ad beswick, k rees, i griebsch, fc taylor, m burke, rr ... · provision, uptake and cost of cardiac...

Provision, uptake and cost of cardiacrehabilitation programmes: improvingservices to under-represented groups

AD Beswick, K Rees, I Griebsch, FC Taylor, M Burke, RR West, J Victory, J Brown, RS Taylor and S Ebrahim

Health Technology Assessment 2004; Vol. 8: No. 41

HTAHealth Technology AssessmentNHS R&D HTA Programme

October 2004

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HTA

Provision, uptake and cost of cardiacrehabilitation programmes: improvingservices to under-represented groups

AD Beswick,1 K Rees,1 I Griebsch,2 FC Taylor,3

M Burke,1 RR West,4 J Victory,5 J Brown,2

RS Taylor6 and S Ebrahim1*

1 Department of Social Medicine, University of Bristol, UK2 MRC Health Services Research Collaboration, Department of Social

Medicine, University of Bristol, UK3 Bristol Heart Institute, University of Bristol, UK4 Wales Heart Research Institute, University of Wales College of Medicine,

Cardiff, UK5 United Bristol Healthcare NHS Trust, UK6 Department of Public Health and Epidemiology, University of

Birmingham, UK

* Corresponding author

Declared competing interests of authors: none

Published October 2004

This report should be referenced as follows:

Beswick AD, Rees K, Griebsch I, Taylor FC, Burke M, West RR, et al. Provision, uptakeand cost of cardiac rehabilitation programmes: improving services to under-representedgroups. Health Technol Assess 2004;8(41).

Health Technology Assessment is indexed in Index Medicus/MEDLINE and Excerpta Medica/EMBASE.

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G

Objectives: To estimate UK need for outpatientcardiac rehabilitation, current provision andidentification of patient groups not receiving services.To conduct a systematic review of literature onmethods to improve uptake and adherence to cardiacrehabilitation. To estimate cost implications ofincreasing uptake of cardiac rehabilitation.Data sources: Hospital Episode Statistics (England).Hospital Inpatient Systems (Northern Ireland). PatientsEpisode Database for Wales. British Association forCardiac Rehabilitation/British Heart Foundationsurveys. Cardiac rehabilitation centres. Patients fromgeneral hospitals. Electronic databases.Review methods: The study analysed hospitaldischarge statistics to ascertain the population need foroutpatient cardiac rehabilitation in the UK. Surveys ofcardiac rehabilitation programmes were conducted todetermine UK provision, uptake and audit activity, andto identify local interventions to improve uptake. Datawere also examined from a trial estimating eligibility forcardiac rehabilitation and non-attendance. A systematicreview of interventions to improve patient uptake,adherence and professional compliance in cardiacrehabilitation was conducted. Estimated costs ofimproving uptake were identified from national survey,systematic review and sampled cardiac rehabilitationprogrammes.Results: In England, Wales and Northern Ireland nearly146,000 patients discharged from hospital with primarydiagnosis of acute myocardial infarction, unstable anginaor following revascularisation were potentially eligiblefor cardiac rehabilitation. In England in 2000, 45–67%of these patients were referred, with 27–41%

attending outpatient cardiac rehabilitation. If alldischarge diagnoses of ischaemic heart disease wereconsidered, nearly 299,000 patients would bepotentially eligible and in England rates of attendanceand referral would be 22–33% and 13–20%respectively. Rates of referral and attendance weresimilar in Wales, but somewhat lower in NorthernIreland. It was found that referral and attendance ofolder people and women at cardiac rehabilitationtended to be low. It was also suggested that patientsfrom ethnic minorities and those with angina or heartfailure were less likely to be referred to or joinprogrammes. A wide range of local interventionssuggested awareness of the problem of uptake. In anNHS-funded randomised controlled trial, possiblyrepresenting more optimal protocol-led care, medicaland nursing staff identified 73–81% of patients withacute myocardial infarction as eligible for cardiacrehabilitation. Excluded patients tended to be olderwith more severe presentation of cardiac disease.Experiences of patients suggested that uptake may beimproved by addressing issues of motivation andrelevance of rehabilitation to future well-being, co-morbidities, site and time of programme, transport andcare for dependants. Systematic review of studiessupported the use of letters, pamphlets or home visitsto motivate patients and the use of trained lay visitors.Self-management techniques showed some value inpromoting adherence to lifestyle changes. Studiesexamining professional compliance found thatprofessional support for practice nurses may have valuein the coordination of postdischarge care. Averagecosts in 2001 of cardiac rehabilitation to the health


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Abstract

Provision, uptake and cost of cardiac rehabilitation programmes:improving services to under-represented groups

AD Beswick,1 K Rees,1 I Griebsch,2 FC Taylor,3 M Burke,1 RR West,4 J Victory,5

J Brown,2 RS Taylor6 and S Ebrahim1*

1 Department of Social Medicine, University of Bristol, UK2 MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol, UK3 Bristol Heart Institute, University of Bristol, UK4 Wales Heart Research Institute, University of Wales College of Medicine, Cardiff, UK5 United Bristol Healthcare NHS Trust, UK6 Department of Public Health and Epidemiology, University of Birmingham, UK* Corresponding author

service per patient completing a cardiac rehabilitationprogramme were about £350 (staff only) and £490(total). If services were modelled on an intermediatemultidisciplinary configuration with three to five keystaff, approximately 13% more patients could betreated with the same budget. Depending on staffingconfiguration an approximate 200–790% budgetincrease would be required to provide cardiacrehabilitation to all potentially eligible patients. Conclusions: Provision of outpatient cardiacrehabilitation in the UK is low and little is known aboutthe capacity of cardiac rehabilitation centres to increasethis provision. There is an uncoordinated approach toaudit data collection and few interventions aimed atimproving the situation have been formally evaluated.Motivational communications and trained lay volunteersmay improve uptake of cardiac rehabilitation, as mayself-management techniques. Experience of low-costinterventions and good practice exists withinrehabilitation centres, although cost information

frequently is not reported. Increased provision ofoutpatient cardiac rehabilitation will require extraresources. Further trials are required to compare thecost-effectiveness of comprehensive multidisciplinaryrehabilitation with simpler outpatient programmes, alsoresearch is needed into economic and patientpreference studies of the effects of different methodsof using increased funding for cardiac rehabilitation. Anevaluation of a range of interventions to promoteattendance in all patients and under-representedgroups would also be useful. The development ofstandards is suggested for audit methods and foreligibility criteria, as well as regular and comprehensivedata collection to estimate the need for and provisionof cardiac rehabilitation. Further areas for interventioncould be identified through qualitative studies, and theextension of low-cost interventions and good practicewithin rehabilitation centres. Regularly updatedsystematic reviews of relevant literature would also beuseful.

Abstract

iv


v

List of abbreviations .................................. vii

Executive summary .................................... ix

1 Background ................................................ 1Cardiac rehabilitation ................................ 1Effectiveness in patients with coronary heart disease ............................................... 1Effectiveness in specific patient groups ..... 2Uptake of cardiac rehabilitation ................ 2Under-representation in cardiac rehabilitation .............................................. 2Barriers to uptake and adherence ............. 4Economic aspects of cardiac rehabilitation .............................................. 5Conclusions ................................................ 6

2 Objectives .................................................. 7

3 Population need for cardiac rehabilitation in the UK .................................................... 9Objectives ................................................... 9Background ................................................ 9Methods ...................................................... 9Results ........................................................ 10Discussion ................................................... 11Conclusions ................................................ 12

4 Provision and uptake of cardiac rehabilitation in the UK: national survey of UK cardiac rehabilitation services ........ 13Objective ..................................................... 13Methods ...................................................... 13Results ........................................................ 13Conclusions ................................................ 15

5 Audit of cardiac rehabilitation in England:National Service Framework for CoronaryHeart Disease recommendations .............. 17Objective ..................................................... 17Background ................................................ 17Methods ...................................................... 17Results ........................................................ 17Discussion ................................................... 19Conclusions ................................................ 20

6 Uptake and adherence in a randomisedcontrolled trial of cardiac rehabilitation after myocardial infarction ........................ 23Objective ..................................................... 23

Introduction ............................................... 23Methods ...................................................... 23Results ........................................................ 23Discussion ................................................... 26Conclusions ................................................ 27

7 Systematic review of interventions to improve uptake, adherence and professional compliance with cardiacrehabilitation .............................................. 29Definitions .................................................. 29Objective ..................................................... 29Methods ...................................................... 29

8 Systematic review of interventions to improve uptake of cardiac rehabilitation .............................................. 31Background ................................................ 31Results ........................................................ 31Discussion ................................................... 34Conclusions ................................................ 38

9 Systematic review of interventions to improveadherence to cardiac rehabilitation .......... 39Background ................................................ 39Results ........................................................ 39Discussion ................................................... 45Conclusions ................................................ 48

10 Systematic review of interventions to improve professional compliance with cardiac rehabilitation ................................. 49Background ................................................ 49Results ........................................................ 49Discussion ................................................... 52Conclusions ................................................ 53

11 Health service costs of cardiac rehabilitation in the UK ............................. 55Objectives ................................................... 55Health service costs associated with cardiac rehabilitation ................................. 55The national budget attributable to cardiac rehabilitation ................................. 58Discussion ................................................... 60Conclusions ................................................ 63

12 Conclusions ................................................ 65What is the population need for cardiacrehabilitation? ............................................ 65

Contents

Contents

Who is not receiving cardiac rehabilitation? ............................................ 65What is the effectiveness of different methods of improving uptake and ofdifferential targeting of cardiac rehabilitation? ............................................ 66What is the potential budget impact of increasing uptake of cardiacrehabilitation using different uptakeinterventions? ............................................. 68

13 Key findings ................................................ 71Implications for healthcare ........................ 71

Acknowledgements .................................... 73

References .................................................. 75

Appendix 1 Need for cardiac rehabilitation in the UK ............................. 83

Appendix 2 Need for and estimated level of cardiac rehabilitation provision in the UK .................................................... 87

Appendix 3 British Association for CardiacRehabilitation additional postal questionnaire .............................................. 91

Appendix 4 Literature search strategies ..................................................... 95

Appendix 5 Inclusion/exclusion form ....... 97

Appendix 6 Data extraction form ............. 99

Appendix 7 Flow diagram of the systematicreview of interventions to improve uptake ofcardiac rehabilitation (QUOROM statementflow diagram) ............................................. 103

Appendix 8 Studies evaluating interventions to improve the uptake of cardiac rehabilitation .............................................. 105

Appendix 9 Studies excluded from the review of interventions to improve uptake of cardiac rehabilitation .............................................. 113

Appendix 10 Flow diagram of the systematicreview of interventions to improve adherenceto cardiac rehabilitation (QUOROM statement flow diagram) ............................ 115

Appendix 11 Studies evaluating interventionsto improve adherence to cardiac rehabilitation .............................................. 117

Appendix 12 Studies excluded from the review of methods to improve adherence tocardiac rehabilitation ................................. 129

Appendix 13 Flow diagram of the systematicreview of interventions to improve professional compliance with cardiacrehabilitation (QUOROM statement flowdiagram) ..................................................... 131

Appendix 14 Studies evaluating interventions to improve professionalcompliance with cardiac rehabilitation ...... 133

Appendix 15 Studies excluded from the review of interventions to improve professional compliance with cardiacrehabilitation .............................................. 139

Appendix 16 Estimates for unit costs fordifferent staff categories and grades .......... 141

Appendix 17 List of equipment ................ 143

Appendix 18 Staff input: average hours perweek ............................................................ 145

Appendix 19 Referral, uptake and completion rates for 30 randomly selected UK cardiac rehabilitation programmes in 2000 ....................................................... 149

Appendix 20 Average cost estimates for cardiac rehabilitation (detailed table) ........ 151

Health Technology Assessment reportspublished to date ....................................... 153

Health Technology Assessment Programme ................................................ 163

vi


vii


AMI acute myocardial infarction

BACR British Association for CardiacRehabilitation

BHF British Heart Foundation

CABG coronary artery bypass graft

CHD coronary heart disease

CI confidence interval

CR cardiac rehabilitation

HES Hospital Episode Statistics(England)

HF heart failure

HIS Hospital Inpatient Systems(Northern Ireland)

ICD-10 International Classification ofDiseases-10

IHD ischaemic heart disease

IQR interquartile range

MI myocardial infarction

NSF-CHD National Service Framework forCoronary Heart Disease

OR odds ratio

PEDW Patient Episode Database forWales

PTCA percutaneous transluminalcoronary angioplasty

QUOROM quality of reporting of meta-analyses

RCT randomised controlled trial

RR relative risk

SD standard deviation

UA unstable angina

VAT value added tax

List of abbreviations

All abbreviations that have been used in this report are listed here unless the abbreviation is well known (e.g. NHS), or it has been used only once, or it is a non-standard abbreviation used only in figures/tables/appendices in which case the abbreviation is defined in the figure legend or at the end of the table.


ix


BackgroundThe National Service Framework for CoronaryHeart Disease (NSF-CHD) identifies patients withacute myocardial infarction and following coronaryrevascularisation as eligible for outpatient cardiacrehabilitation. However, rehabilitation uptakeremains low, particularly in some specific patientgroups. While many barriers to patientparticipation have been described, theeffectiveness of interventions to improve uptakeand adherence has not been assessed by systematicreview. Furthermore, the cost implications ofinterventions to improve uptake and adherenceand of increasing overall provision to meet totalpopulation need have not been estimated.

Objectives� To estimate UK population need and update

estimates of cardiac rehabilitation provision.� To identify patient groups not receiving cardiac

rehabilitation.� To review effectiveness of methods to improve

uptake and adherence to cardiac rehabilitation.� To estimate cost implications of increasing

uptake of cardiac rehabilitation.

Methods� Analysis of hospital discharge statistics to

ascertain the population need for outpatientcardiac rehabilitation in the UK.

� Surveys of cardiac rehabilitation programmes todetermine UK provision, uptake and audit activity,and to identify local interventions to improveuptake. Estimation of eligibility for cardiacrehabilitation and non-attendance in a recent trial.

� Systematic review of interventions to improvepatient uptake, adherence and professionalcompliance in cardiac rehabilitation.

� Assessment of costs of improving uptakeidentified from national survey, systematic reviewand sampled cardiac rehabilitation programmes.

ResultsPopulation need and provisionIn England, Wales and Northern Ireland nearly

146,000 patients discharged from hospital with aprimary diagnosis of acute myocardial infarction,unstable angina or following revascularisation werepotentially eligible for cardiac rehabilitation. InEngland in 2000, 45–67% of these patients werereferred, with 27–41% attending outpatient cardiacrehabilitation. If all discharge diagnoses of ischaemicheart disease (including angina pectoris and heartfailure) were considered, nearly 299,000 patientswould be potentially eligible, with rates of referraland attendance of 22–33% and 13–20%, respectively.Rates of referral and attendance were similar inWales, but somewhat lower in Northern Ireland.

Patient uptakeReferral and attendance of older people andwomen at cardiac rehabilitation tended to be low.There was a suggestion that patients from ethnicminorities and those with angina or heart failurewere less likely to be referred to or joinprogrammes. A wide range of local interventionssuggested awareness of the problem of uptake.

The survey of cardiac rehabilitation centres inEngland identified an uncoordinated approach toaudit, with variations in methods and contentdespite guidelines and the NSF requirements.

In an NHS-funded, multicentre, randomisedcontrolled trial, possibly representing moreoptimal protocol-led care, medical and nursingstaff identified 73–81% of patients with acutemyocardial infarction as eligible for cardiacrehabilitation. Excluded patients tended to beolder with more severe presentation of cardiacdisease. Experiences of patients suggested thatuptake may be improved by addressing issues ofmotivation and relevance of rehabilitation tofuture well-being, co-morbidities, site and time ofprogramme, transport and care for dependants.

Systematic reviewA comprehensive search strategy identified studiesrelating to uptake, adherence or professionalcompliance with cardiac rehabilitation. Of 3261references identified, 957 were acquired aspotentially relevant. Reports were frequently notpublished in easily accessible form. The majorityof studies were small, of short duration and not ofhigh quality. Consequently, none of the findings

Executive summary

x

can be considered definitive. Few studies reportedcost implications.

Eight studies (three randomised) evaluatedmethods to improve patient uptake of cardiacrehabilitation. These supported the use of letters,pamphlets or home visits to motivate patients.Some encouragement was found for the use oftrained lay visitors. Fourteen studies (sevenrandomised) evaluated methods to improveoverall patient attendance or maintenance oflifestyle changes associated with cardiacrehabilitation. Self-management techniquesshowed some value in promoting adherence tolifestyle changes. Six studies (two randomised)evaluated methods to improve patient uptake andadherence to cardiac rehabilitation by improvingprofessional compliance with guidelines and goodpractice. Although no effective interventionsspecifically aimed at improving professionalcompliance were found, professional support forpractice nurses may have value in the coordinationof postdischarge care.

Healthcare costsAverage costs in 2001 of cardiac rehabilitation tothe health service per patient completing a cardiacrehabilitation programme were about £350 (staffonly) and £490 (total). It is estimated thatoutpatient cardiac rehabilitation represented anNHS cost of £15–24 million in the UK. Variationin cost per patient across centres was partlyexplained by the duration of rehabilitation andstaff-to-patient ratio. If services were modelled onan intermediate multidisciplinary configurationwith three to five key staff, approximately 13%more patients could be treated with the samebudget. If the most modest services were provided,40% more patients could be treated. Dependingon staffing configuration an approximate200–790% budget increase would be required toprovide cardiac rehabilitation to all potentiallyeligible patients.

ConclusionsImplications for healthcare� Provision of outpatient cardiac rehabilitation in

the UK is low, well below the NSF-CHD goal of85% of patients with acute myocardial infarctionand following revascularisation being offeredoutpatient cardiac rehabilitation.

� Information on referral to and uptake of cardiacrehabilitation is incomplete, with widely varyingestimates of provision, particularly in under-represented groups. Little is known about the

capacity of cardiac rehabilitation centres toincrease provision.

� There is an uncoordinated approach to auditdata collection.

� Reasons reported by patients for non-attendance are amenable to intervention, butfew interventions have been formally evaluated.

� Many interventions aimed at improving patientuptake, adherence and professional compliancewith guidelines and good practice have beenproposed, but few have been formallyevaluated.

� Motivational communications and trained layvolunteers may improve uptake of cardiacrehabilitation.

� Self-management techniques may help topromote lifestyle change associated with cardiacrehabilitation.

� Information on costs of interventions isfrequently not reported.

� Experience of low-cost interventions and goodpractice exists within rehabilitation centres.

� Increased provision of outpatient cardiacrehabilitation will require extra resources.

Recommendations for researchand development� Trials comparing the cost-effectiveness of

comprehensive multidisciplinary rehabilitationwith simpler outpatient programmes.

� Economic and patient preference studies of theeffects of different methods of using increasedfunding for cardiac rehabilitation, and evaluationsof the impact of any increased funding.

� Evaluation of a range of interventions(including self-management techniques,motivational communication and the use oftrained lay volunteers) to promote attendancein all patients and under-represented groups.

� Development of standardised audit methods inthe context of modern records systems,appropriate training for dedicated staff anddialogue between service contributors.Standardisation of criteria for patient eligibility,regular and comprehensive data collection toestimate the need for and provision of cardiacrehabilitation.

� Identification of further areas for interventionthrough qualitative studies.

� Extension of low-cost interventions and goodpractice within rehabilitation centres.

� Regular updated systematic review of literaturerelating to uptake and adherence to cardiacrehabilitation to include ‘grey’ literature andnon-UK studies.

Executive summary

Cardiac rehabilitationComprehensive cardiac rehabilitation offerspatients with coronary heart disease a long-termprogramme involving medical evaluation,‘prescribed’ exercise, cardiac risk factormodification, education and counselling.1 Inpartnership with a multidisciplinary team ofhealth professionals, patients with cardiac diseaseare encouraged and supported to achieve andmaintain optimal physical and psychosocialhealth.2

In the UK cardiac rehabilitation usually comprisesfour phases3 in which the themes of exercise,education, psychological support and counsellingare addressed to a level appropriate to the stage ofrecovery. Throughout, consideration is given tothe processes of explanation and understanding,4

and the overall aim of long-term maintenance of ahealthy lifestyle.

The first phase takes the form of counselling witha simple programme of education andpsychological support while in hospital.5 Physical,psychological and social needs for cardiacrehabilitation are assessed and advice is given oneveryday activities with encouragement to takelight exercise in the first few weeks at home, thesecond phase of rehabilitation. Home visiting andtelephone contact, and the use of educationalmaterials or a supervised self-help programme,provide support during this period. The thirdphase of rehabilitation is delivered in anoutpatient setting by appropriate healthprofessionals and lasts typically for 6–8 weeks. Keyprogramme elements are supervised exercise,education on secondary prevention and risk factormodification, and psychological approaches torecovery. Maintenance of healthy behaviours aftercompletion of the outpatient programme is thefourth phase of cardiac rehabilitation. Continuedexercise and adherence with lifestyle changes maybe mediated through a cardiac support group.

Effectiveness in patients withcoronary heart diseaseThe effectiveness of cardiac rehabilitation has

been the subject of several randomised trials andreviews.6–9 Most recently, a Cochrane systematicreview concluded that exercise-based cardiacrehabilitation is effective in reducing cardiacdeaths, cardiovascular morbidity and primary riskfactors in patients who have had myocardialinfarction.10 An earlier overview of the evidenceconducted by the NHS Centre for Reviews andDissemination stated that a combination ofexercise, psychological and educationalinterventions is the most effective form of cardiacrehabilitation,11 but the efficacy of combinationsand durations of different components of therehabilitation package remains uncertain. InEngland, the National Service Framework forCoronary Heart Disease (NSF-CHD) concludedthat there is scope for improving services so thatall those in need are offered rehabilitation.12

Evidence for the effectiveness of cardiacrehabilitation mainly derives from studies ofpatients with myocardial infarction and there areinsufficient data to stratify systematic reviews byindication.10 However, the inclusion in reviewedtrials of patients who have undergonerevascularisation, that is, coronary artery bypassgraft (CABG) or percutaneous transluminalcoronary angioplasty (PTCA), or who have hadangina pectoris or coronary artery disease definedby angiography suggests the possibility of benefitfor these groups. Furthermore, while there is noconclusive evidence that cardiac rehabilitationreduces mortality in patients with heart failure, arecent systematic review looking specifically atexercise interventions found physiological benefitsand positive effects on quality of life in selectedsubgroups.13

Guidelines recommend that outpatient cardiacrehabilitation should be available for patientsfollowing myocardial infarction, PTCA and CABG,and for patients with angina, heart failure14 andarrhythmia.15,16 The Fifth Report on the Provisionof Services for Patients with Coronary HeartDisease states that in the UK patients must haveaccess to rehabilitation when required, forexample after a heart attack, cardiac surgery andintervention.17 In England the NSF-CHDidentifies patients who have survived acutemyocardial infarction and those who have


1


Chapter 1

Background

undergone CABG or PTCA as priorities forcardiac rehabilitation.12 When high-quality-cardiacrehabilitation is available to these patients theNSF-CHD recommends that services should beextended to patients with angina and heart failure.In Wales, cardiac rehabilitation should be providedfor all those who have had an episode of acutecoronary syndrome, some of whom will haveundergone a revascularisation procedure.18 TheCanadian Association for Cardiac Rehabilitationstates that cardiac rehabilitation should beconsidered standard, usual care for virtually allpatients with documented cardiovascular disease.19

Effectiveness in specific patientgroupsEvidence for the effectiveness of cardiacrehabilitation in older and female patients islimited, as participants in trials tend to be youngerand predominantly male. In the most recentsystematic review the mean age of patients inexercise only studies was 53 years (range of means50–70 years) and in trials of comprehensivecardiac rehabilitation 56 years (range of means47–63 years).10 Women comprised 4% of patientsin exercise-only and 11% of patients incomprehensive cardiac rehabilitation trials. Trialsshow a bias towards the inclusion of men and mostexcluded older people. However, systematicreviews provide no evidence to suggest that elderlyor female patients benefit less than younger ormale patients.10 Indeed, it is possible that thepatients who would benefit most from cardiacrehabilitation are those excluded from trials on thegrounds of age, gender or co-morbidity.20

In elderly patients the goals of cardiacrehabilitation may differ from those of youngerpatients, and include the preservation of mobility,self-sufficiency and mental function.21 Cardiacrehabilitation may represent an opportunity toprovide effective healthcare and achieve a highquality of life for older patients.22 Similarly, thefrequently lower level of fitness observed inwomen at the time of hospitalisation suggests agreater potential for health improvement withcardiac rehabilitation.23,24

In trials of cardiac rehabilitation the ethnicbackground of patients is seldom reported,10 but itis likely that trial participants are mainly whiteCaucasian. There is neither evidence nor amechanism to suggest lack of benefit in ethnicminority groups.11

Thus, evidence from randomised controlled trials(RCTs), as demonstrated in Figure 1, supports theeffectiveness of cardiac rehabilitation in a range ofcardiac diagnoses including post-myocardialinfarction, post-PTCA, post-CABG, anginapectoris and heart failure. To date, althoughpatients with different cardiac conditions, andfemale, elderly and non-white Caucasian ethnicgroups, have been poorly represented in trials ofcardiac rehabilitation there is no evidence tosuggest that outcomes are less favourable.

Uptake of cardiac rehabilitationAlthough it is considered effective in quickeningrecovery and improving prognosis, not all patientsparticipate in a cardiac rehabilitation programme.Several recent UK surveys have reported theuptake of cardiac rehabilitation by patients with adischarge diagnosis of coronary heart disease.25–29

These are summarised in Table 1.

Surveys in the UK show low levels of patientparticipation (14–43% after myocardial infarction)with similarly low attendance reported inAustralia,30 France,31 New Zealand32 and theUSA.33–35 Low patient participation is aconsequence of low levels of provision, referraland invitation, and of poor uptake by patients.

Under-representation in cardiacrehabilitationPatients participating in cardiac rehabilitationprogrammes have tended to be male, middle-agedand diagnosed with uncomplicated myocardialinfarction.36 Those who do not participate in aprogramme often have greater degrees offunctional impairment and are the patients mostin need of and most likely to benefit fromrehabilitation.20

Variation in referral rates for patients withdifferent cardiac diagnoses reflects the traditionalindication for cardiac rehabilitation services ofmyocardial infarction and CABG.37 CABG patientstend to be younger than those with myocardialinfarction and this may explain some of theincreased rehabilitation uptake seen after CABG(see Table 1).26 Patients admitted for PTCA are lesslikely to be invited or participate, probably as aconsequence of the short hospital stay and thelimited opportunities for recruitment. Also, theprocedure is less invasive and painful than CABG,with a quicker recovery and return to work and

Background

2

normal activities.38,39 Heart failure patients areless likely to be referred for cardiac rehabilitationthan other cardiac patients40 and the complexityof the medical condition is identified as a barrierto physician referral.41 In the UK few programmesrecruit heart failure patients, possibly reflectingthe perceived need for further evaluation ofeffectiveness and safety in this patient group.42 InEngland, provision for both heart failure andangina may be limited by the priorities identifiedin the NSF-CHD: “once Trusts have an effectivesystem recruiting people who have survived amyocardial infarction or who have undergone

coronary revascularisation to high quality cardiacrehabilitation, they should extend theirrehabilitation services to people admitted tohospital with other manifestations of coronaryheart disease, e.g. angina and heart failure.”12

Patients with chronic non-cardiac medicaldisorders may be excluded from cardiacrehabilitation.43 Medical reasons for non-invitationinclude impaired mobility, more severe angina andperipheral arterial disease,29 chronic obstructivepulmonary disease and asthma,39 arthritis andback problems,44 and alcohol addiction.45


3


Review: Exercise-based rehabilitation for coronary heart diseaseComparison: 02 Exercise plus other rehabilitation versus usual care Outcome: 04 Pooled mortality, non-fatal MI, CABG, PTCA

Treatment Control Peto OR Weight Peto ORor subcatogoryStudy

n/N n/N 95% CI % 95% CI

Engblom 29/119 35/109 6.37 0.68 (0.38 to 1.22) WHO Balatonfured 16/80 9/80 2.93 1.93 (0.83 to 4.53) WHO Brussels 25/85 24/81 4.79 0.99 (0.51 to 1.92) WHO Bucharest 16/65 23/64 3.78 0.59 (0.28 to 1.24) WHO Budapest 38/101 29/99 6.18 1.45 (0.81 to 2.61) WHO Dessau 4/29 7/25 1.23 0.42 (0.11 to 1.58) WHO Erfut 13/63 15/56 2.97 0.71 (0.31 to 1.66) WHO Ghent 19/84 12/84 3.51 1.73 (0.80 to 3.77) WHO Helsinki 41/188 56/187 9.95 0.65 (0.41 to 1.04) WHO Kaunas 19/66 17/49 3.37 0.76 (0.34 to 1.68) WHO Prague 15/59 20/53 3.34 0.57 (0.26 to 1.26) WHO Rome 8/34 6/29 1.52 1.18 (0.36 to 3.83) WHO Tel Aviv 14/63 8/51 2.44 1.52 (0.60 to 3.85) WHO Warsaw 6/39 8/40 1.61 0.73 (0.23 to 2.31) Sivarajan 82 10/86 10/84 2.45 0.97 (0.38 to 2.47) Bengtsson 83 12/81 10/90 2.65 1.39 (0.57 to 3.40) Fridlund 91 26/87 39/91 5.73 0.57 (0.31 to 1.05) Oldridge 91 3/99 4/102 0.94 0.77 (0.17 to 3.46) PRECOR 6/60 11/61 2.03 0.52 (0.19 to 1.44) Bertie 92 1/57 4/53 0.66 0.27 (0.04 to 1.59) Schuler/Niebauer 20/56 25/57 3.77 0.71 (0.34 to 1.51) Heller 93 46/213 54/237 10.73 0.93 (0.60 to 1.46) Fletcher 94 3/41 4/47 0.90 0.85 (0.18 to 3.97) SCRIP 26/145 44/155 7.42 0.56 (0.33 to 0.95) Taylor 97 13/293 10/292 3.06 1.31 (0.57 to 3.01) Carlsson 98 CABG 0/33 0/34 Not estimable Carlsson 98 AMI 2/85 2/83 0.54 0.98 (0.14 to 7.05) Lifestyle Heart 14/53 24/40 3.07 0.25 (0.11 to 0.58) Bell 99 8/102 8/102 2.05 1.00 (0.36 to 2.77)

Total (95% CI) 2566 2535 100.00 0.81 (0.70 to 0.93)Total events: 453 (treatment), 518 (control)Test for heterogeneity: χ2 = 34.08, df = 27 (p = 0.16), I2 = 20.8%Test for overall effect: z = 2.88 (p = 0.004)

0.1 0.2 0.5 1 2 5 10

Favours treatment Favours control

FIGURE 1 RCTs of the effects of cardiac rehabilitation. Source: Jollife et al., 200210 with permission of The Cochrane Library. CI, confidence interval; MI, myocardial infarction; OR, odds ratios; WHO, World Health Organization.

Rehospitalisation, health deterioration andplacement in a nursing home are also associatedwith reduced participation in cardiacrehabilitation.46 Patients with communicationdifficulties including short-term memory loss andconfusion, poor cognitive functioning orneurological impairment may be less likely toparticipate in cardiac rehabilitation,39,46–48 and agreater dropout rate has been observed in patientswith symptoms of depression.49

Older patients may not receive the same amountof advice from physicians on cardiac risk reductionas younger patients.46 Invitation to cardiacrehabilitation is often lower in olderpatients.3,29,32,33,39,41,43,46,49–52 In a US survey olderpatients expressed a preference for home-basedprogrammes, whereas younger patients preferredcomprehensive clinic-based programmes.53

Women tend to be under-represented in cardiacrehabilitation.20,32,33,43,54 Referral rates may belower,33,43 possibly reflecting the increased age ofwomen presenting with cardiovascular disease55

and the presence of co-morbid conditions.20

Women may be reluctant to participate in formalcardiac rehabilitation56 and perceived as lessmotivated to attend structured programmes withstrenuous exercise.23 However, rehabilitationprofessionals may seem less helpful and lessencouraging in promoting cardiac rehabilitation

for women.57 Invitation to a predominantly maleexercise group may also serve to discourageparticipation by women.57

Participation rates of patients living in areas of highsocial deprivation are low, probably reflectingreduced uptake rather than referral.27,29,58,59

Patients with no paid employment may also be lesslikely to attend a cardiac rehabilitation programme.59

In a survey of Canadian cardiac rehabilitationprogrammes participation by non-English-speaking patients was seen to be considerablylower than by English-speaking patients.39 Nosimilar surveys have been published in the UK,but a retrospective hospital audit found lowattendance at cardiac rehabilitation amongpatients of South Asian origin.60 This wasattributed to poor access and inadequate use ofinterpreting services by patients and staff, and lackof translated written information.

Barriers to uptake and adherenceCardiac rehabilitation should be accessible andacceptable to patients. A balance must be achievedbetween a programme of sufficient intensity andduration to be effective, and the tendency of along programme to encourage dependence insome and dropout in others.61 Many patients

Background

4

TABLE 1 Uptake of cardiac rehabilitation in recent UK surveys

Author Year of Region Study design Total no. of Participation as survey eligible patients percentage of

eligible patients

Evans et al., 200225 2000 UK CR programme 208,080 total 17% MIsurvey compared (calculated from 44% CABGwith BHF statistics percentages) 6% PTCA

Bethell et al., 200126 1997 UK CR programme 150,000 total 14–23% MIsurvey compared 33–56% CABGwith BHF statistics 6–10% PTCA

Melville et al., 199927 1996 Nottingham CR enrolment lists 261 43% MIcompared with hospital discharge

Campbell et al., 199628 1994 Scotland CR programme 29,294 (calculated 17% CHDsurvey compared from 4980 = with CHD survival 17% of total)

Pell et al., 199629 1994 Glasgow CR department 887 21% MIlists compared (12% completed)with hospital discharge

BHF, British Heart Foundation; CHD, coronary heart disease; CR, cardiac rehabilitation.

make recommended lifestyle changes, but othersmake no change or find it difficult to maintainnew behaviours.62 The initial improvements inexercise tolerance and psychosocial well-beingobserved in some trials are not evident over thelonger term and this has been attributed toreductions in compliance.63 Patients and providershave identified numerous possible reasons for lowlevels of uptake, adherence and professionalcompliance with cardiac rehabilitation.64

Some patients show a lack of interest and arereluctant to change their lifestyle.14,41,46,59,65,66

Affective reactions to disease can lead tomaladaptive responses and fear.44,66,67 The patientmay not perceive that they will benefit fromparticipating in a programme or may receivecontradictory advice from other sources.41,51,68,69

Conversely, after a short period of rehabilitationpatients may be satisfied and choose to continueindependently.70 Patients may dislike classes or thehospital setting.34,51

Patterns of personal or family living can influenceparticipation in cardiac rehabilitation.71

Conflicting work or domestic commitments andtime conflicts are associated with reducedattendance at cardiac rehabilitation.24,51,66,70 Lackof family support may be a barrier to uptake ofcardiac rehabilitation services.44,66

In the USA, reimbursement issues and cost ofrehabilitation services limit attendance at cardiacrehabilitation.14,34 Patients with insurancecoverage for cardiac rehabilitation are more likelyto be referred and programme directors identifyfinancial issues as the major barrier forrehabilitation uptake.37 Fee-for-service patients aremore likely to receive cardiac rehabilitation thanhealth maintenance organisation patients.72 Arequirement for continuous ECG monitoringduring exercise sessions, physician evaluation oftraces and exercise prescription also limitsrehabilitation provision.73

Cardiologists may be more likely to refer patientsto cardiac rehabilitation than primary carephysicians.14,29,50,66 Differing rates of referral mayreflect professional scepticism or a poorknowledge base about the effectiveness of cardiacrehabilitation39,46,62 and it is possible thatphysicians recommend rehabilitation to youngerpatients or those expected to comply.46,74 Thesource of referral may also influence patientattendance at cardiac rehabilitation, with physicianreferral and in particular that of a cardiologistshown to improve uptake.29,39,40,75

The location, convenience and accessibility of acardiac rehabilitation programme influenceattendance.14,34,41,43,66,76 Patients living closer tothe programme are more likely to receive areferral and attend.37,52,65 Patients living in citiesor urban areas are more likely to attend cardiacrehabilitation.39,77 Inconvenient transportation,lack of and cost of transport, and parkingproblems are frequently cited as barriers toattendance at cardiac rehabilitation.34,51,70

Economic aspects of cardiacrehabilitationCosts of cardiac rehabilitation services vary byformat of delivery. The German approach tocardiac rehabilitation with 4–6 weeks of inpatientcare is estimated to cost about seven times that ofan outpatient service.78 Information on the directcosts of outpatient cardiac rehabilitation asprovided in the UK is limited. The results ofrecent UK costs studies25,79–82 are shown in Table 2.

Comparison of studies is difficult as the authorsused different methodologies and sources of costestimates. The most recent BACR/BHF surveysuggests that cost varies widely, with a range of£50–712 per patient treated depending on thelevel of staffing, the equipment used and theintensity of the programme.25 Staffing representsthe most important share, with estimates of64–80% of total direct costs.79,81

Barriers to uptake and adherence may besummarised as follows.

Patient factors:� lack of interest� reluctance to change lifestyle� depression� dislike of classes/hospitals� work or domestic commitments� lack of family support� rural residence.

Service factors:� cost and reimbursement � ECG monitoring requirement� location and accessibility� car parking

Professional factors:� knowledge and attitudes� referral� prejudice (age, race, gender).


5


Little information is available on the costs ofestablishing or expanding a rehabilitation service.Previously, it was considered that the resourcesneeded to establish a cardiac rehabilitationprogramme were present in most districthospitals.3,83 With changes in healthcaremanagement and increasing demands on facilitiesand space this may not now be the case.

ConclusionsOutpatient cardiac rehabilitation should beavailable to patients with a range of cardiovasculardiagnoses and after revascularisation procedures.Previous surveys have suggested that uptake ofoutpatient cardiac rehabilitation services is low,with specific patient groups under-represented. Toquantify the shortfall in cardiac rehabilitationservice availability and uptake, estimates of currentUK need and provision are required.

Barriers to participation in outpatient cardiacrehabilitation have been identified, but theeffectiveness of interventions to improve uptakeand adherence has not been assessed by systematicreview. Such a review is needed to identifyappropriate methods for increasing service useand to suggest areas meriting further research.

Previous economic evaluations of cardiacrehabilitation services have given a wide range ofcost estimates and little information on costs otherthan those attributable to staffing. A thoroughassessment of current UK costs of services isneeded to include staff, overhead, equipment andcapital costs. Furthermore, if greater numbers ofpatients are to receive outpatient cardiacrehabilitation an estimate of the cost implicationsof increasing provision by the establishment ofnew or expansion of existing services is required.

Background

6

TABLE 2 Studies reporting costs of cardiac rehabilitation in the UK

Author Year Type of programme Costs considered Results

Evans et al., 200225 2000 Annual BACR/BHF survey: Staff costs, possibly some £50–712 per patient budget statements from allowances for stationery (median £256)37 centres (2000 prices)

Osika, 200182 1997/98 Based on four cardiac Staff costs, non-staff costs £292 per patient, range rehabilitation centres in (not specified) £250–375 (1997–98 prices)Gwent

Taylor and Kirby, 199981 1995 One UK centre with Staff costs, equipment £140 per patient12-week programme costs, capital costs, £6 per patient per session with two outpatient visits transport (1995 prices)

Gray et al., 199780 1994 Survey of 16 UK centres Staff costs £371 per patient (median with an average of 9.2 £223), £47 per patient per sessions per patient session (median £26) (10.2 hours per patient) (1994 prices)

Turner, 199379 1992 Based on ten cardiac Staff costs, overhead costs, £200 per patient rehabilitation programmes equipment costs, capital (1992 prices)in the Wessex region costs

BACR, British Association for Cardiac Rehabilitation.

The questions posed in this project are asfollows.

� What is the population need for cardiacrehabilitation?

� Who is not receiving cardiac rehabilitation?� What is the effectiveness of different methods of

improving uptake and of differential targetingof cardiac rehabilitation?

� What is the potential budget impact ofincreasing uptake of cardiac rehabilitation usingdifferent uptake interventions?

The questions will be tackled using the followingsources of information:

� population need for cardiac rehabilitation inthe UK from analyses of the English HospitalEpisode Statistics (HES) and equivalent nationaldatabases

� provision and uptake of cardiac rehabilitation inthe UK by means of a national survey of cardiacrehabilitation services, ad hoc surveys andaudits

� uptake and adherence to cardiac rehabilitationfrom a recent multicentre RCT

� a systematic literature review of interventions toincrease patient uptake, adherence andprofessional compliance with cardiacrehabilitation

� the costs associated with improving uptake anddifferential targeting of cardiac rehabilitationfrom the national survey, systematic review andcosting data from sampled cardiac rehabilitationprogrammes.

Improving uptake of cardiac rehabilitation was conceived in a series of related stages: need for rehabilitation (in terms of ability tobenefit from rehabilitation), coverage of existing services; pattern (i.e. by age, gender,ethnicity) of referral to services, and adherence in terms of both acceptance of invitation to attend services and completion of treatment.Interventions to improve uptake could beenvisaged for each of these stages. This process is shown schematically in Figure 2.


7


Chapter 2

Objectives

Need for rehabilitation

Referral

Coverage

Uptake and adherenceAcceptance of invitation

+Completion of treatment

HES

National survey +economic

Adherence in RCT

Systematic review of literature

National survey

Economic appraisal

FIGURE 2 Improving the uptake of cardiac rehabilitation

Objectives� Determination of the population need for

cardiac rehabilitation in the UK by analysis ofthe English HES and similar national databases.

� Estimation of the level of uptake of cardiacrehabilitation by patients with a dischargediagnosis of coronary heart disease.

BackgroundThe NSF-CHD states that every hospital shouldensure that more than 85% of people dischargedfrom hospital with a primary diagnosis of acutemyocardial infarction or after coronaryrevascularisation are offered cardiacrehabilitation.12 When cardiac rehabilitation isavailable to these patients, the NSF-CHDrecommends that this service should be extended to patients with angina and heart failure. However, there is only limited information available on population need, that is, the total number of patients who maybenefit from cardiac rehabilitation and the currentnationwide level of service provision and patientuptake.

MethodsData from the HES for England and similarsources for Wales [Patient Episode Database(PEDW)] and Northern Ireland [HospitalInpatient Systems (HIS)] were used to estimate the need for cardiac rehabilitation, that is, thenumber of patients discharged from hospital whohave the capacity to benefit from this therapy.Scottish data were not available. Data fromEngland, Wales and Northern Ireland werecollected from 1 April 1999 to 31 March 2000 and provide a comprehensive picture of thenumber of patients discharged from hospitals with particular conditions. Information wascollected for all patients discharged alive fromhospital with a primary diagnosis of ischaemicheart disease [International Classification ofDiseases-10 (ICD-10) codes I20–I25].Furthermore, data for subcategories of thesepatients were collected:

1. acute myocardial infarction (ICD-10 code I21)2. heart failure (ICD-10 code I50)3. unstable angina (ICD-10 code I20.0)4. CABG (OPCS-4 codes K40–K46)5. PTCA (OPCS-4 codes K49–K50)6. CABG patients with one or more of the

following discharge diagnoses or procedurecodes: acute myocardial infarction, unstableangina, heart failure or PTCA

7. all other ischaemic heart disease cases.

Categories 1–7 are mutually exclusive, so thatpatients are only recorded once using eitherdiagnosis or procedure codes. In case of multipleevents with the same code each patient was onlycounted once. When a person was admitted morethan once in a year, each extra admission wasincluded.

The total number of patients eligible to receivecardiac rehabilitation was derived by adding thenumbers in categories 1–7. These data werestratified by gender and age groups. Populationstatistics84 were used to derive rates per 100,000individuals.

The uptake of cardiac rehabilitation by eligiblepatients was estimated. Data from the 2000BACR/BHF survey of cardiac rehabilitationservices and an additional short postalquestionnaire (as described in Chapter 4) wereused to obtain the number of services and toestimate the total number of patients referred andjoining outpatient cardiac rehabilitation inEngland, Wales, Scotland and Northern Ireland.In total, 284 centres were identified for the wholeof the UK in 2000 (220 centres in England, 36centres in Scotland, 18 centres in Wales and tencentres in Northern Ireland).

Of these, 191 (67%) responded to the additionalquestionnaire. Where a centre had not responded,a value relating to the upper interquartile range(IQR) derived from the responding centres wasimputed and added to the aggregated figures ofthe responding centres to estimate the upperrange of service provision for England. The lowerrange of service provision was similarly estimatedby imputing, where data were missing for centres,the lower IQR derived from the responding


9


Chapter 3

Population need for cardiac rehabilitation in the UK

centres. Uptake was estimated from the number ofeligible patients (using different need criteriagiven above) and the estimated number ofpatients referred, joining and completing cardiacrehabilitation. These estimates were then linkedwith the population need data.

Analyses were undertaken to estimate the level ofuptake with different criteria of eligibility forcardiac rehabilitation:

� All patients with the above-mentioned dischargediagnoses and procedure codes were consideredeligible.

� Only patients with acute myocardial infarction,unstable angina, CABG and PTCA wereconsidered eligible.

� Only patients younger than 75 years wereconsidered eligible.

The last two analyses were conducted bytruncating the population data using thesespecified criteria.

ResultsBased on hospital discharge statistics it wasestimated that the total numbers of hospitaldischarged patients potentially eligible to receivecardiac rehabilitation in 2000 were as follows:England 266,833; Wales 17,560 and NorthernIreland 13,988. Total counts of discharged caseswith acute myocardial infarction, heart failure,

unstable angina, CABG and PTCA stratified bycountry, gender, age group and rates of dischargediagnoses and procedure code per 100,000 personsare presented in Appendix 1 (Tables 35–37).

Table 3 shows the estimated number of patientsreferred to and joining outpatient cardiacrehabilitation programmes by country. Moredetailed information is shown in Appendix 2(Tables 38–41). Age, gender and diagnosis-specificestimates of need could not be provided as only aminority of cardiac rehabilitation centres were ableto supply relevant information broken down by thevariables required to link estimates of need toservice supply.

Similar proportions of all eligible patients inEngland and Wales were referred to cardiacrehabilitation (between 22 and 36%). However, theproportion of referred patients in NorthernIreland was significantly less (12–17%). Theproportions of all eligible patients joining cardiacrehabilitation programmes in England and Waleswere also similar (13–21%), but joining was lesscommon in Northern Ireland (9–12%).

Using more limited criteria of need for cardiacrehabilitation considering only patients dischargedwith a diagnosis of acute myocardial infarction,unstable angina or a procedure code of CABG orPTCA as eligible, under-provision was lessmarked, with about 45–67% referred to and27–41% joining cardiac programmes in England(see Table 3 for other countries).


10

TABLE 3 Estimated uptake of cardiac rehabilitation by patients with different manifestations of coronary heart disease

England Wales Scotland NorthernIreland

Estimated number of patients referred to CRa 59,400–87,200 4,600–6,400 5,800–9,100 1,700–2,400Estimated number of patients joining CRa 35,700–53,100 3,000–3,600 3,500–6,000 1,200–1,700

Eligibility criteria

All patients 266,800 17,700 NA 14,000% referred to CR 22–33% 26–36% NA 12–17%% joining CR 13–20% 17–21% NA 9–12%

Patients with AMI, unstable angina, CABG 131,100 7,900 NA 6,800and PTCA

% referred to CR 45–67% 59–81% NA 25–36%% joining CR 27–41% 38–46% NA 18–25%

Patients <75 years 202,000 12,700 NA 11,200% referred to CR 30–43% 36–50% NA 15–22%% joining CR 18–26% 24–29% NA 11–15%

a Numbers estimated by imputing the IQR for non-responding centres.AMI, acute myocardial infarction.

Provision was also estimated considering patientsunder age 75 years as eligible. This analysissuggests that 30–43% of patients were referredand 18–26% joined cardiac rehabilitation inEngland (see Table 3 for other countries). Adetailed summary of this analysis is displayed inAppendix 2 (Tables 38–41).

DiscussionThe objective of this analysis was to estimate thepopulation need for cardiac rehabilitation and toprovide up-to-date information about the level ofuptake of cardiac rehabilitation in the UK. Thisinformation should assist healthcare policy makersto improve the provision of cardiac rehabilitationservices to all patients who have the capacity tobenefit.

The analysis suggests that provision of cardiacrehabilitation at the inception of the NSF-CHDwas low. This was still apparent when consideringonly patients with acute myocardial infarction,unstable angina, PTCA and CABG as eligible or,in a second analysis, only patients younger than75 years.

There appears to be variation in service provisionacross the UK, with a higher proportion ofeligible patients referred to and joining cardiacrehabilitation programmes in England and Wales than in Northern Ireland. Since the needfor rehabilitation is substantially greater inNorthern Ireland (and Scotland), this represents a considerable mismatch between uptake andneed.

Although a different approach was used toestimate the level of service provision, the presentfindings are in concordance with previous researchexamining the relationship between need andsupply. Bethell and colleagues estimated thatbetween 14 and 23% of myocardial infarctionpatients, between 33 and 56% of CABG patients,and between 6 and 10% of PTCA patientsattended cardiac rehabilitation in 1997.26 Themost recent update provided by the same groupsuggests that 17% of all myocardial infarction, 44%of all CAGB and 6% of all PTCA patients receivedcardiac rehabilitation in 2000.25 It should beemphasised, however, that this estimate was basedon only 69% of all UK centres. The true level ofprovision may be higher if non-participatingcentres were providing a service with betterreferral and joining rates, but this seemsimprobable.

The analysis presented here illustrates the lack ofcomprehensive and reliable data to estimate thelevel of service provision and should beinterpreted with some caution. By using data fromthe HES a number of assumptions had to be madeto estimate need. Although patients managed athome or in the private sector will be missed, itmay be assumed that the HES are complete and aprimary diagnosis of ischaemic heart diseaseindicates a need for cardiac rehabilitation.Furthermore, it is assumed that each finishedconsultant episode for these diagnoses equates toone person; the ratio of spells to finishedconsultant episodes is generally around one.85

However, the number of discharge diagnoses maybe slightly higher than the number of patientsbecause in some instances myocardial infarctionpatients receive revascularisation procedures suchas CABG or PTCA within a few weeks. The timebetween these two distinctive admissions may notbe sufficient for enrolment in a rehabilitationprogramme after the first event. The estimatesassume that a patient suffering two or more eventsin a year represents a need for two (or more)courses of rehabilitation. This seems legitimate assuch patients may be considered to berehabilitation ‘failures’, and may have slippedthrough the net on earlier occasions.

Another potential limitation is the approachadopted to estimate the current level of serviceprovision. These estimates are based on a postalsurvey with a response rate of 67% of the samplingframe of all cardiac rehabilitation centres existingin 2000 in the whole of the UK. Approximately80% of these centres could provide data for thenumber of patients referred to and joining cardiacrehabilitation programmes and therefore theestimates are based on a sample of about 55% ofall UK centres. However, by imputing the IQR totake account of missing data, the resultingestimates should provide a fair estimate of thecurrent situation.

The apparent inability of centres to providecomprehensive activity data is possibly due to thelack of automated systems to extract these data,lack of audit facilities or centres being in theprocess of installing systems to collect audit datato satisfy the requirements of the NSF-CHD.Therefore, the current level of service provisioncould only be estimated indirectly by assumingthat all patients with a primary diagnosis ofischaemic heart disease are eligible. Some limitingcriteria of need were also used, namely restrictingthe eligibility for cardiac rehabilitation to certain


11


groups of patients (acute myocardial infarction,unstable angina, CABG and PTCA patients, andall ischaemic heart disease patients younger than75 years). A more appropriate approach would beto obtain information on the number of patientsreferred to, joining and completing programmesstratified by gender, age and discharge diagnosisdirect from cardiac rehabilitation centres andrelate these to data that represent need, such asthe HES, or to information obtained fromhospitals in the catchment area of therehabilitation service by means of comprehensivecoronary heart disease registers.

It was not possible to assess the level of uptake ofcardiac rehabilitation by patients of ethnicminority groups for two reasons. First, nationalhospital data stratified by ethnicity were onlyavailable for England. These were not completely

coded for ethnicity, with about 30% missing data.Second, as reported in Chapter 4, the majority ofcentres in the BACR/BHF survey were not able toprovide data on the referral and uptake of cardiacrehabilitation by ethnic minority groups.

ConclusionsThe analysis suggests that the level of serviceprovision of cardiac rehabilitation during 2000 waslow. Therefore, the achievement of the NSF-CHDgoal of 85% of acute myocardial infarction andrevascularisation patients receiving cardiacrehabilitation is far from fulfilled. In addition, theshortcomings of this analysis clearly emphasise theneed for a more comprehensive data collection toestimate reliably the provision of cardiacrehabilitation services and its relationship to need.


12


13


Objective� Assessment of the provision and uptake of

cardiac rehabilitation in the UK by means of anational survey of cardiac rehabilitationservices.

MethodsBACR, with financial backing from the BHF, hasconducted several surveys of cardiac rehabilitationservices in the UK.25,26,86 The authors of thesereports have kindly provided this group with thedata that they collected, and contact details of allservices identified for the latest survey conductedin 2001, which included data from 1 January to 31 December 2000. This latest survey includedquestions concerning the total number of patientsreferred, joining and completing outpatient(phase 3) cardiac rehabilitation, the numbersbroken down by diagnosis of myocardial infarctionor cardiac surgery and by age groups and gender,time spent per week for each programme byvarious staff members, current funding andquestions relating to outcome measures.

For the purposes of the current project there wasalso a need to know the numbers of patients fromtraditionally under-represented groups (women,the elderly, people from ethnic minority groupsand people with heart failure or angina) referred,joining and completing cardiac rehabilitationprogrammes to be able to determine currentservice provision in these groups. There was alsoan interest in knowing how many services activelypromoted adherence to programmes in theseunder-represented groups, and details of whatinterventions were used to achieve this. In termsof the extent of coverage and level of serviceprovision, questions were asked for all patients andthe study also sought to determine whetherservices had spare capacity for additional patients.A short postal questionnaire was devisedspecifically addressing these issues and sent to allthose respondents of the 2000 BACR/BHF survey.

ResultsBy contacting the cardiac rehabilitation liaisonperson for each local health authority in the UK,284 cardiac rehabilitation services were identifiedin 2000. Of these, 242 services responded to theBACR/BHF questionnaire, giving a response rateof 85%. The additional short postal questionnairedevised for the purposes of the current project(see letter of request and questionnaire inAppendix 3) was then sent to those respondents ofthe original survey, asking for information duringthe same period (1 January to 31 December 2000)so that data from the two sets of questionnairescould be linked. The response rate to thisadditional questionnaire following telephoneprompting was 79% (191 questionnaires returned).Data returned were entered into a MicrosoftAccess database and transferred to STATA (Version7) for data cleaning and analysis. Data arepresented as proportions, medians, IQR andrange, or means and standard deviations (SD).

Numbers of patients referred to,joining and completing cardiacrehabilitation programmes in 2000Most services were able to provide this information,as shown by the relatively high number ofresponders in Table 4 (maximum n = 191). Of thetotal number of patients referred, two-thirds ofpatients actually joined cardiac rehabilitationprogrammes and only half of those referredcompleted the programme. The number ofpatients attending individual programmes variedwidely across the UK, as shown by the large ranges.

Capacity to increase provisionThirty-one of 191 centres (16.2%) stated that theyhad spare capacity within their service, and couldaccommodate a median of four (two to 20) extrapatients each week.

Level of service provision across the UKin 2000The content of outpatient cardiac rehabilitationprogrammes was determined by the duration and

Chapter 4

Provision and uptake of cardiac rehabilitation in the UK: national survey of UK cardiac

rehabilitation services

the number and length of sessions for each of thecomponent parts: exercise, health education andpsychological interventions (stress managementand relaxation).

The mean values across services have beenweighted by the number of patients joining eachprogramme. Again, there was a reasonableresponse rate to these questions, as shown by therelatively high numbers who provided data. Table 5highlights just how variable the programmecontent and intensity of each intervention is acrossthe UK. Overall, exercise is the dominantcomponent, with the total time spent by a patientalmost twice that of health education and fourtimes that of psychological interventions. Thisreflects the origins of cardiac rehabilitation, theweight of evidence for benefit from exercise-basedprogrammes and the expertise of the principalmembers of most rehabilitation programmes.

Under-represented groups: number ofreferrals, joiners and completersbroken down by age, gender, diagnosisand ethnicityResponse rates to questions on numbers ofpatients referred to, joining and completingprogrammes from under-represented groups weremuch poorer. Reported reasons included lack ofautomated systems and audit facilities, or thatcentres were in the process of installing systems tocollect audit data to satisfy the requirements of theNSF-CHD.12 The representativeness of Table 6should therefore be interpreted with some caution.The numbers of patients with heart failure orangina, or from ethnic minority groups, were sosmall that it was not possible to look at theproportions of those referred, joining andcompleting rehabilitation. Similar proportions ofjoiners and completers relative to those referredwere seen for postmyocardial infarction patients

Provision and uptake of cardiac rehabilitation in the UK: national survey of UK cardiac rehabilitation services

14

TABLE 4 Overall referral, uptake and completion rates for UK cardiac rehabilitation programmes in 2000

Median IQR Range No. of programmes % of referrals

No. referred per centre 271 164–424 2–1564 156No. joined per centre 172 101–254 2–1066 153 63%No. completed per centre 130 75–186 3–450 133 48%

TABLE 5 Level of service provision for cardiac rehabilitation programmes in 2000

Weighteda mean (SD) Range No.b of programmes providing data

ExerciseNo. of weeks 7.4 (2.1) 1–12 144No. of sessions per week 1.7 (1.5) 1–14 146Average length of sessions (h) 1.2 (0.4) 0.5–3 145Total time spent by patient (h)c 12.9 (1.7) 3–98 143Average no. of patients per session 15.7 (6.2) 1–50 139

Health educationNo. of weeks 6.2 (2.1) 1–12 141No. of sessions per week 1.3 (1.6) 0.25–14 141Average length of sessions (h) 1.0 (0.4) 0.25–3 139Total time spent by patient (h)c 7.0 (2.0) 0.75–98 139Average no. of patients per session 16.1 (6.8) 1–40 132

Psychological interventionNo. of weeks 5.0 (2.7) 1–12 126No. of sessions per week 1.3 (1.5) 1–7 123Average length of sessions (h) 0.8 (0.5) 0.17–2 122Total time spent by patient (h)c 3.2 (2.0) 0.5–16 119Average no. of patients per session 14.6 (6.1) 1–40 116

a Weighted by the size of the service (number of patients who joined). Data not normally distributed were transformedbefore weighting.

b Data were not provided for all questions by all services, so the numbers of respondents to each question are provided.c Calculated as the number of weeks multiplied by the number of sessions per week multiplied by the duration of the

session in hours.


15


(not an under-represented group, here only forcomparison), the over 65-year-olds and malepatients, with slightly fewer women joiningrehabilitation programmes relative to thosereferred. The number of patients post-CABGreferred for cardiac rehabilitation shows relativelyhigher rates of completion than other groups.

Efforts to promote attendance inunder-represented groupsFinally each service was asked whether they madeany special efforts to promote adherence tocardiac rehabilitation programmes in each of theunder-represented groups, and to detail anyinterventions that they used to achieve this. Ofthose services (126/191, 66%) that indicated thatthey promoted attendance in at least one of theunder-represented groups, 46% stated that theypromoted attendance in women, 48% in theelderly, 55% in revascularisation patients, 34% inethnic minority groups, and 17% and 18% inpatients with heart failure and angina, respectively.

Of the 126 services that stated that they promotedattendance in under-represented groups, 97provided details of the interventions that theyused to achieve this. A member of the report teamwith extensive clinical experience of cardiac

rehabilitation delivery examined these free textresponses. Among the under-represented groupsthere emerged themes of a variety of interventionsthat were being, or could be used generically,across the different patient groups, and some thatwere definitely more specific to each of theparticular groups. These are presented in Table 7.The numbers in parentheses refer to the numbersof services which described each particularintervention. The majority of services that statedthat they promoted adherence did so in a way thatwould benefit most patient groups; for example,follow-up phone calls, free transport, home visitsand personalised invitations. Of those interventionsthat were specific to under-represented groups,individualised classes, appropriate ‘buddy’ systems,attendance of relative or spouse were among thosemost commonly stated. Direct referrals fromsurgery and specialist clinics were also used asmethods to ensure uptake and adherence.

ConclusionsAlthough it is feasible to obtain useful informationabout means of improving uptake and adherenceusing ad hoc postal questionnaires, routineelectronic audit data are likely to provide a more

TABLE 6 Under-represented groups: referral, uptake and completion rates for UK cardiac rehabilitation programmes in 2000

Median per IQR Range na % of referralscentre per year

No. of male patients referred 213 111–334 2–1066 83joined 118 66–185 2–747 84 55%completed 84 43–154 2–329 65 39%

No. of female patients referred 85 36–130 1–498 83joined 36 17–60 1–319 84 42%completed 27 12–45 0–140 65 32%

No. of patients aged >65 referred 142 61–228 0–887 66joined 72 37–152 0–596 71 51%completed 54 30–110 4–212 51 38%

No. of black/Asian patients referred 5 1–19 0–196 59joined 2 0–7 0–127 63completed

No. of post-MI patients referred 160 78–286 0–881 97joined 91 49–149 0–446 88 57%completed 66 31–103 0–425 69 41%

No. of CABG patients referred 86 47–142 0–563 91joined 50 22–99 0–407 83 58%completed 45 13–82 0–367 65 52%

No. of HF patients referred 0 0–2 0–28 61joined 0 0–1 0–12 59completed 0 0–1 0–9 46

No. of angina patients referred 6 0–27 0–200 71joined 1 0–8 0–134 70completed 0 0–5 0–73

a Data were not provided for all questions by all services, so the numbers of respondents to each question are provided.HF, heart failure.

comprehensive picture, and more accurate data onreferral and uptake.

Relative to post-myocardial infarction patients,older people and women tended to be less oftenreferred and were less likely to join a programme.Data on ethnic minorities and those with diagnosesof angina and heart failure were too sparse toevaluate formally. However, the low numbersreported indicate that these groups are veryunlikely to be referred or to join programmes.

Many different interventions are reported byservices, suggesting high levels of awareness of the general problem of uptake. Theseinterventions vary in complexity and cost; forthose that are either complex or costly, moreformal evaluation of their effects on uptake and adherence would be valuable. Examples of low-cost, sensible good practice (e.g. telephone call follow-ups) should be widelydisseminated and would not require formalevaluation.

Provision and uptake of cardiac rehabilitation in the UK: national survey of UK cardiac rehabilitation services

16

TABLE 7 Interventions used by cardiac rehabilitation programmes to improve uptake and adherence (number of programmes reportingindicated intervention)

Any intervention (97)

Generic interventionsFollow-up telephone call post-discharge (69)Preassessment clinic appointment and individualisedcoronary heart disease advice (58)Free organised transport (51)Home visit by specialist cardiac/BHF liaison nurse (43)Personalised invitation by letter or telephone to attend (42)Inpatient follow-up and verbal explanation (28)Non-attenders followed up and offered furtherappointments (26)Range and choice of menu options for classes (13)Community GP and practice nurse encourage attendance (5)Choice of sessions offered (venue/day/time) (5)Anxious patients met at the entrance of the venue (1)Travel grants and transport-sharing scheme (1)Invitation letter marketed and evaluated to encourageuptake of classes (1)

Specific interventions for womenWomen patients ‘buddy’ system (15)Individualised exercise plans (14) Separate classes for women (6) Encouragement of husband or friend to attend (6) Choice of community or hospital-site sessions (3)Female volunteer befriending service and help-line (3)Focus groups to assess women’s needs (2)Smaller exercise groups for women (1)Health benefits for women explained (1) Women’s changing facilities (1)Female-only staff to facilitate rehabilitation sessions (1)

Specific interventions for age > 65 yearsSeparate and smaller classes for the elderly/frail (6)Flexible start date if patient slow to recover (4)Elderly patients’ buddy system (3)Relative /spouse encouraged to attend (3)Lower impact exercise class (3)Choice of sessions offered (day and times) (3)Focus groups to assess elderly needs (2)Elderly volunteer befriending service and help-line (2)One-to-one exercise supervision (1)Elderly education sessions (1)Audiotapes of education sessions (1)

Specific interventions for ethnic minority groupsAsian relative/friend encouraged to attend (8)Coronary heart disease leaflets in Asian languages (5)Audiotapes of education sessions (3)Asian-speaking nurses for home visits (5), education andexercise (3)Involvement of Asian support groups (3) Community elders from voluntary sector supportingrehabilitation (3)Asian education programme (3)Asian patient buddy system (2)Provision of culturally sensitive classes (2)Regular Asian focus groups to assess need (1)Separate exercise class for Asian women (1)Encouragement to wear traditional dress (1)

Specific interventions for CABG/PTCASurgical tertiary centre referral system (13)Specific revascularisation programme led by arevascularisation rehabilitation nurse (12)Strong recommendation by surgeon/consultant (2) Theatre list referral system (1)Buddy system (1)Preangiogram talk about rehabilitation (1)Video about cardiac rehabilitation (1)

Specific interventions for anginaSpecific angina education sessions (5)No exclusion to attend (5)Direct referral from rapid-access chest pain clinic (2)Referral while awaiting CABG (1)Buddy system (2)Referral followed up by specialist angina nurse (1)

Specific interventions for heart failureSpecific heart failure programme (9)Community specialist heart failure nurse encouragesattendance (5)No exclusion to classes (4)Low-impact exercise classes (2)Buddy system (1)Community-based programme (1)Audiotapes of health education provided (1)One-to-one exercise supervision (1)


17


Objective� Assessment of cardiac rehabilitation audit

activity by survey of rehabilitation centres.

BackgroundPatient uptake of outpatient cardiac rehabilitationservices is poor, particularly by under-representedgroups including women, the elderly and ethnicminorities.25,33,36 Although guidelines on provisionof services exist,2,4,87 audit of cardiac rehabilitationservices has previously been piecemeal and notroutinely undertaken and, where data exist,adherence to guidelines is poor.88 In England, theNSF-CHD has recognised the benefits ofcomprehensive cardiac rehabilitation and the needfor services to be extended.12 It states that everyhospital should ensure that more than 85% ofpatients discharged with a primary diagnosis ofacute myocardial infarction or after coronaryrevascularisation are offered access to cardiacrehabilitation. This has implications for clinicalgovernance and the need to audit cardiacrehabilitation services.

In view of the NSF stated objectives, the aim wasto ascertain the level of cardiac rehabilitation auditactivity in the south-west of England and areaswith high ethnic minority populations in Londonand the midlands.

MethodsCardiac rehabilitation centres in the south-west ofEngland, London and the Midlands werecontacted by telephone and asked to supply areport on their most recent audit. Information onany special efforts to improve attendance byspecific patient groups (e.g. women, the elderlyand ethnic minorities) was also requested. Centresreporting no available data were asked to providereasons for not undertaking audit. Centres withaudit data or a report available but that did not

submit a copy were contacted a second time bytelephone and subsequently by letter. The medicaldirector of the NHS trust was then contacted,asking the hospital trust to follow-up the request.

ResultsResponse rate

From January to July 2002, 51/57 (89%) of cardiacrehabilitation centres that were approached weresuccessfully contacted. Twenty-six centres (46%)responded to the first telephone request. Furthercontact by telephone and letter led to replies fromone (2%) and eight centres (14%), respectively.Finally, after written communication with medicaldirectors, replies were received from a further 16centres (28%). Audit data were received from 24(42%) centres, nine (16%) reported that an audithad been undertaken but did not send it, and 18(32%) stated that no audit had ever beenundertaken. Two centres supplied their audit asanonymous individual patient data and one centrewas only able to provide an audit report limited toa single ethnic group.

Audit methodsThe means of data collection varied betweencentres. It was not possible to determine themethod of data collection by 12 centres (50%). Ofthose where this was clear, six (50%) relied on a‘paper system’ with retrospective data extractionfrom patient notes and attendance registers, whilesix (50%) used regularly updated computeriseddatabases. Commenting on the collection of data,respondents regarded paper systems as time-consuming, tedious and unreliable, while centresusing computerised methods reported thatfrequently there was a lack of trained staff for datamanagement.

The mean length of audit was 10.4 months(SD 2.8, range 4–12 months). Times for datacollection also varied between centres. Mid-pointdates were in 2002 (two hospitals), 2001 (ten

Chapter 5

Audit of cardiac rehabilitation in England: National Service Framework for Coronary Heart

Disease recommendations

hospitals), 2000 (eight hospitals), 1999 (twohospitals) and 1998 (one hospital). One audit didnot provide dates. The main reasons cited for notcollecting audit data were: time constraints, lack ofadequate resources and computing facilities, lackof appropriate personnel to input data, limited orno audit training, or lack of informationtechnology support for the audit process.

National Service FrameworkThe number of centres collecting information asstated in the NSF-CHD for annual collection ispresented in Table 8. The audit with data on asingle ethnic group is not included.

Of importance is that data received were often notcomparable. Regarding age, only six (26%) centresprovided age information adequate for theassessment of attendance by age group. This wassimilarly the case with ethnicity, where only five(22%) provided information that permittedcomparisons of cardiac rehabilitation uptake byethnic groups. This information was more likely tobe collected by centres in areas with high numbersof patients from ethnic minorities. Eleven out of13 centres (85%) from areas with high ethnicminorities collected information on provision forspecific ethnic minority groups, but in only four(31%) could this be used to assess some feature ofuptake. In areas with relatively low numbers ofpatients from ethnic minorities limitedinformation was reported by five out of 10 centres(50%), with only one centre collecting adequateinformation to assess differences in attendancerates (10%).

Of the 19 centres supplying relevant information,12 (63%) provided rehabilitation for patients withmyocardial infarction, coronary bypass surgery,

angioplasty and heart failure. Six (32%) wereexclusively for myocardial infarction patients andone (5%) for surgical patients.

Audits also contained information not directlyrelevant to the objectives of the NSF. This issummarised in Table 9.

Numbers of patients per yearThe annual baseline mean number of patientsdischarged alive from hospital and eligible forcardiac rehabilitation and the numbers of patientsreferred to, attending and completing cardiacrehabilitation are presented in Table 10 for allcentres and for those providing services to a highproportion of ethnic minorities.

The proportion of discharged patients attendingrehabilitation was 35% (weighted by number ofpatients discharged, SD 12, range 14–54%) and ofthose referred or invited to cardiac rehabilitationattendance was 55% (weighted by number ofpatients invited, SD 12, range 35–80%). Seventy-

Audit of cardiac rehabilitation in England: National Service Framework for Coronary Heart Disease recommendations

18

TABLE 8 Audit activity specified in NSF-CHD

Stated NSF-CHD recommendation No. of centres collectinginformation (%) (n = 23)

No. (%) of patients discharged from hospital after coronary revascularisation or with a 10 (43%)primary diagnosis of AMI

Documentation of arrangements for cardiac rehabilitation in discharge communication to GP 0 (0%)

Information on gender of patients 20 (87%)

Information on age of patients 18 (78%)

Information on ethnic group of patients 16 (70%)

No. recruited to cardiac rehabilitation 21 (91%)

Outcome information: 1 year after discharge, regular physical activity of at least 30 min 2 (9%)duration on average five times a week, not smoking, body mass index < 30 kg/m2

TABLE 9 Additional information included in audits

Additional information collected No. of centrescollectinginformation (%)(n = 23)

Patient reasons for non-attendance 12 (52%)Patient clinical history and risk factors 6 (26%)Secondary prevention outcomes 4 (17%)Patient opinions and satisfaction 2 (9%)Patient’s home postcode 2 (9%)Psychological morbidity 1 (4%)Exercise outcomes 1 (4%)Reasons for non-referral 1 (4%)Referrals by consultant 1 (4%)

seven per cent of patients (weighted by number ofpatients attending, SD 13, range 57–91%) attendinga programme subsequently completed it.

The proportion of patients discharged whocompleted a programme was 32% (weighted bynumber of patients discharged, SD 6, range28–42%). However, this was based on informationfrom only three centres.

In five centres providing a service to a highproportion of ethnic minorities the percentage ofdischarged patients referred was significantlylower than in three centres from other areassurveyed and which provided appropriate data(29% compared with 45%). Otherwise, theproportions of patients referred, attending andcompleting programmes were similar.

Measures reported to improve patientattendance at outpatient cardiacrehabilitationEight centres (35%) reported a variety of measuresto improve attendance and these are summarisedin Table 11. Three of these measures concentratedon the uptake of ethnic minorities, one on womenpatients, but none on the elderly. Regrettably,information evaluating the success of thesemeasures was not available.

DiscussionClinical governance incorporates audit to ensurethat clinical care is up to date and effective.89

However, a commitment to the accuracy,appropriateness, completeness and analysis of


19


TABLE 11 Measures taken to improve attendance at cardiacrehabilitation

No. of centresreportingmeasures toimproveattendance (%)

Community, non-hospital-based 5 (22%)programme

Translator or interpreter 3 (13%)

Evening programme 2 (9%)

Community liaison or link worker 2 (9%)

Women-only programme 1 (4%)

Programme for specific ethnic group 1 (4%)

Programme on days appropriate to 1 (4%)religious beliefs

Satellite services in local hospitals 1 (4%)

Audio information for visually impaired 1 (4%)

TABLE 10 Numbers and proportions of patients discharged alive, referred/invited, attending and completing cardiac rehabilitationper year

Mean no. (SD) Proportion of Proportion of Proportion of of patients (range) dischargeda referred/inviteda attendeda

(no. of centres) (no. of centres) (no. of centres) (no. of centres)

All centresDischarged patients 390 (182)

(167–684) (n = 10)

Referred/invited for cardiac 308 (223) 59% (n = 7)rehabilitation (62–1066) (n = 18)

Attending cardiac rehabilitation 176 (110) 35% (n = 8) 55% (n = 16)(23–533) (n = 19)

Completing cardiac rehabilitation 148 (53) 32% (n = 3) 48% (n = 8) 77% (n = 7)(66–233) (n = 8)

Centres providing service to a high proportion of ethnic minoritiesDischarged patients 398 (184)

(167–620) (n = 6)

Referred/invited for cardiac 334 (262) 60% (n = 5)rehabilitation (62–1066) (n = 11)

Attending cardiac rehabilitation 189 (135) 29% (n = 5) 57% (n = 10)(23–533) (n = 11)

Completing cardiac rehabilitation 137 (58) (66–233) (n = 6) 37% (n = 2) 48% (n = 6) 79% (n = 5)

a For centres providing complete information.

healthcare information is required if judgementsabout clinical quality are to be made and theimpact of clinical governance is to be assessed.90

Major barriers to clinical audit are lack of resources,lack of expertise or support, and organisationaldifficulties.91 This survey highlighted that aminority of centres was able to provide informationon outpatient cardiac rehabilitation audit, with one-third of centres reporting that no audit wasavailable. Some centres reported that audit hadbeen conducted, but were not eager to disseminatethe information outside the hospital. This mayreflect the perceived disadvantages associated withclinical audit of diminished clinical ownership andhierarchical and territorial suspicions.91 Althoughthe medical directors of NHS trusts were contactedfuture studies should consider methods to improvesharing of audit information.

Nearly half of the audits provided some relevantinformation on clinical audit as specified in theNSF-CHD. However, information on potentiallyunder-represented groups was limited. To someextent the style and content of audit reportsprobably reflect local interests and concernsrelating to cardiac rehabilitation provision. Basicinformation on the initiating event in particular,and on referral, invitation, attendance andcompletion was collected in sporadic and non-standard ways. A few audit reports werecomprehensive, with comparison of total numbersof discharged patients and patient attendance andcompletion of outpatient cardiac rehabilitation. Toallow comparison of provision between centres andover time, a baseline figure of total initiatingevents is required, as well as information oninvitation to, and completion of, the programme.Examples of clinical audit tools have beenincluded in cardiac rehabilitation guidelines.2,4

However, with the exception of initiating event,these have been limited in their inclusion ofinformation on potential sources of under-representation. A more recent resource considersage, gender and ethnicity,92 and is currently underevaluation.93 Development and acceptance of acomprehensive, standard audit tool with flexibilityregarding local issues would be helpful for use infuture audits. It may be possible to merge this intoa hospital critical care pathway and routinelycollected Myocardial Infarction National AuditProject (MINAP)94 data. If the targets laid down inthe NSF-CHD are to be met and the healthoutcomes are to be successful then the challengelies in the development of an effective anduncomplicated audit tool that can be appliednationally to serve all cardiac populations.

A difficulty identified in several audits and fromcentres unable to provide information was thatpatients may be referred to a programme fromone or more hospitals or from one hospital toseveral different programmes. This complicatesthe audit of programmes in both urban and ruralsettings. In one city unable to provide auditinformation a group of hospitals reported theimminent introduction of a joint database.

Where available, audits of outpatient cardiacrehabilitation varied considerably in style andcontent. Some were thorough documents coveringmany aspects of audit, whereas other centres hadbeen unable to prepare a formal document butwere able to provide raw data. Some audits wereprepared by staff trained in clinical audit, whereasothers were by less experienced staff or werestudent projects. Other facilitating factors foraudit include modern medical records systems,effective training, dedicated staff, protected time,structured programmes, and a shared dialoguebetween purchasers and providers.91

Only a minority of centres was able to providecomplete information on numbers of patientsreferred (seven centres) and who attended cardiacrehabilitation (eight centres) in relation tonumbers discharged. There was a suggestion thatreferral and invitation of patients were similar incentres providing services in areas with highproportions of ethnic minorities compared withcentres in other areas. However, the proportion ofpatients attending a programme was lower inareas with high ethnic minority populations.Changes to services and interventions to improveuptake of cardiac rehabilitation by ethnic minoritygroups may be indicated.

A series of measures had been undertaken bycentres to help patients to participate inoutpatient cardiac rehabilitation. These rangedfrom holding classes in community settings and attimes to suit patients, to the establishment ofclasses dedicated to women or ethnic groups. Asinterventions may be of interest to other centres,evaluation by controlled trials or within areproducible audit framework would be valuablein determining their overall effectiveness inimproving attendance at outpatient cardiacrehabilitation.

ConclusionsThe findings from this more detailed survey ofaudit activity complement those obtained from the

Audit of cardiac rehabilitation in England: National Service Framework for Coronary Heart Disease recommendations

20

national survey of cardiac rehabilitation servicespresented in Chapter 4. The authors had hopedto be able to find interventions specific to under-represented groups by focusing on services locatedin areas with relatively high proportions of blackand ethnic minorities and with rather more agedpopulations (the south-west of England). However,the quality of audit, the reports and the datacollected were insufficient to support robustinterpretation of the performance of theseservices.

The findings highlight a national uncoordinatedapproach to audit data collection in England withlarge variations in methods and content despitethe standards set out in the NSF and cardiacrehabilitation guidelines. The use of modernmedical records systems, appropriate training fordedicated staff and dialogue between allcontributors to services is suggested. Developmentof a national and policy-driven standardised

audit tool would facilitate the identification ofpatients by cardiac event and the following of allpatients through the cardiac rehabilitation process.

Limited analysis of audit data suggests that uptakeof cardiac rehabilitation is particularly low in areaswith high proportions of ethnic minorities.Information on under-represented groups andlocal interests should be incorporated into auditdata collection in a standardised way so that futurecare can be targeted to the needs of the localcardiac population.

Some cardiac rehabilitation programmes haveattempted to improve attendance with measuresappropriate for all patients or for specific groups.Evaluation and dissemination of information oneffective and ineffective interventions may helpother programmes to improve services and useresources appropriately.


21



23


Objective� To evaluate uptake and adherence using data

from a recent multicentre RCT.95

IntroductionIn the UK provision of rehabilitation for patientsfollowing acute myocardial infarction is arequirement of the NHS-CHD12 and comparableguidelines in Scotland and Wales.2,18 Beforedischarge all patients should be invited toparticipate in a multidisciplinary cardiacrehabilitation and secondary preventionprogramme. Some patient groups are not thoughtto benefit from the exercise component of cardiacrehabilitation after acute myocardial infarction.Patients with more severe cardiac illness and thosewith psychiatric conditions that may compromisesafety are considered ineligible.96 Pragmatically,patients with poor functional capacity, significantco-morbidity, frailty or confusion are not suitablefor outpatient-delivered rehabilitation.Consequently, these factors may influence referraland uptake in clinical practice.

The uptake and adherence achieved in a clinicaltrial setting was examined because this shouldreflect the best that can be achieved in optimalroutine clinical practice.95 It would certainly beunlikely that NSF targets representing a higherlevel of uptake and adherence than that seen in acontemporary trial would be feasible. Whereappropriate, data for all patients discharged aftermyocardial infarction were analysed. For issuesrelating to attendance only those patientsallocated to cardiac rehabilitation were considered.

MethodsPatients were recruited in 18 typical acute generalhospitals in England and Wales. The trial protocolplanned for all potentially eligible myocardialinfarction patients to be identified onconfirmation of diagnosis. At discharge ineligible

patients (significant co-morbidity, etc.) wereexcluded under protocol guidelines of minimalexclusions and reasons were recorded, usually by anominated coronary care unit nurse. Patientseligible for rehabilitation were advised of the trialin an introductory letter.

Each patient was visited by a research interviewerapproximately 1 week after discharge. Patientswere given full details of the trial and, after beingasked for informed consent, answered the baselinestructured interview. Following entry into the trialand central blind randomisation, the names ofpatients allocated to cardiac rehabilitation weregiven to rehabilitation teams for invitation,treatment and follow-up as normal practice for theprogramme.

There were two opportunities for patient selection:by hospital medical or nursing staff (before trialentry) according to criteria in protocol; or bycardiac rehabilitation staff (after randomisation).There were also three opportunities for refusal ofthe trial or rehabilitation by patients: whenadvised of the trial by hospital staff; after a fulldescription of the trial and informed consent bythe research interviewer; or when given the date,time and venue of their first rehabilitationappointment. Patients were interviewed after1 year and asked about their experiences ofcardiac rehabilitation.

ResultsThe collection of names of potentially eligiblepatients and recording of clinical summaries werenot complete in all hospitals. Some progressivelyreduced the flow of forms of excluded patients.Consequently, analyses were undertaken both for all hospitals and for those hospitals in whichrecord-keeping was thought to be nearly complete.

In total, 3264 potentially eligible patients wereidentified in the 18 hospitals. Of these, 1400 werein five hospitals with complete registration.

Chapter 6

Uptake and adherence in a randomised controlled trial of cardiac rehabilitation after

myocardial infarction

Figure 3 shows reasons for exclusion from the trialand overall eligibility for cardiac rehabilitation inthe hospitals with complete registration. Seventy-three per cent of patients had no medical reason(identified during hospital stay by medical ornursing staff) for not attending a programme ofcardiac rehabilitation. Thus, nearly three-quartersof patients discharged within 28 days followingmyocardial infarction were deemed eligible forcardiac rehabilitation.

Follow-up interviews were completed for 959patients randomised to rehabilitation atapproximately 1 year, by when 75 patients haddied. Attendance information for a further91 patients was provided by rehabilitationcoordinators.

Medical reasons for exclusion, identified duringthe hospital stay, are shown in Table 12. Some ofthese patients may have been eligible forrehabilitation at a later date or in a differenthospital (patients awaiting surgery, transferred toanother hospital, having extended hospital stay orbeing readmitted). Including these patients raiseseligibility from 73 to 81%.

Patients excluded from rehabilitation for medicalreasons tended to be older (mean age 71.9 yearscompared with 64.6 years for eligible patients,p < 0.0001) and were more likely to be female(36.5% versus 21.9% males excluded, p < 0.0001).Table 13 shows patient exclusion in males andfemales in different age groups. There was a trendfor increasing exclusion in both men and women

Uptake and adherence in a randomised controlled trial of cardiac rehabilitation after myocardial infarction

24

1400 patients identified with acute myocardial infarction

678 (48%) patients admitted to trial of cardiac rehabilitation

722 (52%) patients excluded from trial

151 (11%) patients chose not to participate in trial (trial and rehabilitation refusals and elective rehabilitation requests)

95 (7%) patients did not participate in the trial for practical reasons (could not speak English, lived outside area, living in nursing home)

103 (7%) patients excluded for reasons concerning the trial (previous attendance at cardiac rehabilitation, interviewer unable to contact)

373 (27%) patients excludedfor medical and relatedreasons

1027 (73%) of patients eligible forcardiac rehabilitation

FIGURE 3 Exclusions from trial hospitals reporting complete myocardial infarction registration

with age. In multivariate analysis the associationbetween gender and exclusion was not significantafter adjustment for age.

Excluded patients tended to have pre-existingcardiovascular disease (previous myocardialinfarction or angina) or more severe presentationof the index myocardial infarction (Table 14).However, previous hypertension was not associatedwith eligibility.

In total, 2144 patients were entered into the trial. Ofthese, 1100 were allocated to cardiac rehabilitation.Attendance figures are shown in Table 15.

Not all patients allocated by the trial torehabilitation were offered cardiac rehabilitation.At least 22% and possibly as many as 33% ofpatients considered eligible by medical or nursingstaff at time of discharge were not offeredrehabilitation by cardiac rehabilitation staff.Patients invited tended to be younger than thosenot invited (mean age 62.8 years compared with68.1 years) with a clear trend for non-invitation inolder age groups (Table 16).

There was a tendency for women to be overlookedmore often than men (31% compared with 22%).In less elderly patients (under 70 years), 18% ofwomen were overlooked compared with 13% ofmen. However, the trend was not significant inmultivariate analysis.

At interview, patients who had been invited tocardiac rehabilitation (n = 721) estimated thenumber of classes that they had attended and, ifappropriate, gave reasons for non-attendance ordropout. Overall, 78% of patients invited torehabilitation attended at least one session. Ofpatients aged 65 years or more 72% attended atleast one session compared with 82% of thoseyounger than 65 (p = 0.001). These data providesupport for the observation that older patients areless likely to attend cardiac rehabilitation thanyounger patients. There were no statisticallysignificant differences in initial uptake betweenmen and women (79% versus 74%).


25


TABLE 12 Reasons for exclusion in hospitals with completepatient registration

No. of patients (%)

Admitted to trial 678 (48.4%)Practical, personal and trial exclusion 349 (24.9%)

Medical exclusion:Significant co-morbidity 75 (5.4%)Frail or confused 154 (11.0%)Transferred to other hospital 75 (5.4%)>28 days in hospital 13 (0.9%)Readmitted within 28 days 16 (1.1%)Awaiting surgery 5 (0.4%)Uncooperative 7 (0.5%)Other 28 (2.0%)

Total 1400

TABLE 13 Medical exclusions by age and gender (1349 patients with age and gender known)

Age at MI (years) Male exclusions Female exclusions All exclusions (% potentially eligible) (% potentially eligible) (% potentially eligible)

<45 14 (25%) 4 (44%) 18 (28%)45–54 21 (13%) 2 (5%) 23 (12%)55–64 38 (16%) 13 (19%) 51 (16%)65–74 50 (19%) 34 (27%) 84 (21%)75–84 53 (34%) 69 (47%) 122 (40%)85+ 18 (56%) 31 (67%) 49 (63%)All ages 194 (21%) 153 (35%) 347 (26%)

TABLE 14 Medical exclusions by previous cardiovascular disease and more severe sequelae of myocardial infarction

Eligible Medical exclusion p

MI previous to index event 16.50% 26.70% p < 0.0001Previous angina 30.50% 44.10% p < 0.0001Previous hypertension 31.70% 31.00% p = 0.441

MI with left ventricular failure 29.10% 49.60% p < 0.0001

MI with cardiogenic shock 1.60% 7.30% p < 0.0001

Patients with a history of cardiovascular diseasebefore the index myocardial infarction wereslightly less likely to attend rehabilitation: previoushypertension (27% versus 21%) and previousmyocardial infarction (30% versus 22%), but thesedifferences were not statistically significant.

If invited, patients who had suffered a more severemyocardial infarction (complicated with leftventricular failure or cardiogenic shock) were aslikely to attend as those without complications.Seventy-seven per cent of patients with left

ventricular failure attended compared with 78% ofthose without. For cardiogenic shock the numbersare small, but of 12 affected patients, 11 attendedrehabilitation (92%) compared with 78% of thosewithout.

Having attended one class, 79% of patientsattended five or more sessions. Women wereslightly less likely than men to attend five or moresessions (75% versus 80%), although this was notstatistically significant.

Reasons reported for not attending or attendingfewer than five sessions are shown in Table 17.

The main reasons given by patients at the 1-yearfollow up interview for non-attendance were lackof interest and perceived illness. However, 34%reported reasons for non-attendance or droppingout that might have been avoided withappropriate management. These includedtransport difficulties, returned to work, holidays,other appointments, administrative failure,dissatisfaction with course, dependent relative,considered unnecessary by department, attendedother course and taking part in another trial.

DiscussionThis analysis showed that some cardiacrehabilitation programmes used selection. Thismay reflect local provision issues or the lesserimportance assigned to rehabilitation of patientsfollowing acute myocardial infarction comparedwith cardiac surgery. Although the analysis ofreasons for exclusion is based on 1400 patientsfrom five hospitals, a less representative

Uptake and adherence in a randomised controlled trial of cardiac rehabilitation after myocardial infarction

26

TABLE 15 Patient attendance in trial rehabilitation groups

No. of patients (%)

Not offered/did not attend 238 (21.6%)Not known whether offered/did not attend 66 (6.0%)Offered/did not attend 162 (14.7%)Attended one class 45 (4.1%)Attended two to four classes 57 (5.2%)Attended five or more classes 454 (41.3%)Attended but number not known 18 (1.6%)Not known whether offered or attended 60 (5.5%)Total 1100

TABLE 16 Non-invitation by age group

Age group (years) Not invited

<45 7 (11.3%)45–54 21 (12.2%)55–64 50 (17.2%)65–74 87 (22.9%)75+ 73 (37.2%)Total 238

TABLE 17 Reasons for non-attendance or attendance at fewer than five sessions in patients offered cardiac rehabilitation

Reason for non-attendance No. of patients (%)

Not interested or lost interest 71 (23.6%)Too ill 62 (20.6%)Transport difficulties 43 (14.3%)Returned to work 18 (6.0%)Holiday or other appointments 15 (5.0%)Recommended not to by doctor or rehabilitation staff 13 (4.3%)Rehabilitation department administrative failure 9 (3.0%)Dissatisfaction with course (age group, male/female, content) 6 (2.0%)Taken ill at rehabilitation class 6 (2.0%)Looking after dependent relative 6 (2.0%)Rehabilitation staff thought unnecessary (fit enough) 3 (1.0%)Attending another rehabilitation course 2 (0.7%)On another trial 1 (0.3%)Not known 46 (15.3%)Total 301


27


sample of hospitals than the 18 trial hospitals, asimilar pattern is observed in the whole sample.

It is not possible to differentiate trial refusals fromcardiac rehabilitation refusals. By refusing toparticipate in the trial, patients may be seekingcardiac rehabilitation or may be turning it down.However, in an audit of rehabilitation servicesboth these patient groups must be considered aseligible. Patients who were excluded from the trialfor methodological (trial) reasons may have beeneligible and contactable if given a definiteinvitation while in hospital. Patients excluded forthe practical reason of living outside the area mayhave been eligible for a cardiac rehabilitationprogramme local to their home. Indeed, it ispossible that these patients received rehabilitationelsewhere. At the time there were no specificinterventions to facilitate uptake by patients whospoke no English, in the study hospitals (specificprogrammes for non-English-speaking patientsmay have been introduced more recently). It isunlikely that they would have receivedrehabilitation elsewhere.

The reasons reported by patients for non-attendance at and for early dropout from a cardiac

rehabilitation programme suggest that uptake maybe improved by addressing issues of motivationand the perceived relevance of rehabilitation tofuture well-being, minor co-morbidities orperceived illness, site and timing of sessions,transport and arrangement of care fordependants.

ConclusionsMedical and nursing staff identified 73–81% ofpatients discharged from hospital after acutemyocardial infarction as being eligible for cardiacrehabilitation. Excluded patients tended to beolder, were more likely to have suffered fromangina or had a previous myocardial infarctionand showed more severe presentation ofcardiovascular disease. Reduced invitation andattendance of women was largely explained bytheir greater age at myocardial infarction. Theexperiences of patients invited to cardiacrehabilitation suggest that uptake may beimproved by addressing issues of motivation andthe perceived relevance of rehabilitation to futurewell-being, co-morbidities, site and time ofsessions, transport and arrangement of care fordependants.


29


Chapters 7–10 present the methods andfindings for a series of related systematic

reviews. The issue of improving uptake was splitinto three major questions: how can recruitment tocardiac rehabilitation be improved; how canpatients’ adherence to cardiac rehabilitation andmaintenance of lifestyle changes be improved; and,how can professionals be encouraged to complywith guidelines and good practice? The sources ofdata to answer these questions may overlap, asresearchers will not necessarily have conceivedtheir questions in the same form as the presentgroup has. With awareness of this, it was ensuredthat each pair of reviewers dealing with a specificquestion read source material with a view toidentifying potential relevance to other questions.

Definitions� Uptake: patients attending any outpatient

cardiac rehabilitation (i.e. successfulrecruitment).

� Adherence: patients attending all or majority ofoutpatient programme, or maintaining lifestylechanges associated with cardiac rehabilitation.

� Professional compliance: healthcareprofessionals complying with guidelines or goodpractice regarding invitation and support ofpatients’ cardiac rehabilitation.

Objective� How effective are different methods for

improving uptake, adherence or professionalcompliance with cardiac rehabilitation?

MethodsA systematic review of interventions to increaseuptake, patient adherence and professionalcompliance with cardiac rehabilitation isdescribed. This was supported by members of the

Cochrane Heart Group (KR, MB) who assistedwith designing search strategies and identifyingreports.

Data sourcesA general search strategy was designed to identifyall studies relating to the uptake, adherence orcompliance with cardiac rehabilitation services.The choice of sources was intended to find bothpublished and unpublished studies (greyliterature). Details of terms used in the search aregiven in Appendix 4. The terms used were thosefor ‘heart disease’ together with terms for ‘cardiacrehabilitation’. A broad approach to rehabilitationterms was chosen to identify not only formalcardiac rehabilitation programmes but also non-traditional programmes that could contribute tocardiac rehabilitation. Studies identified werefurther searched for terms relating to uptake,adherence, compliance and costs. Studymethodology terms were not included, as theintention was to find all studies irrespective ofmethodology used. No language restrictions wereapplied.

The following databases were searched frominception (as appropriate) to June 2001:

� MEDLINE on Ovid� EMBASE on Ovid� the Cochrane Library (2001 Issue 2). This

includes the Cochrane Controlled TrialsRegister, Cochrane Database of SystematicReviews, Database of Reviews of Effectiveness(DARE), HTA Database and NHS EconomicEvaluation Database

� CINAHL on Ovid� PsycINFO on BIDS Silverplatter WebSPIRS� ISI Web of Science and ISI Proceedings� ECONLIT on Silverplatter WebSPIRS� British Library Inside � SIGLE (System for Information on Grey

Literature in Europe)� HMIC (Health Management Information

Consortium database)

Chapter 7

Systematic review of interventions to improve uptake, adherence and professional compliance with

cardiac rehabilitation

� COPAC (joint catalogue of CURL – theConsortium of University Research Libraries)

� National Research Register.

Additional searching of literature:

� The Journal of Cardiopulmonary Rehabilitation,1990–2001, was handsearched.

� Coronary Health Care, 1997–2001, washandsearched.

� Abstracts from conference proceedings werehandsearched:– American Association of Cardiovascular and

Pulmonary Rehabilitation (AACVPR)– American College of Cardiology (ACC)– British Cardiac Society (BCS)– British Association for Cardiac Rehabilitation

(BACR)– European Society of Cardiology (ESC)– International Network of Agencies for Health

Technology Assessment (INAHTA)– Society for Social Medicine (SSM)– World Congress of Cardiology (WCC).

� The reference lists of relevant studies andreviews were scanned.

� Expert opinion was sought.

Study selectionPreliminary literature searches suggested that onlya small number of RCTs would be found and thatnon-randomised studies would form an importantpart of the review. Consequently, all studiesreporting evaluations of interventions wereconsidered. A total of 3261 references wasidentified in the searches, and the title andabstract of each article were examined by at leastone reviewer. Articles were only rejected if thereviewer could determine from the title andabstract that the article was not a report of anintervention. When a paper could not be rejectedwith certainty, the full text of the article wasobtained for further evaluation. A total of 957references was identified as potentially relevantand acquired for more detailed consideration.

There was concern about publication bias andtherefore special efforts were made to identifystudies that might report negative findings bysearching the grey literature, and handsearchingabstracts of scientific meetings. Many of theidentified interventions were found in the greyliterature, which tends to include studies reportinglower effectiveness than those published injournals.97 No attempt was made to contactauthors of studies as a lower response rate wasanticipated for supplementary information fromauthors of conference abstracts and theses

compared with authors of published papers, whichwould tend to bias the information towards studieswith more favourable outcomes.

After the discarding of purely descriptive reportstwo reviewers (from AB, KR, SE, MB, IG, FT andRW) assessed articles using a three-questioninclusion/exclusion form (Appendix 5). A thirdreviewer (SE or KR) resolved disagreements overinclusion/exclusion.

Reports were included for data extraction if thefollowing criteria were met:

� evaluation of intervention to increase uptake,patient adherence or professional compliance tocardiac rehabilitation

� patients with myocardial infarction, CABG orPTCA, with heart failure or angina, or coronaryheart disease

� outcomes relevant to the reviews, specificallynumbers attending and patient adherence tocardiac rehabilitation and its exercise, educationand lifestyle components.

Data extractionOnce the decision had been made to includestudies in the review two reviewers independentlyabstracted the relevant data (data extraction formin Appendix 6). Data extracted included details ofpatients, intervention, study type, quality andresults. No attempt was made to contact authorsfor additional information.

The quality of non-randomised studies wasrecorded in accordance with recent reviews,specifically information relating to selection bias,power and analysis.98 No formal scale was used tocategorise quality, but features of individual studiesare presented in the results sections. The methodof group allocation, sample size, comparison ofgroup characteristics at baseline and concomitantservice changes independent of the interventionare used as the basis for quality assessment.

AnalysisThe systematic review takes the form of threequalitative overviews. No attempt was made topool study results as the number of trials was smalland the study designs and interventions varied.Studies are grouped by quality of evidence. Thebest evidence comes from RCTs while non-randomised and before-and-after study designsprovide less reliable evidence.99,100 Studies werecharacterised by type and size, participants,intervention, comparison group, principal andother outcomes, and authors’ conclusions.

Systematic review of interventions to improve uptake, adherence and professional compliance with cardiac rehabilitation

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BackgroundBarriers to attendance at outpatient cardiacrehabilitation have been identified, but theeffectiveness of interventions to improve uptakehas not been assessed by systematic review. Such areview is needed to identify appropriate methodsfor increasing patient use of services and tosuggest areas meriting further research. For thereview uptake was defined as any patientattendance at outpatient cardiac rehabilitation (i.e. successful recruitment).

ResultsStudies included in review ofinterventions to improve uptake ofcardiac rehabilitationThe flow of articles through the review process isshown in Appendix 7 in accordance with Qualityof Reporting of Meta-analyses (QUOROM).101

Twenty-seven articles reporting 22 studies wereidentified as relevant to the review of methods toimprove uptake of cardiac rehabilitation and wereformally included in the review. Reading by tworeviewers (AB and RW) found eight studiesreporting evaluation of an intervention relating touptake by an appropriate patient group and with arelevant outcome.

A brief summary of each study is shown in Table 18, with detailed descriptions presented inAppendix 8. More than one report was identifiedfrom the trials of Jolly and colleagues102–104 andWyer and colleagues.105,106 The referenceproviding the main source of information for thesystematic review is cited in the tables and text.

Studies excluded from review ofinterventions to improve uptake ofcardiac rehabilitationSixteen papers describing 14 studies selected fordata extraction but not included in the review aresummarised in Appendix 9. One paper reportinga before-and-after study of an intervention to

improve uptake of cardiac rehabilitation by CABGpatients was published after June 2001.112 Eightstudies had either no outcome data113–119 or nocomparison group,120 or the study wasretrospective in design.121 In five studies theoutcomes were referral122,123 or commitment toparticipate,124 or the study was related tosecondary prevention.125–127

Methodological qualities of studiesincluded in review of interventions toimprove uptake of cardiacrehabilitationSix studies reported interventions with a specificobjective of increasing uptake of outpatient cardiacrehabilitation.41,82,104,106,110,111 Two papersdescribed interventions to improve uptake ofcommunity or voluntary services (cardiac or heartclubs) after discharge from inpatient cardiacrehabilitation.108,109 All studies were of patientswith myocardial infarction, and in two studiespatients with angina104 and following cardiacsurgery110 were included.

Three of the eight studies were RCTs, withrandomisation on an individual basis in two106,108

and by general practice in one.104 Methods ofrandomisation and blind outcome assessment wereclearly described for two of the three RCTs104,106

and intervention groups were similar at baseline inall three trials.

Five articles reported non-randomisedcomparisons.41,82,109,110,111 In one study a districtproviding an intervention was compared with adistrict with no intervention.82 The districts hadpopulations with similar demographics that wereserved by the same general hospital. The otherfour papers reported uptake of cardiacrehabilitation in periods before and afterimplementation of an intervention.41,109,110,111

Baseline characteristics of groups were notreported in these studies. One before-and-afterstudy reported percentage uptake but did notprovide patient numbers or tests of statisticalsignificance.110

Chapter 8

Systematic review of interventions to improve uptake of cardiac rehabilitation


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TABLE 18 Studies evaluating interventions to improve uptake of cardiac rehabilitation

Authors, year Study type and Intervention Findings relevant to Commentsand country patients uptake

RCTs

Wyer et al.,2001106

UK

RCT, 87 MIpatients

Letters based on the theoryof planned behaviour (Ajzen& Madden)107 designed toincrease attendance at CR

Uptake of outpatient CR was86% in the interventiongroup and 57% in thecontrol group (p < 0.0025)

Intervention open toalternativeinterpretation; lettersconveying a ‘fear’message

Non-randomised studies

Osika, 200182

UKComparison oftwo districts withdifferentprovision, 175 MIpatients

Weekly home visits bytrained lay volunteers andaccompaniment to first CRsession

In the district with layvolunteer visiting 71% ofpatients attended a firstappointment at outpatientCR compared with 47% inthe control district (p = 0.02)

Intensity of lay volunteervisiting comparable withtypical CR

Krasemann &Busch, 1988109

Germany

200 MI patientsattending indifferent periods

After completion of inpatientCR pamphlet given withinformation designed tomotivate patients to join anoutpatient heart group

66% of patients whoreceived the interventionattended a heart groupcompared with 31% in thecontrol group (p < 0.001)

No baseline groupcomparisons

Mosca et al.,199841

USA

Before-and-afterstudy, 199 MIpatients

Prompt for outpatient CR indischarge critical carepathway

Critical care pathwayassociated with a non-significant increase inoutpatient CR participation(OR 1.9, 95% CI 0.6 to5.5).a


Imich, 1997110

UKBefore-and-afterstudy, MI andcardiac surgery,patient numbernot reported

Nurse support, educationand counselling in thepostdischarge, preoutpatientCR period

Attendance at outpatient CRby invited patients increasedfrom 55% before to 75%after instigation of theprogramme

Patient numbers notreported, so notpossible to assessstatistical significance

Scott et al.,2000111

Australia

a Lower 95% CI estimated.

Before and afterstudy, 649 MIpatients

Dissemination of clinicalguidelines to hospital staffand GPs. Feedback on clinicalindicators

After intervention outpatientCR utilisation increased from24% to 54% (p = 0.003)

Baseline periodcorresponds to CRprogramme start-up

Hillebrand et al., 1995108

Germany

RCT, 94 MIpatients

Following inpatient CRpatients had four telephoneand at home conversationswith social worker over a 6-month period

57% of patients whoreceived the interventionattended a cardiac groupcompared with 27% ofcontrols (p < 0.005)

Outcome is cardiacgroup attendance afterinpatient CR

Jolly et al.,1999104

UK

Cluster RCT, 67general practices,597 MI andangina patients

Liaison nurse encouragespatients to see practice nurseafter discharge and supportspractice nurses. Patient-heldrecord card to prompt andguide follow-up

42% of patients in theintervention group attendedat least one outpatient CRsession compared with 24%of controls (p < 0.001)

Multifacetedintervention.Management of patientsin control practices notexplicit


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Themes identified from the review ofinterventions to improve uptake ofcardiac rehabilitationThe interventions identified in the systematicreview can be grouped into four themes:healthcare professional-led interventions at thepatient level, trained lay volunteers, coordination of postdischarge care at the service level, and written motivationalcommunications.

Healthcare professional-led interventions at thepatient levelThree studies were identified but nonesatisfactorily assessed the value of patient contactwith healthcare professionals in improving cardiacrehabilitation uptake.104,108,110 In the RCT ofHillebrand and colleagues108 attendance at acardiac group after inpatient rehabilitation wassignificantly increased in myocardial infarctionpatients who received regular contact with a socialworker. The social worker–patient contacts attimes relevant to improvements in uptake were avisit in hospital and a telephone call 4 weeks afterdischarge. The authors considered this to be amotivational intervention. In the before-and-afterstudy of Imich110 postdischarge at-home nursingsupport for myocardial infarction and cardiacsurgery patients was associated withimprovements in attendance at outpatient cardiacrehabilitation. However, little information relatingto study quality and conduct was reported. In thenursing intervention reported by Jolly andcolleagues,104 although patients saw a liaisonnurse in hospital before discharge theintervention was aimed mainly at professionalorganisation of care and is discussed in thatsection.

Trained lay volunteersOne study looked at an intervention with trainedlay volunteers.82 In the thesis, Osika82 describesincreased cardiac rehabilitation uptake associatedwith an intervention by trained lay volunteers.The study compared myocardial infarctionpatients in two districts with similar populationsserved by the same general hospital. In onedistrict patients were offered the assistance of apatient who had previously attended cardiacrehabilitation. Patients in the district with the layvolunteer intervention were significantly morelikely to attend the first session of the outpatientcardiac rehabilitation programme. In the absence of randomisation the author attempted to validate the method by reporting similarities in demographics and service access betweengroups.

Coordination of referral and postdischarge careat the service levelInterventions aimed at increasing uptake ofoutpatient cardiac rehabilitation by improving thecoordination of postdischarge care were reportedin three studies.41,104,111 Jolly and colleagues104

reported a cluster RCT of coordination of carebetween hospital and general practice by specialistcardiac liaison nurses for myocardial infarctionand angina patients. Attendance at one or morecardiac rehabilitation sessions was significantlyincreased in the intervention group. Theintervention consisted of three main elements:liaison nurse encouragement for patient to seepractice nurse, liaison nurse support for practicenurses, and prompts and guidance for patients bymeans of a personal record card. The study designdoes not allow the effect of components to beassessed individually. Mosca and colleagues41

compared patient participation before and afterthe introduction of a prompt for cardiacrehabilitation in a discharge critical care pathway.An improvement in participation in outpatientcardiac rehabilitation was observed, but this wasnot statistically significant. Group characteristicswere not reported and other factors may haveinfluenced levels of participation. In the study byScott and colleagues,111 patients admitted tohospital in three periods were compared. Thesewere before, during and after the dissemination ofclinical guidelines and feedback of clinicalindicators to health professionals. The cardiacrehabilitation programme was operational duringthe implementation period and this was used asthe baseline period for evaluation. A steadyincrease in utilisation of the outpatient cardiacrehabilitation service was observed during theimplementation period and the authors attributethis to the intervention. However, no comparisonsof patient characteristics were available for therelevant periods and, although the authors reportthat the new cardiac rehabilitation service was fullyoperational, an increase in uptake might beexpected with a new service.

Motivational communicationsOne study showed significantly increasedoutpatient cardiac rehabilitation uptake aftermotivational letters106 and two showed improvedattendance at an outpatient heart group aftermotivational pamphlets109 or conversations.108 Inthe RCT of Wyer and colleagues,106 motivationalletters were sent to patients at 3 days and 3 weekspostmyocardial infarction. The letters were basedon Ajzen and Madden’s theory of plannedbehaviour107 and designed to influence acceptanceand attendance, although the authors noted that

the intervention many have been interpreted as afear message. Krasemann and Busch109 describeda before-and-after study in which the interventiongroup received a pamphlet with motivationalinformation about outpatient heart groups as acontinuation of inpatient cardiac rehabilitation.Patients in both intervention and comparisongroups received the addresses of local outpatientheart groups. The patients receiving themotivational pamphlet were more likely to attendthe heart group, but no comparison of baselinecharacteristics of the patient groups was reported.The RCT of Hillebrand and colleagues108

evaluated regular contact between a social workerand patients starting at the end of an inpatientcardiac rehabilitation programme. A motivatingconversation predischarge and a telephone callafter 4 weeks were associated with improvedattendance at an outpatient heart group.

Another before-and-after study of an interventionto improve uptake of cardiac rehabilitation waspublished outside the review time-frame.112 Theintervention comprised a telephonecommunication about the benefits of cardiacrehabilitation plus assistance in the referralprocess. The authors reported an increase inenrolment, but the significance of this interventionis not clear, as other between-group comparisonswere not described.

Resource implications of interventionsto improve uptake of cardiacrehabilitationInformation provided on resource use associatedwith effective interventions from studies ofreasonable quality is summarised in Table 19. Theinterventions can be summarised into threecategories: home visits by trained lay volunteers,coordination of referral and postdischarge care bypaid liaison nursing staff; and motivationalcommunication letters or pamphlets distributed bypaid staff.

Studies provided limited information on theresource inputs required. None providedinformation on the costs associated with theseresource inputs. It was unclear from theinformation available whether interventions can beimplemented by existing staff or requireemployment of extra staff and, if so, how many.Osika82 does not specify the number of trained layvolunteers per patient population required tocarry out home visits in order to encouragepatients’ attendance for cardiac rehabilitation. Themain cost incurred by the health service is thatassociated with the one-off training programme

provided by the hospital for the lay volunteers. Acardiac rehabilitation coordinator, a counsellor, aresuscitation officer and a safety officer conductedthe training, which comprised seven 5-hoursessions. The specific time input of each staff type,however, was not clearly specified, nor was it clearhow many lay volunteers were trained over thisperiod. Lay volunteers were reimbursed mileagecosts to attend for training and home visits, butthese were not quantified.

Similarly, the staff implications of liaison nursecoordination of referral and postdischarge carewere unclear. The intervention evaluated by Jollyand colleagues104 comprised three cardiac liaisonnurses who coordinated the referral andpostdischarge care of 277 patients over 18months. This suggests that one nurse could beresponsible for coordinating the referral andpostdischarge care of 62 patients per annum. It isunderstood that these liaison nurses were newappointments. Although mentioned in the study,transport costs incurred by the liaison nursevisiting practices and by the practice nursesattending training and support groups were notquantified, nor was the resource input or cost oftraining the liaison and practice nurses.

The use of motivational letters and pamphletsmay require some initial preparation and printing,but at little additional resource input to thestandard programme invitation, as these are likelyto replace existing letters. Motivational telephoneconversations and home visits by social workerswill require staff time and transport costs, butthese were not quantified in the study byHillebrand and colleagues.108

Further interventions that may improveuptake of cardiac rehabilitationsuggested in the literatureThe literature review identified a number ofsuggested interventions for improving uptake ofcardiac rehabilitation. Although these potentialinterventions were not evaluated, the studiesprovided some evidence to suggest methodsmeriting further investigation. Examples ofinterventions excluded from the review at bothformal extraction and the earlier inclusion stage,but with possible value in improving uptake, aresummarised thematically in Table 20.

DiscussionFew studies aimed at improving uptake ofoutpatient cardiac rehabilitation were found. The


34

source of studies was diverse with five paperspublished in peer-reviewed journals, two as theses(the paper by Wyer and colleagues106 waspublished after June 2001 but had previously beenwritten as a thesis) and one as a conferenceabstract. The systematic review identified studiesof four types of intervention aimed towardsimproving uptake of outpatient cardiacrehabilitation and heart groups: written or auralmotivational communications, healthcareprofessional-led interventions at the patient level,coordination of referral and postdischarge care atthe service level, and lay volunteers.

The evidence for benefits from motivationalcommunications was reasonably good, withimprovements in uptake of outpatient cardiacrehabilitation and heart groups shown in tworandomised trials106,108 and one before-and-afterstudy.109 Methods of communication used werewritten letters106 or pamphlets,109 or conversationwith a health professional.108

No conclusions can be drawn on the effectivenessof an intensive home-based nurse-led approach inpromoting outpatient cardiac rehabilitationuptake, owing to the limited information in theone report looking at this type of intervention.110

A multifaceted approach to the coordination oftransfer of care from hospital to general practiceincluding patient self-management was effective inimproving cardiac rehabilitation uptake in arandomised trial.104 Particular aspects of theintervention were not evaluated separately, and itis not possible to compare the relative importanceof inpatient nurse contact, professional support ofpractice nurses and self-empowerment of patientswith record cards. Issues relating to study qualitylimit further support from two non-randomisedtrials.41,111

Regular support and practical assistance from layvolunteers was effective in improving uptake ofoutpatient cardiac rehabilitation in a non-


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TABLE 19 Resource implications of interventions to improve uptake of cardiac rehabilitation (only considering period of interventionrelating to improving uptake)

Staff Equipment Consumables Notes

Lay volunteers

Home visits by trained lay volunteers andaccompaniment to firstCR session (Osika, 200182)

Multidisciplinary teamproviding 35 hourstraining per group ofvolunteers

Car mileage for sevenlocal visits per patient,training at hospital

Considerable timedemands on volunteers

Coordination of referral and postdischarge care

Liaison nurseencouragement to seepractice nurse. Supportfor practice nurses.Patient-held record card.(Jolly et al., 1999104)

Three cardiac liaisonnurses visit bothpatients and practicenurses

Telephone calls; trainingfor cardiac liaison nursesand practice nurses; carmileage allowance fortraining and supportmeetings

The study employedthree nurses managingthe care of 277 patientsin 18 months

Motivational communication

Telephone and at-homeconversations with socialworker (Hillebrand et al.,1995108)

Social worker visitspatients

Telephone calls; carmileage for one localvisit per patient

Motivational lettersdesigned to increaseattendance (Wyer et al.,2001106)

(Support staff; minimalrevision of normalpractice)

Letters and postage Letters substitute forexisting invitations

Pamphlet withinformation designed tomotivate patients to joinoutpatient heart groups(Krasemann & Busch,1988109)

(Support staff; minimalrevision of normalpractice)

Pamphlets

randomised trial of demographically similardistricts with different service provision.82

All authors reported benefit for interventions toimprove uptake of outpatient cardiacrehabilitation. This observation should be treated

with caution, as it is suggestive of positivepublication bias.141 However, the wide-rangingsearch of grey literature including conferenceabstracts and theses should have identified studiesconsidered of limited value for dissemination byauthors and publishers. Although it is reasonable


36

TABLE 20 Further interventions that may improve uptake of cardiac rehabilitation suggested in the literature

Authors, date Intervention Description of report

Non-specificSuskin et al., 2000124 Physician endorsement RCT. Outcome is intent to

participate in CR

Caulin-Glaser & Education of health professionals Before-and-after study. Outcome Schmeizel, 2000123 is referral to CR

Kalayi et al., 1999122 Computerised referral pathway Before-and-after study. Outcomeis referral to CR

Cannistra et al., 1995128 Early social services involvement could improve social Prospective study comparing support and therefore uptake and adherence, by reducing black and white womenhome stress

Beach et al., 199671 Self-care limitations assessment may help to assess, plan and Longitudinal interviewsfacilitate healthy perceptions and behaviour post-MI and promote CR

Tack & Gilliss, 1990129 Early information and follow-up can improve recovery Prospective, longitudinal expectations, give support and promote healthy coping and interviewsCR uptake

Hershberger et al., Assessment of patient personality type could give a better Retrospective study1999130 indicator of compliance, uptake and adherence, and allow

professionals to target those most in need

Alternative methods of provisionDeBusk et al., 1985131 Home-based rehabilitation with ECG monitoring RCT. Comparison of methods of

delivery

Lewin et al., 1992132 Home-based rehabilitation RCT. Effectiveness

Shaw, 1999133 Physiologically monitored exercise and health education Reviewover the Internet

Ades et al., 2000134 Home-based telephone-monitored CR Trial: group allocation by distancefrom CR. Comparison ofmethods of delivery

Roitman et al., 1998135 Case-management and risk stratification Review

Bethell & Mullee, 1990136 Community-based CR: achieves high patient uptake RCT. Effectiveness

Pell & Morrison, 199851 Community-based CR: more patient friendly, improving Audituptake, particularly if run in socially deprived areas

Contractor et al., 2000137 Community-based CR: may increase accessibility of services RCT. Effectiveness

Interventions for womenRadley et al., 199857 Implementing a one-off women-only education session in a Retrospective study

CR programme may help to address gender-sensitive issues e.g. returning to sexual relations and housework

Moore, 1996138 Women-specific social support. Strategies to improve social Focus-group interviewssupport: better exercise variety and choice, and social opportunities during the programme

Brezinka et al., 1998139 Women-specific counselling and smaller exercise sessions Comparative semistructuredinterviews and questionnaires

Cannistra et al., 199224 Provision of childcare/home-help for women attending Prospective study comparing men outpatient CR and women

Toobert et al., 1998140 Women’s retreat could increase uptake by improving RCT. Effectivenessemotional social support and relationships with CR staff

to anticipate some improvement, it is not knownhow many similar or different interventions havebeen tried without success and, becauseunsuccessful, not reported. Similarly, equivocalresults relating to cardiac rehabilitation uptakemay not have been included in publications ofstudies with multiple findings. Three of the eightstudies included in the review reported substantialmaterial on other outcomes or observations, whichwould have merited full publication.

It would be inappropriate to draw firmconclusions relating costs to effectiveness of theinterventions described in the above studies. Theirresource use implications are not clearly described.However, order of magnitude costs may beinferred and these suggest a wide range in impliedcosts. Motivational interventions need not becostly, as they may replace the existing method ofinvitation. Individual home visits clearly add tothe costs of a service otherwise provided in anoutpatient setting. However, more visiting isbecoming part of postdischarge care and cardiacrehabilitation. The study by Jolly and colleagues104

was an evaluation of the introduction of liaisonnurses (which would certainly be more costly) andmay serve to define their role in supportingpatients and other healthcare professionals andcoordinating postdischarge care. Incorporation ofmotivational elements into home visiting may beappropriate, with little further implications forresources.

The literature contained many suggestedinterventions as facilitators of improved uptake ofcardiac rehabilitation, but with no relevantevaluation. At the service level, appropriateeducation of health professionals and use ofdischarge care pathways and case managementmay improve referral and subsequent attendanceat rehabilitation.122–124,135 In a similar vein to themotivational approach of Wyer and colleagues106

the form of the recommendation to attend may beimportant, with endorsement by a physician ofpossible value.124

Early support postdischarge by healthcareprofessionals may be appropriate in promotingcardiac rehabilitation and improving uptake.128,129

In addition, at an early stage the assessment ofpatients with regard to self-care limitations andpersonality type may be helpful in the targeting,planning and optimisation of postdischarge care,including rehabilitation.71,130

Home-based programmes are frequently used inthe period between hospital discharge and

attendance at outpatient cardiac rehabilitation.142

The home-based programme usually takes theform of a written booklet with an exerciseschedule, psychosocial interventions andeducation relating to risk factor managementappropriate for the early stages of recovery. Thismay serve to maintain patient motivation tolifestyle change in a period with limited contactwith health professionals and hence promote lateruptake of outpatient rehabilitation services. Thismerits further evaluation.

Home-based cardiac rehabilitation has also beenpromoted as a substitute for attendance at anoutpatient programme.131,132 Trials have shownsimilar effectiveness in risk factor managementand patient quality of life after home-based andoutpatient methods. Appropriately delivered andassessed home-based cardiac rehabilitation may bea safe and effective form of provision for low- tomoderate-risk patients. However, application ofthe home-based approach as a means to improvethe reach of cardiac rehabilitation services shouldreplicate the methods used in the trials ofeffectiveness and include frequent nurse visits,multidisciplinary input, psychological evaluationand thorough assessment. Patient acceptance of ahome-based package does not equate to uptake ofcardiac rehabilitation and the demonstration ofcomparability with an existing service may merelybe observation of similar natural recovery in thepatient groups. Consequently, home-basedrehabilitation is not an appropriate substitute foroutpatient services in patients with more severedisease or those with low motivation or lack ofinterest. It may have value in motivated low- tomoderate-risk patients, particularly those livingdistant from current services. If there is arequirement for monitoring and assessment thiscould be undertaken using telemedicineapproaches, including ECG monitoring andtelephone contact during exercise sessions.131,133,134

An alternative approach to cardiac rehabilitationprovision outside the hospital setting is the use offacilities in the community.51,136,137 The serviceprovided can be identical to the outpatientprogramme in content and multidisciplinarynature but avoid features associated with reducedattendance at hospital, including accessdifficulties. Similarly, factors limiting the uptake ofhome-based cardiac rehabilitation may be avoided,including reduced reliance on patient self-motivation. Cardiac rehabilitation in a communitysetting merits evaluation as a method forimproving patient uptake and may be particularlyvaluable in socially deprived areas.51


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The need to adapt cardiac rehabilitation servicesto suit female patients has been acknowledged byseveral authors.57,128,138–140 Many female patientshave a higher level of psychosocial impairmentand lower level of physical function than men, andtherefore need gender-specific approaches torehabilitation.139 Suggested interventions toimprove uptake include a women-only educationsession,57 appropriate exercise choices,138 specificcounselling,139 strategies to improve socialsupport,138 provision of childcare and home-help,24 and a women’s retreat.140

There are numerous reports of reasons for non-attendance and under-representation in outpatientcardiac rehabilitation, so it is surprising that thesystematic review of published literature identifiedso few evaluations of interventions to improveuptake. All those found were generic interventionsapplicable to all patients. The effectiveness ofsimple targeted interventions to facilitateattendance is not reported in the literature. Noevaluations of interventions were reported toaddress the frequently cited patient reasons fornon-attendance of perceived illness, transportdifficulties, inconvenient timing or dependentrelatives. Transport schemes, non-hospital settings,programmes for specific patient groups (singlegender, elderly, ethnic minority groups) andprovision of respite care for dependants have beensuggested, but not evaluated as possible measuresfor improving service uptake. It is possible that

some programme coordinators have recogniseddeficits and the need for improvement in services and implemented changes: provision ofservices for a patient group previously nottargeted for rehabilitation is likely to show initial improvement in uptake; but this is aHawthorne effect which may not be sustained.However, the lack of evidence for benefit foundfor the use of critical care pathways and thelimited evidence for other interventionsdemonstrate the requirement for good qualityRCTs of new methods.

ConclusionsThe systematic review of the literature suggeststhat approaches aimed at motivating patients maybe of value in improving the uptake of cardiacrehabilitation. The content of invitation letters,pamphlets and home visits may be used as avehicle for motivational messages. Someencouragement was also found for use of trainedlay visitors in facilitating patient attendance atcardiac rehabilitation. The implied costs ofinterventions varied widely.

Overall, few trials aimed at improving uptake ofcardiac rehabilitation were identified. The needfor trials of interventions applicable to all patientsand targeting specific under-represented groups issuggested by observational studies.


39


BackgroundFollowing successful recruitment of patients to acardiac rehabilitation programme it is importantto promote patient adherence to the programmeand to maintain associated lifestyle changes. Thissystematic review aims to assess the effectiveness ofmethods for increasing patient adherence tocardiac rehabilitation and to suggest areas forfurther research. For the review adherence wasdefined as patient attendance at all or the majorityof a programme, or maintenance of lifestylechanges associated with cardiac rehabilitation.

ResultsStudies included in the review ofinterventions to improve adherencewith cardiac rehabilitationIn Appendix 10 the flow of articles through thereview process is shown in accordance withQUOROM.101 Thirty-eight articles reporting 37studies identified as relevant to the review ofmethods to improve adherence to outpatientcardiac rehabilitation and its components wereformally included in the review. A broad definitionof adherence was applied, with included studiesreporting attempts to improve overall programmeattendance or compliance with aspects of cardiacrehabilitation. In-depth reading by two reviewers(KR and AB) found 14 studies reportingevaluation of an intervention relating toadherence in an appropriate patient group andwith a relevant outcome. Only studies with anexplicit statement in their objectives that theintervention under evaluation was designed topromote adherence or those studies withobjectives that were explicitly to examine theeffects of an intervention on adherence wereincluded in the review.

Studies were characterised by study design andsize, the study participants, nature of theintervention, comparison group, principal andother outcomes, and authors’ conclusions.

A brief summary of studies is presented in Table 21, with further details in Appendix 11. Tworeports were identified describing the study ofMiller and colleagues.143,144

Studies excluded from the review ofinterventions to improve adherence to cardiac rehabilitationPapers not included in the review are summarisedin Appendix 12. Nine out of 23 studies excludedfrom the review looked at the effectiveness ofdifferent rehabilitation formats: home-basedcardiac rehabilitation,73,131,134,158 differentintensities or duration of exercise training, 159–161

group counselling162 or structured teaching.163

These were not included in the review as theyreported effectiveness of interventions with nospecific aim at improving patient adherence tocardiac rehabilitation. Thirteen studies had eitherno relevant outcome126,164–172 or no comparisongroup.173–175 One study presented retrospectivedata with no indication of how patients came toreceive an intervention.121

Methodological qualities of studiesincluded in the review of interventionsto improve adherence to cardiacrehabilitationFourteen studies were identified, of which halfwere RCTs145–151 and half were non-randomisedstudies.143,144,152–157 One randomised147 and onenon-randomised study156 reported two distinctinterventions. In the non-randomised studiespatients were designated to groups by alternateallocation,143,144,152 before and afterimplementation of an intervention154,156,157 and byrandom allocation with some non-randomallocation aimed at increasing numbers in theintervention group.153 In two studies the allocationto groups was not clearly described.155,156

In six studies patients with one specific diagnosiswere included and in eight studies less specificselection was applied. Patients represented weremyocardial infarction (nine studies), CABG (eightstudies), angina (three studies), PTCA (three

Chapter 9

Systematic review of interventions to improve adherence to cardiac rehabilitation


40

TABLE 21 Studies evaluating interventions to improve adherence to cardiac rehabilitation

Authors, year Study type and Intervention Outcome relevant to Commentsand country patients adherence

RCTs

Oldridge &Jones, 1983145

Canada

RCT, 120 MI,CABG and anginapatients

Self-management: agreementto participate in exerciserehabilitation programmesigned by patient andcoordinator; self-report diarywith monitoring of heartrates; questionnaires of dailyactivities; weight loss andsmoking diaries. Progressdiscussed with coordinator atregular intervals

Attendance at >60% ofexercise sessions was 54% inthe intervention group and42% in the control group(not statistically significant)

Daltroy, 1985146

USARCT, 174 MI,CABG, PTCA andangina patients

Persuasive telephoneeducation intervention toimprove patient adherenceto exercise regimens. Oralcommitment to attend.Spouse telephone counselling

Attendance at exercisesessions by patients was63.8% in the interventiongroup and 62.2% in thecomparison group (notstatistically significant)

Mahler et al.,1999147

USA

RCT with twointerventiongroups and onecontrol group,215 CABGpatients

Post-CABG surgeryvideotape. (1) Mastery:depicts patients as calm andconfident, making steadyprogress with relative ease.(2) Coping: recoveryportrayed as steady forwardprogression of ups anddowns

Exercise complianceimproved with bothinterventions compared withcontrols (p < 0.02 to p < 0.05). Reduction indietary cholesterol andsaturated fat at 1 month inboth intervention groupscompared with controls (p < 0.05) but not at 3 months

Aish & Isenberg, 1996148

Canada

RCT, 104 MIpatients

Nursing intervention ofnutritional self-care. Foodhabits assessed andsuggestions for changes givenwith patient commitment.Follow-up telephone calls

Total dietary and saturatedfat significantly reduced inthe intervention group (p < 0.01). Also significantimprovements in food habits(p < 0.05)

Ashe, 1993149

USAAllocation byform in sealedenvelope, 41 MI, CABG,angina, valveproblem patients

Motivational relapseprevention during the CRprogramme: identification offactors interfering withadherence; goals forprogramme; coping withslips; stressors affectinglifestyle. Also stressmanagement, exercise andrelaxation procedure

Total adherence to themaximum number ofexercise sessions was 90% inthe intervention group and89% in the control group(not significant)

continued


41


TABLE 21 Studies evaluating interventions to improve adherence to cardiac rehabilitation (cont’d)


Hopper,1995150

USA

RCT, 80 MI,CABG,angioplastypatients

Monthly telephone contactby a cardiac nurse orexercise physiologist topromote exercise, healthydiet, medication usage, riskfactor knowledge andidentification of symptoms

No difference betweengroups in exercise habit orintention to exercise.Conditions that facilitated theperformance of exercisewere improved in theintervention group comparedwith control (p < 0.05)

Losses to follow-up of45% in the interventiongroup and 47% incontrols

Duncan et al.,2001151

USA

RCT, eight heartfailure patients

Behavioural feedbackintervention on dietarysodium intake. Discussion ofproblem-solving strategies toreduce sodium intake

Sodium intake wassignificantly less in theintervention group (1569 vs2836 mg, p < 0.05)

Small feasibility study,four patients in eachgroup

Leslie &Schuster,1991152

USA

Alternateallocation, 30 MI,CABG,angioplasty,coronary diseasepatients

Written exercise contractnegotiated with the patient.On completion of thecontract patients received areward

No significant difference inattendance in intervention(90%) and control (89%).Significant increase inexercise knowledge in theintervention group

Miller et al.,1988,143

1989144

USA

Alternateallocation, 115 MI patients

Nurse intervention toimprove medical regimen. (1) Assessment: attitudes andregimen compliance. (2) Problem identification. (3) Goal setting

No significant differences inhealth behaviour and attitudescales

Repeated self-evaluationquestionnaires and visitsmay have acted asintervention in controlgroup

Lack, 1985153

USA Part random, partnon-randomised,48 CHD, MI,CABG patients

Insight-orientated grouppsychotherapy. Supportive,cooperative and goaldirected. Highlight andpromote change in non-compliance with physicianrecommendations

Self-report measures ofcompliance 2.57 forintervention and 2.37 controlgroups (not significant).Intervention group attended88.4% of the prescribedexercise sessions comparedwith 75.7% in the controlgroup (p < 0.05)

Marshall et al.,1986154

USA

Patients seen indifferent periods,60 CABGpatients

Nurse-led structuredteaching programme toincrease patients’ knowledgeand compliance tomedication, diet, smokingcessation and exercise

Overall compliance scoreassessed by self-report was86.8 in the interventiongroup, and 79.5 in thecontrol group (p < 0.05).Compliance better inintervention than controlgroup for activity (15.6 vs 7blocks walked, p < 0.005)

Huerin et al.,1998155

Argentina

Non-randomisedstudy, 509 CHDpatients

Adherence strategy withsigned commitment torehabilitation, familyinvolvement, sports,recreational activities andtalks

Attendance at ≥ 66%sessions. RR 2.3 (95% CI 1.8to 2.9) at 12 weeks, 2.9 (2.3to 3.7) at 24 weeks, 4.25(3.2 to 5.6) at 52 weeks (log-rank test between strategies,p < 0.001)

No information ongroup allocation


continued

studies), heart failure (one study), valvereplacement (one study) and non-specific coronaryheart disease (four studies).

In eight studies (two randomised) the outcome wasattendance at exercise sessions.145,146,149,152,153,155–157

In six studies (four randomised) the outcome wasquestionnaire assessment of diet or exercisebehaviours to determine compliance with lifestylechanges.143,144,147,148,150,151,154

The method of randomisation was described intwo of the seven RCTs145,146 and blind outcomeassessment in one randomised study.146 None ofthe seven non-randomised studies reported blindoutcome assessment. Baseline characteristics ofintervention and comparison groups weredescribed in three randomised trials,146,148,150 andin one trial patients were stratified by factorspredictive of dropout from cardiacrehabilitation.145 In five non-randomised studiesbaseline characteristics of patients werereported.143,144,152–155 Eight studies providedinformation on losses to follow-up.143–147,149,150,152,153 In one randomised study lossto follow-up was particularly high at 45–47%.150

Themes identified from the review ofinterventions to improve adherence tocardiac rehabilitationInterventions to improve adherence to cardiacrehabilitation or elements of the rehabilitationprocess were varied and frequently multifaceted.

However, five general themes are apparent: formalpatient commitment, spouse or familyinvolvement, strategies to aid self-management,education, and psychological intervention. Studieswith more than one component are included ineach appropriate theme.

Formal patient commitmentIn four studies an agreement between the patientand the programme staff was a key element of theintervention.145,146,152,155 In the trial of Leslie andSchuster152 the intervention was solely a writtencontingency contract with rewards for successfulcompletion of attainable exercise behaviours.Patients were allocated alternatively to interventionand comparison groups, which were reasonablywell matched. Attendance rates at exercise sessionswere similar in the two groups, although patientsin the contract group showed a significant increasein exercise knowledge compared with controls.Overall participation at exercise sessions wasnotably high (90%). In the RCT of Oldridge andJones,145 a self-managed adherence promotingstrategy incorporating signed commitment wasassociated with a non-significant improvement inattendance at an exercise rehabilitationprogramme. Huerin and colleagues155 reported asignificant increase in cardiac rehabilitationattendance in patients receiving an adherence-promoting strategy with signed agreement, butlittle information was presented on the allocationof patients to groups. Daltroy146 reported an RCTin which oral commitment was included in a


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TABLE 21 Studies evaluating interventions to improve adherence to cardiac rehabilitation (cont’d)


McKenna et al.,1998156

UK

(1) Non-randomisedstudy. (2) MIpatientscompared withhistorical controls

(1) Low-intensity exercise forpatients unable to take partin standard exercise owing toco-morbidity. (2) Women-only groups

Attendance was 82% in thelow-intensity exercise groupand 34% in the standardrehabilitation comparisongroup. Significance notassessed as patient numbersnot reported. Attendance inthe women-only group was75%, compared with 6%historically

Patient numbers notreported. Themagnitude of changescannot be assessed

Erling &Oldridge,1985157

Canada

Before-and-afterstudy, 90 CHDpatients

Spouse support in outpatientCR. Compares baselinebefore spouse participation,patients with spouseparticipation and patientswith no spouse participation

Attendance increased from44% to 90% for programmewith spouse participation (p < 0.001), and 67% forprogramme with no spouseparticipation (p < 0.05)

RR, relative risk.

persuasive telephone intervention to improvepatient adherence to an exercise programme. Noimprovement in attendance was seen in patientsreceiving the intervention.

Spouse or family involvement Three studies included an intervention directed at the patient’s spouse or family.146,155,157 Erlingand Oldridge157 reported a before-and-after studyin which a spouse support programme wasassociated with significantly increased patientattendance at a cardiac rehabilitation programme.The authors showed no baseline comparisons ofthe two groups. In the RTC of persuasivetelephone education, Daltroy146 providedtelephone counselling to patient spouses. Noimprovement in attendance was associated withthe intervention. Family involvement was also acomponent of the adherence strategy of Huerinand colleagues.155 Improved outpatient cardiacrehabilitation attendance was observed, but lack ofinformation on group allocation limits the value ofthe study.

Strategies to aid self-management Five studies reported interventions based on self-management techniques.143–145,148,149,151 In theRCT of Oldridge and Jones,145 as well as signedagreement, patients completed and receivedfeedback on self-report diaries of heart rate, dailyactivities, weight loss and smoking habit. Theintervention was associated with a non-significantincrease in attendance at the exerciserehabilitation programme. Aish and Isenberg148

reported an RCT of nutritional self-care based onthe model of Orem,176 in which patients had foodhabits assessed and individualised nutritionalgoals set. Significant improvements in dietaryvariables were achieved in the self-care patients. Asimilar programme of assessment, problemidentification and goal setting was assessed in atrial by Miller and colleagues,143,144 in whichpatients were allocated alternatively tointervention and control after completion of acourse of inpatient rehabilitation. Regimencompliance measured by health behaviour andattitude scales did not differ between groups. Theauthors noted that the frequent completion of self-evaluation questionnaires and data collection visitsby nurses may have served as an effectiveintervention in the control group. In the thesis byAshe149 an apparently randomised approach wasused to evaluate a motivational relapse preventionprogramme, based on Marlatt and Gordon’smodel,177 for patients after an outpatient cardiacrehabilitation programme. Patients were allocatedto groups according to the forms contained in

sealed envelopes. As with other self-managementinterventions this included assessment, problemidentification and goal setting. Adherence toexercise was similar in the intervention andcontrol groups. However, it should be noted thatthe control patients received an interventionwhich, although not designed as a motivationalprogramme, did provide patients with anequivalent number of extra sessions of exerciseeducation. A small RCT described by Duncan andcolleagues151 applied self-management andbehavioural feedback methods to the control ofsodium intake. Heart failure patients attending acardiopulmonary rehabilitation programme wererandomised to receive an intervention withassessment of sodium intake, discussion ofproblem-solving strategies and follow-up. Patientsreceiving the intervention had a significantlyreduced sodium intake.

Educational intervention Four studies of educational interventions aimed atimproving adherence to components of cardiacrehabilitation were identified.146,147,150,154 TheRCT reported by Daltroy included an educationalintervention in the form of telephonecounselling.146 This was designed as a persuasivecommunication with emphasis on the benefits ofexercise, realistic expectations of recovery andcoping methods. Attendance at exerciseprogrammes was not improved in the group withthe educational intervention. In the RCT ofMahler and colleagues147 patients were showneducational videotapes before discharge fromhospital. The tapes provided informationregarding recovery delivered by a healthcareexpert. Compliance with exercise and dietaryadvice measured by questionnaire was increased inpatients receiving the intervention. The authorssuggest that presenting the information in aformat describing a realistic coping approach torecovery may be beneficial. Hopper150 describedan RCT of regular educational and supportivetelephone calls. Although no difference was shownin exercise behaviour between groups, thosepatients receiving the supportive educationalintervention did report improvement in conditionsfacilitating the performance of exercise. Marshalland colleagues154 compared the effect of nurse-ledstructured and non-structured postoperativeteaching in two consecutive groups of patients.Patient characteristics and risk factors were similarin the two groups. Measures of compliance basedon self-report of activity, smoking, and acomposite of activity, smoking, diet andmedications were improved in the structuredteaching group.


43


Psychological intervention One intervention describing a specificallypsychological intervention was identified.153

Lack153 describes an insight-orientated grouppsychotherapy intervention in a partiallyrandomised study. The randomised group wasaugmented with non-randomised patients if therewere insufficient numbers to form an interventiongroup. For the intervention patients wereencouraged to communicate thoughts and feelingsand to promote changes in behaviours likely toaffect recovery. Self-report and physiologicalmarkers of compliance to exercise were littlechanged by the intervention. However, there was asignificantly higher attendance at exercise sessionsin the patients receiving the psychotherapyintervention.

Other interventions Two reports described interventions that did notfit into the above themes.155,156 McKenna andcolleagues156 reported that attendance wasincreased after implementation of women-onlyand low-intensity exercise programmes. Numbersin comparison groups and patient characteristicswere not reported. In the study by Huerin andcolleagues155 recreational activities and sports wereincluded in the adherence strategy. Again, thereporting precludes any assessment of value.

Resource implications of interventionsto improve adherence to cardiacrehabilitation Information provided on resource use associatedwith effective interventions from studies ofreasonable quality is summarised in Table 22. Theinterventions can be summarised into twocategories: strategies to aid self-management, and

educational interventions. Studies providedlimited information on the resource inputs and noinformation on the costs associated with theseresource inputs.

It is unclear whether the strategies to aid self-management can be implemented by existing staffor require the employment of extra staff and, if so,how many. The intervention described by Aish andIsenberg148 consisted of two interviews with anurse for dietary assessment and three follow-uptelephone calls by a nurse for each patient. Thefirst interview was conducted in hospital and thesecond at a home visit. Duncan and colleagues151

evaluated a similar intervention, but in their studyboth interviews were conducted during outpatientcardiac rehabilitation sessions. In both studiespatients were also required to complete a 3-daydietary intake log. The videotape intervention ofMahler and colleagues147 was provided in hospitalbefore discharge. After initial preparation ofeducational material the main resource input ofthe intervention would be the appropriateaudiovisual equipment.

Further interventions that may improveadherence to cardiac rehabilitationsuggested in the literatureThe literature review identified a number ofsuggested interventions for improving adherenceto cardiac rehabilitation. Although these potentialinterventions were not evaluated, the studiesprovided some evidence to suggest methodsmeriting further investigation. Examples ofinterventions excluded from the review at bothformal extraction and the earlier inclusion stage,but with possible value in improving uptake, aresummarised thematically in Table 23.


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TABLE 22 Resource implications of interventions to improve adherence to cardiac rehabilitation

Staff Equipment Consumables Notes

Strategy to aid self-management

Nursing intervention ofnutritional self-care (Aish & Isenberg, 1996148)

Nurse Telephone One visit in hospital andlocal visit; threetelephone calls perpatient; dietary records

Behavioural feedback ondietary sodium (Duncanet al., 2001151)

Nurse Two interviews duringoutpatient rehabilitation;dietary records

Educational intervention

Post-CABG surgeryvideotape (Mahler et al.,1999147)

Video recordingand player

Video shown in hospitalbefore discharge

DiscussionInformation came from journals (seven studies),theses (three studies) and conference abstracts(four studies). It was disappointing to find thatsome evaluations of potentially valuable methodsto improve adherence to outpatient cardiacrehabilitation and its components were only foundin the grey literature, with little chance of beingread by health professionals.

Systematic review of the literature identified fivemain intervention themes: formal patientcommitment, spouse or family involvement,strategies to aid self-management, education, andpsychological therapy.

The review of the literature gave little support tothe use of written and oral commitments topromote exercise adherence. The one studylooking exclusively at written contracting showed


45


TABLE 23 Further interventions that may improve adherence to cardiac rehabilitation suggested in the literature

Authors, year Intervention Purpose of study

Non-specificMcGee & Horgan, 199254 Former patients as models may help to promote adherence Audit

Tooth & McKenna, Strategy to improve self-efficacy. Patient modelling on video Review1996178 and audiotape and in leaflets. Patients view other patients

(e.g. healthy meal preparation)

Koikkalainen et al., Social skill and taste-training may remove barriers to a Structured interviews1996179 healthy lifestyle

Knapp & Blackwell, Offering specific and practical assistance for spouses Review1985180 (e.g. menus and recipes) to help improve, lifestyle change

Edgren, 1998181 Hydrotherapy as part of the exercise component. To Generic case study and interviewsincrease self-training patients attend a gym and/or hydro session weekly

Lee et al., 1996161 Lower intensity exercise programme RCT of effectiveness

Oldridge, 1984182 Vary programme and include swimming and different Reviewexercise equipment

DeBusk et al., 1994183 Case management and risk stratification. A more RCT of effectivenessRoitman, et al., 1998135 individualised package of care may lead to improved Review

adherence

Hoepfel-Harris, 1980184 Provide classes at convenient times, including before work ReviewComoss, 1988185 and evenings ReviewEmery, 1995186 Review

Interventions for womenRadley et al., 199857 A one-off women-only education session may help to Retrospective study

address gender-sensitive rehabilitation issues

Moore & Kramer, 1996187 Women-specific social support, exercise variety and choice, Focus-group interviewsand social opportunities

Brezinka et al., 1998139 Women-specific counselling and smaller exercise sessions Comparative semistructuredinterviews and questionnaires

Toobert et al., 1998140 Women’s retreat to improve emotional social support and RCT of effectivenessrelationships with cardiac rehabilitation staff

Cannistra et al., 199224 Provision of childcare or home-help for women attending Prospective comparison study of cardiac rehabilitation men and women

Interventions for the elderlyAllen & Redman, 1996188 Awareness of elderly-specific hindrances. Shorter education Review

sessions with less information run at a slower pace

Interventions for ethnic groupsCaulin-Glaser & Take account of cultural and racial differences when Prospective observational studySchmeizel, 2000123 attempting to improve diet and exercise habits.

African–American males showed fewer improvements in diet than Caucasians

Eftekhari et al., 2000189 Translation and presentation of educational material for Programme descriptionAsian patients

no effect using a non-randomised design.152

Attendance in both intervention and controlgroups was high at about 90%. A randomised trialof a self-management programme incorporatingsigned agreement to participate as an adjunct toan exercise rehabilitation programme showed anon-significant improvement in attendance.145

The small benefit cannot be attributed entirely towritten communication as the interventionincluded several other self-managementapproaches. Similarly, in a study of persuasiveintervention by telephone with additional spousecounselling, oral commitment constituted one partof the intervention.146 No improvement inattendance was attributed to this package ofmeasures. One further study provided littlemethodological information to substantiate anobserved improvement in cardiac rehabilitationafter an adherence strategy incorporating signedcommitment.155 Overall, the value of formalcommitment in promoting adherence to cardiacrehabilitation is not supported by evidence fromthe literature. The identification of only one studylooking specifically at written agreement toparticipate, but in which attendance was uniformlyhigh in intervention and comparison groups maysuggest the need for more trials. However, it isprobable that the use of written and oralcommitment has better application in thepromotion of outpatient cardiac rehabilitationuptake rather than adherence.

Evidence for the benefit of spouse or familyinvolvement in increasing rehabilitation adherencewas limited by the designs of studies. One studylooking specifically at a spouse supportprogramme provided no information on baselinecharacteristics or group allocation.157 In anotherrandomised study telephone counselling forspouses was provided in addition to a moreintensive patient counselling intervention, but noimprovement in attendance was observed.146

Another study incorporated family involvementinto an adherence-promoting strategy, but littleinformation on the design or conduct of the studywas reported.155 None of these studies addressedspecifically the issue of spouse or familyinvolvement in promoting rehabilitationattendance in an adequately designed trial.Evidence for the effectiveness of counselling andsupport in helping spouses and families to copewith patient illness suggests that interventions mayhave value other than in promoting adherence tocardiac rehabilitation.144,190

Studies reporting strategies to aid self-management aimed at improving adherence to

rehabilitation goals give some suggestion ofbenefit. In a randomised trial of self-evaluationand information feedback on exercise and riskfactors a non-significant improvement inattendance at rehabilitation was observed.145 Inthis trial patients were also asked for writtencommitment. Another randomised trial reportedimprovements in dietary habits,148 and a small,randomised trial showed reduced sodium intakeafter individualised assessment and goal setting.151

However, two trials, one randomised149 and theother with non-random allocation to groups,143,144

suggested no benefit for assessment and goalsetting in improving health behaviours or exerciseadherence. The authors noted that controlpatients in these studies received regular self-evaluation questionnaires and nurse visits for datacollection143,144 or an educational interventionunrelated to self-management,149 which may haveaffected outcomes. In trials a repeatedlyadministered evaluation tool may act as anintervention. In conclusion, the uses of appropriatetechniques promoting self-management in specificareas of rehabilitation are at least worthy offurther study.

Studies of educational interventions to improveadherence to components of cardiac rehabilitationgave little encouragement. No benefits ofeducation and counselling on attendance at anexercise programme were seen in two RCTs usingtelephone interventions.146,150 A predischargevideotaped educational intervention was effectivein improving exercise and dietary compliance.147

Although this may be of benefit in the early phasesof rehabilitation it is likely to have limited value inthe promotion of adherence to outpatient cardiacrehabilitation. However, the study did suggest thatpresentation of information in a format describingrecovery based on a coping approach may be mosteffective. The importance of the method ofdissemination of educational information was alsosuggested by a before-and-after study showingbenefit for a structured teaching approach.154

One partially randomised study reported apsychological intervention aimed at improvingexercise adherence.153 Although no significantimprovement in self-reported exercise wasobserved, the patients receiving a 12-weekpsychotherapy intervention attended more cardiacrehabilitation exercise sessions. This improvedattendance may be a consequence of thepsychological features of the intervention or of theextra requirement to attend the rehabilitationcentre. The lack of an effect on self-reportedexercise tends to support the latter.


46

Two studies reported other approaches toimproving adherence. These were the inclusion ofrecreational activities and sports in theprogramme155 and the introduction of outpatientcardiac rehabilitation designed specifically forwomen.156 Little can be learned from either studyas insufficient information on patients and studymethods was reported.

Little information on the costs associated witheffective interventions can be inferred from thepublished reports. One can do little more thanguess the time commitment of nursing staff toundertake these extra tasks. Strategies to improvepatient self-management, such as dietaryassessments, could be incorporated into outpatientcardiac rehabilitation session and may thereforenot require home visits. Nurses would still requiretraining in the evaluation of diet and the analysisof questionnaire data, and this may serve toformalise assessment and procedures already inplace in cardiac rehabilitation.

With respect to the educational intervention,videos are frequently used to provide informationto patients before discharge, and presentation ofinformation in an alternative delivery formatwould not have resource implications. However,initial preparation or purchase of appropriateeducational videos would be required.

Outside those trials aimed at improving adherenceto cardiac rehabilitation several interventions havebeen suggested but not evaluated. These includemore approaches based around improvements inpatient self-efficacy. The inclusion in programmesof previous patients or representation on video ofbehaviour of model patients showing appropriatelifestyle change (e.g. relating to food preparation)may be a useful format for delivery ofinformation.54,178 Similarly, practical demonstrationthat a healthy diet can be palatable and enjoyablemay be a method to promote adherence to dietarychange.179 In these areas of intervention theinvolvement of spouses may be appropriate.180

Alternative forms of exercise, includingswimming,182 hydrotherapy181 and lower intensitytraining,161 may be worthy of evaluation inimproving adherence to rehabilitation.Programmes with lower exercise intensities may bemore likely to achieve maximum attendance,161

but an extended length programme may berequired to maintain benefits.144 Slower paced andless detailed sessions may be appropriate in theprovision of educational information to elderlypatients.188

Women patients may prefer different kinds ofexercise to men and be more likely to adhere torehabilitation other than treadmill and cycle.187

Other interventions that may improve adherenceby women patients suggested in the literatureinclude education, counselling and social supportaddressing issues specific to women’srecovery.57,139,187 Provision of childcare or home-help for women attending cardiac rehabilitationmay improve adherence.24

Taking into account cultural and racial differencesin the promotion of exercise and diet may help toimprove adherence by ethnic groups torehabilitation.123 Translation of educationalmaterials and presentation in an appropriate waymay improve adherence in ethnic minoritygroups.189

Other forms of rehabilitation based around riskstratification and case management are suggestedas methods to improve patient adherence,135,183

but the effectiveness of this approach comparedwith outpatient rehabilitation with appropriateoutcome measures is not known. Similarly,provision of support at a women’s retreat mayserve to promote lifestyle change, although itseffectiveness as an adjunct to outpatient care hasnot been evaluated.140

Providing classes at times to suit patients mayimprove adherence to cardiac rehabilitation.Patients may find it easier to attend classes timedbefore work and in the evening.184–186

The systematic review of the literature found fewstudies of sufficient quality to make specificrecommendations of methods to improveadherence to outpatient cardiac rehabilitation andits components. The most promising approach wasthe use of self-management techniques basedaround individualised assessment, problemsolving, goal setting and follow-up. This is mostlikely to be effective in improving specific aspectsof rehabilitation, including exercise and diet.Further investigation of this approach may be bestcarried out by a systematic review of self-management interventions in less specific patientgroups than considered here. Patient commitmentto attend did not suggest benefit in the promotionof adherence to aspects of outpatient cardiacrehabilitation, but may be useful in improvinguptake of rehabilitation. Other interventionsidentified in the literature may already bestandard practice: use of educational video andclasses, and psychological support are features ofthe modern rehabilitation programme. Similarly,


47



48

spouse and family support may be provided as anadjunct to a rehabilitation programme for reasonsunrelated to patient adherence.

Perhaps the most disappointing outcome of thereview is the dearth of literature reporting theevaluation of simple interventions aimed atimproving adherence to cardiac rehabilitation forall patients or specific groups of patients. Nointerventions were reported to address thefrequently cited patient reasons for non-adherenceof perceived recovery, illness, transport difficulties,inconvenient timing or care of dependentrelatives. Similarly, no evaluations were identifiedof programmes designed to improve adherencefor specific patient groups frequently under-represented in outpatient cardiac rehabilitation(including women, the elderly and ethnic minoritygroups). The lack of published studies may reflectan under-appreciation by both rehabilitation staffand journal editors of the value of trials inevaluating new interventions to improveadherence to cardiac rehabilitation. Surveys andaudits suggest that programme coordinators mayrecognise deficits and the need for improvementsin services and implement changes to provisionwithout formal evaluation. The ineffectiveness ofseveral types of intervention to improve adherenceto cardiac rehabilitation identified in thissystematic review demonstrates that innovations inservices should be tested in well-designed studies.

ConclusionsThe systematic review identified few studies ofsufficient quality to assess the effectiveness ofinterventions to improve adherence to cardiacrehabilitation. Half of the studies found were insources outside the mainstream of medicalliterature.

Self-management techniques suggested somevalue in the promotion of specific aspects oflifestyle change and a further review in a broadercontext of health and disease may be appropriate.Educational interventions aimed at improvingadherence gave equivocal results and suggest thatthe format of the intervention merits furtherstudy.

Observational studies identify many areas whereinterventions may serve to improve patientadherence to cardiac rehabilitation, and surveysand audits show that interventions have alreadybeen implemented. The systematic review of theliterature suggests that, before implementation,interventions should be evaluated in well-conducted studies with economic assessment, andthe results disseminated widely and reviewedregularly.


49


BackgroundBarriers to attendance at and adherence withoutpatient cardiac rehabilitation associated withservice factors have been identified. However, theeffectiveness of interventions to improveprofessional compliance with the provision ofcardiac rehabilitation has not been assessed bysystematic review. This systematic review aims toassess the effectiveness of methods for increasingprofessional compliance with cardiac rehabilitationand to identify areas meriting further research.The review includes interventions to encouragehealthcare professionals to comply with guidelinesor good practice regarding invitation and supportof patients’ cardiac rehabilitation.

ResultsStudies included in the review ofinterventions to improve professional compliance with cardiacrehabilitationEighteen articles reporting 17 studies wereidentified as relevant to the review of methods toimprove professional compliance with cardiacrehabilitation and were formally included in thereview. Reading by three reviewers (SE, FT andAB) found six studies reporting evaluation of anintervention relating to an appropriate patientgroup and with a relevant outcome. The flow ofarticles through the review process is shown inaccordance with QUOROM in Appendix 13.101

Studies were characterised by type and size,participants, intervention, comparison group,principal and other outcomes, and authors’conclusions.

A brief summary of studies is presented in Table 24,with further details in Appendix 14. More thanone report was identified from the trial of Jollyand colleagues102–104 and the reference providingthe main source of information for the systematicreview is cited in the tables and text.

Studies excluded from the review ofinterventions to improve professional compliance with cardiacrehabilitationEleven studies selected for data extraction but notincluded in the review are summarised inAppendix 15. More than one report was identifiedfrom the trial of Campbell and colleagues.125,126

The excluded studies either had no relevantoutcome data,116,117,125–127,164,171,191 provided onlydescriptions of services with no outcomes119,175,192

or were retrospective in design.116

Methodological qualities of studiesincluded in the review of interventionsto improve professional compliancewith cardiac rehabilitationSix studies were identified that evaluatedinterventions to improve professional compliancewith cardiac rehabilitation. Two reported RCTs. Inone trial randomisation was on an individualbasis,124 but no other information on the methodof randomisation, blind outcome assessment orbaseline characteristics of groups was reported. Inthe other trial patients were randomised bygeneral practice.104 The authors of this trialdescribed methods of randomisation, blindoutcome assessment and baseline characteristics ofgroups. Loss to follow-up was low in this study.None of the other studies reported loss to follow-up. Four studies described outcomes in periodsbefore and after implementation of anintervention.41,111,122,123 Baseline groupcharacteristics for appropriate periods were notreported in any of these studies.

In three studies the outcome wasattendance,41,104,111 in two referral122,123 and inone patient commitment to attend cardiacrehabilitation.124 Four studies included onlymyocardial infarction patients.41,111,122,124 Onestudy included myocardial infarction and anginapatients104 and another only post revascularisationpatients.123

Chapter 10

Systematic review of interventions to improve professional compliance with cardiac rehabilitation

Themes identified from the review ofinterventions to improve professionalcompliance with cardiac rehabilitationThree themes of interventions were identified inthe systematic review: improvement of the referralprocess, coordination of transfer of care, andphysician endorsement.

Improvement of referral process Four studies were identified that evaluatedmethods to improve the referralprocess.41,111,122,123 In a study comparing periodsbefore and after the introduction of an electronic

referral pathway Kalayi and colleagues122 observeda significant increase in patient referral to cardiacrehabilitation. The intervention was initiated witha referral section on the electronic patient recordof patients discharged with a diagnosis ofmyocardial infarction. Subsequently, feedback onreferral was given to ward staff. No information ongroup characteristics before and after interventionwas provided and large differences betweenmonthly and longer term referral rates suggest thepresence of other sources of referral variability.Mosca and colleagues41 compared patientparticipation before and after the introduction of a


50

TABLE 24 Studies evaluating interventions to improve professional compliance with cardiac rehabilitation

Authors, year Study type and Intervention Findings relevant to Commentsand country patients uptake

RCTs

Jolly et al.,1999104

UK

Cluster RCT, 67general practices,597 MI andangina patients

Liaison nurse supportspractice nurses andencourages patients to seepractice nurse afterdischarge. Patient-heldrecord card to prompt andguide follow-up

42% of patients in theintervention group attendedat least one outpatient CRsession compared with 24%of controls (p < 0.001)

Multifacetedintervention.Management of patientsin control practices notexplicit


Kalayi et al.,1999122

UK


Electronic referral pathwaywith feedback to ward staffon referral rates

After intervention referralincreased from 194/298(65%) to 208/263 (79%) (p = 0.0002)

Disparity between long-term and short-termreferral rates

Mosca et al.,199841

USA


Prompt for outpatient CR indischarge critical carepathway

Critical care pathwayassociated with a non-significant increase inoutpatient CR participation(OR 1.9, 95% CI 0.6 to 5.5)


Caulin-Glaser &Schmeizel,2000123

USA

Before-and-afterstudy. Post-revascularisationpatients. Patientnumbers notspecified

Educational intervention forhealthcare providers on thecomprehensive nature andbenefits of CR. Instructionsfor nurses to discuss CR withpatients and encouragediscussion of referral withphysicians

In-hospital referral increasedby 50% (p < 0.05). Physicianoffice referral increased by61% (p < 0.05)

Abstract only

Scott et al.,2000111

Australia


Dissemination of clinicalguidelines to hospital staffand general practitioners.Feedback on clinicalindicators

After intervention outpatientCR utilisation increased from24% to 54% (p = 0.003)

Baseline periodcorresponds to CRprogramme start-up

Suskin et al.,2000124

Canada

RCT, 50 patients Attending physician provideswritten endorsement

62% of patients in theintervention group gavecommitment to participate inCR compared with 38% inthe control group (p = 0.08)

Abstract only

prompt for cardiac rehabilitation in a dischargecritical care pathway. An improvement inparticipation in outpatient cardiac rehabilitationwas observed, but this was not statisticallysignificant. Group characteristics were notreported and other factors may have influencedlevels of participation. Caulin-Glaser andSchmeizel123 reported the implementation of aneducational intervention for healthcare providers.Information on cardiac rehabilitation, including itscomprehensive nature and benefits, was given tomedical and nursing staff and on health outcomesand cost-effectiveness to members of the clinicalcardiology council. After the intervention both in-hospital and physician office referral weresignificantly increased. Again, no baselineinformation to assess comparability of patientgroups was provided. In the study of Scott andcolleagues111 patients admitted to hospital in threeperiods were compared. These were before, duringand after the dissemination of clinical guidelinesand feedback of clinical indicators to healthprofessionals. The cardiac rehabilitationprogramme was operational during theimplementation period and this was used as thebaseline period for evaluation. A steady increase inutilisation of the outpatient cardiac rehabilitationservice was observed during the implementationperiod and the authors attribute this to theintervention. However, no comparison of patientcharacteristics was available for the relevantperiods and, although the authors report that thenew cardiac rehabilitation service was fullyoperational, an increase in uptake might beexpected with the new service.

Coordination of postdischarge care Jolly and colleagues104 reported a cluster RCT ofcoordination of care of myocardial infarction andangina patients between hospital and generalpractice by specialist cardiac liaison nurses.Attendance at one or more cardiac rehabilitationsessions was significantly increased in theintervention patients. The intervention consistedof three main elements: liaison nurse support forpractice nurses, liaison nurse encouragement for

patients to see the practice nurse, and promptsand guidance for patients by means of a personalrecord card. The study design does not allow theeffect of components to be assessed individually.

Physician endorsement Suskin and colleagues124 conducted an RCTcomparing attending physician cardiacrehabilitation endorsement with a genericendorsement. The intervention was associatedwith a non-significant increase in patient-reportedintent to participate in cardiac rehabilitation. Nobenefit was observed for in-person delivery of theendorsement. Little information on the conduct ofthe trial or patient characteristics was reportedand the outcome of intention to attend issomewhat removed from actual attendance atcardiac rehabilitation.

Resource implications of intervention toimprove professional compliance withcardiac rehabilitationInformation provided on resource use associatedwith the only effective intervention of reasonablequality is summarised in Table 25. As describedearlier, in the study by Jolly and colleagues104

three liaison nurses were employed withresponsibility for the coordination of postdischargecare of 277 patients over 18 months, a yearlyaverage of 62 patients per nurse. Transport costsincurred by liaison nurses visiting practices and bythe practice nurses attending training and supportgroups were not quantified, nor was the resourceinput or cost of training liaison and practicenurses.

Further interventions that may improve professional compliance withcardiac rehabilitation suggested in theliteratureThe literature review identified a number ofsuggested interventions for improving professionalcompliance with cardiac rehabilitation. Althoughthese potential interventions were not evaluatedthe studies provided some evidence to suggestmethods meriting further investigation. Examples


51


TABLE 25 Resource implications of intervention to improve professional compliance with cardiac rehabilitation

Staff Equipment Consumables Patient costs

Coordination of postdischarge care

Liaison nurse support forpractice nurses (Jolly et al., 1999104)

Three cardiac liaisonnurses

Training for cardiacliaison nurses andpractice nurses

The study employedthree nurses involving atotal of 277 patients in18 months

of interventions excluded from the review at bothformal extraction and the earlier inclusion stage,but with possible value in improving professionalcompliance, are summarised thematically in Table 26.

DiscussionThe healthcare professional has a pivotal role inrecruitment of patients to cardiac rehabilitation,and their contribution is dependent on education,compliance with guidelines and coordination ofservices. Few studies aimed at improvingprofessional compliance with outpatient cardiacrehabilitation were found. Three studies werepublished in peer-reviewed journals and three asconference abstracts.

Evaluations of three types of intervention wereidentified by systematic review: improvement ofthe referral process, coordination of postdischargecare, and physician endorsement of cardiacrehabilitation.

None of the four studies reporting interventionsto improve the referral process included adequatemethodological information. The use of a before-and-after study design might have provided someevidence on the effectiveness of interventions, butthe lack of group comparisons and programmefactors influencing patient attendance precludes

this. This is disappointing, as the inclusion ofcardiac rehabilitation in a critical care pathwayeffective in promoting discharge medication isappealing. Similarly, improving referral bydissemination of clinical guidelines andsubsequent feedback of clinical indicators tohealth professionals merits further evaluation.

A multifaceted approach to the coordination oftransfer of care from hospital to general practiceincluding liaison nurse support for practice nurseswas effective in improving cardiac rehabilitationuptake in a randomised trial. Particular aspects ofthe intervention were not evaluated separately,and it is not possible to compare the relativeimportance of professional support of practicenurses, in-hospital nurse–patient contact and self-empowerment of patients with record cards. Thepossibility of referral of patients from generalpractice suggests that the involvement of practicenurses may be of particular value in the referral ofangina patients who have not been admitted tohospital.

The value of physician endorsement inencouraging patient participation in cardiacrehabilitation was not confirmed. However, somesupport for further evaluation is suggested by therandomised trial of Suskin and colleagues,124 wherea non-significant tendency for increased patientcommitment was seen in patients who had receivedan endorsement from an attending physician.


52

TABLE 26 Further interventions that may improve professional compliance with cardiac rehabilitation suggested in the literature

Authors, year Intervention Purpose of study

Parks et al., 200032 Appointment of CR programme director to lead, audit and Auditcommission appropriate resources

Parks et al., 200032 Programme run in accordance with national guidelines Audit

Young & Kahana, 198946 Physicians and insurers educated on benefits for patient Retrospective observationalBittner et al., 199937 groups Retrospective observational

Comoss 1988185 Referring physicians involved in programme Review

Stokes, 2000193 Education for CR coordinators and staff Review

Parks et al., 200032 Explicit criteria for CR eligibility Audit

King & Teo, 1998194 Streamlining of referral Review

Parks et al., 200032 Centralised CR attendance and contact records Audit

Levknecht et al. 1997116 Clinical pathway and clinical quality improvement tool Programme description

Cannistra et al., 1995128 Early social services involvement to improve social support Prospective comparisonand hence uptake of CR

Effron et al., 1986195 CR commenced earlier Retrospective observational

Roitman et al., 1998135 Removal of time restriction for start of programme Review

Systematic review of the literature did not identifyany well-evaluated methods specifically aimed atimproving professional compliance to cardiacrehabilitation. One multifaceted approachsuggested benefit, but the importance of theintervention relating to improvement inprofessional compliance could not be distinguishedfrom other patient-directed aspects of theintervention. The resource and therefore costimplications of this intervention are also unclear.

All interventions identified were aimed atimproving overall cardiac rehabilitationattendance. It was surprising that no evaluationsof interventions targeted at service improvementsfor specific patient groups were reported.Frequently under-represented patient groupsinclude women, the elderly, ethnic minorities andpatients with more severe presentation of diseaseor co-morbidity.

Although few trials were found with the intentionof improving cardiac rehabilitation uptake andadherence by improving professional compliance,several areas for intervention are suggested in theliterature. Many may already be regular practice,but some may have application in the provision ofservices to under-represented groups.

Uptake of rehabilitation services is influenced bythe knowledge and enthusiasm of the physicianand providers in the referral process.46,62,194

Consequently, education of physicians andproviders on the benefits of cardiac rehabilitationmay help to improve referral and uptake.37,46 Thismay be accomplished best by the involvement ofreferring physicians in the programme.185 Acoherent approach to the education of programmecoordinators and staff on the benefits of cardiacrehabilitation and its application in patient groupsmay lead to better understanding of patienteligibility and thus wider invitation.193

Appointment of a programme director to lead,audit and commission appropriate resources forcardiac rehabilitation may lead to improvementsin service management and provision.32 This mayfacilitate the running of programmes inaccordance with national guidelines, which mayhelp to improve provision.32

Although none of the studies included in thesystematic review was of adequate quality tosuggest that the use of clinical pathways may be ofvalue in the management of cardiac rehabilitationreferral, this approach may merit furtherinvestigation. The use of clinical pathways with

explicit criteria for patient eligibility may be anappropriate way to manage and streamlinereferral and invitation.32,116,194

Flexibility in timing of care and support may beimportant in improving uptake of services. Visits athome by healthcare professionals may serve toprovide continuity of care and improve uptake ofcardiac rehabilitation.128 The provision of cardiacrehabilitation early after discharge may coincidewith the time of patients’ greatest need forsupport and greatest motivation, and earlyinvitation and provision may be rewarded byincreased uptake.195 Some patients may not find aparticular date for commencing rehabilitationsuitable, and flexibility and removal of timerestrictions may lead to an increase in uptake.135

The general scarcity of evaluated methods mayreflect an under-appreciation of the value of trialsin evaluating new interventions. Programmecoordinators may recognise deficits and the needfor improvements in services and implementchanges without formal evaluation. For example, itmay be assumed that incorporation of a promptfor referral in a discharge summary would be aneffective way of ensuring referral. However, thisdoes not necessarily mean that the crucialoutcome of increased patient uptake andattendance at cardiac rehabilitation will beachieved. The systematic review of the literaturesuggests that well-designed studies are required totest interventions aimed at improving professionalcompliance with cardiac rehabilitation.

ConclusionsLittle research has been conducted aimed atimproving professional compliance with cardiacrehabilitation. The systematic review identified fewstudies that specifically looked at improvingpatient uptake and adherence by intervening atthe level of healthcare professional activities.

The conduct of the healthcare professional iscentral in the recruitment of patients to cardiacrehabilitation and their contribution is dependenton education, compliance with guidelines andcoordination of services. Changes within cardiacrehabilitation services aimed at improving patientuptake and adherence should be evaluated in well-designed studies and the results disseminated andreviewed; otherwise, ineffective and inappropriatemethods may become routine clinical practice.


53



55


Objectives� To estimate the health service costs associated

with cardiac rehabilitation programmes in theUK.

� To estimate the national budget attributable tooutpatient cardiac rehabilitation in the UK.

� To explore how coverage could be increased ifdifferent configurations of service wereprovided within the existing budget.

� To explore how coverage could be increasedwith additional funding.

Health service costs associatedwith cardiac rehabilitation MethodsThe costs associated with the provision of cardiacrehabilitation services from the health serviceperspective were estimated by considering thestaff, overheads, building capital and equipmentcosts. The costs borne by patients such as travelcosts or expenses for special clothing were notincluded, but it was recognised that these couldhave important implications if patients perceivedthem to be large enough to deter their attendance.

The BACR/BHF survey, described in Chapter 4,provided information on the typical number ofhours per week by broad staff categories spent inoutpatient (phase 3) cardiac rehabilitationprogrammes. The additional questionnaireprovided information on the number of patientsreferred, joining and completing cardiacrehabilitation, the total number of sessions, andnumber and length of sessions per week.

Centres that responded to the short questionnaireand provided information on staff input (n = 186;

65% of all UK centres identified by BACR/BHF)were stratified by a criterion of multidisciplinarityof staff input. This was based on the assumptionthat a greater variety of staff input is a proxy forhigher service quality. The following professionalcategories were considered to be relevant to anoutpatient cardiac rehabilitation programme(hereafter referred to as ‘key staff ’):

� physician (GP, cardiologist, general physician)� nurse� physiotherapist/sport scientist� occupational therapist� psychologist� dietitian� pharmacist.

Three groups were defined according to thenumber of different types of key staff: group 1having more than five different types of key staff,group 2 having three to five types of key staff, andgroup 3 having two or fewer. The total number ofcentres in each of these groups is shown in Table 27. Ten centres within each group werechosen at random to conduct a more detailedcosting study.

Staff costsAll 30 centres in the random sample werecontacted between April and June 2002 andprovided more detailed information on the gradesof staff working in 2000 (the year of theBACR/BHF survey). Staff costs were estimated bymultiplying the average numbers of hours perweek worked for each grade of staff by the hourlypay for that grade. Hourly pay rates werecalculated by dividing the midpoint of the relevantpay scale by the numbers of hours of expectedwork per annum, excluding annual leave, bankholidays, and training/study and sickness days. All

Chapter 11

Health service costs of cardiac rehabilitation in the UK

TABLE 27 Stratification of cardiac rehabilitation centres (n = 186) by number of different types of key staff

Group No. of different types of key staff No of centres %

1 >5 38 20.42 3–5 135 72.63 ≤ 2 13 7.0

pay scales were those prevailing on 1 April 2001and included employers’ on-costs (employers’contribution to national insurance plus 4% ofsalary contribution to superannuation).196

Salaries information was taken fromwww.nhscareers.nhs.uk.197 A detailed summary ofunit cost estimates for different staff categoriesand grades is shown in Appendix 16.

Non-staff-related costsNon-staff-related costs refer to the overheads,building capital and equipment costs associatedwith running cardiac rehabilitation services. Mostcardiac rehabilitation services tend to use anumber of different facilities to deliver thedifferent components of the programme and donot have these figures readily available. Hence,allowances for indirect overheads (the costs of thesupport services such as human resources, financeand estates required to carry out the services main functions) and building capital (the costsassigned to treatment and non-treatment space)

relative to the midpoint of the relevant pay scalewere based on Netten and colleagues196 (seeAppendix 16).

The required equipment was based on currentrecommendations from the BACR (see Appendix17). The unit costs were obtained from thecoordinator of the cardiac rehabilitation team ofthe Bristol Royal Infirmary. An equivalent annualcost was estimated by using an annuity factor of6% and assumed lifespan of 5 years. Annual costsaccounted for approximately £861 [value addedtax (VAT) included].

Direct overheads, that is, the costs associated withlighting, heating and cleaning, were assumed to be11% of the sum of staff costs, indirect overheads,building capital and equipment costs. This wasbased on previous studies carried out in hospitalsettings where the direct overheads were found toaccount for 4–18% (midpoint 11%) of totalcosts.198–200


56

TABLE 28 Average hours per week by staff category

Staff grade Group 1a Group 2b Group 3c

(n = 10) (n = 10) (n = 10)

Nurse grade:B 0.95E 7.2F 11.38 12.75 3G 21.40 16.15 9.25H 13.05 5.75 0.4

Physiotherapist:Helper 2Basic 0.20Senior I 10.05 5.4 2.7Senior II 1.4 1.2Superintendent III 2.6Superintendent IV 0.6

Sport scientist 1.9Exercise physiologist 3.8 0.4Occupational therapist:

Basic 0.8Senior 2.7 0.05 0.3Head 0.6

Dietitian 0.47 0.18Senior dietitian 0.58 0.46

Pharmacist 0.46 0.35Physician 0.38 0.75Clinical psychologist 0.67 0.3Cardiac technician 0.7 2 0.5Social worker 0.1Secretary 4.2 5.04 0.3Total (SD) 74.7 (5.8) 62.6 (4.7) 18.0 (2.9)

a Centres with more than five key staff.b Centres with three to five key staff.c Centres with two or fewer key staff.

The total cost of cardiac rehabilitation wasestimated for each centre, and the cost per patientreferred, joined and completed estimated. Thecost per hour was also estimated, taking the costper patient completing the programmes as thedenominator. The costs of each centre within agroup were then averaged. A weighted averagecost was also estimated, using the proportion ofcentres nationally falling within each group (seeTable 27).

Results Information on the weekly staff input by staffcategory and grade for each centre in the randomsample is shown in Table 28 (a detailed summaryof staff resource data for each centre is given inAppendix 18). Group 1 had higher levels ofweekly staff input (75 hours) than centres ingroups 2 (62 hours) and 3 (18 hours).

The average duration of the programmes bygroup is shown in Table 29. Centres that employmore than five different key staff (group 1) providethe most intensive service per patient, with anaverage duration of 29 hours per patient. Thiscompares to 24 hours per patient for group 2centres and 20 hours for group 3 centres (detailsgiven in Appendix 19). Table 29 also gives, bygroup, the absolute number of patients referred,

joining and completing cardiac rehabilitationprogrammes. This varied widely, with the highestaverage numbers being in group 2.

The average staff costs and average total costs ofcardiac rehabilitation are presented for each groupin Table 30 (more details shown in Appendix 20).There was a considerable difference in the cost ofan average centre and in the average cost perpatient between each group. The total averagecost per patient completing the programme was£542 for group 1, £317 for group 2 and £186 forgroup 3. Staff costs accounted for 73% of the totalcosts for centres in groups 1 and 2, and 70% forcentres in group 3 (based on cost per centre).

Figure 4 illustrates that nursing costs are the mostimportant share of total staff costs, accounting forabout 62% of total staff costs in group 1 centres,67% in group 2 and 71% in group 3.Physiotherapy costs are the second most importantshare of total costs, accounting for about 23% ingroup 1 and group 3 centres, and for about 14%in group 2 centres.

Weighted average staff and total costs are shown inTable 30. The weighted average cost per patientcompleting a cardiac rehabilitation programmewas £354 (staff costs only) and £486 (total costs).


57


TABLE 29 Service provision, referral, uptake and completion rates for 30 UK cardiac rehabilitation centres in 2000 (stratified by staff mix)

Group 1 Group 2 Group 3(n = 10) (n = 10) (n = 10)

Mean Median Mean Median Mean Median

Hours per patient 29.0 27 24 215 20 17.5No. referred 282.4 289 352.5 255 170.7 150No. joined 157.3 148 194.3 172 97.9 104

% of referrals 56 51 55 67 57 69No. completed 126.3 104 158 150 89 92

% of referrals 45 36 45 59 52 62

TABLE 30 Average cost estimates for cardiac rehabilitation (2000/01 prices)

Costs (£) Group 1 Group 2 Group 3 Weighted costs

Staff Total Staff Total Staff Total Staff Total costs costs costs costs costs costs costs costs

Per year/centre 53,100 72,700 42,100 57,400 12,400 17,600 42,300 57,700Per patient referred 243 330 137 186 127 249 157 220Per patient joined 421 571 236 320 174 324 269 371Per patient completed 542 738 317 429 186 344 354 486Per hour 20 27 14 20 14 30 15 22

The national budget attributableto cardiac rehabilitationMethodsThe budget attributable to outpatient (phase 3)cardiac rehabilitation was estimated separately forEngland, Wales, Scotland and Northern Irelandusing data from the BACR/BHF survey and theadditional questionnaire (as described in Chapter4). The total number of patients completing acardiac rehabilitation programme was estimatedfor each country. Where centres did not providedata, the IQR derived from responding centres forthat country was used to calculate total numbers.

The budget for each country was estimated bymultiplying the number of patients (reported aslower and upper bound) completing a cardiacrehabilitation programme by the weighted totalaverage costs per patient completing cardiacrehabilitation (£486; see Table 30).

These estimated budget figures were then used toexplore how coverage could be increased if adifferent configuration of cardiac rehabilitationservices were provided. An estimate was made ofthe number of patients that could be treated ifrehabilitation services were entirely provided incentres with three to five key staff (as in group 2,see above) or in a different scenario, in centreswith two or fewer key staff (as in group 3). In

addition, an estimate was made of the necessarybudget increase to provide cardiac rehabilitationto all potentially eligible patients using data fromthe analysis presented in Chapter 3. Thisestimation was undertaken by assuming that, first,cardiac rehabilitation would be uniformly providedin group 2 centres and, second, cardiacrehabilitation would be uniformly provided ingroup 3 centres.

This study also explored how additional fundingcould increase coverage. If unit costs per patientfall as the number of patients completing therehabilitation programme rises (i.e. centresexperience economies of scale), additional fundingwill imply that the number of extra patientstreated is higher than proportionate. A possibleassociation between staffing costs per patient andthe number of patients treated was, therefore,examined. First, the log-transformed costs andlog-transformed numbers of patients were plotted,as both variables have a log-normal distribution.Secondly, a simple log-linear regression model wasused to estimate the relationship between costs perpatient, as the dependent variable, and the annualnumber of patients completing the rehabilitationprogramme, as the independent variable. Anadditional model was estimated, controlling fornumbers of staff employed on cardiacrehabilitation. The regression coefficient fornumber of patients in these log-linear regression


58

0

10

20

30

40

50

60

70

80

90

100

1 2 3

Group

Prop

ortio

n of

tota

l cos

ts (%

)

Others

Physician

Psychology

Dietetics

Pharmacy

Occupational therapy

Physiotherapy

Nursing

FIGURE 4 Proportion of total staff costs attributable to staff categories

models measures the elasticity of the cost perpatient with respect to the number of patientscompleting the programme, that is, thepercentage change in costs for a given percentagechange in number of patients.

Results The estimated budgets attributable to cardiacrehabilitation by country are shown in Table 31.The current budget was estimated to beapproximately £12.5–19.0 million in England,£1.2–2.3 million in Scotland, £1.0–1.7 million inWales and £0.4–0.7 million in Northern Ireland.Overall, this would result in a budget estimate of£15.2–23.6 million for outpatient cardiacrehabilitation for the whole of the UK.

Table 32 shows the estimated impact of a change inservice configuration for two different scenarios bycountry. It was estimated that approximately 5,300

more patients across the UK could be treated ifthe service were provided in cardiac rehabilitationcentres with the staffing level of those in the‘group 2’ sample. This corresponds to a 13%increase in coverage compared with the currentsituation. If services were provided with cardiacrehabilitation centres with low staffing levels(group 3), approximately 16,490 more patientscould be treated, corresponding to a 41% increasein coverage compared with the current situation.

As shown in Chapter 3, around 266,800 patientswere potentially eligible for cardiac rehabilitationin England in 2000. Assuming that group 2services were uniformly provided, an annualbudget of approximately £115 million would berequired for the provision of cardiac rehabilitationto all patients. This represents a 630% increase inthe estimated current budget attributable tocardiac rehabilitation.


59


TABLE 31 Estimated budget attributable to cardiac rehabilitation by country (2000/01 prices)

England Wales Scotland Northern Ireland

Estimated no. of patients completing 25,700–39,000 2,100–3,500 2,500–4,700 1,000–1,400outpatient cardiac rehabilitationa

Estimated budget attributable to outpatient £12,513,000– £1,018,000– £1,222,000– £487,000–cardiac rehabilitation 18,975,000 1,683,000 2,276,000 658,000

a Numbers were estimated by using information form the BACR/BHF survey for 2000. Data for non-responding centreswere imputed by IQR for the relevant country.

TABLE 32 Estimated impact of a change in service configuration given current budget

England Wales Scotland Northern Ireland

Estimated no. of patients completing outpatient 25,700–39,000 2,100–3,500 2,500–4,700 1,000–1,400cardiac rehabilitation in 2000 (current service provision)

Estimated no. of patients able to be treated 26,100–44,200 2,400–3,900 2,800–5,300 1,100–1,500with a group 2 type service (i.e. three to five key staff) without expanding budget

Estimated no. of additional patients if all treated 4,300 400 500 200with a group 2 type service (based on the midpoint of the ranges reported above)

% increase in coverage 13 13 13 13

Estimated no. of patients able to be treated 36,400–55,100 3,000–4,900 3,600–6,600 1,400–1,900with a group 3 type service (i.e. two or fewer key staff) without expanding budget

Estimated no. of additional patients if all treated 13,400 1,100 1,500 500with a group 3 type service (based on the midpoint of the ranges reported above)

% increase in coverage 41 41 41 41

Using a more limited criterion of need, namely,considering only patients with acute myocardialinfarction, unstable angina, CAGB and PTCA aseligible, an annual budget of approximately £56million would be required for the provision ofcardiac rehabilitation, an increase of 260% in thecurrent budget.

By extending the provision of cardiacrehabilitation using staffing configurations ofgroup 3 services, an approximate annual budgetof between £45 and £92 million would be requiredfor treating all potentially eligible patients. Thisrepresents a 200–500% increase in the currentannual budget attributable to cardiacrehabilitation.

Figure 5 shows the relationship between annualnumbers of patients completing cardiacrehabilitation and the staff costs per patients. Itsuggests that the costs fall as the annual patientthroughput increases. Figure 6 shows the samerelationship but stratified by group.

The simple regression showed no significantrelationship between staff costs per patient andnumbers of patients completing cardiacrehabilitation (Table 33).

Further exploration of the data, making allowancefor the differing staffing patterns in groups 1–3,showed a clear relationship between costs andnumbers completing cardiac rehabilitation withineach group. The results of this model includinggroup as an independent dummy variable are

shown in Table 34. The equations for predictingthe staff costs per patient completing cardiacrehabilitation are as follows:

Group 1: ln (cost per patient) = 7.33 – 0.245 ln (number of patients)

Group 2: ln (cost per patient) = 7.33 – 0.245 ln (number of patients) –0.733

Group 3: ln (cost per patient) = 7.33 – 0.245 ln (number of patients) –1.489

This suggests that cardiac rehabilitation centresexperience economies of scale when different levelsof multidisciplinarity of staff input, as in ourdefined groups, are taken into account. The costper patient falls as the annual number of treatedpatients rises, although this was dependent oncontrolling for the multidisciplinarity of staffrunning the programme. Roughly, a 1% increase inthe number of patients completing the programmeleads to a 0.245% fall in the staff cost per patientcompleting the programme. This means thatincreasing patient throughput, by increasedfunding, may result in greater opportunity toincrease coverage than might be expected.

DiscussionThe results of this analysis suggest a weightedaverage staffing cost of £354 and a weighted totalaverage cost of £486 per patient successfullycompleting a cardiac rehabilitation programme(2000/01 prices). Although previous studies havepresented figures for the cost of cardiac


60

TABLE 33 Regression model for staff costs per patient completing cardiac rehabilitation (ln costs)

� SE 95% CI p

Constant 5.97 0.643 4.647 to 7.286 <0.0001ln no. of patients –0.10 0.143 –0.94 to 0.193 0.49

R2 = 0.02, n = 30, F = 0.49, p = 0.49

TABLE 34 Regression model for staff costs per patient completing cardiac rehabilitation (ln costs), controlling for group

� SE 95% CI p

Constant 7.33 0.592 6.11 to 8.55 <0.0001ln no. of patients –0.245 0.117 –0.488 to –0.002 0.048Group 1 – – – –Group 2 –0.733 0.335 –1.422 to –0.042 0.038Group 3 –1.489 0.340 –2.190 to –0.788 <0.0001

R2 = 0.44, n = 30, F = 6.66, p < 0.002


61


50

200

400

800St

aff c

osts

per

pat

ient

(log

sca

le)

100 200 400Annual no. of patients completing CR (log scale)

FIGURE 5 Relationship between size (as measured by annual throughput of patients) and unit cost (staff costs) of cardiacrehabilitation programmes (all centres)

50

200

400

800

100 200 400

100 200 400 200 400

Group 3

Annual no. of patients completing CR (log scale)

Group 1 Group 2

50

200

400

800

Staf

f cos

ts p

er p

atie

nt (l

og s

cale

)

100

FIGURE 6 Relationship between size (as measured by annual throughput of patients) and unit cost (staff costs) of cardiacrehabilitation programmes by group


62

rehabilitation in the UK, they have been lesscomprehensive in their cost estimates.Nonetheless, the present findings are consistentwith their findings, which suggested an averagecost of cardiac rehabilitation per treated patient inthe region of £200–£400.25,79–82

For example, Gray and colleagues80 estimated acost of £371 per patient completing a cardiacrehabilitation programme (median £223; 1994prices). This was based on a sample of 16 cardiacrehabilitation centres in England and Wales, buttheir estimate excluded non-staff costs andcontributions by non-specifically funded staff.Average staff costs of £350–425 (2001 prices) wereestimated by the Scottish Intercollegiate GuidelinesNetwork (SIGN) guideline development group,assuming 500 referred patients per year and a 90%uptake.2 Based on the funding information givenby 37 centres in the most recent BACR/BHFsurvey, Evans and co-workers25 reported a cost of£50–712 (median £256) per patient completingcardiac rehabilitation.

By using information from the BACR/BHF surveyand an additional questionnaire, all staffcontributions could be measured and valued. Theanalysis shows that centres with higher levels of staffmix provide a more expensive service per patienttreated than centres that employ fewer types of keystaff. This is due to a longer duration of cardiacrehabilitation programmes offered by centres ingroup 1 (29 hours per patient) compared with theaverage duration of programmes offered by centresin group 2 (24 hours) and group 3 (20 hours), aswell as the higher weekly staff input intoprogrammes offered by centres with more types ofkey staff. This did not correspond with highernumbers of patients entering and completing theprogrammes. Thus, patients treated in centres witha higher level of multidisciplinarity received themost intense rehabilitation programme in terms ofthe duration of the programme and staff/patientratio. Although the heterogeneity of cardiacrehabilitation services has long been acknowledged,evidence is lacking to suggest that programmeswith a higher level of multidisciplinarity offerimproved patient outcomes. Such services may noteven represent higher service quality; for example,adherence was lower in the most multidisciplinaryand intensive services.

This analysis has some limitations. Ideally,information on non-staff related costs such as directoverheads and capital costs should have beenobtained from each rehabilitation centre in thesample. From a practical point of view, this was not

feasible. The advantage of this study is the size ofthe sample, which allowed the cost differences dueto different staff configurations to be explored indetail.

The costs of equipment were also included, basedon current recommendations from the BACR.However, this list did not include equipment forundertaking ECG-exercise testing. Cardiacrehabilitation centres may carry out exercise testingbefore and after cardiac rehabilitation to assesspatients and will, therefore, incur higher costs.Annual costs of equipment (treadmills, consumablesfor ECG, etc.) have been estimated to account forapproximately £25,000 (Sally Turner, Alton CardiacRehabilitation Centre: personal communication, 2 December 2002).

Some extrapolations had to be made to calculatethe total numbers of patients completing aprogramme, because not all centres replied to thesurvey and provided comprehensive activity data.This is possibly due to their lack of automatedsystems to extract these data, lack of audit facilitiesor being in the process of installing systems tocollect audit data to satisfy the requirements of theNSF-CHD. However, the authors believe that theirestimate of an annual budget attributable to cardiacrehabilitation of £15.2–23.6 million for the whole ofthe UK is a refined update of previous budgetestimates, for example, £8–34 million by Taylor andKirby81 based on a converted US cost estimate.

The results of the simple budget analysis show thatby providing a service as offered in group 3 centres,the overall service provision could be increased byapproximately 40% with current funding. Providingcardiac rehabilitation as offered in group 2 centres,which represents the average cardiac service in theUK, could lead to an approximately 13% increasein coverage. This could be of importance givenlimited resources and the large extent of unmetneed, as shown in Chapter 3.

The resource implications for extending cardiacrehabilitation to a greater proportion of eligiblepatients and to other groups of patients asrecommended by the NSF-CHD are not clear.Only a minority of centres, as reported in Chapter4, state that they have spare capacity. It is also notobvious whether the difference between thenumber of referred and enrolled patientsrepresents spare capacity, as many centres havewaiting lists that restrict the number of patientsreceiving treatment. Therefore, the extension ofcardiac rehabilitation may require extra resources.The costs of these resources will be dependent on

local factors such as current provision of staff, theopportunity costs of extending the role of existingstaff employed in other areas, existing (spare)capacity and facilities and, if not available, thecosts of hiring facilities, for example in communitysport centres.

This study confirms the finding that cardiacrehabilitation centres experience economies ofscale, as first reported by Gray and colleagues.80

However, this was only apparent whenmultidisciplinarity of staff input, as defined by thethree groups, was explicitly taken into account. Thisfinding suggests that any budget increase couldlead to a more than proportionate improvement incoverage of cardiac rehabilitation services.

This analysis considers only the direct costs ofcardiac rehabilitation. Future assessments of thecost-effectiveness of cardiac rehabilitation need toconsider the future savings associated withreduced subsequent healthcare utilisation relatedto cardiac disease. The inclusion of future costsrelated to successfully rehabilitated patients livinglonger and requiring health services unrelated tocardiac disease is more controversial. Also to beconsidered are the future productivity gainsassociated, for example, with earlier return towork. The inclusion of costs incurred by patientssuch as expenses for travelling and specialclothing will depend on the perspective fromwhich the costs analysis is conducted. A fulleconomic evaluation requires the comparison ofthe resource use changes with improved healthconsequences, that is, the effectiveness of cardiacrehabilitation.

ConclusionsThe average costs of cardiac rehabilitation to thehealth service per patient successfully completing

a cardiac rehabilitation programme are about£350 (staff costs only) and £490 (total costs) perpatient. Outpatient cardiac rehabilitationrepresents an NHS cost of between £15.2 and 23.6million in the UK. Cost variation across centres ispartly explained by a higher dose of interventionin terms of duration and staff/patient ratio. Thereis a need to quantify the heterogeneity of servicesin terms of benefits. Trials comparing complexmultidisciplinary rehabilitation with simplerregimens require evaluation of their costs andeffectiveness.

If all services were modelled on the most commonconfiguration of staffing (group 2), approximately13% more patients could be treated with the sameannual budget, but if the simpler group 3 serviceswere to be uniformly provided, 40% more patientscould be treated. The levels of need for cardiacrehabilitation, using the more modest criteria ofneed (see Chapter 3), suggest that, at best, fewerthan 30–43% of eligible patients are referred and,of these, about half join cardiac rehabilitationprogrammes. This suggests that the capacity toincrease provision by 40% within current budgetswould meet between 42 and 60% of thepopulation need for treatment.

Higher funding would be needed to increaseprovision to match need and to meet NSF-CHDtargets. An approximate 260–630% increase in theannual current budget is required, to treat allpotentially eligible patients depending on thestaffing configurations of the cardiac rehabilitationprogramme. However, increased spending couldlead to a more than proportionate increase incoverage. Further work is required to examine thebest ways of using any increased funding, as it islikely that the potential of different services toincrease capacity will vary markedly, and theassociated costs will differ if, for example, newcapital schemes are required.


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Outpatient cardiac rehabilitation should beavailable to patients with a range of

cardiovascular diagnoses and afterrevascularisation procedures, but previous studieshave shown that uptake is low, particularly in somespecific patient groups. While many barriers toparticipation have been described, theeffectiveness of interventions to improve uptakeand adherence has not been assessed by systematicreview. Furthermore, the cost implications ofinterventions to improve uptake and adherenceand of increasing overall provision to meet totalpopulation need have not been estimated.Conclusions presented here are based around theobjectives set in Chapter 2.

What is the population need forcardiac rehabilitation?Population need for cardiac rehabilitation in theUK in 1999–2000 was assessed from hospitaldischarge statistics in England, Wales andNorthern Ireland. The researchers were unable touse equivalent data for Scotland.

Two criteria for eligibility for cardiac rehabilitationwere considered: patients with acute myocardialinfarction, unstable angina or following arevascularisation procedure; and all patientsdischarged alive with a primary diagnosis ofischaemic heart disease or followingrevascularisation. The former, more conservativeestimate of need, identified nearly 146,000patients per year as eligible for cardiacrehabilitation in England, Wales and NorthernIreland. The latter gives a considerably largerestimate of 299,000 patients per year, but includespatients with chronic ischaemic heart disease,some of whom may be considered eligible forparticipation in some programmes and who maybenefit from rehabilitation. Although thesepatients are not currently specified as immediatepriorities for cardiac rehabilitation, for example inthe NSF-CHD, many may be deserving ofrehabilitation or appropriate lifestyle advice andmodification as services develop.

Who is not receiving cardiacrehabilitation?To estimate the level of cardiac rehabilitationprovision, data from the 2000 BACR/BHF surveyof cardiac rehabilitation centres were combinedwith hospital discharge statistics. The overallresponse rate of survey centres was 67% and IQRswere imputed for non-responders. This gave arange of estimates of numbers of patients referredto and joining a cardiac rehabilitation programme.

It was estimated that in England about 53% (range45–67%), in Wales about 72% (range 59–81%) andin Northern Ireland about 30% (range 25–36%) ofacute myocardial infarction, unstable angina andrevascularisation patients were referred to cardiacrehabilitation in 2000. The proportions of patientsjoining a programme were about 33% (range27–41%), 40% (range 38–46%) and 22% (range18–25%), respectively. As this considers only thelimited eligibility criteria as the denominator itreflects an overestimate if centres providedservices to other patient groups. Applying the lessinclusive eligibility criteria of any ischaemic heartdisease or revascularisation, it was estimated thatin England about 26%, in Wales about 32% and inNorthern Ireland about 14% of patients werereferred to cardiac rehabilitation in 2000. Thecorresponding figures for patients joining aprogramme were 16%, 18% and 11%, respectively.A survey of rehabilitation centres suggested thatan average of about 63% of all patients referredjoined a programme and that about 48% ofreferrals completed a course.

There appeared to be variation in serviceprovision across the UK, with a higher proportionof eligible patients referred to and joining cardiacrehabilitation programmes in England and Walesthan in Northern Ireland. Since the need forrehabilitation is substantially greater in NorthernIreland (and Scotland), this represents aconsiderable disparity between uptake and need.

The data demonstrate that many eligible patientswho may derive benefit are not referred or invited,

Chapter 12

Conclusions

do not respond to invitation, or do not adhere tocardiac rehabilitation. Some of the shortfall inreferral and invitation may be explained by theclinical eligibility criteria used in selecting patientsas appropriate for cardiac rehabilitation. Thisselection is mainly by health status beforedischarge. From the clinical exclusion data in anRCT with minimal exclusions, about 81% ofpatients were identified as eligible forrehabilitation after myocardial infarction and,although slightly lower than the 85% stated in theNSF-CHD, this is a reasonable overall estimate.The remaining 19% of patients were consideredunsuitable for outpatient rehabilitation, mainly onthe basis of co-morbidity or frailty. This is not tosay that these patients may not gain materiallyfrom secondary prevention or individually selectedcomponents of cardiac rehabilitation. Indeed,many eligible and included patients may only besuited to, and gain benefit from, specific aspects ofrehabilitation.

The definition of eligibility is important. In anRCT setting with minimal exclusions andappropriate documentation the eligibility criteriaare clearly defined. In a non-trial setting thepossibility arises that eligibility can be flexible andtake on a role in rationing services. This may, inpart, explain the extra tier of exclusion observedwithin the randomised trial context in that, afterreferral, coordinators tended to exclude olderpatients and those with more severe presentationof coronary heart disease from outpatient cardiacrehabilitation, possibly on the basis of an exercisetest. Clearly, frail, elderly people and those withco-morbidity are capable of benefiting fromrehabilitation, as shown by trials of geriatricassessment and rehabilitation units, and everydaypractice within the NHS. The nature ofrehabilitation for such patients may be lessintensive than for other patients and may involveattendance at a day hospital. Some linkagebetween cardiac rehabilitation and health servicesfor elderly people would be desirable to ensurethat appropriate rehabilitation is available to all,regardless of age.

Under-represented groupsIn the national survey and in the RCT, uptake ofcardiac rehabilitation tended to be lower in olderpatients than in younger age groups. However,having attended one class there was no evidenceto suggest that older patients were more likely todrop out of rehabilitation. Women were less likelyto attend in both settings, but in the trial this waslargely explained by the increased age of womenat presentation. It is not possible to draw firm

conclusions about the attendance of black or Asiangroups as national database data were incompletefor coding of ethnicity, and in the survey ofrehabilitation centres numbers referred to andattending cardiac rehabilitation tended to be low.

Accessibility of informationGathering data on patient need, eligibility andrehabilitation activity was problematic. To simplifythe process and make estimates more precise,national analysis of audit data would be preferableto ad hoc surveys. Unfortunately, audit was foundto be underdeveloped in cardiac rehabilitation.The survey in England showed an uncoordinatedapproach to data collection and audit, withconsiderable variation in methods and content.With the standards set out in the NSF-CHD,reproducible and comparable methods should bein place, but little evidence was found to suggestthat this was so. The use of modern medicalrecords systems and gathering of data with anational and policy-driven standardised tool aredesirable. This would allow assessment of allstages of the rehabilitation process, starting withthe original coronary heart disease diagnosis orprocedure, and would include information onpossible causes of under-representation.

Some programme coordinators reported thatdirect referral systems from surgery and clinicswere in place aimed at improving uptake ofcardiac rehabilitation. The use of methods topromote direct referral suggests that audit canbridge the gap between inpatient care andoutpatient cardiac rehabilitation.

What is the effectiveness ofdifferent methods of improvinguptake and of differentialtargeting of cardiac rehabilitation?Barriers to participation in outpatientcardiac rehabilitationInterviews with patients randomised to attendrehabilitation in a trial confirmed commonlyperceived reasons for non-attendance at cardiacrehabilitation. The main reasons for non-attendance or dropout were: lack of interest,illness, transport difficulties, scheduling and careof dependants. These responses suggest that someaspects of non-attendance are amenable tointervention by addressing issues of motivation,perceived relevance of cardiac rehabilitation tofuture well being, co-morbidities, the site and timeof sessions, transport and arrangement of care fordependents.

Conclusions

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Interventions used in cardiacrehabilitation centresThe survey of cardiac rehabilitation coordinatorsfound a high level of awareness of the problem oflow uptake. Sixty-six percent of services thatresponded indicated that they had implementedmeasures to improve attendance. Interventionsappropriate to all patients included follow-uptelephone calls, personalised invitation, homevisits and free transport. More specificinterventions for under-represented groups(women, the elderly, ethnic minorities, patientswith heart failure or angina) includedindividualised classes, buddy systems and inclusionin the programme of a spouse or relative.

Many interventions were reported and somerepresent the application of common-sensemethods. Nevertheless, studies to show thesustainable effectiveness of interventions arenecessary if the long-term benefits of interventionsare to be confirmed and the value of interventionsdisseminated more widely. The possibility existsthat a common-sense intervention may have anegative effect on attendance. For example,patients collected last and returned home firstmay value free hospital transport as part of theoverall rehabilitation package, whereas patientssubjected to an extended journey and long transittimes may find this an inconvenience thatinfluences subsequent participation.

Although the RCT represents the gold standard inthe evaluation of new interventions, this may beconsidered inappropriate by a cardiacrehabilitation professional attempting to provideservices to all patients. As a possible alternative toRCTs, improvement in uptake attributable to anintervention may be identified by audit. However,reproducible audit procedures need to be in placefirst.

Systematic review of the literatureTo identify studies of interventions with the aim ofimproving uptake and adherence to cardiacrehabilitation, three systematic reviews werecarried out. The issue of improving uptake andadherence was split into three major questions:how can recruitment to cardiac rehabilitation beimproved (uptake); how can patients’ adherence tocardiac rehabilitation and maintenance of lifestylechanges be improved; and how can professionalsbe encouraged to comply with guidelines andgood practice? These were designed to identifyinterventions to improve all aspects of referral andinvitation, uptake and adherence to cardiacrehabilitation.

The comprehensive systematic review of literaturecovered a large range of databases andhandsearches. Studies identified were published injournals, theses and conference abstracts. It wasdisappointing to find that nearly half of thestudies reporting potentially valuable methods topromote cardiac rehabilitation were found only inthe grey literature, with little opportunity foraccess by interested healthcare professionals.Sharing of information is essential if effectivemethods are to be implemented. Of the studiesidentified, a minority were RCTs.

Although some studies that looked at alteringpatient behaviour were identified, there was verylittle literature on interventions aimed atencouraging healthcare professional compliancewith guidelines or good practice regardinginvitation and support of patients’ cardiacrehabilitation. As the conduct of the healthcareprofessional is central in the recruitment ofpatients to cardiac rehabilitation it seems logical tostudy interventions relating to professionaleducation, compliance with guidelines andcoordination of services. In one RCT amultifaceted approach to transfer of care fromhospital to general practice was associated withincreased cardiac rehabilitation uptake. However,the relative importance of one specific aspect ofthe intervention directly concerning professionalcompliance could not be evaluated.

The systematic literature review identified someinterventions to help improve patient uptake ofcardiac rehabilitation. Invitation letters,pamphlets, telephone calls and home visits may beused to convey a motivational message. Trainedlay volunteers providing support to patients in theperiod before an outpatient programme mayfacilitate subsequent attendance at cardiacrehabilitation.

Following successful recruitment of patients tocardiac rehabilitation it is important that patientsadhere to the programme and maintain anyassociated lifestyle changes. Methods based onimprovements in self-efficacy and behaviouralfeedback showed promise in improving andsustaining risk factor management.

Possible interventions suggested in the literature,but which have not been evaluated in trials, wereidentified as areas for future research. These werebased on observations in trials, reviews and patientinterviews. Interventions relating to professionalcompliance include education of healthcareprofessionals on the benefits of cardiac


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rehabilitation, appointment of a programmedirector, use of clinical pathways with explicitpatient eligibility criteria, flexibility in programmestart dates, flexibility in programme times, andhome visiting to provide continuity of care.Suggested interventions to improve uptake includeearly support and planning postdischarge byhealthcare professionals, adaptation of services forunder-represented groups, use of communityfacilities, provision of services in a communitysetting, and for motivated patients withappropriately supervised delivery, home-basedmethodologies. Unevaluated interventions toimprove adherence include further approachesbased on self-efficacy, including demonstrations ofbehaviours by previous patients, which may be ofparticular value in promoting dietary change.Alternative forms of exercise or diet modificationmay help to improve adherence, and this may beespecially useful for women, elderly people andminority ethnic groups. The use of different formsof rehabilitation such as home-based programmesmay be acceptable in highly motivated patientswith less severe coronary heart disease.

The identification of so many interventions inneed of evaluation suggests that there is value inthe study of factors determining attendance. Well-conducted qualitative studies in providers andparticularly in patients may be useful inidentifying the attitudes, beliefs and valuesassociated with successful cardiac rehabilitation.Since this review was completed, a qualitativestudy of factors influencing enrolment in cardiacrehabilitation has been published.201 This studysuggested that physician recommendation,encouragement from family and friends, andaccess to transportation are important factors inpromoting enrolment.

What is the potential budgetimpact of increasing uptake ofcardiac rehabilitation usingdifferent uptake interventions?Service duration and configurationThe effectiveness of different intensities andmultidisciplinarity of cardiac rehabilitation is notknown. Systematic reviews include a wide range ofinterventions both more and less intense thancurrent UK recommendations, but to date noattempt has been made to stratify effectiveness byservice model.

The BACR/BHF survey of cardiac rehabilitationacross the UK showed wide variations in intensity,

programme content and staffing. However, themean levels of service provision suggest that an 8-week programme with 2 hours per week ofexercise training, 1 hour per week of educationand half an hour per week of psychologicalintervention is typical.

In the UK, three service configurations wereidentified, based on numbers of different types ofkey staff. A service involving three to five key staffis most commonly provided, with 73% ofprogrammes reporting this configuration. Fewprogrammes had lower staffing levels, but 20% ofprogrammes had more than five key staff. Untilevidence is available on the effectiveness of moreintensive interventions it seems reasonable to baseprojections on the moderate service configurationwith its multidisciplinary structure.

Costs of cardiac rehabilitationThe average costs of cardiac rehabilitation to thehealth service per patient successfully completinga programme were estimated at about £350 (staffcosts only) and £490 (total costs) at 2000/01 prices.In the UK this equates to an NHS cost of between£15.2 and £23.6 million. This range representsthe uncertainty in identifying the total number ofpatients receiving cardiac rehabilitation in the UK.The lower figure is the number of patientscompleting a programme in centres whoresponded to the BACR/BHF survey, and thehigher figure is an extrapolation of identifiedservice levels to all known UK programmes. As theBACR/BHF database is an established and well-respected resource, it is likely that the non-responding centres are more recent and smallerprogrammes. Consequently, an overall UK costestimate greater than £15.2 million but less than£23.6 million is probable. Again, this highlightsthe importance of consistent national audit inguiding the provision of cardiac rehabilitation.

A minority of centres reported spare capacity andthis would have only a small potential impact onoverall provision. On the basis of unmet needidentified in the survey and applying theconservative eligibility criteria of acute myocardialinfarction, unstable angina and revascularisation,it was estimated that a budget increase ofapproximately 260% would be required,representing an overall annual budget of about£56 million at 2000/01 prices. Clearly, this wouldbe considerably greater if more than five key staffwere included in the programme and theeligibility criteria were extended to all patientswith a discharge diagnosis of coronary heartdisease or heart failure, or following

Conclusions

68

revascularisation. This may imply a budgetincrease of up to 630% and an annual budget ofapproximately £115 million.

Other costs may be involved in the extension ofprovision, depending on local factors such ascurrent levels of staffing, the opportunity costs ofextending the role of existing staff, existing sparecapacity and facilities and, if not available, thecosts of hiring facilities, for example in communitysport centres. Conversely, economies of scale mayserve to reduce the extra budget required.

Additional costs of increasing uptakeand adherenceOrder of magnitude costs of interventions toimprove uptake and adherence with cardiacrehabilitation may be inferred and these suggest awide range of implied costs. Motivationalinterventions could replace existing methods of

invitation at minimal cost, and the incorporationof motivational elements into an establishedhome-visiting schedule may have little furtherimplication for resources. The use of layvolunteers in promoting uptake of cardiacrehabilitation is likely to be more costly, withextensive training requirements and travel costs.Similarly, the introduction of liaison nursecoordination of transfer of care would be costly ifrecruitment of new staff was required. However, itmay serve to define the role of the establishedliaison nurse in supporting patients and otherhealthcare professionals and coordination ofpostdischarge care. Strategies aimed at improvingself-management could be incorporated intooutpatient cardiac rehabilitation sessions, andtraining of rehabilitation staff in lifestyleevaluation may serve to formalise assessment andprocedures already in place in cardiacrehabilitation.


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Implications for healthcare� Provision of outpatient cardiac rehabilitation in

the UK is well below the NSF-CHD goal of 85%of patients with acute myocardial infarction andrevascularisation being offered outpatientcardiac rehabilitation.

� Information on referral to and uptake of cardiacrehabilitation is incomplete, with widely varyingestimates of provision, particularly in under-represented groups. Little is known about thecapacity of cardiac rehabilitation centres toincrease provision.

� There is an uncoordinated approach to auditdata collection.

� Reasons reported by patients for non-attendance are amenable to intervention, butfew interventions have been formally evaluated.

� Many interventions aimed at improving patientuptake, adherence and professional compliancewith guidelines and good practice have beenproposed, but few have been formallyevaluated.

� Motivational communications and trained layvolunteers may help to improve uptake ofcardiac rehabilitation.

� Self-management techniques may help topromote and sustain lifestyle changes associatedwith cardiac rehabilitation.

� Qualitative studies in providers and patientsmay identify attitudes, beliefs and valuesassociated with cardiac rehabilitation.

� Information on costs of interventions isfrequently not reported.

� Experience of low-cost interventions and goodpractice exists within many cardiacrehabilitation centres.

� Increased provision of outpatient cardiacrehabilitation will require additional resources.

Recommendations for research anddevelopment� Trials comparing the cost-effectiveness of

comprehensive multidisciplinary rehabilitationwith simpler outpatient programmes.

� Economic and patient preference studies of theeffects of different methods of using increasedfunding for cardiac rehabilitation, andevaluations of the impact of any increasedfunding.

� Evaluation of a range of interventions and goodpractice (including self-managementtechniques, motivational communication andthe use of trained lay volunteers) to promoteattendance in all patients and under-represented groups.

� Development of standardised audit methods inthe context of modern records systems,appropriate training for dedicated staff anddialogue between service contributors.Standardisation of criteria for patient eligibility,regular and comprehensive data collection toestimate the need for and provision of cardiacrehabilitation.

� Identification of further areas for interventionthrough qualitative studies.

� Extension of low-cost interventions and goodpractice in rehabilitation.

� Regular updated systematic review of literaturerelating to uptake and adherence to cardiacrehabilitation to include literature not readilyavailable to providers and non-UK studies.

Chapter 13

Key findings


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We are grateful to Judith Jolliffe, Jo Coast,Karl Karsch, David Thompson and Bob

Lewin for their involvement in the early phase ofthe project. We also thank Hugh Bethell and SallyTurner for allowing us access to the BritishAssociation for Cardiac Rehabilitation/BritishHeart Foundation survey data; Roy Maxwell andDavidson Ho (HES), Farzana Nadeem (PEDW)and Ciara Kennedy (HIS) for supplying data onpopulation need; and the staff of rehabilitationcentres that contributed additional survey data,audits and relevant information.

Contributors to survey of audit activityin UK cardiac rehabilitation centresWe are grateful for the assistance of rehabilitationand audit staff from the following centres: KatrinaCreedon (Birmingham Heartlands and SolihullNHS Trust), Claire Brereton-Worsman (BradfordHospitals NHS Trust), Gillian Matthews (CornwallPartnership NHS Trust), Ashley Davidson (EastSomerset NHS Trust), Mark Giles (GloucestershireHospitals NHS Trust), Alison Child (Guy’s and StThomas’ Hospital NHS Trust), Maureen Barry(Homerton Hospital NHS Trust), Judith Imich(Kings College Hospital NHS Trust), Pat Marley(The Lewisham Hospital NHS Trust), Sheila Ryan(Newham Primary Care Trust), Tony Andrews(North Devon Healthcare NHS Trust), ValerieNangle (North Middlesex University HospitalTrust), John Outhwaite and Julie Thompson(Plymouth Hospitals NHS Trust), Victoria Sievey(Royal Bournemouth and Christchurch NHSTrust), Alison Brown (Royal Cornwall NHS Trust),Alison Davey (Royal Free Hampstead NHS Trust),Margaret Wicks (Royal United Hospital Bath NHSTrust), Rosalind Leslie (Royal Wolverhampton

NHS Trust), Dee Hannah (St Mary’s NHS Trust),Maggie Kelly (Salisbury Health Care NHS Trust),Margaret Pritchard (Sandwell Healthcare NHSTrust), Suzy Young and Lynne Kilner (SouthDevon Healthcare NHS Trust), Petra Haig (SouthWarwickshire General Hospitals NHS Trust),Amanda Daniel (United Bristol Healthcare Trust),Mark Walsh (Walsall Hospitals NHS Trust), BrianColeman (Whipps Cross University Hospital NHSTrust) and Linda Barratt (Worcester AcuteHospitals NHS Trust).

Contributions of authorsAndrew Beswick (Research Associate) contributedto the systematic review, audit and RCT, andprepared the report. Karen Rees (Research Fellow)acted as project coordinator and contributed tothe systematic review and survey of UK provision.Ingolf Griebsch (Research Associate) preparedhealth service costs and population need. FionaTaylor (Public Health Specialist Trainee)contributed to the systematic review and auditsurvey. Margaret Burke (Trials Search Coordinatorfor the Cochrane Heart Group) carried out theliterature searches. Robert West (Reader inEpidemiology) contributed to the systematicreview and RCT attendance, design and planning. Jackie Victory (Cardiac RehabilitationSister) contributed to the audit survey and the UK survey of provision. Jacqueline Brown(MRC Senior Scientist) prepared health service costs. Rod Taylor (Senior Lecturer in Public Health and Epidemiology) worked on the UK survey of provision. Shah Ebrahim(Professor of Epidemiology and Ageing) workedon the systematic review and coordinated theproject.

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Appendix 1

Need for cardiac rehabilitation in the UK

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00s)

AM

IH

FU

AC

AB

GP

TC

AC

AB

Gp

Oth

ers

AM

IH

FU

AC

AB

GP

TC

AC

AB

Gp

Oth

ers

Fem

ale

35–4

43,

368.

427

115

442

4611

323

1,23

28.

00.

413

.11.

43.

40.

736

.645

–54

3,45

1.0

1,15

486

2,07

231

152

372

4,91

533

.42.

560

.09.

015

.22.

114

2.4

55–6

42,

398.

52,

585

261

4,00

588

61,

165

233

9,80

310

7.8

10.9

167.

036

.948

.69.

740

8.7

65–7

42,

253.

24,

586

808

6,14

81,

399

1,31

641

013

,777

203.

535

.927

2.9

62.1

58.4

18.2

611.

575

–84

1,60

1.2

4,76

71,

232

5,89

248

843

517

211

,105

297.

776

.936

8.0

30.5

27.2

10.7

693.

585

+73

7.5

1,97

373

21,

983

1218

24,

455

267.

599

.326

8.9

1.6

2.4

0.3

604.

1

Mal

e35

–44

3,45

0.0

1,76

888

1,58

735

966

791

3,92

351

.22.

646

.010

.419

.32.

611

3.7

45–5

43,

446.

35,

543

470

4,97

71,

951

2,53

142

014

,122

160.

813

.614

4.4

56.6

73.4

12.2

409.

855

–64

2,36

1.5

7,97

71,

138

8,32

54,

638

3,81

896

824

,906

337.

848

.235

2.5

196.

416

1.7

41.0

1,05

4.7

65–7

41,

949.

98,

568

1,75

29,

422

4,77

32,

625

1,08

324

,755

439.

489

.948

3.2

244.

813

4.6

55.5

1,26

9.6

75–8

41,

017.

85,

379

1,39

95,

711

1,05

863

837

112

,074

528.

513

7.5

561.

110

4.0

62.7

36.5

1,18

6.3

85+

265.

51,

156

356

1,07

419

234

2,24

743

5.3

134.

140

4.4

7.2

8.7

1.5

846.

2

Both

35–4

46,

818.

42,

040

103

2,03

140

578

011

45,

157

29.9

1.5

29.8

5.9

11.4

1.7

75.6

45–5

46,

897.

26,

698

557

7,05

22,

262

3,05

449

219

,043

97.1

8.1

102.

232

.844

.37.

127

6.1

55–6

44,

760.

010

,570

1,39

912

,336

5,52

44,

983

1,20

134

,731

222.

129

.425

9.2

116.

110

4.7

25.2

729.

665

–74

4,20

3.0

13,1

622,

562

15,5

776,

173

3,94

11,

493

38,5

6131

3.2

61.0

370.

614

6.9

93.8

35.5

917.

575

–84

2,61

9.0

10,1

562,

634

11,6

071,

546

1,07

354

323

,195

387.

810

0.6

443.

259

.041

.020

.788

5.6

85+

1,00

3.1

3,13

41,

089

3,06

431

416

6,71

331

2.4

108.

630

5.5

3.1

4.1

0.6

669.

3To

tal

26,3

00.7

45,7

608,

344

51,6

6715

,941

13,8

723,

849

127,

400

174.

031

.719

6.4

60.6

52.7

14.6

484.

4

Sour

ce: H

ES, E

ngla

nd. A

MI,

acut

e m

yoca

rdia

l inf

arct

ion;

HF,

hear

t fa

ilure

; CA

BG, c

oron

ary

arte

ry b

ypas

s gr

aft;

PTC

A, p

ercu

tane

ous

tran

slum

inal

cor

onar

yan

giop

last

y; U

A, u

nsta

ble

angi

na; C

ABG

p, C

ABG

with

AM

I or

HF

or P

TCA

or

UA

with

in o

ne a

dmiss

ion

episo

de; A

ll ot

hers

: all

patie

nts

who

hav

e be

enad

mitt

ed m

ore

than

onc

e an

d w

ith m

ore

than

one

disc

harg

e di

agno

sis.


85


TA

BLE

36

Nee

d fo

r car

diac

reha

bilit

atio

n in

Wal

es

Gen

der

Age

Po

pula

tion

Cou

nts

Rat

es p

er 1

00,0

00

grou

p(i

n 10

00s)

AM

IH

FU

AC

AB

GP

TC

AC

AB

Gp

Oth

ers

AM

IH

FU

AC

AB

GP

TC

AC

AB

Gp

Oth

ers

Fem

ale

35–4

420

1.9

220

371

33

8610

.90.

018

.30.

51.

51.

542

.645

–54

197.

866

911

412

215

310

33.4

4.6

57.6

6.1

10.6

2.5

156.

755

–64

160.

820

532

258

4842

1566

212

7.5

19.9

160.

429

.926

.19.

341

1.7

65–7

414

4.2

374

6135

167

3825

998

259.

442

.324

3.4

46.5

26.4

17.3

692.

175

–84

108.

534

711

235

019

815

962

319.

810

3.2

322.

617

.57.

413

.888

6.6

85+

44.2

152

7697

00

040

634

3.9

171.

921

9.5

0.0

0.0

0.0

918.

6

Mal

e35

–44

203.

299

661

1517

720

848

.73.

030

.07.

48.

43.

410

2.4

45–5

419

6.5

408

3431

185

9831

916

207.

617

.315

8.3

43.3

49.9

15.8

466.

255

–64

156.

661

074

507

205

146

721,

657

389.

547

.332

3.8

130.

993

.246

.01,

058.

165

–74

125.

260

316

257

018

393

631,

614

481.

612

9.4

455.

314

6.2

74.3

50.3

1,28

9.1

75–8

469

.342

012

132

948

1422

938

606.

117

4.6

474.

769

.320

.231

.71,

353.

585

+15

.991

2265

01

021

157

2.3

138.

440

8.8

0.0

6.3

0.0

1,32

7.0

Both

35–4

440

5.1

122

698

1620

1029

430

.11.

524

.23.

94.

92.

572

.645

–54

394.

247

643

426

9711

936

1,22

612

0.8

10.9

108.

124

.630

.29.

131

1.0

55–6

431

7.4

816

106

765

253

188

872,

320

257.

133

.424

1.0

79.7

59.2

27.4

730.

965

–74

269.

497

822

392

225

013

188

2,61

236

3.0

82.8

342.

292

.848

.632

.796

9.6

75–8

417

7.9

768

233

680

6722

371,

903

431.

713

1.0

382.

237

.712

.420

.81,

069.

785

+60

.124

398

162

01

061

840

4.3

163.

126

9.6

0.0

1.7

0.0

1,02

8.3

Tota

l1,

624.

13,

403

709

3,05

368

348

125

88,

973

209.

543

.718

8.0

42.1

29.6

15.9

552.

5

Sour

ce: P

EDW

.

Appendix 1

86 TA

BLE

37

Nee

d fo

r car

diac

reha

bilit

atio

n in

Nor

ther

n Ire

land

Gen

der

Age

Po

pula

tion

Cou

nts

Rat

es p

er 1

00,0

00

grou

p(i

n 10

00s)

AM

IH

FU

AC

AB

GP

TC

AC

AB

Gp

Oth

ers

AM

IH

FU

AC

AB

GP

TC

AC

AB

Gp

Oth

ers

Fem

ale

35–4

412

0.1

263

192

70

8521

.62.

515

.81.

75.

80.

070

.845

–54

98.7

8211

102

1147

025

883

.111

.110

3.3

11.1

47.6

0.0

261.

455

–64

80.3

181

3618

931

950

550

225.

444

.823

5.4

38.6

118.

30.

068

4.9

65–7

467

.627

110

527

638

790

693

400.

915

5.3

408.

356

.211

6.9

0.0

1,02

5.1

75–8

446

.327

714

423

65

240

477

598.

331

1.0

509.

710

.851

.80.

01,

030.

285

+17

.594

5455

00

010

153

7.1

308.

631

4.3

0.0

0.0

0.0

577.

1

Mal

e35

–44

115.

910

86

7416

630

252

93.2

5.2

63.8

13.8

54.4

0.0

217.

445

–54

96.7

331

3527

074

247

181

934

2.3

36.2

279.

276

.525

5.4

1.0

846.

955

–64

75.6

468

117

514

183

358

31,

401

619.

015

4.8

679.

924

2.1

473.

54.

01,

853.

265

–74

54.1

478

171

494

126

227

11,

214

883.

531

6.1

913.

123

2.9

419.

61.

82,

244.

075

–84

28.4

249

138

215

2531

043

687

6.8

485.

975

7.0

88.0

109.

20.

01,

535.

285

+6.

140

4337

00

059

655.

770

4.9

606.

60.

00.

00.

096

7.2

Both

35–4

423

613

49

9318

700

337

56.8

3.8

39.4

7.6

29.7

0.0

142.

845

–54

195.

341

346

372

8529

41

1,07

721

1.5

23.6

190.

543

.515

0.5

0.5

551.

555

–64

155.

964

915

370

321

445

33

1,95

141

6.3

98.1

450.

913

7.3

290.

61.

91,

251.

465

–74

121.

774

927

677

016

430

61

1,90

761

5.4

226.

863

2.7

134.

825

1.4

0.8

1,56

7.0

75–8

474

.852

628

245

130

550

913

703.

237

7.0

602.

940

.173

.50.

01,

220.

685

+23

.613

497

920

00

160

567.

841

1.0

389.

80.

00.

00.

067

8.0

Tota

l80

7.3

2,60

586

32,

481

511

1,17

85

6,34

532

2.7

106.

930

7.3

63.3

145.

90.

678

6.0

Sour

ce: H

IS, N

orth

ern

Irel

and.


87


Appendix 2

Need for and estimated level of cardiac rehabilitation provision in the UK

Appendix 2

88 TA

BLE

38

Nee

d an

d es

timat

ed le

vel o

f pro

visio

n in

Eng

land

(to

tal n

umbe

r of c

ardi

ac re

habi

litat

ion

cent

res

n=

220

)

Mea

nSD

Med

ian

IQR

nSu

m o

f N

on-r

espo

ndin

g To

tal s

um o

f pat

ient

s al

l pat

ient

sce

ntre

s (n

)(r

espo

ndin

g pl

us n

on-

resp

ondi

ng c

entr

es)

Mea

nM

edia

nIQ

R

No.

of p

atie

nts

refe

rred

to

CR

349.

024

4.33

279.

018

0–45

011

740

,840

103

76,7

9369

,577

59,3

80–8

7,19

0N

o. o

f pat

ient

s jo

inin

g C

R20

8.6

141.

817

7.5

112–

277

114

23,7

8110

645

,893

42,5

9635

,653

–53,

143

Elig

ible

pat

ient

s (s

ourc

e: H

ES)

No.

of

Pro

port

ion

of p

atie

nts

refe

rred

to

Pro

port

ion

of p

atie

nts

join

ing

pati

ents

CR

(%

) D

ata

for

non-

resp

onde

rs

CR

(%

) D

ata

for

non-

resp

onde

rs

impu

ted

impu

ted

Mea

nM

edia

nIQ

RM

ean

Med

ian

IQR

All

patie

nts

with

prim

ary

diag

nosis

of I

HD

266,

833

2926

22–3

317

1613

–20

All

patie

nts

disc

harg

ed w

ith A

MI,

CA

BG, P

TCA

, UA

131,

089

5953

45–6

735

3327

–41

All

patie

nts

with

prim

ary

diag

nosis

of I

HD

<75

yea

rs

202,

001

3834

29–4

323

2118

–26

IHD

, isc

haem

ic h

eart

dise

ase.


89


TA

BLE

39

Nee

d an

d es

timat

ed le

vel o

f pro

visio

n in

Wal

es (

tota

l num

ber o

f car

diac

reha

bilit

atio

n ce

ntre

sn

= 1

8)

Mea

nSD

Med

ian

IQR

nSu

m o

f N

on-r

espo

ndin

g To

tal s

um o

f pat

ient

s (r

espo

ndin

g pl

us n

on-r

espo

ndin

g al

l pat

ient

sce

ntre

s (n

)ce

ntre

s)

Mea

nM

edia

nIQ

R

No.

of p

atie

nts

refe

rred

to

CR

316.

717

0.7

311

180–

400

103,

167

85,

701

5,65

54,

607–

6,36

7N

o. o

f pat

ient

s jo

inin

g C

R18

5.4

93.0

150

119–

248

132,

410

53,

337

3,16

03,

005–

3,65

0

Elig

ible

pat

ient

s (s

ourc

e: P

EDW

)N

o. o

f P

ropo

rtio

n of

pat

ient

s re

ferr

ed t

o C

R (

%)

Pro

port

ion

of p

atie

nts

join

ing

CR

(%

) pa

tien

tsD

ata

for

non-

resp

onde

rs im

pute

dD

ata

for

non-

resp

onde

rs im

pute

d

Mea

nM

edia

nIQ

RM

ean

Med

ian

IQR

All

patie

nts

with

prim

ary

diag

nosis

of I

HD

17,6

5033

3226

–36

1918

17–2

1A

ll pa

tient

s di

scha

rged

with

AM

I, C

ABG

, PTC

A, U

A

7,87

872

7259

–81

4240

38–4

6A

ll pa

tient

s w

ith p

rimar

y di

agno

sis o

f IH

D <

75 y

ears

12,7

2845

4436

–50

2625

24–2

9

TA

BLE

40

Nee

d an

d es

timat

ed le

vel o

f pro

visio

n in

Nor

ther

n Ire

land

(to

tal n

umbe

r of c

ardi

ac re

habi

litat

ion

cent

res

n=

10)

Mea

nSD

Med

ian

IQR

nSu

m o

f N

on-r

espo

ndin

g To

tal s

um o

f pat

ient

s (r

espo

ndin

g pl

us n

on-r

espo

ndin

g al

l pat

ient

sce

ntre

s (n

)ce

ntre

s)

Mea

nM

edia

nIQ

R

No.

of p

atie

nts

refe

rred

to

CR

205.

510

1.9

196

141.

5–26

9.5

482

26

2,05

51,

998

1,67

1–2,

439

No.

of p

atie

nts

join

ing

CR

146.

560

.415

410

7–18

64

586

61,

465

1,51

01,

228–

1,70

2

Elig

ible

pat

ient

s (s

ourc

e: H

IS)

No.

of

Pro

port

ion

of p

atie

nts

refe

rred

to

CR

(%

) P

ropo

rtio

n of

pat

ient

s jo

inin

g C

R (

%)

pati

ents

Dat

a fo

r no

n-re

spon

ders

impu

ted

Dat

a fo

r no

n-re

spon

ders

impu

ted

Mea

nM

edia

nIQ

RM

ean

Med

ian

IQR

All

patie

nts

with

prim

ary

diag

nosis

of I

HD

13,9

8815

1412

–17

1111

9–12

All

patie

nts

disc

harg

ed w

ith A

MI,

CA

BG, P

TCA

, UA

6,

780

3030

25–3

622

2218

–25

All

patie

nts

with

prim

ary

diag

nosis

of I

HD

<75

yea

rs11

,248

1818

15–2

213

1311

–15

Appendix 2

90 TA

BLE

41

Estim

ated

leve

l of p

rovis

ion

in S

cotla

nd (

tota

l num

ber o

f car

diac

reha

bilit

atio

n ce

ntre

s n

= 3

6)

Mea

nSD

Med

ian

IQR

nSu

m o

f N

on-r

espo

ndin

g To

tal s

um o

f pat

ient

s (r

espo

ndin

g pl

us n

on-r

espo

ndin

g al

l pat

ient

sce

ntre

s (n

)ce

ntre

s)

Mea

nM

edia

nIQ

R

No.

of p

atie

nts

refe

rred

to

CR

207.

315

0.4

198.

565

–340

244,

975

127,

462

7,35

75,

755–

9,05

5N

o. o

f pat

ient

s jo

inin

g C

R13

2.2

101.

310

047

–218

212,

777

154,

761

4,27

73,

482–

6,04

7

Dear Cardiac Rehab Coordinator,

We have recently been funded by the NHS Health Technology Assessment Research & Developmentprogramme to look at the provision, uptake and adherence to cardiac rehabilitation programmes incurrently under-represented groups, which includes women, elderly people, Black and Asian groups, andpatients with diagnoses of angina, heart failure and post-revascularisation. As part of this work, we needan up-to-date picture of current service provision. We are aware that you have recently completed aquestionnaire for the BHF/BACR survey, and we are collaborating with Dr Bethell and Sally Turner to usethe data you have kindly provided. There are a few additional questions we need to ask that were notcovered in the recent survey. We know you are extremely busy people so we have put together a shortquestionnaire that complements the BHF/BACR survey, that should only take a few minutes to complete.Any data will be added to the main BHF/BACR database. To be consistent, we are asking for informationrelevant to the period 1st January to 31st December 2000. Please contact us if you have any queriesregarding this. Please could you return the completed questionnaire in the SAE or fax through to FAO K Rees.

Thank you so much for your help with this important work

Very best wishes

Dr Karen Rees, BHF Research Fellow


91


Appendix 3

British Association for Cardiac Rehabilitation additional postal questionnaire

Appendix 3

92

ID

ADDITIONAL SHORT QUESTIONNAIRE TO COMPLEMENT THE BHF/BACR

DATABASE OF UK CARDIAC REHABILITATION CENTRES 2001

1. How long is your supervised phase 3 programme for each patient? (please give an

average figure for each component of CCR, relevant to your programme)

Exercise component

Health education component (e.g. Healthy diet, smoking cessation)

Psychological component (e.g. Relaxation/stress management) if given

No. weeks Average no.

of sessions patients/session

Total for whole programme – if unable to break down into component sessions

No. sessions/week Average length











93


2. Do you make any special efforts to promote attendance at rehab sessions for any

of the following groups? (TICK ANY THAT APPLY)

Women Patients with heart failure

People aged 65+ Patients with angina

Black and Asian groups Patients who have had

CABG/PTCA

Please provide details of the methods you use:

3. Do you have any spare capacity within your current service for

additional patients?

Yes No

If yes, please indicate the number of additional patients patients/

that could be included without any increase in resources: week

4. During the last year approximately how many patients were referred?

Total Male Female 65+ years post-MI CABG/PTCA

Heart Angina Black and Asian groups

Failure

Appendix 3

94

During the year how many patients joined the programme?



Failure

Of these patients, how many (eventually) completed the programme?



Failure

With many thanks for your help in completing this questionnaire. Please could you

post back in the envelope provided, or fax through (FAO K Rees)

by 31 st October 2001

CR Coordinator/contact.......................................................................................

CR Programme, where based................................................................................

Region.....................................................................................................................

Search terms for major databases are given.These terms were adapted appropriately for

other databases.

Search strategy for MEDLINE1 exp Heart diseases/2 coronary.tw.3 cardiac.tw.4 CABG.tw.5 myocardial.tw.6 angina.tw.7 heart failure.tw.8 heart disease$.tw.9 or/1-8

10 exp Rehabilitation/11 exp Rehabilitation centers/12 exp Rehabilitation nursing/13 rehabil$.tw.14 Aftercare/15 aftercare.tw.16 Convalescence/17 convalescen$.tw.18 recuperat$.tw.19 or/10-1820 9 and 1921 exp Heart diseases/rh [Rehabilitation]22 20 or 2123 Patient education/24 exp Counseling/25 exp Exercise therapy/26 Exercise/27 exp Psychotherapy/28 (patient adj2 educat$).tw.29 counsel$.tw.30 (behavi$ adj2 therap$).tw.31 psychosocial$.tw.32 ((lifestyle or life-style) adj2 intervent$).tw.33 ((exercise$ or fitness) adj5 (treatment or

intervent$ or program$)).tw.34 ((lifestyle or life-style) adj5 (intervent$ or

program$ or treatment$)).tw.35 Nurse practitioners/36 "nurse practitioner$".tw.37 or/23-3638 9 and 3739 (secondary adj5 prevent$).tw.40 Survival rate/41 (reduc$ adj5 (morbid$ or mortal$)).tw.

42 Patient readmission/43 rehospitali$.tw.44 ((improv$ or increase$ or decrease$) adj5

(recover$ or function)).tw.45 Disease management/46 (disease adj2 manage$).tw.47 Recovery of function/48 exp "Costs and cost analysis"/49 compliance.tw.50 adheren$.tw.51 non-compliance.tw.52 costs.tw.53 Patient compliance/54 or/39-5355 37 and 54 and 956 22 or 55

Search strategy for EMBASE1 exp Heart disease/2 coronary.tw.3 cardiac.tw.4 CABG.tw.5 myocardial.tw.6 angina.tw.7 heart failure.tw.8 heart disease$.tw.9 or/1-8

10 exp rehabilitation/11 exp rehabilitation center/12 rehabil$.tw.13 exp convalescence/14 convalescen$.tw.15 recuperat$.tw.16 or/10-1517 9 and 1618 exp Heart disease/rh19 Heart rehabilitation/20 or/17-1921 exp patient education/22 exp counseling/23 exp kinesiotherapy/24 exp exercise/25 exp psychotherapy/26 (patient adj2 educat$).tw.27 counsel$.tw.28 (behavi$ adj2 therap$).tw.29 psychosocial$.tw.30 ((lifestyle or life-style) adj5 (intervent$ or


95


Appendix 4

Literature search strategies

program$ or treatment$)).tw.31 ((exercise$ or fitness$) adj5 (treatment$ or

intervent$ or program$)).tw.32 Nurse practitioner/33 "nurse practitioner$".tw34 or/21-3335 9 and 3436 exp survival/37 (patient$ adj2 readmi$).tw.38 rehospitali$.tw.39 ((secondary or tertiary) adj5 prevent$).tw.40 (reduc$ adj5 (mortal$ or morbid$)).tw.41 ((improv$ or increase$ or decrease$) adj5

(recover$ or function$)).tw.42 (disease$ adj2 manag$).tw.43 exp aftercare/44 aftercare.tw.45 exp economic evaluation/56 costs.tw.57 Patient compliance/58 (compliance or non-compliance).tw.59 adheren$.tw.50 Patient satisfaction/51 or/36-5052 35 and 5145 20 or 52

The results of all searching were downloaded intoa reference management database and thensearched across all fields for the following terms:

AdherenceDropout*Drop-out*ComplyComplianceNoncomplianceParticipant*ParticipationReferral*Nonattend*Attend*Refusal*Patient attitude*Patient satisfaction*Barrier*Nonparticipant*Non-participant*Treatment refusalMotivat*CostCostsEconom*

Appendix 4

96


97


Appendix 5

Inclusion/exclusion form

Uptake and adherence tocardiac rehabilitation

Databasenumber

Date assessedExcluded? Included?First author

Uptake A AProf compliance B BAdherence C CAudits/descriptive I I

Source and date

Economic E E

Intervention toincrease uptake bypatients

Intervention toimproveprofessionalcompliance

Interventionto improveadherence

Reviewer (initials)

1. Is an interventionevaluated?

2. Patients:AMI, CABG, PTCA,Angina, Heart Failure,Other CVD (Specify)

3. Outcome:people attending,losses to follow up,adherence (medical advice,therapy, clinical events,rehospitalisation, costs)

If 1, 2 and 3 yes then include study

4. Reason for exclusion

Other information

5. Audit/descriptive information

6. Economic information


99


Appendix 6

Data extraction form

Appendix 6

100

Data extraction form – HTA SR of uptake, patient adherence and professional compliance

Reference:

Database ID: Date:

Reviewer: (initials)

Subject relevant to: (circle all that apply)

A – Intervention to increase uptake by patients

B – Intervention to improve professional compliance

C – Intervention to improve patient adherence

1. Data Source: (circle) Published only Unpublished only mixed

Country of publication/recruitment –

2. Study type: (circle)

Between group comparisons: RCT (adequate allocation concealment)

Quasi RCT (inadequate allocation concealment, e.g. alternate allocation, by hospital No., DoB etc.)

Non-randomised trial (e.g. Allocation to groups but no attempt at randomisation)

Before and after study (comparing outcomes in different groups of patients before and after an intervention)

Within group comparisons: Before and after study (comparing outcomes in the same patients before and after an intervention)

3. Quality of studies:

Creation of comparison groups

a) generation of random sequence method_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

b) concealment of allocation method_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

c) how allocation occurred (e.g. patient or doctor preference) detail _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

d) balance groups by design (e.g. matching) detail _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

e) within group comparisons (circle if applies)

Comparability of groups

a) Were comparison groups similar at baseline? Yes No Unclear

b) Were prognostic factors identified? Yes No Unclear

c) Was case-mix adjustment used to account for differences between groups? Yes No Unclear

d) (For within group comparisons only) — were only paired responses analysed? Yes No Unclear


101


Blinding of outcomes

a) Were outcomes assessed blind/independently of intervention? Yes No Unclear

Follow-up

a) Was there equal follow-up between groups? Yes No Unclear

b) What was the overall loss to follow-up? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Not reported

Sample

a) Prospective or retrospective sampling? Prospective Retrospective

b) Were inclusion and exclusion criteria specified? Yes No Unclear

c) Was the sample size planned (e.g. sample size calculation included)? Yes No Unclear

d) Is representativeness of the sample assessed? (add comments) Yes No Unclear

_ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _

4. Participants studied: (circle all that apply)

Diagnosis

Post MI CABG/PTCA Heart Failure (chronic / secondary to MI) Angina

Participants

Men Women Age limited (specify) Ethnic Minority Groups

For the whole sample:

Mean age (range) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Percentage men _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Case mix (specify, e.g. 100% MI or mixed diagnoses and proportions) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Percentage white (if known) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Inclusion/Exclusion criteria (if stated) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

5. Intervention (investigator’s description in as much detail as possible, including theoretical basis,

intensity and duration, group or individual, setting, etc.)

A – Intervention to increase uptake by patients

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _

B – Intervention to improve professional compliance

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _

C – Intervention to improve patient adherence

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _

Appendix 6

102

Description of comparison group (treatment or usual care) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _

_ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ __

Duration of follow-up (not duration of intervention) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _

6. Outcomes: (circle all that apply)

Specified primary outcome (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _

Attendance rates Adherence to rehabilitation/medical advice/therapy(give criteria used) (give criteria used)

Clinical events Rehospitalisation Costs Changes in risk factors

Other (specify)

Number of follow-up measurement points (give time intervals, e.g. 6 months, 1 year)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _

7. Study comparisons: (if multiple time points, use longest duration of follow-up)

Characteristics Intervention/Before

Control/After

(additional columnfor 3 arm trial or 3time phase studies)

Baseline characteristics:Number randomisedAge (mean SD range)Sex (% male)Outcomes:Attendance Nos (%)Adherence to medication/therapy – Nos adhering (%)Adherence to medication/therapy – Nos adhering (%)Losses to follow-up Nos (%)Specified primary outcome: N(%)Clinical events: N(%)Total Mortality N(%)Cardiac Mortality N(%)Non-fatal MI N(%)Revascularisation N(%)CVD event (stroke/TIA) N(%)Other N(%)Hospitalisation/RehospitalisationNumber (%) of patientsNumber of occasionsCosts (specify what)Other outcomes:

8. Notes (what did the investigators find? Interesting features?)


103


Appendix 7

Flow diagram of the systematic review of interventions to improve uptake of cardiac

rehabilitation (QUOROM statement flow diagram)

Potentially relevant publications identifiedand screened for retrieval

3261

Publications retrieved for more detailedevaluation

957Publications excluded on the basis of titleand abstract:

No intervention evaluated 776

No outcome pertaining to uptakeof cardiac rehabilitation 154

Publications included for data extraction

27 (22 studies)

Studies included in review

8

Studies excluded from review:

Published after June 2001 1No outcome 6No comparison group 1Retrospective design 1Outcome is referral 2Outcome is patient commitment 1Outcome relates to secondaryprevention 2

__Total 14

Publications excluded on the basis of titleand abstract (clear evidence that sourcepaper did not describe intervention inappropriate patient group)

2304


105


Appendix 8

Studies evaluating interventions to improve theuptake of cardiac rehabilitation

Appendix 8

106 Stu

die

s ar

e li

sted

in

ter

ms

of

stu

dy

des

ign

an

d t

he

hie

rarc

hy

of

evid

ence

, w

ith

RC

Ts

firs

t.

Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

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e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

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ff gr

oup:

m

easu

re a

nd

outc

omes

au

thor

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coun

try

% m

en,

invo

lved

, int

ensi

ty,

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ils o

f re

sult

san

d re

sult

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nclu

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s,

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licat

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n ag

e fo

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rest

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feat

ures

type

)(S

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tcom

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if st

ated

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r et

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105,

106

UK

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nal a

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pat

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ndom

ised

Patie

nts

wer

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nded

ase

aled

num

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den

velo

pe w

ith a

nom

inal

lett

er. H

alf o

f the

enve

lope

s al

so c

onta

ined

an in

terv

entio

n le

tter

.En

velo

pe c

onte

nts

know

n to

a r

esea

rch

assis

tant

onl

y an

d ha

dbe

en a

lloca

ted

toin

terv

entio

n or

con

trol

by r

ando

m n

umbe

ras

signm

ent.

Enve

lope

sgi

ven

to p

atie

nts

innu

mer

ical

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er. C

Rnu

rse

not

awar

e of

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upas

signe

d to

; how

ever

, no

proc

edur

e in

pla

ce t

ost

op p

atie

nts

telli

ngnu

rse

whi

ch le

tter

rece

ived

. Com

paris

ongr

oups

sim

ilar

at b

asel

ine

All

patie

nts

post

-MI.

Mea

nag

e 63

yea

rs,

87%

men

Lett

ers

base

d on

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theo

ry o

f pla

nned

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r (A

jzen

and

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198

6107 )

desig

ned

to in

crea

seat

tend

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at

outp

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ntC

R w

ere

give

n to

patie

nts

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ys p

ost-

MI

and

sent

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eeks

pos

t-M

I. T

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rst

lett

er w

asde

signe

d to

influ

ence

acce

ptan

ce a

nd t

hese

cond

was

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d to

influ

ence

att

enda

nce.

Patie

nts

also

rec

eive

d a

nom

inal

lett

er o

f tha

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at 3

day

s an

d th

est

anda

rd le

tter

det

ailin

gco

urse

dat

es a

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nt t

oco

ntro

l pat

ient

s. A

fter

allo

catio

n to

gro

ups

the

CR

nurs

e sa

w a

ll pa

tient

sfo

r ro

utin

e as

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men

tan

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rson

al in

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tion

toth

e pr

ogra

mm

e. F

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s w

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edth

e of

fer

of a

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ce a

brie

f sec

ond

lett

er w

asse

nt w

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em w

ell

and

info

rmin

g th

em t

hat

they

wer

e st

ill w

elco

me

to c

onta

ct t

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eam

Nom

inal

lett

erof

tha

nks

give

nto

pat

ient

s at

3da

ys p

ost-

MI

and

the

stan

dard

lett

erde

taili

ngco

urse

dat

es

Upt

ake

defin

ed a

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tend

ance

at

the

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nt C

Rpr

ogra

mm

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ptak

ew

as 8

6% in

the

inte

rven

tion

grou

pan

d 57

% (a

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ate

59%

) in

the

cont

rol g

roup

(�2

=7.

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f = 1

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5)

Wom

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ly t

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ved

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tend

ance

A s

igni

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tim

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t in

upt

ake

of o

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CR

was

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in t

he g

roup

that

rec

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d th

ele

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ence

acc

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and

atte

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ce. T

heau

thor

s no

te t

hat

the

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rven

tion

may

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orke

d by

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as a

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in le

tter

: “re

sear

ch h

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own

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nce

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ce t

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ng fr

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n th

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plem

enta

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eory

of p

lann

edbe

havi

our

cont

inue

d


107


Aut

hors

, St

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type

Stud

y qu

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rtic

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Inte

rven

tion

: det

ails

C

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ipal

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omm

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: ye

ar a

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and

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% m

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, int

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ty,

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ils o

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san

d re

sult

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nclu

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licat

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n ag

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ures

type

)(S

D),

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tcom

e as

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men

tet

hnic

ity

if st

ated

Hill

ebra

ndet

al.,

1995

108

Ger

man

y(jo

urna

l)

Rela

tes

toat

tend

ance

at

outp

atie

nthe

art

grou

paf

ter

inpa

tient

CR

Para

llel

grou

p RC

T,94

pat

ient

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ndom

ised.

Resu

ltsre

port

ed

for

87(4

patie

nts

died

, thr

eere

fuse

dfo

llow

-up)

Met

hod

of r

ando

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tion

and

allo

catio

nco

ncea

lmen

t un

clea

r.C

ompa

rison

gro

ups

wer

e sim

ilar

at b

asel

ine

Post

-MI

patie

nts

atte

ndin

gin

patie

nt C

Rpr

ogra

mm

e.M

ean

age

52(3

3–60

) yea

rs,

89%

men

Spec

ial o

utpa

tient

car

epr

ogra

mm

e to

sup

port

blue

-col

lar

wor

kers

afte

rM

I to

join

cor

onar

ygr

oups

. The

pro

gram

me

cons

isted

of f

our

diffe

rent

con

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atio

nsbe

twee

n pa

tient

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al w

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hone

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act

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r 4

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ks,

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e vi

sit a

fter

3 m

onth

s an

d te

leph

one

cont

act

afte

r 6

mon

ths

No

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atie

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repr

ogra

mm

e

Att

enda

nce

at c

ardi

acgr

oup

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r12

mon

ths.

In t

hegr

oup

with

spe

cial

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atie

nt c

are

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of p

atie

nts

atte

nded

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rdia

c gr

oup

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d w

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< 0

.005

)

The

aut

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not

e th

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atin

g ef

fect

of a

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tpat

ient

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e as

a li

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n in

patie

nt C

Ran

d ca

rdia

c gr

oups

cont

inue

d

Appendix 8

108

Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

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n P

rinc

ipal

out

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e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

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ing

sett

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sta

ff gr

oup:

m

easu

re a

nd

outc

omes

au

thor

s’

coun

try

% m

en,

invo

lved

, int

ensi

ty,

deta

ils o

f re

sult

san

d re

sult

sco

nclu

sion

s,

(pub

licat

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mea

n ag

e fo

llow

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r us

ual c

are

inte

rest

ing

feat

ures

type

)(S

D),

ou

tcom

e as

sess

men

tet

hnic

ity

if st

ated

Jolly

et

al.,

1999

104

UK

(jour

nal)

Also

Bra

dley

et

al.,

199

7102

and

Jolly

et

al.,

1998

103

67 g

ener

alpr

actic

esra

ndom

ised

with

in s

trat

a(b

y fu

nd-

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ing

stat

us,

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ance

from

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lC

Rpr

ogra

mm

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d nu

mbe

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who

le-

time

part

ner

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vale

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.27

7 pa

tient

sfr

omra

ndom

ised

inte

rven

tion

prac

tices

and

320

from

cont

rol

prac

tices

No

deta

ils o

fra

ndom

isatio

npr

oced

ure.

Fol

low

-up

ofpa

tient

s ca

rrie

d ou

t by

anu

rse

not

resp

onsib

le fo

rde

liver

ing

the

inte

rven

tion

to t

hepa

tient

’s p

ract

ice.

Pow

erca

lcul

atio

ns r

epor

ted

for

seru

m c

hole

ster

olch

ange

, dist

ance

wal

ked

and

smok

ing.

Com

paris

on g

roup

sw

ere

simila

r at

bas

elin

e.Lo

ss t

o fo

llow

-up

was

10%

in in

terv

entio

ngr

oup

and

9% in

con

trol

grou

p. A

naly

sis w

as b

yin

tent

ion

to t

reat

but

excl

uded

dea

ths

Patie

nts

regi

ster

ed w

ith67

gen

eral

prac

tices

in a

spec

ified

geog

raph

ical

area

. Pat

ient

sad

mitt

ed t

oho

spita

l with

MI (

71%

) or

with

ang

ina

ofre

cent

ons

et(<

3m

onth

s)se

en in

hos

pita

l(2

9%).

Patie

nts

wer

e ju

dged

wel

l eno

ugh

topa

rtic

ipat

e by

med

ical

and

nurs

ing

staf

f on

the

war

d or

incl

inic

Spec

ialis

t ca

rdia

c lia

ison

nurs

es c

oord

inat

ed t

hetr

ansf

er o

f car

e be

twee

nho

spita

l and

gen

eral

prac

tice.

The

liai

son

nurs

e sa

w p

atie

nts

inho

spita

l and

enc

oura

ged

them

to

see

the

prac

tice

nurs

e af

ter

disc

harg

e.Su

ppor

t w

as p

rovi

ded

topr

actic

e nu

rses

by

regu

lar

cont

act,

incl

udin

ga

tele

phon

e ca

ll sh

ortly

befo

re p

atie

nt d

ischa

rge

to d

iscus

s ca

re a

nd b

ook

a fir

st fo

llow

-up

visit

to

the

prac

tice.

Pra

ctic

enu

rses

wer

e en

cour

aged

to t

elep

hone

the

liai

son

nurs

e to

disc

uss

prob

lem

s or

to

seek

advi

ce o

n cl

inic

al o

ror

gani

satio

nal i

ssue

s.Ea

ch p

atie

nt w

as g

iven

apa

tient

-hel

d re

cord

car

dw

hich

pro

mpt

ed a

ndgu

ided

follo

w-u

p at

stan

dard

inte

rval

s

No

cont

act

betw

een

spec

ialis

tca

rdia

c lia

ison

nurs

es a

ndge

nera

lpr

actic

es. N

otex

plic

itly

stat

ed, b

utun

ders

tood

to

be n

ore

com

men

da-

tion

to s

eepr

actic

e nu

rse

and

no p

atie

nt-

held

rec

ord

Seru

m c

hole

ster

ol,

bloo

d pr

essu

re,

dist

ance

wal

ked

in 6

min

utes

and

sm

okin

gce

ssat

ion

did

not

diffe

r be

twee

ngr

oups

. Bod

y m

ass

inde

x w

as s

light

lylo

wer

in t

hein

terv

entio

n gr

oup.

Mor

e pa

tient

s in

the

inte

rven

tion

grou

pat

tend

ed a

t le

ast

one

outp

atie

nt C

R se

ssio

nco

mpa

red

with

cont

rols

(42%

vs

24%

, p<

0.0

01).

The

diffe

renc

e w

as m

ost

mar

ked

in a

ngin

apa

tient

s (4

2% v

s10

%)

The

pro

gram

me

prov

idin

g co

ordi

nate

dfo

llow

-up

care

by

spec

ialis

t ca

rdia

c lia

ison

nurs

es d

id n

ot im

prov

ehe

alth

out

com

es, b

utw

as e

ffect

ive

inpr

omot

ing

at le

ast

one

outp

atie

nt C

R se

ssio

nat

tend

ance

cont

inue

d


109


Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff gr

oup:

m

easu

re a

nd

outc

omes

au

thor

s’

coun

try

% m

en,

invo

lved

, int

ensi

ty,

deta

ils o

f re

sult

san

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

mea

n ag

e fo

llow

-up

peri

od fo

r us

ual c

are

inte

rest

ing

feat

ures

type

)(S

D),

ou

tcom

e as

sess

men

tet

hnic

ity

if st

ated

Osik

a, 2

00182

UK

(the

sis)

Non

-ra

ndom

ised

stud

y. O

nedi

stric

t w

ithin

terv

entio

n(9

8 pa

tient

s)an

d on

edi

stric

tw

ithou

t(7

7pa

tient

s)

Gro

ups

simila

r at

base

line

Post

-MI

patie

nts

invi

ted

to a

tten

d an

outp

atie

nt C

Rpr

ogra

mm

e.M

ean

age

72ye

ars,

78%

men

Hom

e vi

sitin

g by

lay

volu

ntee

rs. V

isito

rs w

ere

trai

ned

5 ho

urs

per

day

for

up t

o 7

days

. Pat

ient

sw

ere

visit

ed fo

rap

prox

imat

ely

30m

inut

es e

ach

wee

kfo

r 6

wee

ks. L

ayvo

lunt

eers

pro

vide

dad

vice

rel

atin

g to

reha

bilit

atio

n an

d of

fere

dto

acc

ompa

ny t

he p

atie

ntto

the

firs

t ou

tpat

ient

CR

appo

intm

ent

Dist

rict

with

no la

yvo

lunt

eer

visit

ing

Att

enda

nce

at fi

rst

outp

atie

nt C

Rap

poin

tmen

t. In

the

dist

rict

with

lay

volu

ntee

r vi

sitin

g 71

%of

pat

ient

s at

tend

ed a

first

app

oint

men

t at

outp

atie

nt C

R. In

the

cont

rol d

istric

t 47

%at

tend

ed (p

= 0

.02)

.N

o di

ffere

nce

inse

vera

l clin

ical

outc

omes

and

indi

cato

rs a

t fir

st C

Rat

tend

ance

The

lay

volu

ntee

rho

me

visit

ing

serv

ice

was

ass

ocia

ted

with

incr

ease

d up

take

of

outp

atie

nt C

R se

rvic

es

Kra

sem

ann

and

Busc

h, 1

98810

9

Ger

man

y(jo

urna

l)

Rela

tes

toat

tend

ance

at

an o

utpa

tient

hear

t gr

oup

afte

r an

inpa

tient

CR

prog

ram

me

Non

-ra

ndom

ised

tria

l.20

0pa

tient

sst

udie

d

Gro

ups

of p

atie

nts

atte

ndin

g in

diff

eren

tpe

riods

. No

info

rmat

ion

com

parin

g gr

oups

at

base

line.

156

pat

ient

sfo

llow

ed u

p. L

oss

tofo

llow

-up

22%

All

mal

epa

tient

s po

st-

MI

Afte

r co

mpl

etio

n of

an

inpa

tient

CR

prog

ram

me

patie

nts

wer

e gi

ven

apa

mph

let

with

info

rmat

ion

abou

tou

tpat

ient

hea

rt g

roup

sde

signe

d to

mot

ivat

epa

tient

s to

join

. The

book

let

cont

aine

dge

nera

l inf

orm

atio

nab

out

hear

t di

seas

e,in

clud

ing

nutr

ition

,ex

erci

se, r

elax

atio

n an

dm

edic

atio

n. P

atie

nts

wer

e al

so g

iven

the

addr

esse

s of

loca

lou

tpat

ient

hea

rt g

roup

s

Afte

rco

mpl

etio

n of

an in

patie

nt C

Rpr

ogra

mm

epa

tient

s w

ere

give

n th

ead

dres

ses

oflo

cal o

utpa

tient

hear

t gr

oups

Num

ber

of p

atie

nts

who

join

ed a

nou

tpat

ient

hea

rt g

roup

afte

r 6

mon

ths.

78

patie

nts

wer

efo

llow

ed u

p in

bot

hth

e in

terv

entio

n an

dco

ntro

l gro

ups.

66.

5%of

pat

ient

s w

hore

ceiv

ed t

hein

terv

entio

n at

tend

eda

hear

t gr

oup

com

pare

d w

ith 3

1.0%

in t

he c

ontr

ol g

roup

(�2

= 2

0, d

f = 1

, p

< 0

.001

)

The

aut

hors

rep

ort

that

the

info

rmat

ive

pam

phle

t us

ed t

om

otiv

ate

patie

nts

was

asso

ciat

ed w

ithin

crea

sed

atte

ndan

ceat

out

patie

nt h

eart

grou

ps. P

atie

nts

rank

ed s

ourc

es o

fin

form

atio

n: p

erso

nal

conv

ersa

tion

with

doct

or, p

amph

let,

lect

ures

, per

sona

l tal

ksw

ith c

arin

g pe

rson

san

d ta

lks

with

oth

erpa

tient

s

cont

inue

d

Appendix 8

110

Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff gr

oup:

m

easu

re a

nd

outc

omes

au

thor

s’

coun

try

% m

en,

invo

lved

, int

ensi

ty,

deta

ils o

f re

sult

san

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

mea

n ag

e fo

llow

-up

peri

od fo

r us

ual c

are

inte

rest

ing

feat

ures

type

)(S

D),

ou

tcom

e as

sess

men

tet

hnic

ity

if st

ated

Mos

ca e

t al

.,19

9841

USA

(con

fere

nce

abst

ract

)

Befo

re-

and

afte

r-st

udy.

Com

paris

onof

out

patie

ntC

Rpa

rtic

ipat

ion

rate

s in

tw

o6-

mon

thpe

riods

with

a to

tal o

f19

9pa

tient

s

No

info

rmat

ion

onba

selin

e ch

arac

teris

tics

ofth

e tw

o gr

oups

All

patie

nts

post

-MI.

Mea

nag

e 61

yea

rs,

with

68%

men

Crit

ical

car

e pa

thw

aypr

ompt

ing

refe

rral

for

outp

atie

nt C

R

Befo

reim

plem

enta

tion

of c

ritic

al c

are

path

way

Ove

rall

part

icip

atio

nat

out

patie

nt C

R w

as54

%, a

s de

term

ined

by p

atie

nt s

elf-

repo

rt.

The

crit

ical

car

epa

thw

ay w

asas

soci

ated

with

a n

on-

signi

fican

t in

crea

se in

outp

atie

nt C

Rpa

rtic

ipat

ion

(OR

1.9,

95%

C

I 0.6

to

5.5)

The

aut

hors

con

clud

eth

at a

sys

tem

sap

proa

ch, i

nvol

ving

apr

ompt

for

outp

atie

ntC

R re

ferr

al a

s pa

rt o

f adi

scha

rge

criti

cal c

are

path

way

, may

pote

ntia

lly in

crea

sera

tes

of p

artic

ipat

ion

inC

R fo

r w

omen

Imic

h, 1

99711

0

UK

(jour

nal)

Befo

re-

and

afte

r-st

udy.

Com

paris

onof

12-

mon

thau

dit

perio

ds

No

info

rmat

ion

on t

henu

mbe

rs o

f pat

ient

s or

base

line

char

acte

ristic

s of

the

two

grou

ps

Post

-MI a

ndpo

stca

rdia

csu

rger

y pa

tient

s

Post

disc

harg

e, p

re-

outp

atie

nt C

R ho

me

visit

s by

tra

ined

com

mun

ity n

urse

s. F

orM

I pat

ient

s th

is w

as2–

3w

eeks

afte

rdi

scha

rge

and

for

hear

tsu

rger

y pa

tient

s4–

5w

eeks

. Visi

ts w

ere

aim

ed a

t: re

duct

ion

ofan

xiet

y le

vels,

ena

blin

gpa

tient

s to

mak

e an

dm

aint

ain

lifes

tyle

cha

nges

,id

entif

ying

pro

blem

s or

pote

ntia

l pro

blem

s, a

ndpr

ovid

ing

patie

nts

with

supp

ort,

educ

atio

n an

dco

unse

lling

. The

num

ber

and

freq

uenc

y of

hom

evi

sits

wer

e de

pend

ent

onin

divi

dual

req

uire

men

t

Patie

nts

disc

harg

edfr

om h

ospi

tal

befo

re t

henu

rse

hom

e-vi

sitin

gpr

ogra

mm

ew

as in

stig

ated

Patie

nt p

erce

ptio

n of

the

post

disc

harg

eho

me

visit

ing

serv

ice.

Att

enda

nce

atou

tpat

ient

CR

byin

vite

d pa

tient

sin

crea

sed

from

55%

befo

re t

o 75

% a

fter

inst

igat

ion

of t

hepr

ogra

mm

e. A

spa

tient

num

bers

are

not

give

n, t

hesig

nific

ance

of t

his

cann

ot b

e de

term

ined

Intr

oduc

tion

ofpo

stdi

scha

rge

hom

evi

sits

by t

rain

edco

mm

unity

nur

ses

repo

rted

to

beas

soci

ated

with

an

incr

ease

d at

tend

ance

at o

utpa

tient

CR cont

inue

d


111


Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff gr

oup:

m

easu

re a

nd

outc

omes

au

thor

s’

coun

try

% m

en,

invo

lved

, int

ensi

ty,

deta

ils o

f re

sult

san

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

mea

n ag

e fo

llow

-up

peri

od fo

r us

ual c

are

inte

rest

ing

feat

ures

type

)(S

D),

ou

tcom

e as

sess

men

tet

hnic

ity

if st

ated

Scot

t et

al.,

2000

1111

Aus

tral

ia(jo

urna

l)

Befo

re- a

ndaf

ter-

stud

y.C

ompa

rison

of c

linic

alin

dica

tors

inth

ree

perio

ds:

pre-

inte

rven

tion

(133

patie

nts)

,im

plem

ent-

atio

n of

inte

rven

tion

(271

patie

nts)

,an

d po

st-

inte

rven

tion

(245

pat

ient

s)

Pre-

and

post

inte

rven

tion

grou

psw

ere

simila

r at

bas

elin

e,bu

t no

info

rmat

ion

was

repo

rted

for

the

inte

rven

tion

perio

d.O

utpa

tient

CR

prog

ram

me

was

not

fully

oper

atio

nal i

n th

epr

eint

erve

ntio

n pe

riod.

Aut

hors

ass

umed

tha

tpa

tient

cha

ract

erist

ics,

diag

nost

ic m

etho

ds a

ndtr

eatm

ent

mod

aliti

esw

ould

rem

ain

esse

ntia

llyun

chan

ged

thro

ugho

utth

e st

udy

Post

-MI

patie

nts.

Pat

ient

char

acte

ristic

son

ly a

vaila

ble

for

pre-

and

post

inte

rven

tion

grou

ps. M

ean

age

66 y

ears

,66

% m

en

Diss

emin

atio

n of

evid

ence

-bas

ed c

linic

algu

idel

ines

for

the

man

agem

ent

of A

MI t

oho

spita

l sta

ff an

d G

Ps.

Info

rmat

ion

on c

linic

alin

dica

tors

was

fed

back

to a

ll ho

spita

l con

sulta

ntph

ysic

ians

, sen

ior

emer

genc

y st

aff,

med

ical

serv

ice

dire

ctor

s an

dse

nior

clin

icia

ns. A

s pa

rtof

the

feed

back

the

obse

rved

pro

port

ion

ofpa

tient

s re

ceiv

ing

the

trea

tmen

ts w

asco

mpa

red

with

a q

ualit

yth

resh

old

or m

inim

umle

vel o

f util

isatio

nin

dica

tive

of a

rea

sona

ble

stan

dard

of c

are.

Loc

alpr

ovid

ers

coul

d co

mpa

rean

d im

prov

e th

eir

own

prac

tice

Befo

redi

ssem

inat

ion

of e

vide

nce-

base

d cl

inic

algu

idel

ines

Clin

ical

indi

cato

rch

ange

s pr

e- t

opo

stin

terv

entio

n. N

och

ange

s w

ere

seen

in�

-blo

cker

, asp

irin

oran

giot

ensin

con

vert

ing

enzy

me

inhi

bito

r us

e.Li

pid-

low

erin

g dr

ugus

e in

crea

sed

from

23%

to

56%

(p<

0.00

3).

Out

patie

nt C

R se

rvic

ebe

cam

e op

erat

iona

l at

star

t of

inte

rven

tion

perio

d an

d sh

owed

ast

eady

incr

ease

inut

ilisa

tion

rate

from

24%

to

54%

(p=

0.00

3)

The

aut

hors

sug

gest

that

clin

ical

gui

delin

esco

mbi

ned

with

feed

back

of c

linic

alin

dica

tors

to

heal

thpr

ofes

siona

ls w

ere

usef

ul in

impr

ovin

gqu

ality

of c

are,

incl

udin

g ou

tpat

ient

CR

utili

satio

n in

MI

patie

nts.

How

ever

, the

impr

ovem

ent

may

be

due

to p

aral

lel c

hang

esin

leve

ls of

pro

visio

n


113


Appendix 9

Studies excluded from the review of interventions to improve uptake of cardiac rehabilitation

Authors, year Intervention Reason for exclusion

Campbell et al., 1998125,126 Nurse-led clinic giving secondary prevention Outcome: use of secondary assessment and advice prevention, not attendance at CR

Caulin-Glaser & Schmeizel, 2000123 Education of health professionals about CR Outcome: referral not attendance

Feder et al., 1999127 Leaflets promoting secondary prevention. Outcome: attendance at a general Also general practices received letters practice and drug prescribing, not summarising effective secondary prevention CR

Foresman, 1997120 Telephone invitation to CR programme No comparison group

Johnson, 2000118 Nurse telephone follow-up No data: descriptive

Kalayi et al., 1999122 Computerised referral pathway Outcome: referral not attendance

Keck et al., 1991,113 Keck & Comprehensive motivation programme Budde,1996114 integrated into CR to improve attendance No data: descriptive

at heart group after inpatient CR

Levknecht et al., 1997116 Outpatient clinical pathway No outcome data: descriptive

McCarney et al., 2000119 General practice database identifies patients No data: descriptivefor home visit by health visitor to improve secondary prevention

Mehta et al., 2000121 Quality improvement initiative: critical care Retrospective study. Allocation to pathway, patient education tool and staff groups according to physician education preference

Millar 1993115 Home visit by cardiac support worker No data: descriptive

Pasquali et al., 2001112 Telephone call describing CR benefits and Out of review periodassistance with referral

Suskin et al., 2000124 Physician endorsement Outcome: commitment toparticipate, not attendance

Tod et al., 1998117 Integration of primary and secondary care No outcome data: descriptive


115


Appendix 10

Flow diagram of the systematic review of interventions to improve adherence to cardiac

rehabilitation (QUOROM statement flow diagram)


3261




No outcome pertaining toadherence with cardiac rehabilitation 143


38 (37 studies)


14

Studies excluded from review

Effectiveness of rehabilitationformats 9No outcome relating to adherence 10No comparison group 3Retrospective design 1

__Total 23


2304


117


Appendix 11

Studies evaluating interventions to improve adherence to cardiac rehabilitation

Appendix 11

118 Stu

die

s ar

e li

sted

in

ter

ms

of

stu

dy

des

ign

an

d t

he

hie

rarc

hy

of

evid

ence

, w

ith

RC

Ts

firs

t.

Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff gr

oup:

det

ails

m

easu

re a

nd r

esul

tsou

tcom

es

auth

ors’

co

untr

y %

men

, mea

n in

volv

ed, i

nten

sity

, of

usu

al c

are

and

resu

lts

conc

lusi

ons,

(p

ublic

atio

nag

e (S

D),

fo

llow

-up

peri

od fo

r in

tere

stin

g fe

atur

esty

pe)

ethn

icit

y if

stat

edou

tcom

e as

sess

men

t

Old

ridge

&Jo

nes,

198

3145

Can

ada

(jour

nal)

Para

llel g

roup

RCT.

120

patie

nts

rand

omise

d.Pa

tient

sst

ratif

ied

bysm

okin

gst

atus

,oc

cupa

tion,

leisu

re h

abits

and

num

ber

ofpr

ior

infa

rctio

nsbe

fore

rand

omisa

tion.

The

seva

riabl

es w

ere

show

n to

be

pred

icto

rs o

fdr

opou

t ba

sed

on p

revi

ous

expe

rienc

e of

this

grou

p

Patie

nts

rand

omise

dus

ing

a lis

t of

ran

dom

num

bers

. Met

hod

ofal

loca

tion

conc

ealm

ent

uncl

ear.

Blin

d as

sess

men

t of

outc

omes

unc

lear

.U

ncle

ar w

heth

erco

mpa

rison

gro

ups

wer

e sim

ilar

atba

selin

e. L

osse

s to

follo

w-u

p (d

efin

ed a

sno

n-at

tend

ance

at

eigh

t co

nsec

utiv

ere

habi

litat

ion

sess

ions

) wer

e sim

ilar

in t

he in

terv

entio

nan

d co

ntro

l gro

ups

(21%

and

16%

)

Mix

ed C

HD

patie

nts,

MI 7

3%,

CA

BG 1

6%,

angi

na 1

2%.

Mea

n ag

e 50

.5ye

ars,

all

men

Usu

al c

ompr

ehen

sive

card

iac

reha

bilit

atio

n pr

ogra

mm

e, p

lus

self-

man

agem

ent

tech

niqu

esin

clud

ing

an a

gree

men

t to

part

icip

ate

in t

he p

rogr

amm

efo

r 6

mon

ths

to b

e sig

ned

byth

e pa

tient

and

coo

rdin

ator

,an

d se

lf-re

port

dia

ries

toco

mpl

ete

and

be d

iscus

sed

with

the

coo

rdin

ator

at

regu

lar

inte

rval

s. D

iarie

s in

clud

edsix

grap

hs fo

r pl

ottin

g se

lf-m

onito

red

subm

axim

al h

eart

rate

s ea

ch m

onth

, at

33%

,50

% a

nd 7

5% o

f the

max

imum

pow

er o

utpu

t ac

hiev

ed in

the

prev

ious

exe

rcise

tes

t, an

d six

24-h

our

reca

ll qu

estio

nnai

res

ofda

ily a

ctiv

ities

on

a ra

ndom

lych

osen

day

to

be c

ompl

eted

each

mon

th. I

n ad

ditio

n, a

wei

ght

loss

dia

ry t

o fil

l in

each

wee

k w

as g

iven

to

thos

e w

hoin

itial

ly a

gree

d to

lose

wei

ght,

and

simila

r di

arie

s to

rec

ord

num

ber

of c

igar

ette

s sm

oked

each

day

. Fol

low

-up

at t

he e

ndof

the

inte

rven

tion

perio

d of

6m

onth

s

Usu

alco

mpr

ehen

sive

card

iac

reha

bilit

atio

npr

ogra

mm

e

Com

plia

nce

defin

ed a

sat

tend

ance

at

60%

or

mor

e of

the

sch

edul

ed 4

8su

perv

ised

card

iac

reha

bilit

atio

n se

ssio

ns. (

Ifan

y pa

tient

faile

d to

att

end

four

con

secu

tive

sess

ions

they

wer

e co

ntac

ted

byte

leph

one

and

urge

d to

cont

inue

.) D

ata

pres

ente

das

inte

ntio

n to

tre

at.

Com

plia

nce

rate

was

54%

in t

he in

terv

entio

n gr

oup,

and

42%

in t

he c

ontr

olgr

oup;

the

se r

ates

wer

eno

t st

atist

ical

ly s

igni

fican

t.A

tten

danc

e of

dro

pout

sw

as s

imila

r in

the

inte

rven

tion

and

cont

rol

grou

ps (2

1% v

s 16

%) a

ndw

as a

lso s

imila

r fo

rco

mpl

iers

(74%

vs

76%

).N

ot a

ll pa

tient

s in

the

inte

rven

tion

grou

p sig

ned

the

agre

emen

t to

part

icip

ate.

Com

plia

nce

was

sig

nific

antly

hig

her

inth

e 48

sub

ject

s w

ho s

igne

d(6

5%),

than

in t

he 1

5 w

hore

fuse

d (2

0%)

Ove

rall,

no

impr

ovem

ent

in c

ompl

ianc

e w

ithre

habi

litat

ion

sess

ions

was

seen

in p

atie

nts

rand

omise

d to

apr

ogra

mm

e of

sel

f-m

anag

emen

t te

chni

ques

,in

clud

ing

signe

dag

reem

ent

and

diar

ies.

Ina

subg

roup

ana

lysis

, the

auth

or fo

und

high

erco

mpl

ianc

e ra

tes

in t

hose

patie

nts

in t

hein

terv

entio

n gr

oup

who

signe

d th

e ag

reem

ent

topa

rtic

ipat

e th

an in

tho

sew

ho d

id n

ot, a

ndsu

gges

ted

the

need

for

furt

her

inve

stig

atio

n of

self-

man

agem

ent

com

plia

nce-

impr

ovin

gst

rate

gies

cont

inue

d


119


Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff in

volv

ed,

grou

p: d

etai

ls

mea

sure

and

res

ults

outc

omes

au

thor

s’

coun

try

% m

en, m

ean

inte

nsit

y, fo

llow

-up

peri

od

of u

sual

car

ean

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

age

(SD

),

for

outc

ome

asse

ssm

ent

inte

rest

ing

feat

ures

type

)et

hnic

ity

if st

ated

Dal

troy

, 198

5146

USA

(jour

nal)

Para

llel g

roup

RCT,

174

patie

nts

rand

omise

d

Met

hod

ofra

ndom

isatio

n an

dal

loca

tion

conc

ealm

ent

uncl

ear.

Out

com

eas

sess

ors

wer

ebl

ind

to g

roup

allo

catio

n, a

ndco

mpa

rison

grou

ps w

ere

simila

r at

bas

elin

e.N

o lo

sses

to

follo

w-u

pre

port

ed a

t 3

mon

ths,

the

perio

d at

whi

chm

ost

data

are

pres

ente

d. S

tudy

was

pow

ered

to

dete

ct a

14%

diffe

renc

e in

atte

ndan

ce o

ver

3m

onth

s

Mix

ed C

HD

patie

nts,

81%

MI,

63%

with

ahi

stor

y of

ang

ina,

17%

pos

t-C

ABG

.M

ean

age

53.8

year

s, 8

8% m

en,

95%

whi

te

Ora

l per

suas

ive

com

mun

icat

ion

and

educ

atio

n in

terv

entio

n to

impr

ove

patie

nt a

dher

ence

toex

erci

se r

egim

ens.

Inte

rven

tion

deve

lope

d fr

om in

terv

iew

s w

ithpr

evio

us p

atie

nts

and

thei

r sp

ouse

sto

elic

it th

e m

ost c

omm

on b

elie

fsof

ben

efits

and

dra

wba

cks

to th

eex

erci

se p

rogr

amm

e. P

atie

nts

inth

e in

terv

entio

n gr

oup

rece

ived

an

oral

per

suas

ive

com

mun

icat

ion

onth

e te

leph

one

in s

crip

ted

coun

selli

ng fo

rmat

to: c

onvi

nce

them

of t

he b

enef

its o

f reg

ular

exer

cise

, war

n th

em o

f lik

ely

draw

back

s so

that

exp

ecta

tions

wou

ld b

e re

alist

ic, a

cqua

int t

hem

with

met

hods

use

d by

oth

erpa

tient

s to

cop

e w

ith d

raw

back

s,an

d el

icit

an o

ral c

omm

itmen

t to

atte

nd a

t lea

st tw

o cl

asse

s pe

rw

eek

for

the

first

6 w

eeks

. In

addi

tion,

pat

ient

s re

ceiv

ed a

mai

led

writ

ten

pers

uasiv

e co

mm

unic

atio

nto

rei

nfor

ce th

ese

poin

ts. S

pous

esal

so r

ecei

ved

tele

phon

e co

unse

lling

to e

ncou

rage

the

patie

nt to

att

end

and

disc

uss

met

hods

that

oth

erpa

tient

s sp

ouse

s fo

und

usef

ul. A

writ

ten

com

mun

icat

ion

tore

info

rce

thes

e po

ints

was

also

sen

tto

the

spou

se to

incr

ease

the

spou

se’s

supp

ort.

Patie

nts

also

rece

ived

a p

amph

let w

ithin

form

atio

n on

ben

efits

and

draw

back

s of

exe

rcise

. All

com

mun

icat

ion

was

tailo

red

toin

divi

dual

pat

ient

s ba

sed

on d

ata

colle

cted

by

ques

tionn

aire

at

base

line

Com

paris

ongr

oup

patie

nts

and

spou

ses

rece

ived

the

sam

e pa

mph

let

with

info

rmat

ion

on t

he b

enef

itsan

d dr

awba

cks

of e

xerc

ise, a

sth

e in

terv

entio

ngr

oup.

Thi

s w

asdo

ne s

o al

lpa

tient

s w

ould

have

the

sam

ein

duce

men

t to

ente

r th

epr

ogra

mm

e. It

was

tho

ught

unlik

ely

that

thi

ssin

gle

inte

rven

tion

wou

ld p

rodu

cela

stin

gbe

havi

oura

lch

ange

Att

enda

nce

at e

xerc

isese

ssio

ns o

ver

3 m

onth

s.A

tten

danc

e fo

r pa

tient

s in

the

inte

rven

tion

grou

p w

as63

.8%

, and

62.

2% in

the

com

paris

on g

roup

.Su

bgro

up a

naly

sis r

evea

led

that

am

ong

the

inte

rven

tion

grou

p,at

tend

ance

was

gre

ater

amon

g be

tter

edu

cate

dpa

tient

s. S

pous

epa

rtic

ipat

ion,

age

, gen

der

and

occu

patio

n w

ere

not

asso

ciat

ed w

ith a

tten

danc

e,al

thou

gh t

he n

umbe

rs in

thes

e su

bgro

ups

are

likel

yto

be

too

smal

l to

draw

firm

con

clus

ions

Ove

rall,

no

signi

fican

tim

prov

emen

t in

atte

ndan

ce a

t ex

erci

sese

ssio

ns w

ith t

hein

terv

entio

n. T

here

isso

me

sugg

estio

n th

ated

ucat

iona

l lev

el is

afa

ctor

ass

ocia

ted

with

atte

ndan

ce

cont

inue

d

Appendix 11

120

Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff in

volv

ed,

grou

p: d

etai

ls

mea

sure

and

res

ults

outc

omes

au

thor

s’

coun

try

% m

en, m

ean

inte

nsit

y, fo

llow

-up

peri

od

of u

sual

car

ean

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

age

(SD

),

for

outc

ome

asse

ssm

ent

inte

rest

ing

feat

ures

type

)et

hnic

ity

if st

ated

Mah

ler

et a

l.19

9914

7

USA

(jour

nal)

Para

llel g

roup

RCT,

tw

oin

terv

entio

ngr

oups

and

one

cont

rol

grou

p,21

5pa

tient

sra

ndom

ised

Met

hod

ofra

ndom

isatio

n an

dal

loca

tion

conc

ealm

ent

uncl

ear.

Blin

das

sess

men

t of

outc

omes

unc

lear

.U

ncle

ar w

heth

erco

mpa

rison

grou

ps w

ere

simila

r at

bas

elin

e,as

dem

ogra

phic

data

are

not

pres

ente

dse

para

tely

for

each

gro

up.

Ove

rall

loss

es t

ofo

llow

-up

at3

mon

ths

wer

e9%

Con

secu

tive

elec

tive

first

tim

eC

ABG

, mea

n ag

e61

.4 (3

.2ye

ars)

,86

.5%

men

,83

.3%

whi

te

Vide

otap

e in

terv

entio

npo

stsu

rger

y, s

hort

ly b

efor

edi

scha

rge

to e

nhan

ce c

ompl

ianc

ew

ith e

xerc

ise a

nd d

iet.

Two

vide

otap

e in

terv

entio

ns:

(1)M

aste

ry T

ape:

dep

icts

pat

ient

sas

cal

m a

nd c

onfid

ent

at t

he t

ime

of h

ospi

tal d

ischa

rge,

mak

ing

stea

dy p

rogr

ess

with

no

com

plic

atio

ns d

urin

g 6

mon

ths,

and

adju

stin

g to

the

rec

omm

ende

dex

erci

se a

nd lo

w-f

at d

iet

with

rela

tive

ease

; (2)

Cop

ing

Tape

:ed

ited

so t

he s

ame

patie

nts

men

tion

conc

erns

the

y ar

eex

perie

ncin

g ab

out

hosp

ital

rele

ase

and

cope

with

effo

rt, b

utsu

cces

sful

ly, w

ith a

var

iety

of

diffi

culti

es (e

.g. f

atig

ue, d

iet

chan

ges)

, so

the

reco

very

ispo

rtra

yed

as a

ste

ady

forw

ard

prog

ress

ion

of u

ps a

nd d

owns

.Ex

erci

se a

nd d

ieta

ry c

ompl

ianc

eas

sess

ed a

t 1

and

3 m

onth

spo

stdi

scha

rge

Stan

dard

disc

harg

epr

epar

atio

n fr

omon

e of

the

tw

oho

spita

ls w

here

recr

uitm

ent

took

plac

e. N

oat

tem

pt w

asm

ade

toin

terf

ere

with

this.

Con

siste

dal

mos

tex

clus

ivel

y of

advi

ce n

ot t

o lif

tto

o m

uch,

and

inst

ruct

ions

rega

rdin

g th

eim

port

ance

of

exer

cise

and

mai

ntai

ning

alo

w-f

at d

iet

Com

plia

nce

with

life

styl

ech

ange

s. E

xerc

iseco

mpl

ianc

e as

sess

ed w

ith a

simpl

e qu

estio

nnai

re o

fle

isure

-tim

e ex

erci

se (h

owm

any

times

in t

he p

ast

7da

ys t

hey

part

icip

ated

inlig

ht, m

oder

ate

and

stre

nuou

s ex

erci

se).

Die

tary

com

plia

nce

was

asse

ssed

from

the

chol

este

rol–

satu

rate

d fa

tsu

bsca

le o

f the

die

t ha

bit

surv

ey. A

t 3

mon

ths

exer

cise

com

plia

nce

was

impr

oved

with

bot

hin

terv

entio

ns (p

< 0

.05)

,bu

t im

prov

emen

ts w

ere

grea

test

for

the

Cop

ing

Tape

at

1m

onth

for

mod

erat

e ex

erci

se, a

nd a

t3

mon

ths

for

stre

nuou

sex

erci

se. B

oth

inte

rven

tion

grou

ps s

how

ed a

red

uctio

nin

die

tary

cho

lest

erol

and

satu

rate

d fa

t at

1 m

onth

(p<

0.0

5), b

ut n

odi

ffere

nces

wer

e se

en a

t3

mon

ths

Anx

iety

and

self-

effic

acy

belie

fs.

Hyp

othe

sised

that

the

sew

ould

affe

ctco

mpl

ianc

e

The

aut

hors

hyp

othe

sised

that

eith

er t

ape

wou

ldre

sult

in im

prov

edou

tcom

es c

ompa

red

with

cont

rol,

but

also

tha

t th

eC

opin

g Ta

pe w

ould

exhi

bit

the

high

est

self-

effic

acy

belie

fs a

ndgr

eate

st c

ompl

ianc

e. T

hey

conc

lude

d th

at v

iew

ing

eith

er t

ape

prov

ed t

o be

an e

ffect

ive

met

hod

for

incr

easin

g di

etar

y an

dex

erci

se c

ompl

ianc

edu

ring

the

first

3 m

onth

spo

stsu

rger

y

cont

inue

d


121


Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff in

volv

ed,

grou

p: d

etai

ls

mea

sure

and

res

ults

outc

omes

au

thor

s’

coun

try

% m

en, m

ean

inte

nsit

y, fo

llow

-up

peri

od

of u

sual

car

ean

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

age

(SD

),

for

outc

ome

asse

ssm

ent

inte

rest

ing

feat

ures

type

)et

hnic

ity

if st

ated

Aish

& Is

enbe

rg,

1996

148

Can

ada

(jour

nal)

Para

llel g

roup

RCT,

104

patie

nts

rand

omise

d

Met

hod

ofra

ndom

isatio

n an

dal

loca

tion

conc

ealm

ent

uncl

ear.

Com

paris

ongr

oups

wer

esim

ilar

at b

asel

ine.

Blin

d as

sess

men

tof

out

com

esun

clea

r. Lo

sses

to

follo

w-u

p no

tre

port

ed

MI p

atie

nts,

maj

ority

firs

t M

I.Pa

tient

s re

crui

ted

whi

le in

hos

pita

l.M

ean

age

62 (1

1)ye

ars,

60%

men

Nur

sing

inte

rven

tion

of n

utrit

iona

lse

lf-ca

re b

ased

on

Ore

m’s

theo

ry.17

6H

ome

visit

to

colle

ctba

selin

e 3-

day

diet

rec

ord,

ass

ess

food

hab

its a

nd p

rovi

dein

form

atio

n ab

out

nutr

ition

al g

oals

for

heal

thy

hear

ts, a

nd d

eter

min

ew

heth

er t

hese

wer

e be

ing

met

.Su

gges

tions

for

chan

ges

give

n an

da

com

mitm

ent

on t

he p

art

of t

hepa

tient

sou

ght

to m

ake

thes

ech

ange

s. T

hree

follo

w-u

pte

leph

one

calls

ove

r 6

wee

ks a

nda

furt

her

hom

e vi

sit t

o co

llect

3-

day

diet

rec

ord

and

asse

ss fo

odha

bits

at

7w

eeks

pos

tdisc

harg

e.D

ata

com

pare

d be

twee

n ba

selin

ean

d 7

wee

ks p

ostd

ischa

rge

Con

trol

gro

upre

ceiv

ed fo

llow

-up

tel

epho

neca

lls a

nd h

ome

visit

at

7w

eeks

to c

olle

ct d

ata

on3-

day

diet

ary

reco

rd a

ndas

sess

food

habi

ts. A

dvic

eab

out

diet

was

not

give

n un

less

the

patie

ntin

trod

uced

the

subj

ect

Adh

eren

ce t

o di

etar

yad

vice

ass

esse

d fr

omdi

etar

y re

cord

and

food

habi

ts q

uest

ionn

aire

. Tot

alfa

t an

d sa

tura

ted

fat

perc

enta

ge o

f cal

orie

s w

assig

nific

antly

red

uced

in t

hein

terv

entio

n gr

oup

(p<

0.01

). Si

gnifi

cant

impr

ovem

ent

on t

he fo

odha

bits

que

stio

nnai

re w

asse

en in

the

inte

rven

tion

grou

p (p

< 0

.05)

App

raisa

l of s

elf

care

and

eat

ing

habi

ts w

hich

show

edim

prov

emen

tw

ith t

hein

terv

entio

n,an

d se

lf-ef

ficac

yfo

r he

alth

yea

ting,

whi

chsh

owed

no

chan

ge w

ithth

ein

terv

entio

n

The

aut

hors

con

clud

e th

atth

is nu

rsin

g in

terv

entio

nw

as e

ffect

ive

atsu

ppor

ting

heal

thy

eatin

gan

d pa

tient

s’ s

elf-

care

agen

cy

cont

inue

d

Appendix 11

122

Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff in

volv

ed,

grou

p: d

etai

ls

mea

sure

and

res

ults

outc

omes

au

thor

s’

coun

try

% m

en, m

ean

inte

nsit

y, fo

llow

-up

peri

od

of u

sual

car

ean

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

age

(SD

),

for

outc

ome

asse

ssm

ent

inte

rest

ing

feat

ures

type

)et

hnic

ity

if st

ated

Ash

e, 1

99314

9

USA

(PhD

the

sis)

Qua

si RC

T,41

pat

ient

sra

ndom

ised

Allo

catio

n to

grou

ps b

ypr

esen

ting

patie

nts

with

apa

cket

con

tain

ing

a fo

rm c

oded

Aor

B. B

lind

asse

ssm

ent

ofou

tcom

es u

ncle

ar.

Sim

ilarit

y of

grou

ps a

t ba

selin

eun

clea

r. O

vera

lllo

sses

to

follo

w-

up 2

2%

Subj

ects

rec

ruite

dfr

om a

pha

se 2

card

iac

reha

bilit

atio

npr

ogra

mm

e.M

ixed

car

diac

patie

nts

incl

udin

gM

I, C

ABG

, ang

ina

and

patie

nts

with

valv

e pr

oble

ms.

Mea

n ag

e 62

(ran

ge33

–77)

year

s,ge

nder

not

men

tione

d, 9

5%w

hite

Mot

ivat

iona

l rel

apse

pre

vent

ion

inte

rven

tion

rece

ived

dur

ing

the

cour

se o

f the

car

diac

reh

abili

tatio

npr

ogra

mm

e. T

he c

ardi

acre

habi

litat

ion

prog

ram

me

cons

isted

of th

ree

wee

kly

exer

cise

ses

sions

of 3

0–40

min

utes

ove

r 2–

3m

onth

s.T

he in

terv

entio

n w

as s

tart

ed a

fter

four

or

five

exer

cise

ses

sions

. The

inte

rven

tion

was

bas

ed o

n M

arla

ttan

d G

ordo

n’s

mod

el.17

7Pa

tient

sre

ceiv

ed in

divi

dual

ses

sions

, one

aw

eek

for

3 w

eeks

. Ses

sion

1: u

sing

pret

est i

nfor

mat

ion,

fact

ors

foun

dto

inte

rfer

e w

ith a

dher

ence

wer

ein

trod

uced

. Pat

ient

s di

scus

sed

thei

rpe

rcep

tions

on

the

valu

e of

exer

cise

, list

ed th

eir

goal

s fo

r th

epr

ogra

mm

e an

d an

ticip

ated

outc

omes

. Ses

sion

2: p

atie

nts

wer

ein

trod

uced

to d

ecisi

on-m

akin

gco

ncep

ts a

nd c

ogni

tive

inte

rfer

ence

fact

ors.

Disc

ussio

n w

ith r

egar

d to

copi

ng w

ith ‘s

lips’

and

intr

oduc

tion

to a

ppro

pria

te w

ays

to r

efra

me

pers

pect

ives

. Pat

ient

s fil

led

in d

aily

activ

ity s

heet

s. S

essio

n 3:

focu

sed

on th

e im

port

ance

of l

ifest

yle

bala

nce.

Pat

ient

s w

ere

aske

d to

refe

r to

dai

ly a

ctiv

ity s

heet

s to

intr

oduc

e co

ncep

ts o

f sho

ulds

and

wan

ts. S

tres

sors

wer

e id

entif

ied

that

may

impa

ct o

n lif

esty

le b

alan

cean

d di

scus

sed,

as

was

the

impo

rtan

ce o

f pos

itive

thin

king

and

use

of m

edic

atio

n. P

atie

nts

also

took

par

t in

a st

ress

man

agem

ent

exer

cise

and

rel

axat

ion

proc

edur

e

Dur

ing

the

cour

se o

f the

exer

cise

prog

ram

me

patie

nts

rece

ived

a ‘b

enig

n’ed

ucat

ion

inte

rven

tion,

whi

ch c

over

edba

sic e

xerc

iseco

ncep

ts,

guid

elin

es fo

rpr

oper

exe

rcise

part

icip

atio

n,ex

erci

se t

ips

and

hand

outs

, and

the

bene

fits

ofex

erci

se

Tota

l adh

eren

ce t

o th

em

axim

um n

umbe

r of

exer

cise

ses

sions

. Thi

s w

as90

% in

the

inte

rven

tion

grou

p an

d 89

% in

the

cont

rol g

roup

(not

signi

fican

t)

Vario

usps

ycho

logi

cal

mea

sure

s us

edto

det

erm

ine

rela

tions

hips

with

atte

ndan

ce

Man

y hy

poth

eses

tes

ted

with

rel

ativ

ely

smal

lnu

mbe

r of

pat

ient

s. T

heau

thor

s co

nclu

de t

hat

they

foun

d no

diff

eren

ces

betw

een

grou

ps o

nm

easu

res

of a

dher

ence

,se

lf-m

otiv

atio

n, s

elf-

effic

acy

or in

tern

al h

ealth

locu

s of

con

trol

cont

inue

d


123


Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff in

volv

ed,

grou

p: d

etai

ls

mea

sure

and

res

ults

outc

omes

au

thor

s’

coun

try

% m

en, m

ean

inte

nsit

y, fo

llow

-up

peri

od

of u

sual

car

ean

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

age

(SD

),

for

outc

ome

asse

ssm

ent

inte

rest

ing

feat

ures

type

)et

hnic

ity

if st

ated

Hop

per,

1995

150

USA

(PhD

the

sis)

Para

llel g

roup

RCT,

80

patie

nts

rand

omise

d

No

deta

ils o

fm

etho

d of

rand

omisa

tion

oral

loca

tion

conc

ealm

ent.

Blin

d as

sess

men

tof

out

com

esun

clea

r. G

roup

ssim

ilar

at b

asel

ine.

46%

loss

to

follo

w-u

p.

Mix

ed C

HD

patie

nts:

49%

MI,

16%

CA

BG, 3

%an

giop

last

y, 8

% M

Ian

d C

ABG

, 10%

MI a

nd a

ngio

plas

ty,

15%

MI,

CA

BGan

d an

giop

last

y.M

ean

age

58ye

ars,

83%

men

Dur

ing

the

12m

onth

s fo

llow

ing

card

iac

reha

bilit

atio

n pa

tient

sre

ceiv

ed m

onth

ly s

truc

ture

dte

leph

one

inte

rvie

ws

with

aca

rdia

c nu

rse

or a

n ex

erci

seph

ysio

logi

st fr

om t

he r

ehab

ilita

tion

team

. Int

ervi

ews

prov

ided

soc

ial

supp

ort

and

enco

urag

emen

t,la

sted

for

abou

t 15

min

utes

, and

addr

esse

d th

e ar

eas

of c

onsis

tent

exer

cise

, mai

nten

ance

of a

hea

lthy

diet

, con

siste

ncy

with

med

icat

ion,

know

ledg

e of

cur

rent

blo

odpr

essu

re a

nd c

hole

ster

ol le

vels,

and

sym

ptom

s th

at r

equi

red

med

ical

att

entio

n. H

ealth

prof

essio

nals

prov

ided

ass

istan

ce if

imm

edia

te c

are

was

req

uire

d.Po

stal

que

stio

nnai

re fo

llow

-up

12m

onth

s af

ter

com

plet

ion

of C

Rpr

ogra

mm

es

No

supp

ort

orte

leph

one

calls

afte

r C

R fr

omre

habi

litat

ion

staf

f

Exer

cise

hab

it, in

tent

ion

toex

erci

se a

nd c

ondi

tions

that

faci

litat

ed o

rdi

scou

rage

d th

epe

rfor

man

ce o

f exe

rcise

asse

ssed

by

self-

com

plet

edqu

estio

nnai

re. N

odi

ffere

nce

in e

xerc

ise h

abit

or in

tent

ion

to e

xerc

iseas

soci

ated

with

the

inte

rven

tion.

Con

ditio

nsth

at fa

cilit

ated

the

perf

orm

ance

of e

xerc

isew

ere

impr

oved

in t

hein

terv

entio

n gr

oup

com

pare

d w

ith c

ontr

ol(p

<0

.05)

Exer

cise

conf

iden

cesc

ale

(sel

f-ef

ficac

y),

pers

onal

attit

udes

sca

le(d

epre

ssio

n),

rest

ing

and

exer

cise

blo

odpr

essu

re, b

lood

lipid

s an

dgr

aded

max

imal

exer

cise

tes

t.N

o di

ffere

nces

betw

een

inte

rven

tion

and

cont

rol

The

aut

hor

conc

lude

s th

atpe

rson

al in

depe

nden

ce o

fpa

rtic

ipan

ts a

fter

a C

Rpr

ogra

mm

e ca

n be

impr

oved

by

mea

ns o

fte

leph

one

cont

act

cond

ucte

d af

ter

conc

lusio

n of

the

prog

ram

me

cont

inue

d

Appendix 11

124

Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff in

volv

ed,

grou

p: d

etai

ls

mea

sure

and

res

ults

outc

omes

au

thor

s’

coun

try

% m

en, m

ean

inte

nsit

y, fo

llow

-up

peri

od

of u

sual

car

ean

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

age

(SD

),

for

outc

ome

asse

ssm

ent

inte

rest

ing

feat

ures

type

)et

hnic

ity

if st

ated

Dun

can

et a

l.,20

0115

1

USA

(con

fere

nce

proc

eedi

ngs)

Para

llel g

roup

RCT,

eig

htpa

tient

sra

ndom

ised.

Feas

ibili

tyst

udy,

hen

cesm

all

num

bers

No

deta

ils o

fm

etho

d of

rand

omisa

tion,

allo

catio

nco

ncea

lmen

t,bl

indi

ng o

fou

tcom

eas

sess

ors,

com

para

bilit

y of

grou

ps a

t ba

selin

eor

loss

es t

ofo

llow

-up

Hea

rt fa

ilure

patie

nts

who

wer

ecu

rren

tlypa

rtic

ipat

ing

in a

card

iac

reha

bilit

atio

npr

ogra

mm

e. N

ode

tails

of a

ge o

rge

nder

, mea

nej

ectio

n fr

actio

n24

%

Car

diac

reh

abili

tatio

n pl

usbe

havi

oura

l fee

dbac

k in

terv

entio

non

die

tary

sod

ium

inta

ke.

Feed

back

giv

en o

n a

3-da

y di

etar

ylo

g of

sod

ium

inta

ke, d

iscus

sion

ofpr

oble

m-s

olvi

ng s

trat

egie

s to

redu

ce fu

ture

sod

ium

inta

ke

Patie

nts

in t

here

habi

litat

ion

prog

ram

me

com

plet

ed t

he

3-da

y di

etar

y lo

gon

sod

ium

inta

ke

Repe

at o

f the

3-d

ay d

ieta

rylo

g of

sod

ium

inta

ke a

t th

een

d of

the

inte

rven

tion

perio

d, a

nd c

ompl

etio

n of

the

belie

fs a

bout

die

t in

stru

men

t(m

easu

re o

f ben

efits

and

barr

iers

rel

ated

to

diet

ary

sodi

um a

dher

ence

). So

dium

inta

ke w

as s

igni

fican

tly le

ss in

the

inte

rven

tion

grou

p (1

569

vs 2

836

mg,

p<

0.05

), an

dth

ese

patie

nts

iden

tifie

dsig

nific

antly

few

er b

arrie

rs t

oad

herin

g to

sod

ium

reco

mm

enda

tions

Very

sm

all f

easib

ility

stu

dyw

ith o

nly

four

pat

ient

sra

ndom

ised

to e

ach

grou

p. In

terv

entio

n of

beha

viou

ral f

eedb

ack

had

posit

ive

effe

cts

on s

odiu

min

take

and

att

itude

sto

war

ds a

dher

ence

to

reco

mm

ende

d so

dium

leve

ls

Lesli

e &

Sch

uste

r,19

9115

2

USA

(jour

nal)

Qua

si RC

T,30

pat

ient

sra

ndom

ised

Alte

rnat

eal

loca

tion

toin

terv

entio

n or

cont

rol.

Blin

das

sess

men

t of

outc

omes

unc

lear

.T

he c

ompa

rison

grou

ps w

ere

simila

r at

bas

elin

ein

ter

ms

of a

gean

d ge

nder

but

ther

e w

ere

mor

eC

ABG

and

few

erM

I pat

ient

s in

the

cont

rol g

roup

.T

here

was

a 7

%ov

eral

l los

s to

follo

w-u

p ov

er a

n8-

wee

k pe

riod

Mix

ed C

HD

patie

nt: M

I 25%

,C

ABG

43%

,an

giop

last

y 18

%,

othe

r co

rona

rydi

seas

e 14

%.

Mea

n ag

e55

.6ye

ars,

71%

men

Con

tinge

ncy

cont

ract

ing.

Con

trac

ting

in t

his

stud

y is

defin

edas

a w

ritte

n co

ntra

ct n

egot

iate

dw

ith t

he p

atie

nt, s

tatin

g ho

w lo

ngth

ey w

ill e

xerc

ise fo

r to

mai

ntai

nth

eir

hear

t ra

te a

t a

cert

ain

leve

l,on

how

man

y da

ys t

hat

wee

k, in

retu

rn fo

r a

rew

ard.

Pat

ient

sch

ose

rew

ards

tha

t w

ere

gene

rally

acce

ptab

le p

rovi

ding

the

y w

ere

not

dam

agin

g to

hea

lth. E

xam

ples

incl

uded

die

tary

rec

ipes

, T-s

hirt

sor

loan

of e

xerc

ise e

quip

men

t. A

llco

ntra

ctin

g do

ne b

y th

e ed

ucat

ion

coor

dina

tor

of t

he c

ardi

acre

habi

litat

ion

prog

ram

me,

with

sess

ions

last

ing

for

10 m

inut

esea

ch w

eek

for

8 w

eeks

. Con

trac

tbe

havi

ours

wer

e de

signe

d to

be

atta

inab

le, a

nd e

xerc

ise s

essio

nsw

ere

rout

inel

y sc

hedu

led

thre

etim

es a

wee

k. U

pon

com

plet

ion

ofth

e co

ntra

ct p

atie

nts

rece

ived

thei

r re

war

d. P

atie

nts

also

rece

ived

1ho

ur o

f for

mal

educ

atio

n ea

ch w

eek.

Fol

low

-up

asse

ssm

ent

at 8

wee

ks

Patie

nts

in t

heco

mpa

rison

grou

p re

ceiv

edth

e sa

me

1ho

urpe

r w

eek

offo

rmal

edu

catio

nas

the

inte

rven

tion

grou

p

Exer

cise

kno

wle

dge

test

and

adhe

renc

e to

exe

rcise

sess

ions

. The

re w

as a

signi

fican

t in

crea

se in

exe

rcise

know

ledg

e sc

ores

at

8 w

eeks

in t

he in

terv

entio

n gr

oup,

but

no d

iffer

ence

in a

tten

danc

era

tes

betw

een

the

inte

rven

tion

and

cont

rol

grou

ps (9

0% a

nd 8

9%,

resp

ectiv

ely)

The

re w

as n

o ef

fect

of

the

inte

rven

tion

onpr

ogra

mm

e at

tend

ance

.T

he a

utho

rs c

oncl

ude

that

the

incr

ease

in e

xerc

isekn

owle

dge

sugg

ests

tha

tth

e co

ntin

genc

yco

ntra

ctin

g pr

oces

sm

aybe

an

inte

rven

tion

wor

thy

of c

onsid

erat

ion

in a

dditi

on t

o tr

aditi

onal

grou

p le

ctur

es

cont

inue

d


125


Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff in

volv

ed,

grou

p: d

etai

ls

mea

sure

and

res

ults

outc

omes

au

thor

s’

coun

try

% m

en, m

ean

inte

nsit

y, fo

llow

-up

peri

od

of u

sual

car

ean

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

age

(SD

),

for

outc

ome

asse

ssm

ent

inte

rest

ing

feat

ures

type

)et

hnic

ity

if st

ated

Mill

er e

t al

.,19

8814

3

Mill

er, e

t al

.,19

8914

4

USA

(jour

nals)

Qua

si RC

T.11

5 pa

tient

sra

ndom

ised

Alte

rnat

eal

loca

tion

toin

terv

entio

n or

cont

rol.

Blin

das

sess

men

t of

outc

omes

unc

lear

.T

he c

ompa

rison

grou

ps w

ere

simila

r at

bas

elin

e.T

here

was

an

11%

ove

rall

loss

to fo

llow

-up

over

a 60

-day

per

iod,

and

30%

loss

to

follo

w-u

p at

1ye

ar

All

patie

nts

recr

uite

d fr

om in

patie

nt c

ardi

acre

habi

litat

ion

prog

ram

mes

(one

of t

hree

sim

ilar

prog

ram

mes

)fo

llow

ing

a fir

stun

com

plic

ated

MI.

Age

ran

ge30

–65

year

s, 8

1%m

en. D

ata

avai

labl

e fo

r on

lyth

ose

patie

nts

follo

wed

up,

not

all t

hose

rand

omise

d

All

patie

nts

had

10–1

5da

ys o

fca

rdia

c re

habi

litat

ion

in h

ospi

tal,

incl

udin

g ad

vice

on

diet

, act

ivity

,sm

okin

g an

d m

edic

atio

n. A

t 30

days

pos

tdisc

harg

e nu

rses

visi

ted

patie

nts

at h

ome

to d

eliv

er a

nin

terv

entio

n to

impr

ove

med

ical

regi

men

adh

eren

ce w

hich

cons

isted

of t

hree

ste

ps:

(1) A

sses

smen

t: da

ta o

btai

ned

onpa

tient

sel

f-as

sess

men

t of

att

itude

san

d pe

rcei

ved

belie

fs o

f oth

ers

tow

ards

reg

imen

com

plia

nce,

pers

onal

psy

chol

ogic

al a

nd s

ocie

tal

adju

stm

ents

, and

rep

orte

dre

gim

en c

ompl

ianc

e by

pat

ient

and

spou

se, p

redi

scha

rge

and

30da

yspo

stdi

scha

rge.

(2) P

robl

emid

entif

icat

ion:

dat

a fr

om s

tep

1w

ere

eval

uate

d by

the

pat

ient

,sp

ouse

and

nur

se. P

robl

em a

reas

wer

e de

fined

and

fact

ors

cont

ribut

ing

to n

on-c

ompl

ianc

ew

ere

disc

usse

d. (3

) Goa

l set

ting:

on t

he b

asis

of p

robl

ems

iden

tifie

d, a

ltern

ativ

e ac

tions

wer

edi

scus

sed

and

a he

alth

pla

n w

ithsp

ecifi

c go

als

was

dev

elop

ed.

Ass

essm

ent

of c

ompl

ianc

e w

ithm

edic

al r

egim

en a

t fo

llow

-up

hom

e vi

sits

at 6

0 da

ys a

nd 1

yea

r

All

patie

nts

had

10–1

5 da

ys o

fca

rdia

cre

habi

litat

ion

inho

spita

l,in

clud

ing

advi

ceon

die

t, ac

tivity

,sm

okin

g an

dm

edic

atio

n.Pa

tient

sin

terv

iew

edbe

fore

disc

harg

ean

d vi

sited

at

hom

e 30

day

spo

stdi

scha

rge

toco

llect

asse

ssm

ent

data

as fo

r th

ein

terv

entio

ngr

oup.

Ass

essm

ent

ofco

mpl

ianc

e w

ithm

edic

al r

egim

enat

follo

w-u

pho

me

visit

s at

60da

ys a

nd1

year

Com

plia

nce

with

med

ical

regi

men

, div

ided

into

die

t,sm

okin

g, a

ctiv

ity, s

tres

s an

dm

edic

atio

ns. V

ario

us h

ealth

beha

viou

r an

d at

titud

esc

ales

use

d to

ass

ess

this.

No

signi

fican

t di

ffere

nces

wer

e se

en b

etw

een

inte

rven

tion

and

cont

rol

grou

ps a

t 60

days

or

1ye

arpo

stdi

scha

rge

The

aut

hors

con

clud

e th

atno

diff

eren

ces

wer

efo

und

betw

een

the

inte

rven

tion

or c

ontr

olgr

oups

for

med

ical

regi

men

adh

eren

ce. T

heau

thor

s ob

serv

ed t

hat

attit

udes

and

per

ceiv

edbe

liefs

of o

ther

s w

ere

pred

ictiv

e of

adh

eren

cean

d sh

ould

be

incl

uded

inan

y re

habi

litat

ion

prog

ram

me.

Rep

eate

dse

lf-ev

alua

tion

ques

tionn

aire

s an

d nu

rse

visit

s m

ay h

ave

acte

d as

an in

terv

entio

n in

the

cont

rol g

roup

cont

inue

d

Appendix 11

126

Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff in

volv

ed,

grou

p: d

etai

ls

mea

sure

and

res

ults

outc

omes

au

thor

s’

coun

try

% m

en, m

ean

inte

nsit

y, fo

llow

-up

peri

od

of u

sual

car

ean

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

age

(SD

),

for

outc

ome

asse

ssm

ent

inte

rest

ing

feat

ures

type

)et

hnic

ity

if st

ated

Lack

, 198

5153

USA

(P

hD t

hesis

)

Qua

si RC

T,48

pat

ient

sra

ndom

ised,

data

pres

ente

d fo

r34

com

plet

ers

Patie

nts

rand

omly

assig

ned

toin

terv

entio

n or

cont

rol a

s th

eypr

esen

ted

them

selv

es. O

noc

casio

ns w

here

ther

e w

ere

insu

ffici

ent

num

bers

to

form

an in

terv

entio

ngr

oup,

the

aut

hors

depa

rted

from

thei

r st

anda

rdra

ndom

isatio

n an

dpr

iorit

y w

as g

iven

to t

hein

terv

entio

ngr

oup,

hen

ce t

his

grou

p is

larg

er

(n=

22

vs

n=

12)

. Blin

ding

of o

utco

me

asse

ssor

s un

clea

r.C

ompa

rison

grou

ps w

ere

simila

r at

bas

elin

e.O

vera

ll lo

sses

to

follo

w-u

p 29

%

Patie

nts

refe

rred

to c

ardi

acre

habi

litat

ion.

Mix

ed C

HD

patie

nts:

62%

MI,

24%

CA

BG, 1

5%bo

th. M

ean

age

59(r

ange

28–7

2ye

ars)

,86

.8%

men

12-w

eek

psyc

hoth

erap

yin

terv

entio

n an

d its

impa

ct o

npa

tient

com

plia

nce

with

pres

crib

ed r

egim

en in

the

car

diac

reha

bilit

atio

n se

ttin

g. P

atie

nts

rece

ived

the

inte

rven

tion

whe

nth

ey fi

rst

star

ted

the

card

iac

reha

bilit

atio

n se

ssio

n. In

terv

entio

nco

nsist

ed o

f 90-

min

ute

sess

ions

once

a w

eek

for

3m

onth

s, o

r12

or 1

5 se

ssio

ns o

f ins

ight

-or

ient

ated

gro

up p

sych

othe

rapy

.T

he p

rimar

y fo

cus

was

to

help

the

grou

p to

com

mun

icat

e th

ough

tsan

d fe

elin

gs w

ith t

he a

ssoc

iate

daf

fect

s. T

he t

hera

pist

cre

ated

an

atm

osph

ere

that

was

sup

port

ive,

coop

erat

ive

and

goal

dire

cted

. The

seco

ndar

y fo

cus

was

to

high

light

and

prom

ote

chan

ge in

tho

sebe

havi

ours

and

sty

les

of r

elat

ing

that

ref

lect

ed a

mal

adap

tive

cont

rol o

rient

atio

n, e

.g. h

esita

ncy

or r

efus

al t

o co

mpl

y w

ith p

hysic

ian

reco

mm

enda

tions

, or

resis

tanc

e to

grou

p pa

rtic

ipat

ion.

Per

iod

offo

llow

-up

at e

nd o

f int

erve

ntio

npe

riod

of 3

mon

ths

Con

trol

gro

upre

ceiv

ed u

sual

card

iac

reha

bilit

atio

n

Phys

iolo

gica

l mar

kers

of

com

plia

nce

with

exe

rcise

(hea

rt r

ate

and

bloo

dpr

essu

re).

Att

enda

nce

atpr

escr

ibed

exe

rcise

sess

ions

, and

sel

f-re

port

of

exer

cise

at

hom

e: r

ated

as

poor

(onc

e a

wee

k fo

r le

ssth

an 2

0 m

inut

es o

r no

ne,

scor

e 0–

1), g

ood

(thr

eetim

es a

wee

k fo

r20

–30

min

utes

, sco

re 2

) or

exce

llent

(mor

e th

an t

hree

times

a w

eek

for

mor

eth

an 3

0 m

inut

es, s

core

3).

Mea

n sc

ores

for

self-

repo

rtm

easu

res

of c

ompl

ianc

ew

ere

2.57

and

2.3

7 fo

r th

ein

terv

entio

n an

d co

ntro

lgr

oups

, res

pect

ivel

y, o

ver

the

3m

onth

per

iod.

The

inte

rven

tion

grou

pat

tend

ed 8

8.4%

of t

hepr

escr

ibed

exe

rcise

sess

ions

, the

con

trol

gro

up75

.7%

(p<

0.0

5)

The

aut

hors

con

clud

e th

atth

e an

alys

es s

how

ed n

oef

fect

of t

heps

ycho

ther

apy

inte

rven

tion

on p

atie

ntco

mpl

ianc

e m

easu

red

byph

ysio

logi

cal o

r se

lf-re

port

mea

sure

s. T

hey

did,

how

ever

,de

mon

stra

te t

hat

patie

nts

rece

ivin

g th

e in

terv

entio

nat

tend

ed s

igni

fican

tlym

ore

pres

crib

ed e

xerc

isese

ssio

ns

cont

inue

d


127


Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff in

volv

ed,

grou

p: d

etai

ls

mea

sure

and

res

ults

outc

omes

au

thor

s’

coun

try

% m

en, m

ean

inte

nsit

y, fo

llow

-up

peri

od

of u

sual

car

ean

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

age

(SD

),

for

outc

ome

asse

ssm

ent

inte

rest

ing

feat

ures

type

)et

hnic

ity

if st

ated

Mar

shal

l et

al.,

1986

154

USA

(jour

nal)

Non

-ra

ndom

ised

tria

l,60

patie

nts

stud

ied

Dat

a w

ere

colle

cted

from

cont

rols

first

(n=

30) a

nd t

hen

inte

rven

tion

patie

nts

(n=

30).

Com

paris

ongr

oups

wer

esim

ilar

at b

asel

ine.

Sam

plin

g w

aspr

ospe

ctiv

e an

din

clus

ion

crite

riaw

ere

spec

ified

.Lo

sses

to

follo

w-

up n

ot r

epor

ted

CA

BG p

atie

nts.

Elec

tive

CA

BGpe

rfor

med

by

the

sam

e gr

oup

ofsu

rgeo

ns. M

ean

age

59 (r

ange

46–7

8ye

ars)

,70

% m

en

Stru

ctur

ed t

each

ing

prog

ram

me

toin

crea

se p

atie

nts’

kno

wle

dge

and

com

plia

nce

to m

edic

atio

n, d

iet,

smok

ing

cess

atio

n an

d ex

erci

sepo

st s

urge

ry. T

each

ing

guid

ede

velo

ped

by n

urse

s w

ithco

nsid

erab

le e

xper

ienc

e w

ith t

his

patie

nt g

roup

, and

use

d by

nur

ses.

Follo

w-u

p as

sess

men

t at

4–6

wee

ks p

osts

urge

ry

Rece

ived

teac

hing

by

unst

ruct

ured

met

hod

Com

plia

nce

with

die

t,m

edic

atio

n, s

mok

ing

cess

atio

n an

d ac

tivity

, and

know

ledg

e. C

ompl

ianc

eas

sess

ed b

y se

lf-re

port

.Pa

tient

s w

ere

assig

ned

asc

ore

on fo

llow

-up

visit

of

com

plia

nce

base

d on

indi

vidu

al r

isk fa

ctor

s.O

vera

ll co

mpl

ianc

e sc

ores

wer

e 86

.8 in

the

inte

rven

tion

grou

p, a

nd79

.5 in

the

con

trol

gro

up(p

<0.

05).

Com

plia

nce

was

bet

ter

in t

hein

terv

entio

n th

an in

the

cont

rol g

roup

for

activ

ity(1

5.6

vs 7

blo

cks

wal

ked,

p<

0.00

5). N

one

of t

hepa

tient

s in

the

inte

rven

tion

grou

p re

port

ed n

on-

com

plia

nce

with

any

of t

heris

k fa

ctor

s m

easu

red

Kno

wle

dge

scor

es p

ost

surg

ery

wer

esim

ilar

for

the

stru

ctur

ed a

ndun

stru

ctur

edte

achi

ng g

roup

s

The

aut

hors

con

clud

e th

atov

eral

l com

plia

nce

and

activ

ity le

vels

wer

esig

nific

antly

hig

her

post

surg

ery

in t

hest

ruct

ured

tea

chin

g gr

oup

Hue

rin e

t al

.,19

9815

5

Arg

entin

a(c

onfe

renc

epr

ocee

ding

s)

Non

-ra

ndom

ised

tria

l,50

9pa

tient

sst

udie

d,in

terv

entio

ngr

oup

n=

229,

cont

rol g

roup

n=

280

Com

paris

ongr

oups

wer

esim

ilar

at b

asel

ine

and

sam

plin

g w

aspr

ospe

ctiv

e. N

ofu

rthe

r de

tails

are

give

n

Patie

nts

with

CH

D. M

ean

age

56 (S

D 1

0) y

ears

,67

.5%

men

Trad

ition

al r

ehab

ilita

tion

and

anad

here

nce

stra

tegy

whi

ch in

clud

eda

signe

d co

mm

itmen

t to

reha

bilit

atio

n, fa

mily

invo

lvem

ent,

spor

ts a

nd r

ecre

atio

nal a

ctiv

ities

to

incr

ease

pat

ient

com

mitm

ent

and

invo

lvem

ent

in a

var

iety

of

activ

ities

, and

thr

ee w

eekl

y ta

lks

on C

HD

-rel

ated

top

ics.

Fol

low

-up

at 1

2, 2

4 an

d 52

wee

ks

Trad

ition

alre

habi

litat

ion

Com

plia

nce

expr

esse

d as

rela

tive

risks

, def

ined

as

atte

ndan

ce a

t 66

% o

rm

ore

sess

ions

. 12

wee

ks,

RR 2

.3 (9

5% C

I 1.8

to

2.9)

,24

wee

ks, R

R 2.

9 (2

.3 t

o3.

7), 5

2w

eeks

, RR

4.25

(3.2

to

5.6)

(log

-ran

k te

stbe

twee

n st

rate

gies

p<

0.00

1)

The

aut

hors

con

clud

e th

atat

eac

h tim

e-po

int,

the

adhe

renc

e st

rate

gy g

roup

show

ed s

igni

fican

tlybe

tter

com

plia

nce

with

card

iac

reha

bilit

atio

n

cont

inue

d

Appendix 11

128

Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff in

volv

ed,

grou

p: d

etai

ls

mea

sure

and

res

ults

outc

omes

au

thor

s’

coun

try

% m

en, m

ean

inte

nsit

y, fo

llow

-up

peri

od

of u

sual

car

ean

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

age

(SD

),

for

outc

ome

asse

ssm

ent

inte

rest

ing

feat

ures

type

)et

hnic

ity

if st

ated

McK

enna

et

al.,

1998

156

UK

(con

fere

nce

proc

eedi

ngs)

Two

stud

yde

signs

: non

-ra

ndom

ised

tria

l, ex

erci

sevs

. sta

ndar

dre

habi

litat

ion,

and

anev

alua

tion

ofa

wom

en-o

nly

prog

ram

me

com

pare

dw

ith h

istor

ical

cont

rols.

No

info

rmat

ion

on p

atie

ntnu

mbe

rs

No

mor

e de

tails

pres

ente

d ab

out

how

the

stu

dies

wer

e co

nduc

ted

MI p

atie

nts,

mea

nag

e 62

yea

rs, 7

5%m

en. M

ean

age

ofth

e w

omen

-onl

ygr

oup

was

60ye

ars

Two

inte

rven

tions

exa

min

ed.

(1) L

ow-in

tens

ity e

xerc

ise t

oin

crea

se c

ompl

ianc

e, o

ffere

d to

patie

nts

who

wer

e pr

evio

usly

unab

le t

o ta

ke p

art

in s

tand

ard

exer

cise

ow

ing

to c

o-m

orbi

dity

.T

he c

ompa

rison

gro

up w

ere

stan

dard

reh

abili

tatio

n. (2

)W

omen

-onl

y gr

oups

: com

plia

nce

with

reh

abili

tatio

n. H

istor

ical

lyco

mpl

ianc

e in

wom

en w

ithst

anda

rd r

ehab

ilita

tion

was

6%

Stan

dard

reha

bilit

atio

nA

tten

danc

e at

car

diac

reha

bilit

atio

n. A

tten

danc

ew

as 8

2% in

the

low

-in

tens

ity e

xerc

ise g

roup

and

34%

in t

he s

tand

ard

reha

bilit

atio

n co

mpa

rison

grou

p. A

tten

danc

e in

the

wom

en-o

nly

grou

p w

as75

%

The

aut

hors

con

clud

e th

atta

ilore

d ex

erci

se fo

rdi

ffere

nt p

atie

nt g

roup

sin

crea

sed

com

plia

nce

with

the

exe

rcise

com

pone

nt o

f sta

ndar

dre

habi

litat

ion.

Pat

ient

num

bers

not

rep

orte

d.T

he m

agni

tude

of c

hang

esca

nnot

be

asse

ssed

Erlin

g &

Old

ridge

,19

8515

7

Can

ada

(con

fere

nce

proc

eedi

ngs)

Befo

re-

and

afte

r-st

udy

Pros

pect

ive

sam

plin

g, in

clus

ion

crite

ria n

otsp

ecifi

ed. N

oot

her

deta

ilsab

out

how

the

stud

y w

asco

nduc

ted

CH

D p

atie

nts.

No

othe

r de

tails

Spou

sal s

uppo

rt p

rogr

amm

e:sp

ousa

l par

ticip

atio

n in

car

diac

reha

bilit

atio

n. N

ot a

ll sp

ouse

sat

tend

ed, s

o co

mpa

rato

rs a

reba

selin

e be

fore

spo

use

part

icip

atio

n (n

= 3

0), s

pous

epa

rtic

ipat

ion

in c

ardi

acre

habi

litat

ion

(n=

30)

and

no

spou

se p

artic

ipat

ion

(n=

30)

.Fo

llow

-up

at 6

mon

ths

Patie

ntco

mpl

ianc

ebe

fore

intr

oduc

tion

ofth

e sp

ouse

supp

ort

prog

ram

me

Att

enda

nce

at c

ardi

acre

habi

litat

ion

sess

ions

defin

ed a

s th

ose

who

atte

nded

at

leas

t 50

% o

fth

e se

ssio

ns. B

efor

e th

esp

ousa

l int

erve

ntio

nat

tend

ance

was

44%

, afte

rth

e sp

ousa

l sup

port

prog

ram

me

whe

re t

hesp

ouse

par

ticip

ated

inre

habi

litat

ion

patie

ntat

tend

ance

was

90%

(p<

0.00

1), a

nd w

here

the

spou

se d

id n

ot a

tten

d th

isw

as 6

7%

The

aut

hors

con

clud

e th

atev

en fo

r pa

tient

s w

hose

spou

ses

did

not

atte

ndre

habi

litat

ion

ther

e w

ere

bene

ficia

l effe

cts

of g

roup

supp

ort

whe

n th

e sp

ousa

lpr

ogra

mm

e w

as r

unni

ngco

mpa

red

with

the

pres

pous

al p

rogr

amm

e


129


Appendix 12

Studies excluded from the review of methods to improve adherence to cardiac rehabilitation


Ades et al., 2000134 Home-based telephone-monitored Authors report on effectiveness of CR formats. Patients CR compared with outpatient CR were not randomised but allocated to home-based

telephone monitored CR if living in remote area orunable to attend outpatient CR due to work or timeconstraints

Baile & Engel 1978173 Follow-up of non-compliant No comparison groupcoronary care unit patients

Barnason & Postdischarge telephone follow-up No relevant outcomeZimmerman, 1995167 or group teaching

Blumenthal et al., 1988159 Comparison of high- and low- Comparison of rehabilitation intensities. Authors report intensity exercise training on effectiveness. RCT of patients representative of

most US CR programmes

Brubaker et al., 1996160 Comparison of standard and Comparison of rehabilitation duration. Authors report extended length CR benefit from continuing CR for >1 year. Retrospective

non-randomised comparison of patients who attended3 months or >1 year of CR

Campbell et al., 1998126 Nurse-run clinics in general practice No relevant outcome

Carlson et al., 200073 Comparison of traditional and partly Comparison of rehabilitation formats. Authors report home-based CR increased total exercise sessions with partly home-

based programme. Randomised trial

DeBusk et al., 1985131 Comparison of home and group Comparison of rehabilitation formats. Authors report exercise training on effectiveness. Randomised trial

Dracup et al., 1984162 Group counselling No relevant outcomes.

Gordon & Haskell, 1997168 Physician-supervised, nurse No comparison group. No relevant outcomescase-manager CR model

Labrador et al., 1998169 Physician-directed, nurse-supervised No relevant outcomescase-management programme

Lee et al., 1996161 Comparison of high- and low- Comparison of rehabilitation intensities. Authors report intensity exercise training on effectiveness. Randomised trial

Linde & Janz, 1979164 Postoperative teaching programme No relevant outcomes

Mehta et al., 2000121 Quality improvement initiative: Retrospective study. Allocation to groups according to critical care pathway, patient physician preferenceeducation tool and staff education

Penckofer & Llewellyn, Comparison of education by Comparison of education interventions. Authors report 1989163 structured and unstructured methods little extra benefit from structured teaching. Not

randomised

Senaratne et al., 2001171 Lipid management by cardiac Outside search period. No relevant outcomerehabilitation nurse

Skof et al., 2001172 Comparison of late outpatient and No relevant outcomeinpatient CR

continued

Appendix 12

130


Sparks et al., 1993158 Home-based telephone-monitored Comparison of rehabilitation formats. Authors report CR compared with outpatient CR on effectiveness. Randomised trial.

Starkey et al., 2000175 Computer-facilitated secondary No comparison groupprevention programme

Stern & Cleary, 1981174 Low-level exercise programme No comparison group

Unden et al., 1993165 Nurse support No relevant outcome

Vale et al., 2000170 Telephone coaching by dietitian No relevant outcome

van Elderen et al., 1994166 Group health education programme No relevant outcome


131


Appendix 13

Flow diagram of the systematic review of interventions to improve professional compliancewith cardiac rehabilitation (QUOROM statement

flow diagram)


3261




No outcome pertaining to professionalcompliance with cardiac rehabilitation 163


18 (17studies)


6

Studies excluded from review:

No outcome 7No comparison group 2Retrospective design 1Descriptive only 1

__Total 11


2304


133


Appendix 14

Studies evaluating interventions to improve professional compliance with cardiac rehabilitation

Appendix 14

134 Stu

die

s ar

e li

sted

in

ter

ms

of

stu

dy

des

ign

an

d t

he

hie

rarc

hy

of

evid

ence

, w

ith

RC

Ts

firs

t.

Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff gr

oup:

m

easu

re a

nd

outc

omes

au

thor

s’

coun

try

% m

en,

invo

lved

, int

ensi

ty,

deta

ils o

f re

sult

san

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

mea

n ag

e fo

llow

-up

peri

od fo

r us

ual c

are

inte

rest

ing

feat

ures

type

)(S

D),

ou

tcom

e as

sess

men

tet

hnic

ity

if st

ated

Jolly

, et

al.,

1999

104

UK

(jour

nal)

Also

Bra

dley

etal

., 19

9710

2

and

Jolly

et

al.,

1998

103

67 g

ener

alpr

actic

esra

ndom

ised

with

in s

trat

a(b

y fu

nd-

hold

ing

stat

us,

dist

ance

from

loca

lC

Rpr

ogra

mm

ean

d nu

mbe

rof

who

le-

time

part

ner

equi

vale

nts)

,27

7 pa

tient

sfr

omra

ndom

ised

inte

rven

tion

prac

tices

and

320

from

cont

rol

prac

tices

No

deta

ils o

fra

ndom

isatio

npr

oced

ure.

Fol

low

-up

ofpa

tient

s ca

rrie

d ou

t by

anu

rse

not

resp

onsib

le fo

rde

liver

ing

the

inte

rven

tion

to t

hepa

tient

’s p

ract

ice.

Pow

erca

lcul

atio

ns r

epor

ted

for

seru

m c

hole

ster

olch

ange

, dist

ance

wal

ked

and

smok

ing.

Com

paris

on g

roup

sw

ere

simila

r at

bas

elin

e.Lo

ss t

o fo

llow

-up

was

10%

in in

terv

entio

ngr

oup

and

9% in

con

trol

grou

p. A

naly

sis w

as b

yin

tent

ion

to t

reat

but

excl

uded

dea

ths

Patie

nts

regi

ster

ed w

ith67

gen

eral

prac

tices

in a

spec

ified

geog

raph

ical

area

. Pat

ient

sad

mitt

ed t

oho

spita

l with

MI (

71%

) or

with

ang

ina

ofre

cent

ons

et(<

3 m

onth

s)se

en in

hos

pita

l(2

9%).

Patie

nts

wer

e ju

dged

wel

l eno

ugh

topa

rtic

ipat

e by

med

ical

and

nurs

ing

staf

f on

the

war

d or

incl

inic

Spec

ialis

t ca

rdia

c lia

ison

nurs

es c

o-or

dina

ted

the

tran

sfer

of c

are

betw

een

hosp

ital a

nd g

ener

alpr

actic

e. T

he li

aiso

nnu

rse

saw

pat

ient

s in

hosp

ital a

nd e

ncou

rage

dth

em t

o se

e th

e pr

actic

enu

rse

afte

r di

scha

rge.

Supp

ort

was

pro

vide

d to

prac

tice

nurs

es b

yre

gula

r co

ntac

t, in

clud

ing

a te

leph

one

call

shor

tlybe

fore

pat

ient

disc

harg

eto

disc

uss

care

and

boo

ka

first

follo

w-u

p vi

sit t

oth

e pr

actic

e. P

ract

ice

nurs

es w

ere

enco

urag

edto

tel

epho

ne t

he li

aiso

nnu

rse

to d

iscus

spr

oble

ms

or t

o se

ekad

vice

on

clin

ical

or

orga

nisa

tiona

l iss

ues.

Each

pat

ient

was

giv

en a

patie

nt-h

eld

reco

rd c

ard

whi

ch p

rom

pted

and

guid

ed fo

llow

-up

atst

anda

rd in

terv

als

No

cont

act

betw

een

spec

ialis

tca

rdia

c lia

ison

nurs

es a

ndge

nera

lpr

actic

es. N

otex

plic

itly

stat

ed, b

utun

ders

tood

to

be n

ore

com

men

d-at

ion

to s

eepr

actic

e nu

rse

and

no p

atie

nt-

held

rec

ord

Seru

m c

hole

ster

ol,

bloo

d pr

essu

re,

dist

ance

wal

ked

in 6

min

utes

and

sm

okin

gce

ssat

ion

did

not

diffe

r be

twee

ngr

oups

. Bod

y m

ass

inde

x w

as s

light

lylo

wer

in t

hein

terv

entio

n gr

oup.

Mor

e pa

tient

s in

the

inte

rven

tion

grou

pat

tend

ed a

t le

ast

one

outp

atie

nt C

R se

ssio

nco

mpa

red

with

cont

rols

(42%

vs

24%

, p<

0.0

01).

The

diffe

renc

e w

as m

ost

mar

ked

in a

ngin

apa

tient

s (4

2% v

s10

%)

The

pro

gram

me

prov

idin

g co

ordi

nate

dfo

llow

-up

care

by

spec

ialis

t ca

rdia

c lia

ison

nurs

es d

id n

ot im

prov

ehe

alth

out

com

es, b

utw

as e

ffect

ive

inpr

omot

ing

at le

ast

one

outp

atie

nt C

R se

ssio

nat

tend

ance

cont

inue

d


135


Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff gr

oup:

m

easu

re a

nd

outc

omes

au

thor

s’

coun

try

% m

en,

invo

lved

, int

ensi

ty,

deta

ils o

f re

sult

san

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

mea

n ag

e fo

llow

-up

peri

od fo

r us

ual c

are

inte

rest

ing

feat

ures

type

)(S

D),

ou

tcom

e as

sess

men

tet

hnic

ity

if st

ated

Susk

in e

t al

.,20

0012

4

Can

ada

(con

fere

nce

abst

ract

)

RCT,

50

patie

nts

rand

omise

d

No

info

rmat

ion

onra

ndom

isatio

n pr

oced

ure

or b

asel

ine

char

acte

ristic

s of

the

tw

opa

tient

gro

ups

Post

-MI

patie

nts.

76%

men

Writ

ten

endo

rsem

ent

byat

tend

ing

phys

icia

nG

ener

icen

dors

emen

tSe

lf-re

port

edco

mm

itmen

t to

part

icip

ate

in C

R w

as62

% in

tho

se w

hore

ceiv

ed t

he p

hysic

ian

endo

rsem

ent

com

pare

d w

ith 3

8%in

tho

se r

ecei

ving

age

neric

end

orse

men

t(p

= 0

.08)

No

effe

ct o

fm

etho

d of

deliv

ery

(in-

pers

on v

sno

t)

The

aut

hors

sug

gest

furt

her

stud

y re

quire

dto

eva

luat

e w

heth

erph

ysic

ian

endo

rsem

ent

impr

oves

CR

part

icip

atio

n

Kala

yi e

t al

.,19

9912

2

UK

(jour

nal)

Befo

re- a

ndaf

ter-

stud

y.C

ompa

rison

of C

Rre

ferr

al r

ates

befo

rein

terv

entio

n(2

98 p

atie

nts)

and

afte

rin

terv

entio

n(2

63 p

atie

nts)

No

info

rmat

ion

onba

selin

e ch

arac

teris

tics

ofth

e tw

o pa

tient

gro

ups

Post

-MI

patie

nts.

No

info

rmat

ion

onag

e or

gen

der

of g

roup

s

Elec

tron

ic r

efer

ral

path

way

with

feed

back

to w

ard

staf

f on

refe

rral

rate

s. T

he r

efer

ral

path

way

was

initi

ated

whe

n a

CR

refe

rral

scre

en w

as a

utom

atic

ally

flagg

ed u

p on

the

elec

tron

ic p

atie

nt r

ecor

dof

tho

se p

atie

nts

with

adi

scha

rge

diag

nosis

of M

I

Befo

reim

plem

enta

tion

of r

efer

ral

path

way

inte

rven

tion

Afte

r in

terv

entio

nre

ferr

al in

crea

sed

from

194

/298

(65%

)to

208

/263

(79%

) (p

= 0

.000

2)

Mon

thly

refe

rral

rat

eat

sta

rt o

fst

udy

15/3

7(4

0%).

With

in3

mon

ths

ofin

terv

entio

nm

onth

lyre

ferr

al 3

5/39

(90%

)

The

aut

hors

not

e th

atas

wel

l as

impr

ovin

gpa

tient

car

e th

e us

e of

elec

tron

ic r

efer

ral a

ndfe

edba

ck o

f ref

erra

lra

tes

was

of b

enef

it to

staf

f, sa

ving

tim

ere

ferr

ing

and

iden

tifyi

ng p

atie

nts

Mos

ca e

t al

.,19

9841

USA

(con

fere

nce

abst

ract

)

Befo

re-

and

afte

r-st

udy.

Com

paris

onof

out

patie

ntC

Rpa

rtic

ipat

ion

rate

s in

two

6-m

onth

perio

ds w

itha

tota

l of

199

patie

nts

No

info

rmat

ion

onba

selin

e ch

arac

teris

tics

ofth

e tw

o gr

oups

All

patie

nts

post

-MI.

Mea

nag

e 61

yea

rs,

68%

men

Crit

ical

car

e pa

thw

aypr

ompt

ing

refe

rral

for

outp

atie

nt C

R

Befo

reim

plem

enta

tion

of c

ritic

al c

are

path

way

Ove

rall

part

icip

atio

n at

outp

atie

nt C

R w

as54

%, a

s de

term

ined

by

patie

nt s

elf-r

epor

t. T

hecr

itica

l car

e pa

thw

ayw

as a

ssoc

iate

d w

ith a

non-

signi

fican

t inc

reas

ein

out

patie

nt C

Rpa

rtic

ipat

ion

(OR

=1.

9, 9

5% C

I 0.6

to 5

.5)

The

aut

hors

con

clud

eth

at a

sys

tem

sap

proa

ch, i

nvol

ving

apr

ompt

for

outp

atie

ntC

R re

ferr

al a

s pa

rt o

f adi

scha

rge

criti

cal c

are

path

way

, may

pote

ntia

lly in

crea

sera

tes

of p

artic

ipat

ion

inC

R fo

r w

omen co

ntin

ued

Appendix 14

136

Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff gr

oup:

m

easu

re a

nd

outc

omes

au

thor

s’

coun

try

% m

en,

invo

lved

, int

ensi

ty,

deta

ils o

f re

sult

san

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

mea

n ag

e fo

llow

-up

peri

od fo

r us

ual c

are

inte

rest

ing

feat

ures

type

)(S

D),

ou

tcom

e as

sess

men

tet

hnic

ity

if st

ated

Cau

lin-G

lase

r&

Sch

mei

zel,

2000

123

USA

(con

fere

nce

abst

ract

)

Befo

re-

and

afte

r-st

udy.

Com

paris

onof

out

patie

ntC

Rpa

rtic

ipat

ion

rate

s in

tw

o5-

mon

thpe

riods

.Pa

tient

num

bers

not

spec

ified

No

info

rmat

ion

onba

selin

e ch

arac

teris

tics

ofth

e tw

o pa

tient

gro

ups

Post

-re

vasc

ular

isa-

tion

patie

nts.

No

info

rmat

ion

on a

ge o

rge

nder

of

grou

ps

Educ

atio

nal i

nter

vent

ion

for

heal

thca

re p

rovi

ders

on t

he c

ompr

ehen

sive

natu

re a

nd b

enef

its o

fC

R, w

ith p

artic

ular

emph

asis

on w

omen

.C

onsis

ted

of g

rand

roun

ds fo

r m

edic

al a

ndnu

rsin

g st

aff,

mon

thly

revi

ew o

f hea

lthou

tcom

es a

nd c

ost-

effe

ctiv

enes

s of

CR

with

clin

ical

car

diol

ogy

coun

cil,

plac

emen

t of

CR

info

rmat

ion

inex

amin

atio

n of

fices

, and

inst

ruct

ions

for

nurs

es t

odi

scus

s C

R w

ith p

atie

nts

and

enco

urag

e di

scus

sion

of r

efer

ral w

ithph

ysic

ians

Befo

reim

plem

enta

tion

of e

duca

tiona

lin

terv

entio

n

In-h

ospi

tal r

efer

ral

incr

ease

d by

50%

(p

< 0

.05)

. Phy

sicia

nof

fice

refe

rral

incr

ease

d by

61%

(p

< 0

.05)

. Mal

e an

dfe

mal

e re

ferr

al r

ates

incr

ease

d by

41%

(p

< 0

.05)

and

65%

(p<

0.0

5),

resp

ectiv

ely

The

aut

hors

con

clud

eth

at a

ppro

pria

tely

desig

ned

educ

atio

nal

inte

rven

tions

are

succ

essf

ul in

alte

ring

beha

viou

rs o

fhe

alth

care

per

sonn

elan

d im

prov

ing

refe

rral

to C

R

cont

inue

d


137


Aut

hors

, St

udy

type

Stud

y qu

alit

yPa

rtic

ipan

ts’

Inte

rven

tion

: det

ails

C

ompa

riso

n P

rinc

ipal

out

com

e O

ther

C

omm

ents

: ye

ar a

nd

and

size

case

-mix

, in

clud

ing

sett

ing,

sta

ff gr

oup:

m

easu

re a

nd

outc

omes

au

thor

s’

coun

try

% m

en,

invo

lved

, int

ensi

ty,

deta

ils o

f re

sult

san

d re

sult

sco

nclu

sion

s,

(pub

licat

ion

mea

n ag

e fo

llow

-up

peri

od fo

r us

ual c

are

inte

rest

ing

feat

ures

type

)(S

D),

ou

tcom

e as

sess

men

tet

hnic

ity

if st

ated

Scot

t et

al.,

2000

111

Aus

tral

ia(jo

urna

l)

Befo

re- a

ndaf

ter-

stud

y.C

ompa

rison

of

clin

ical

indi

cato

rs in

thre

e pe

riods

:pr

eint

erve

ntio

n(1

33pa

tient

s),

impl

emen

tatio

nof

inte

rven

tion

(271

pat

ient

s)an

d po

stin

ter-

vent

ion

(245

patie

nts)

Pre-

and

post

inte

rven

tion

grou

ps w

ere

simila

r at

base

line,

but

no

info

rmat

ion

was

repo

rted

for

the

inte

rven

tion

perio

d.O

utpa

tient

CR

prog

ram

me

was

not

fully

ope

ratio

nal i

n th

epr

eint

erve

ntio

npe

riod.

Aut

hors

assu

med

tha

t pa

tient

char

acte

ristic

s,di

agno

stic

met

hods

and

trea

tmen

tm

odal

ities

wou

ldre

mai

n es

sent

ially

unch

ange

d th

roug

hout

the

stud

y

Post

-MI

patie

nts.

Patie

ntch

arac

teris

tics

only

ava

ilabl

efo

r pr

e- a

ndpo

stin

ter-

vent

ion

grou

ps.

Mea

n ag

e66

year

s, 6

6%m

en

Diss

emin

atio

n of

evid

ence

-bas

ed c

linic

algu

idel

ines

for

the

man

agem

ent

of A

MI t

oho

spita

l sta

ff an

d G

Ps.

Info

rmat

ion

on c

linic

alin

dica

tors

was

fed

back

to a

ll ho

spita

l con

sulta

ntph

ysic

ians

, sen

ior

emer

genc

y st

aff,

med

ical

serv

ice

dire

ctor

s an

dse

nior

clin

icia

ns. A

s pa

rtof

the

feed

back

the

obse

rved

pro

port

ion

ofpa

tient

s re

ceiv

ing

the

trea

tmen

ts w

asco

mpa

red

with

a q

ualit

yth

resh

old

or m

inim

umle

vel o

f util

isatio

nin

dica

tive

of a

rea

sona

ble

stan

dard

of c

are.

Loc

alpr

ovid

ers

coul

d co

mpa

rean

d im

prov

e th

eir

own

prac

tice

Befo

redi

ssem

inat

ion

of e

vide

nce-

base

d cl

inic

algu

idel

ines

Clin

ical

indi

cato

rch

ange

s pr

e- t

opo

stin

terv

entio

n. N

och

ange

s w

ere

seen

in�

-blo

cker

, asp

irin

oran

giot

ensin

con

vert

ing

enzy

me

inhi

bito

r us

e.Li

pid-

low

erin

g dr

ugus

e in

crea

sed

from

23%

to

56%

(p<

0.00

3).

Out

patie

nt C

R se

rvic

ebe

cam

e op

erat

iona

l at

star

t of

inte

rven

tion

perio

d an

d sh

owed

ast

eady

incr

ease

inut

ilisa

tion

rate

from

24%

to

54%

(p

= 0

.003

)

The

aut

hors

sug

gest

that

clin

ical

gui

delin

esco

mbi

ned

with

feed

back

of c

linic

alin

dica

tors

to

heal

thpr

ofes

siona

ls w

ere

usef

ul in

impr

ovin

gqu

ality

of c

are,

incl

udin

g ou

tpat

ient

CR

utili

satio

n in

MI

patie

nts.

How

ever

, the

impr

ovem

ent

may

be

due

to p

aral

lel c

hang

esin

leve

ls of

pro

visio

n


139


Appendix 15

Studies excluded from the review of interventionsto improve professional compliance with

cardiac rehabilitation


Axtell et al., 2001191 Inclusion of pharmacist in MI care Outcome: use of medication

Campbell et al., 1998125,126 Nurse-led clinic giving secondary prevention Outcome: use of secondary assessment and advice prevention, not attendance at CR.

Feder et al., 1999127 General practices received letters with summary Outcomes: attendance at a generalof effective secondary prevention with reference practice and drug prescribing, not to local guidelines. Also prompts to patients CR

Hillert et al., 2000192 Risk factor management through physician No comparison groupeducation, participation and consensus development

Levknecht et al., 1997116 Outpatient clinical pathway No outcome data: descriptive

Linde & Janz, 1979164 Nurse training to master’s level in postoperative Inpatient programme. Outcome: teaching programme patient knowledge and follow-up.

Data not interpretable

McCarney et al., 2000119 General practice database identifies patients for No data: descriptivehome visit by health visitor to improve secondary prevention

Mehta et al., 2000121 Quality improvement initiative: critical care Retrospective study. Allocation to pathway; patient education tool and staff groups according to physician education preference

Senaratne et al., 2001171 Lipid management by cardiac rehabilitation nurse Outside search period. Outcome:lipid levels

Starkey et al., 2000175 Computer-facilitated secondary prevention No comparison groupprogramme

Tod et al., 1998117 Integration of primary and secondary care No outcome data: descriptive


141


Appendix 16

Estimates for unit costs for different staff categories and grades

Staff category Costs (£)

Salarya Salary Over- Capital Total Staff Total on-costs headsb costsc hours costs costs

worked per per per yearc hourd hour

Staff nurse B grade 11,820 1,507e 2,216 1,288 1,575 8 11Staff nurse E grade 18,222 2,323e 2,216 1,288 1,575 13 15Staff nurse F grade 21,010 2,679e 2,216 2,263 1,575 15 18Staff nurse G grade 23,948 3,053 2,216 2,263 1,575 17 20Staff nurse H grade 26,540 3,384e 2,216 2,263 1,575 19 22Physiotherapist helper 10,865 1,130 2,216 2,775 1,584 8 11Physiotherapist basic 17,202.50 2,193f 2,216 4,302 1,512 13 17Physiotherapist senior I 23,452 2,990 2,216 4,302 1,512 17 22Physiotherapist senior II 20,670 2,635f 2,216 4,302 1,512 15 20Physiotherapist superintendent III 25,832.50 3,294f 2,216 4,302 1,512 19 24Physiotherapist superintendent IV 23,452.50 2,990f 2,216 4,302 1,512 17 22Sport scientist 22,767.50 2,903f 2,216 4,302 1,512 17 21Exercise physiologist (MTO 3) 20,647 2,632f 2,216 4,302 1,512 15 20Occupational therapist basic 17,202.50 2,193g 2,216 4,302 1,512 13 17Occupational therapist senior I/II 21,785 2,778 2,216 4,302 1,512 16 21Occupational therapist head 26,467.50 3,375g 2,216 4,302 1,512 20 24Dietitian 21,785 2,778e 2,216 3,606 1,554 16 20Dietitian senior I/II 23,452.50 2,990e 2,216 3,606 1,554 17 21Pharmacist 32,983.50 4,205e 2,216 3,606 1,554 24 28GP NA NA NA NA NA 54 62Medical consultant 67,064 9,664 24,320 4,161 1,640 47 64Clinical psychologist 38,316 5,364 3,978 2,144 1,476 30 34Cardiac technician (MTO 4) 25,118 3,203e 2,216 4,302 1,512 19 23Social worker 19,951 2,709 3,399 2,007 1,554 15 18Secretary NA NA NA NA NA 10 13

a Salaries information from www.nhscareers.nhs.uk, March 2002.197 Salaries are based on the midpoint of the relevant scaleprevailing at 1 April 2001, except for GP, medical consultant, secretary and social worker (source: Netten et al., 2001196).All costs are given as 2000/01 values (overheads, capital overheads).

b Comprise estimates for indirect overheads (administrative services) (source: Netten et al.196). Indirect overheads for allother staff for which Netten et al.196 do not provide estimates are assumed to be the same as for staff in the same group.

c Based on Netten et al.196 Capital overheads for all other staff for which Netten et al.196 do not provide estimates areassumed to be the same as for staff in the same group.

d Comprises only salary and salary on-costs.e On-costs are estimated assuming the same on-costs/salary ratio as for staff nurse G grade. f On-costs are estimated assuming the same on-costs/salary ratio as for physiotherapist senior I. g On-costs are estimated assuming the same on-costs/salary ratio as for occupational therapist senior I/II. MTO, medical technical officer.

Costs of equipment for outpatient cardiac rehabilitation (phase 3), are shown below. (Source: cardiacrehabilitation programme, Bristol Royal Infirmary.) All prices include VAT.

Life Fitness upright cycle LC9100 £2770.65Cardiosport watches ‘Cardiosport Go’ (×15) £375.41Reebok step (×2) £78.00Physio Med Rehab Bouncer £57.57Yellow Theraband exercise roll (50 yards) £38.77York Probells in carry case (×2) £19.90Theraband exercise ball (Antiburst) (45 cm) (×2) £19.97Pro Fitness exercise mats (×15) £89.85Physio Med rehab support rails £46.94Theraband exercise ball (Antiburst) (55 cm) (×2) £27.02Duflex deluxe Gym Mate £82.19

–––––––––––––––––––––––––––––––Total: £3606.27 (VAT included)


143


Appendix 17

List of equipment


145


Appendix 18

Staff input: average hours per week

TABLE 42 Average hours per week by staff category for centres in group 1 (more than five key staff)

Staff category Centre Centre Centre Centre Centre Centre Centre Centre Centre Centre 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10

Nursing gradeBEF 20.0 37.5 18.5 37.5G 38.0 37.5 37.5 26.0 37.5 37.5H 37.5 37.5 18.0 37.5

PhysiotherapistHelperBasic 2.0Senior I 9.0 4.0 10.0 49.5 3.0 18.0 7.0Senior IISuperintendent III 26.0Superintendent IV 6.0

Sport scientist

Exercise physiologist 37.5 0.5

Occupational therapistBasic 1.0 7.0Senior 7.0 6.0 8.0 2.0Head 6.0

Dietician 4.0 0.32 0.33Senior dietitian 0.33 0.16 1.0 0.2 3.0 1.0 0.125

Pharmacist 0.5 0.16 1.0 0.16 1.0 0.12 0.16 1.0 0.125 0.33

Physiciana 0.15 0.2 0.41 3.0 0b

Clinical psychologist 0.75 4.0 0.16 0b 0.5 1.0 0.33

Cardiac technician 3.0 4.0

Social worker 1.0

Secretary 25.0 2.0 10.0 5.0

Total 70.4 122.8 83.5 67.2 95.0 67.6 39.5 103.0 41.8 56.5

a Includes cardiologists, consultants, clinical assistants and GPs.b Centres indicated the contribution of these staff groups in their questionnaire, but stated that their contribution was rather

advisory and did not include any time involvement.

Appendix 18

146

TABLE 43 Average hours per week by staff category for centres in group 2 (three to five key staff)

Staff category Centre Centre Centre Centre Centre Centre Centre Centre Centre Centre 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10

Nursing gradesB 9.5E 15.0 37.5 19.5F 22.5 75.0 30.0G 75.0 10.0 2.0 37.5 37.0H 37.5 20.0

PhysiotherapistHelper 6.0 14.0BasicSenior I 10.0 4.0 11.0 6.0 2.0 21.0Senior II 2.0 12.0Superintendent IIISuperintendent IV

Sport scientist 6.0 13.0

Exercise physiologist

Occupational therapistBasicSenior 0.5Head

Dietitian 0.25 0.25 0.15 0.16 1.0Senior dietitian 3.0 0.62 1.0

Pharmacist 0.25 1.0 0.25 0.5 0.32 0.04 1.0 0.16

Physiciana 0.5 7.01

Clinical psychologist 3.0

Cardiac technician 4.0

Social worker 16.0

Secretary 12.0 0.35 30.0 8.0

Total 33.0 90.0 123.0 23.5 5.3 39.7 72.0 75.3 64.0 100.5

a Includes cardiologists, consultants, clinical assistants and GPs.


147


TABLE 44 Average hours per week by staff category for centres in group 3 (two or fewer key staff)

Staff category Centre Centre Centre Centre Centre Centre Centre Centre Centre Centre3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10

Nursing gradeBEF 30.0G 4.0 52.5 21.0 2.0 12.0 1.0H 4.0

PhysiotherapistHelperBasicSenior I 14.0 6.0 2.0 1.0 4.0Senior II 4.0 2.0 6.0Superintendent IIISuperintendent IV

Sport scientist 4.0

Exercise physiologist

Occupational therapistBasicSenior 1.0 2.0Head

DietitianSenior dietitian

Pharmacist

Physiciana

Clinical psychologist

Cardiac technician 5.0

Social worker

Secretary 3.0

Total 18.0 53.5 32.0 6.0 6.0 21.0 4.0 1.0 1.0 38.0

a Includes cardiologists, consultants, clinical assistants and GPs.


149


Appendix 19

Referral, uptake and completion rates for30 randomly selected UK cardiac rehabilitation

programmes in 2000

Group 1a Group 2b Group 3c

(n = 10) (n = 10) (n = 10)

Hours per patient 29.0 (8.9) 24.0 (8.6) 20.0 (12.3)27.0 21.5 17.5

(21–48) (15–38) (6–48)

Patients referred to CR 282.4 (169.5) 352.5 (244.5) 170.7 (142.5)289.5 255.5 150

(84–578) (130–855) (3–400)

Patients joined CR 157.3 (97.6) 194.3 (104.7) 97.9 (73.3)148.0 171.5 103.5

(46–381) (73–429) (2–216)

% of referrals 55.7 55.1 57.351.1 67.1 69.0

Patients completed CR 126.3 (90.4) 158.1 (100.8) 88.8 (67.2)104.5 150.5 92.5

39–319 44–392 2–195

% of referrals 44.7 44.8 5236.0 58.9 61.6

Data are shown as mean (SD) and median (in italics) (range).a Centres with more than five key staff.b Centres with three to five key staff.c Centres with two or fewer key staff.


151


Appendix 20

Average cost estimates for cardiac rehabilitation (detailed table)

Appendix 20

152

Cos

ts (

£)G

roup

1a

Gro

up 2

bG

roup

3c

(n=

10)

(n=

10)

(n=

10)

Staf

f cos

ts o

nly

Tota

l cos

tsSt

aff c

osts

onl

yTo

tal c

osts

Staf

f cos

ts o

nly

Tota

l cos

ts

Per

year

/cen

tre

53,0

87 (1

8,25

1)72

,676

(25,

485)

42,1

25 (2

4,05

9)57

,353

(32,

146)

12,3

83 (1

2,68

8)17

,638

(16,

752)

51,3

2369

,834

43,3

3758

,362

8,40

012

,797

(26,

658–

85,8

69)

(37,

183–

118,

299)

(3,6

07–7

8,52

6)(5

,932

–105

,763

)(7

14–3

8,15

7)(1

,888

–50,

886)

Per

patie

nt r

efer

red

243

(143

)33

0 (1

77)

137

(92)

186

(120

)12

7 (9

4)24

9 (2

43)

175

245

113

156

105

156

(88–

441)

(123

–587

)(2

8–35

7)(4

5–47

0)(1

0–25

4)(1

6–66

0)

Per

patie

nt jo

ined

421

(187

)57

1 (2

46)

236

(167

)32

0 (2

17)

174

(132

)32

4 (2

99)

466

639

212

293

118

192

(159

–777

)(2

21–9

48)

(36–

651)

(59–

856)

(26–

382)

(44–

944)

Per

patie

nt c

ompl

eted

542

(225

)73

8 (2

98)

317

(228

)42

9 (2

95)

186

(133

)34

4 (2

95)

553

750

259

354

139

230

(224

–846

)(3

14–1

118)

(48–

716)

(79–

947)

(26–

382)

(44–

944)

Per

patie

nt c

ompl

eted

/hou

r20

(9)

27 (1

2)14

(11)

20 (1

4)14

(15)

30 (4

1)20

2711

157

10(5

–33)

(7–4

5)(1

–38)

(2–4

9)(1

–40)

(1–1

10)

Dat

a ar

e sh

own

as m

ean

(SD

) and

med

ian

(in it

alic

s) (r

ange

).a

Cen

tres

with

mor

e th

an fi

ve k

ey s

taff.

bC

entr

es w

ith t

hree

to

five

key

staf

f.c

Cen

tres

with

tw

o or

few

er k

ey s

taff.


163

Health Technology AssessmentProgramme

Prioritisation Strategy GroupMembers

Chair,Professor Tom Walley, Director, NHS HTA Programme,Department of Pharmacology &Therapeutics,University of Liverpool

Professor Bruce Campbell,Consultant Vascular & GeneralSurgeon, Royal Devon & ExeterHospital

Professor Shah Ebrahim,Professor in Epidemiology of Ageing, University of Bristol

Dr John Reynolds, ClinicalDirector, Acute GeneralMedicine SDU, RadcliffeHospital, Oxford

Dr Ron Zimmern, Director,Public Health Genetics Unit,Strangeways ResearchLaboratories, Cambridge

HTA Commissioning BoardMembers

Programme Director, Professor Tom Walley, Director, NHS HTA Programme,Department of Pharmacology &Therapeutics,University of Liverpool

Chair,Professor Shah Ebrahim,Professor in Epidemiology ofAgeing, Department of SocialMedicine, University of Bristol

Deputy Chair, Professor Jenny Hewison,Professor of Health CarePsychology, Academic Unit ofPsychiatry and BehaviouralSciences, University of LeedsSchool of Medicine

Dr Jeffrey AronsonReader in ClinicalPharmacology, Department ofClinical Pharmacology,Radcliffe Infirmary, Oxford

Professor Ann Bowling,Professor of Health ServicesResearch, Primary Care andPopulation Studies,University College London

Professor Andrew Bradbury,Professor of Vascular Surgery,Department of Vascular Surgery,Birmingham HeartlandsHospital

Professor John Brazier, Directorof Health Economics, Sheffield Health EconomicsGroup, School of Health &Related Research, University of Sheffield

Dr Andrew Briggs, PublicHealth Career Scientist, HealthEconomics Research Centre,University of Oxford

Professor Nicky Cullum,Director of Centre for EvidenceBased Nursing, Department ofHealth Sciences, University ofYork

Dr Andrew Farmer, SeniorLecturer in General Practice,Department of Primary HealthCare, University of Oxford

Professor Fiona J Gilbert,Professor of Radiology,Department of Radiology,University of Aberdeen

Professor Adrian Grant,Director, Health ServicesResearch Unit, University ofAberdeen

Professor F D Richard Hobbs,Professor of Primary Care &General Practice, Department ofPrimary Care & GeneralPractice, University ofBirmingham

Professor Peter Jones, Head ofDepartment, UniversityDepartment of Psychiatry,University of Cambridge

Professor Sallie Lamb, ResearchProfessor in Physiotherapy/Co-Director, InterdisciplinaryResearch Centre in Health,Coventry University

Professor Julian Little,Professor of Epidemiology,Department of Medicine andTherapeutics, University ofAberdeen

Professor Stuart Logan,Director of Health & SocialCare Research, The PeninsulaMedical School, Universities ofExeter & Plymouth

Professor Tim Peters, Professorof Primary Care Health ServicesResearch, Division of PrimaryHealth Care, University ofBristol

Professor Ian Roberts, Professorof Epidemiology & PublicHealth, Intervention ResearchUnit, London School ofHygiene and Tropical Medicine

Professor Peter Sandercock,Professor of Medical Neurology,Department of ClinicalNeurosciences, University ofEdinburgh

Professor Mark Sculpher,Professor of Health Economics,Centre for Health Economics,Institute for Research in theSocial Services, University of York

Professor Martin Severs,Professor in Elderly HealthCare, Portsmouth Institute ofMedicine

Dr Jonathan Shapiro, SeniorFellow, Health ServicesManagement Centre,Birmingham

Ms Kate Thomas,Deputy Director,Medical Care Research Unit,University of Sheffield

Professor Simon G Thompson,Director, MRC BiostatisticsUnit, Institute of Public Health,Cambridge

Ms Sue Ziebland,Senior Research Fellow,Cancer Research UK,University of Oxford

Current and past membership details of all HTA ‘committees’ are available from the HTA website (www.ncchta.org)


Health Technology Assessment Programme

164

Diagnostic Technologies & Screening PanelMembers

Chair,Dr Ron Zimmern, Director ofthe Public Health Genetics Unit,Strangeways ResearchLaboratories, Cambridge

Ms Norma Armston,Freelance Consumer Advocate,Bolton

Professor Max BachmannProfessor Health Care Interfaces, Department of Health Policy and Practice,University of East Anglia

Professor Rudy BilousProfessor of Clinical Medicine &Consultant Physician,The Academic Centre,South Tees Hospitals NHS Trust

Dr Paul Cockcroft, Consultant MedicalMicrobiologist/LaboratoryDirector, Public HealthLaboratory, St Mary’s Hospital, Portsmouth

Professor Adrian K Dixon,Professor of Radiology,Addenbrooke’s Hospital,Cambridge

Dr David Elliman, Consultant in Community Child Health, London

Professor Glyn Elwyn,Primary Medical Care Research Group,Swansea Clinical School,University of WalesSwansea

Dr John Fielding,Consultant Radiologist,Radiology Department,Royal Shrewsbury Hospital

Dr Karen N Foster, ClinicalLecturer, Dept of GeneralPractice & Primary Care,University of Aberdeen

Professor Antony J Franks,Deputy Medical Director, The Leeds Teaching HospitalsNHS Trust

Mr Tam Fry, HonoraryChairman, Child GrowthFoundation, London

Dr Edmund Jessop,Medical Adviser,National SpecialistCommissioning Advisory Group(NSCAG), Department ofHealth, London

Dr Jennifer J Kurinczuk,Consultant ClinicalEpidemiologist,National PerinatalEpidemiology Unit,Oxford

Dr Susanne M Ludgate, MedicalDirector, Medical DevicesAgency, London

Dr William Rosenberg, SeniorLecturer and Consultant inMedicine, University ofSouthampton

Dr Susan Schonfield, CPHMSpecialised ServicesCommissioning, CroydonPrimary Care Trust

Dr Margaret Somerville,Director of Public Health,Teignbridge Primary Care Trust

Professor Lindsay WilsonTurnbull, Scientific Director,Centre for MR Investigations &YCR Professor of Radiology,University of Hull

Professor Martin J Whittle,Head of Division ofReproductive & Child Health,University of Birmingham

Dr Dennis Wright, ConsultantBiochemist & Clinical Director,Pathology & The KennedyGalton Centre, Northwick Park& St Mark’s Hospitals, Harrow

Pharmaceuticals PanelMembers

Chair,Dr John Reynolds, ClinicalDirector, Acute GeneralMedicine SDU, OxfordRadcliffe Hospital

Professor Tony Avery, Professor of Primary HealthCare, University of Nottingham

Professor Stirling Bryan,Professor of Health Economics,Health Services Management Centre,University of Birmingham

Mr Peter Cardy, ChiefExecutive, Macmillan CancerRelief, London

Dr Christopher Cates, GP andCochrane Editor, Bushey HealthCentre

Professor Imti Choonara,Professor in Child Health,University of Nottingham,Derbyshire Children’s Hospital

Mr Charles Dobson, SpecialProjects Adviser, Department ofHealth

Dr Robin Ferner, ConsultantPhysician and Director, WestMidlands Centre for AdverseDrug Reactions, City HospitalNHS Trust, Birmingham

Dr Karen A Fitzgerald,Pharmaceutical Adviser, Bro TafHealth Authority, Cardiff

Mrs Sharon Hart, ManagingEditor, Drug & TherapeuticsBulletin, London

Dr Christine Hine, Consultant inPublic Health Medicine, Bristol South & West PrimaryCare Trust

Professor Stan Kaye,Professor of Medical Oncology,Consultant in MedicalOncology/Drug Development,The Royal Marsden Hospital

Ms Barbara Meredith,Project Manager ClinicalGuidelines, Patient InvolvementUnit, NICE

Dr Frances Rotblat, CPMPDelegate, Medicines ControlAgency, London

Professor Jan Scott,Professor of PsychologicalTreatments,Institute of Psychiatry,University of London

Mrs Katrina Simister, NewProducts Manager, NationalPrescribing Centre, Liverpool

Dr Richard Tiner, MedicalDirector, Association of theBritish Pharmaceutical Industry

Dr Helen Williams,Consultant Microbiologist,Norfolk & Norwich UniversityHospital NHS Trust



165

Therapeutic Procedures PanelMembers

Chair, Professor Bruce Campbell,Consultant Vascular andGeneral Surgeon, Royal Devon& Exeter Hospital

Dr Mahmood Adil, Head ofClinical Support & HealthProtection, Directorate ofHealth and Social Care (North),Department of Health,Manchester

Dr Aileen Clarke,Reader in Health ServicesResearch, Public Health &Policy Research Unit,Barts & the London School ofMedicine & Dentistry,Institute of Community HealthSciences, Queen Mary,University of London

Mr Matthew William Cooke,Senior Clinical Lecturer andHonorary Consultant,Emergency Department,University of Warwick, Coventry& Warwickshire NHS Trust,Division of Health in theCommunity, Centre for PrimaryHealth Care Studies, Coventry

Dr Carl E Counsell, SeniorLecturer in Neurology,University of Aberdeen

Dr Keith Dodd, ConsultantPaediatrician, DerbyshireChildren’s Hospital

Professor Gene Feder, Professorof Primary Care R&D, Barts &the London, Queen Mary’sSchool of Medicine andDentistry, University of London

Professor Paul Gregg,Professor of OrthopaedicSurgical Science, Department ofOrthopaedic Surgery,South Tees Hospital NHS Trust

Ms Bec Hanley, FreelanceConsumer Advocate,Hurstpierpoint

Ms Maryann L. Hardy,Lecturer, Division of Radiography,University of Bradford

Professor Alan Horwich,Director of Clinical R&D, TheInstitute of Cancer Research,London

Dr Phillip Leech, PrincipalMedical Officer for PrimaryCare, Department of Health,London

Dr Simon de Lusignan,Senior Lecturer, Primary CareInformatics, Department ofCommunity Health Sciences,St George’s Hospital MedicalSchool, London

Dr Mike McGovern, SeniorMedical Officer, Heart Team,Department of Health, London

Professor James Neilson,Professor of Obstetrics andGynaecology, Dept of Obstetricsand Gynaecology,University of Liverpool,Liverpool Women’s Hospital

Dr John C Pounsford,Consultant Physician, NorthBristol NHS Trust

Dr Vimal Sharma,Consultant Psychiatrist & HonSnr Lecturer,Mental Health Resource Centre,Victoria Central Hospital,Wirrall

Dr L David Smith, ConsultantCardiologist, Royal Devon &Exeter Hospital

Professor Norman Waugh,Professor of Public Health,University of Aberdeen


Health Technology Assessment Programme

166Current and past membership details of all HTA ‘committees’ are available from the HTA website (www.ncchta.org)

Expert Advisory NetworkMembers

Professor Douglas Altman,Director of CSM & CancerResearch UK Med Stat Gp,Centre for Statistics inMedicine, University of Oxford,Institute of Health Sciences,Headington, Oxford

Professor John Bond,Director, Centre for HealthServices Research,University of Newcastle uponTyne, School of Population &Health Sciences,Newcastle upon Tyne

Mr Shaun Brogan, Chief Executive, RidgewayPrimary Care Group, Aylesbury

Mrs Stella Burnside OBE,Chief Executive,Office of the Chief Executive.Trust Headquarters,Altnagelvin Hospitals Health &Social Services Trust,Altnagelvin Area Hospital,Londonderry

Ms Tracy Bury, Project Manager, WorldConfederation for PhysicalTherapy, London

Mr John A Cairns, Professor of Health Economics,Health Economics ResearchUnit, University of Aberdeen

Professor Iain T Cameron,Professor of Obstetrics andGynaecology and Head of theSchool of Medicine,University of Southampton

Dr Christine Clark,Medical Writer & ConsultantPharmacist, Rossendale

Professor Collette Mary Clifford,Professor of Nursing & Head ofResearch, School of HealthSciences, University ofBirmingham, Edgbaston,Birmingham

Professor Barry Cookson,Director, Laboratory of HealthcareAssociated Infection,Health Protection Agency,London

Professor Howard Stephen Cuckle, Professor of ReproductiveEpidemiology, Department ofPaediatrics, Obstetrics &Gynaecology, University ofLeeds

Professor Nicky Cullum, Director of Centre for EvidenceBased Nursing, University of York

Dr Katherine Darton, Information Unit, MIND – TheMental Health Charity, London

Professor Carol Dezateux, Professor of PaediatricEpidemiology, London

Mr John Dunning,Consultant CardiothoracicSurgeon, CardiothoracicSurgical Unit, PapworthHospital NHS Trust, Cambridge

Mr Jonothan Earnshaw,Consultant Vascular Surgeon,Gloucestershire Royal Hospital,Gloucester

Professor Martin Eccles, Professor of ClinicalEffectiveness, Centre for HealthServices Research, University ofNewcastle upon Tyne

Professor Pam Enderby,Professor of CommunityRehabilitation, Institute ofGeneral Practice and PrimaryCare, University of Sheffield

Mr Leonard R Fenwick, Chief Executive, Newcastleupon Tyne Hospitals NHS Trust

Professor David Field, Professor of Neonatal Medicine,Child Health, The LeicesterRoyal Infirmary NHS Trust

Mrs Gillian Fletcher, Antenatal Teacher & Tutor andPresident, National ChildbirthTrust, Henfield

Professor Jayne Franklyn,Professor of Medicine,Department of Medicine,University of Birmingham,Queen Elizabeth Hospital,Edgbaston, Birmingham

Ms Grace Gibbs, Deputy Chief Executive,Director for Nursing, Midwifery& Clinical Support Servs, West Middlesex UniversityHospital, Isleworth

Dr Neville Goodman, Consultant Anaesthetist,Southmead Hospital, Bristol

Professor Alastair Gray,Professor of Health Economics,Department of Public Health,University of Oxford

Professor Robert E Hawkins, CRC Professor and Director ofMedical Oncology, Christie CRCResearch Centre, ChristieHospital NHS Trust, Manchester

Professor F D Richard Hobbs, Professor of Primary Care &General Practice, Department ofPrimary Care & GeneralPractice, University ofBirmingham

Professor Allen Hutchinson, Director of Public Health &Deputy Dean of ScHARR,Department of Public Health,University of Sheffield

Dr Duncan Keeley,General Practitioner (Dr Burch& Ptnrs), The Health Centre,Thame

Dr Donna Lamping,Research Degrees ProgrammeDirector & Reader in Psychology,Health Services Research Unit,London School of Hygiene andTropical Medicine, London

Mr George Levvy,Chief Executive, MotorNeurone Disease Association,Northampton

Professor James Lindesay,Professor of Psychiatry for theElderly, University of Leicester,Leicester General Hospital

Professor Rajan Madhok, Medical Director & Director ofPublic Health, Directorate ofClinical Strategy & PublicHealth, North & East Yorkshire& Northern Lincolnshire HealthAuthority, York

Professor David Mant, Professor of General Practice,Department of Primary Care,University of Oxford

Professor Alexander Markham, Director, Molecular MedicineUnit, St James’s UniversityHospital, Leeds

Dr Chris McCall, General Practitioner, The Hadleigh Practice, Castle Mullen

Professor Alistair McGuire, Professor of Health Economics,London School of Economics

Dr Peter Moore, Freelance Science Writer,Ashtead

Dr Andrew Mortimore, Consultant in Public HealthMedicine, Southampton CityPrimary Care Trust

Dr Sue Moss, Associate Director, CancerScreening Evaluation Unit,Institute of Cancer Research,Sutton

Professor Jon Nicholl, Director of Medical CareResearch Unit, School of Healthand Related Research,University of Sheffield

Mrs Julietta Patnick, National Co-ordinator, NHSCancer Screening Programmes,Sheffield

Professor Robert Peveler,Professor of Liaison Psychiatry,University Mental HealthGroup, Royal South HantsHospital, Southampton

Professor Chris Price, Visiting Chair – Oxford, Clinical Research, BayerDiagnostics Europe, Cirencester

Ms Marianne Rigge, Director, College of Health,London

Dr Eamonn Sheridan,Consultant in Clinical Genetics,Genetics Department,St James’s University Hospital,Leeds

Dr Ken Stein,Senior Clinical Lecturer inPublic Health, Director,Peninsula TechnologyAssessment Group, University of Exeter

Professor Sarah Stewart-Brown, Director HSRU/HonoraryConsultant in PH Medicine,Department of Public Health,University of Oxford

Professor Ala Szczepura, Professor of Health ServiceResearch, Centre for HealthServices Studies, University ofWarwick

Dr Ross Taylor, Senior Lecturer, Department of General Practiceand Primary Care, University of Aberdeen

Mrs Joan Webster, Consumer member, HTA –Expert Advisory Network

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