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Clinical and cost effectiveness of cardiac rehabilitation presented to the group developing the NICE guideline: Secondary prevention in primary and secondary care for patients following a myocardial infarction. Angela Cooper PhD Email: acooper@rcgp.org.uk.

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angela cooper phd email acooper@rcgp org uk

Clinical and cost effectiveness of cardiac rehabilitation presented to the group developing the NICE guideline: Secondary prevention in primary and secondary care for patients following a myocardial infarction

Angela Cooper PhD

Email: acooper@rcgp.org.uk

national collaborating centre for primary care
National Collaborating Centre for Primary Care
  • Based at the Royal College of General Practitioners
  • Commissioned by National Institute for Health and Clinical Excellence (NICE) to develop clinical guidelines
  • Centre has the experience and expertise to develop clinical guidelines along with a group of relevant health care professionals and patient representatives
slide3

Post MI Guideline Timetable

  • Initiation and scoping (6 months)
  • Development, reviewing evidence, drafting recommendations, writing document (18 months)
    • Cardiac rehabilitation
    • Lifestyle
    • Drug therapy
  • Validation including a public consultation
cardiac rehabilitation
Cardiac rehabilitation
  • Originally focused on exercise training
  • More recent programmes emphasise overall risk factor and behavioural modification

Post MI Guideline

  • Develop key clinical questions
  • Over 30 000 papers were retrieved from searching scientific databases
  • 1290 studies were ordered and assessed
  • 195 studies were critically appraised and presented to the guideline development group
comprehensive cardiac rehabilitation
Comprehensive cardiac rehabilitation
  • Comprehensive cardiac rehabilitation in patients after MI reduces all-cause and cardiovascular mortality rates provided it includes an exercise component
    • Based on 3 systematic reviews: Brown et al 2003, Joliffe et al 2003, Clark et al 2005
cost effectiveness of comprehensive cardiac rehabilitation
Cost effectiveness of comprehensive cardiac rehabilitation
  • Cardiac rehabilitation in patients after MI compared no cardiac rehabilitation is cost effective
    • Based on economic model requested by GDG (Leo Nherera, using clinical effectiveness from 3 recent systematic reviews)
  • The estimated incremental cost effectiveness ratio was about £8000 per quality adjusted life year
  • This ratio is generally regarded as value for money for the NHS
safety in the exercise component of comprehensive cardiac rehabilitation
Safety in the exercise component of comprehensive cardiac rehabilitation
  • There is no evidence that stable patients are harmed by the exercise component of cardiac rehabilitation
  • Exercise training does not appear to endanger stable patients with left ventricular dysfunction
    • Otsuka et al 2003: 3 months of exercise training,no incidence of heart failure or cardiac death
    • Giannuzzi et al 1997: 6 months exercise training, improvement in unfavourable remodelling response
    • Dubach et al 1997: 2 months exercise training, increased exercise capacity
  • Limited evidence on safety of exercise component of cardiac rehabilitation in older people (studies recruit patients with mean age 55 years)
psychological and social support
Psychological and social support
  • Psychological intervention as part of a cardiac rehabilitation programme (e.g. risk factor counselling / theory behaviour change) reduces the risk of depression, anxiety and non-fatal MI
    • Rees et al 2004 systematic review
  • Social isolation or lack of a social support network associated with increased mortality and morbidity
    • Mookadam et al 2004 systematic review
  • There is limited evidence (based on three studies of married couples) that involving spouses may have beneficial effects on family anxiety
    • Van Horn et al 2002 systematic review
education and information provision
Education and information provision
  • Education and stress management programmes reduce cardiac mortality and MI recurrence in post MI patients
    • Dusseldorp et al 1999 systematic review
  • Education and stress management programmes may aid in return to work, and reduce anxiety at 3 months following an MI
    • Petrie et al 2002 randomised controlled trial
    • Mayou et al 2002 randomised controlled trial
patient engagement in cardiac rehabilitation
Patient engagement in cardiac rehabilitation
  • Uptake improved by motivational communication (e.g. written letters / pamphlets / conversation with a healthcare professional)
  • Adherence (e.g. formal patient commitment / family involvement / education / aids to self-management / psychological interventions)
    • few studies of sufficient quality to make specific recommendations
    • most promising approach: use of self-management techniques based around individualised assessment, problem-solving, goal-setting and follow up
      • Based on Beswick et al 2004 Health Technology Assessment
groups requiring specific consideration
Groups requiring specific consideration
  • Ethnic minority groups
  • Patients living in socially deprived areas
  • Patients living in rural areas
  • Women
  • Older patients
    • No randomised controlled trial evidence found of interventions to improve either uptake or adherence to cardiac rehabilitation
cost effectiveness of methods for increasing uptake
Cost effectiveness of methods for increasing uptake
  • The use of letters, or telephone calls plus a visit from a healthcare professional to improve uptake of cardiac rehabilitation was found to be cost effective
    • Based on economic model requested by GDG (Leo Nherera, using effectiveness data from Beswick at al 2004)
  • Letters: estimated incremental cost effectiveness ratio was about £8000 compared with usual care per quality adjusted life year
  • Telephone calls plus health professional visit: ratio was about £8500 compared with letters
  • These ratios are considered value for money for the NHS
summary of evidence
Summary of evidence
  • Comprehensive cardiac rehabilitation has a significant positive effect on survival in post MI patients and is cost effective
  • Methods to improve uptake are cost effective
  • Further studies in patients requiring special consideration and also in adherence to cardiac rehabilitation programmes are warranted
slide14
Key provisional recommendations from the Post MI guideline stakeholder consultation draft: August 2006
  • All patients (regardless of their age) should be given advice about and offered a cardiac rehabilitation programme with an exercise component
  • Comprehensive cardiac rehabilitation programmes should include health education and stress management components
  • Reminders such as letters or telephone calls in combination with contact from a healthcare professional should be used to improve uptake of cardiac rehabilitation

Expected publication date: 23rd May 2007

the post mi guideline methods team

The post MI Guideline Methods Team

Clinical Advisor – Dr Jane Skinner

Chairman – Prof Gene Feder

SHSRF – Dr Angela Cooper

Health Economist – Leo Nherera

Information Scientist – Gill Ritchie

Guideline Lead – Nancy Turnbull

Project Manager – Meeta Kathoria

the post mi guideline development team

The post MI guideline development team

Patient representatives – David Thomson, John Walsh

BHF Cardiac specialist nurse – Anne White

Consultant cardiologist – Dr Adam Timmis

General Practitioners – Dr Keith MacDermott,

Dr Rubin Minhas

Pharmacist – Helen Williams

Physiotherapist – Helen Squires

Public health consultant – Dr Chris Packham

angela cooper phd email acooper@rcgp org uk1

Clinical and cost effectiveness of cardiac rehabilitation presented to the group developing the NICE guideline: Secondary prevention in primary and secondary care for patients following a myocardial infarction

Angela Cooper PhD

Email: acooper@rcgp.org.uk

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