehabilitation, number of people	193	608	89	213	332	322
Proportion of patients who had ACS (ICD-10: I20.0; I21; I22; I24) and received rehabilitation care at the third stage of medical cardiac rehabilitation, %	1.8	5.7	0.9	2.6	4.0	4.3
– of these, the number of patients of working age, abs.	80	541	26	82	168	152

 

The number of patients with CHD in the Perm Krai increased slightly between 2018 and 2023—by approximately 4,000 people (from 76,870 to 80,867), which corresponds to an increase of 2 %. This indicates that the situation remains relatively stable. Despite the increase in the total number of patients with CHD, the number of those who are under dispensary observation is significantly lower: in 2023, only 65,322 patients were under observation, which is about 68 % of all CHD patients. This indicator is significantly lower than the values recommended by the Russian Ministry of Health, which indicates the need to improve the medical examination system to ensure proper monitoring of the health status of such patients. The number of ACS cases decreased from 10,552 in 2018 to 7,436 in 2023, which is a positive trend. This may be due to improvements in the prevention of cardiovascular diseases. The rate of follow-up care for patients with ACS rose to 79.9 % in 2023, reflecting the efforts of healthcare facilities to monitor the condition of these patients after acute episodes of the disease.

Thus, despite the overall stability of the situation with CHD, there is a serious problem with insufficient coverage of dispensary observation by nosology. At the same time, there has been an improvement in relation to patients with ACS, where the number of cases and the level of dispensary observation show positive changes.

The results of the audit regarding the organization of rehabilitation measures in the Perm Krai are also of interest. The proportion of patients who underwent the first stage of rehabilitation after ACS decreased threefold, from 87.4 % in 2018 to 36.1 % in 2023. This trend indicates possible problems with the availability or quality of first-stage cardiac rehabilitation services. Despite the decline in the indicator for the first stage, there has been an increase in the proportion of patients receiving rehabilitation services in the second and third stages. In the second stage (in specialized departments), this indicator increased from 2.2 % to 5.4 %, and in the third stage, from 1.8 % to 4.3 %. The increase was particularly noticeable in the cohortof patients of working age, where their number increased twofold. These changes may indicate a shift in resources and efforts toward later stages of rehabilitation, possibly due to improvements in the organization of specialized care. However, the decline in coverage at the first stage of rehabilitation requires further analysis, as it plays an important role in restoring the patient's health immediately after the acute phase of the disease.

According to federal statistical observation forms No. 12 (FSOF No. 12), in 2023, there was low coverage of dispensary observation of newly identified patients with CVD (67.8 % vs. 73.1% in the Russian Federation), CHD (68.0 % vs. 78.8 % in the Russian Federation), patients after MI (84.3 % vs. 91.0 % in the Russian Federation), and ACVA (83.4 % vs. 91.0 % in the Russian Federation), which requires additional analysis, including an assessment of the quality of visit registration in medical information systems (MIS) (Table 2). It is necessary to check whether all cases of disease have been recorded in the MIS. It is possible that some patients have not been properly recorded or that data on them is missing. It is important to ensure that patient information is updated in a timely manner, as outdated data may distort the true picture presented in the reports. It is necessary to assess how regularly each patient undergoes medical examinations. There may be delays or missed appointments, which reduces the effectiveness of monitoring. It is necessary to identify the reasons why patients may not attend clinic check-ups. This may be due to a lack of information, inconvenient schedules, or insufficient motivation on the part of doctors or patients. In addition, it is advisable to assess the accessibility of medical facilities for patients, especially in remote areas. If the nearest medical facility is difficult to reach, this may reduce the frequency of visits. A separate audit is required with regard to the number of specialists capable of conducting medical examinations. Staff shortages can also lead to delays in patient care.

 

Table 2. Indicators of dispensary observation coverage for patients with CVD in the Perm Krai in 2023 according to data from FFSO No. 12 and monitoring of the reduction in mortality from CHD, CVB FSHI CRIHCI of the Ministry of Health of Russia

Nosology	Source of data	Coverage by dispensary observation, Perm Krai, 2023, %	Coverage of dispensary observation, Russian Federation, 2023, %
CVD (total incidence)	FFSO No. 12	81.1	77.5
CVD (newly diagnosed)	FFSO No. 12	67.8	73.1
AH (total incidence)	FFSO No. 12	92.4	86.9
AH (newly diagnosed)	FFSO No. 12	87.6	83.9
CHD (total incidence)	FFSO No. 12	88.8	85.1
CHD (newly diagnosed)	FFSO No. 12	68.0	78.8
CHD	Monitoring by the Ministry of Health of the Russian Federation	84.0	79.9
MI	FFSO No. 12	84.3	91.6
ACS	Monitoring by the Ministry of Health of the Russian Federation	83.6	80.2
ACVA	FFSO No. 12	83.4	90.1
ACVA	Monitoring by the Ministry of Health of the Russian Federation	85.8	60.0
CVD	FFSO No. 12	55.3	61.4
CVD (first identified)	FFSO No. 12	67.0	72.5
CVD	Monitoring by the Ministry of Health of the Russian Federation	83.4	59.9

 

In the Perm Krai, advanced consultation rooms have been set up at the Clinical Cardiology Dispensary to provide specialized medical care to patients at high risk of developing cardiovascular diseases. In these rooms, doctors provide consultations in the following areas anticoagulant therapy – treatment of patients with blood clotting disorders, including prevention of thrombosis and thromboembolism; anti-thrombosis therapy – prescription of drugs that reduce platelet aggregation, which helps prevent blood clots; lipid metabolism disorders – diagnosis and correction of dyslipidemia; heart failure – assessment of the patient's condition, selection of treatment and monitoring of disease progression, as well as pulmonary hypertension – diagnosis and treatment of elevated pressure in the pulmonary artery. These rooms are designed to improve patients' quality of life and reduce the risk of complications associated with cardiovascular disease. Referrals to these highly specialized rooms are made by a cardiologist or local general practitioner.

A remote monitoring (RM) project for patients at high risk of cardiovascular disease was launched in the Perm Krai in 2021 [4; 5]. Its goal is to provide timely assistance to patients in the high-risk group, especially those who have had a myocardial infarction, ACVA, or who have chronic heart failure or complications after COVID-19. The RM program in the Perm Krai consists of telephone calls made every 3–4 weeks by a medical operator to patients enrolled in the RM program. Based on the results of these calls, a conclusion is formed about the patient's condition and the need for an in-person consultation with the attending physician, referrals for additional examinations, and changes in treatment tactics is determined [5].

Issues of modern therapy and the organization of medical institutions are actively discussed at various educational events, including those organized by the Clinical Cardiology Dispensary in conjunction with PSMU. These events help doctors exchange experiences, learn about new treatment methods, and discuss topical issues such as dispensary observation of patients in polyclinics. This is an important part of continuing medical education, which contributes to improving the quality of medical care.

Conclusions

1. In view of the identified features of the organization and conduct of dispensary observation and rehabilitation of patients with ACS and CVD in the Perm Krai, it seems appropriate to include several key measures in the activities of medical organizations:
2. Organization of monthly analysis of the quality of dispensary observation in the region's MOs, with an assessment of its effectiveness for patients with CVD. Particular attention should be paid to institutions with a high frequency of emergency calls and hospitalizations due to exacerbation of cardiovascular pathology.
3. If deficiencies are identified in dispensary observation, additional visits by specialists from leading regional institutions should be organized to provide consultation and training to local staff.
4. Conducting monthly analyses of continuity between inpatient and outpatient stages of medical care, including ensuring timely registration for dispensary care and inclusion of patients in subsidized drug provision programs.
5. Conducting additional activities aimed at raising public awareness of the symptoms of acute cardiovascular conditions.
6. Conduct monthly monitoring of the dynamics of the indicator for hospitalization within the first two hours of the onset of symptoms, especially in areas where the population delays seeking medical care.
7. Strengthening measures to ensure compliance with all stages of rehabilitation, including outpatient care, to ensure a comprehensive approach to restoring patients' health.

About the authors

N. A. Koryagina

Ye.A. Vagner Perm State Medical University

Author for correspondence.
Email: nina11-85@mail.ru
ORCID iD: 0000-0001-5980-2364

DSc (Medicine), Associate Professor, Professor of the Department of Outpatient Therapy, Chief Non-Staff Therapist of the Ministry of Health of Perm Krai

Russian Federation, Perm

G. N. Spasenkov

Cardiology Clinic

Email: nina11-85@mail.ru
ORCID iD: 0000-0003-1085-5814

PhD (Medicine), Cardiologist, Chief Non-Staff Cardiologist of the Ministry of Health of Perm Krai

Russian Federation, Perm

N. S. Karpunina

Ye.A. Vagner Perm State Medical University

Email: nina11-85@mail.ru
ORCID iD: 0000-0003-3127-1797

DSc (Medicine), Associate Professor, Professor of the Department of Hospital Therapy and Cardiology

Russian Federation, Perm

O. B. Melekhova

Ye.A. Vagner Perm State Medical University

Email: nina11-85@mail.ru
ORCID iD: 0009-0004-9151-939X

Assistant of the Department of Outpatient Therapy

Russian Federation, Perm

References

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