Angela Cooper PhD Email: acooper@rcgp.org.uk

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

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

3. Post MI Guideline Timetable • Initiation and scoping (6 months) • Development, reviewing evidence, drafting recommendations, writing document (18 months) • Cardiac rehabilitation • Lifestyle • Drug therapy • Validation including a public consultation

4. Cardiac rehabilitation • Originally focused on exercise training • More recent programmes emphasise overall risk factor and behavioural modification Post MI Guideline • Develop key clinical questions • Over 30 000 papers were retrieved from searching scientific databases • 1290 studies were ordered and assessed • 195 studies were critically appraised and presented to the guideline development group

5. Comprehensive cardiac rehabilitation • Comprehensive cardiac rehabilitation in patients after MI reduces all-cause and cardiovascular mortality rates provided it includes an exercise component • Based on 3 systematic reviews: Brown et al 2003, Joliffe et al 2003, Clark et al 2005

6. Cost effectiveness of comprehensive cardiac rehabilitation • Cardiac rehabilitation in patients after MI compared no cardiac rehabilitation is cost effective • Based on economic model requested by GDG (Leo Nherera, using clinical effectiveness from 3 recent systematic reviews) • The estimated incremental cost effectiveness ratio was about £8000 per quality adjusted life year • This ratio is generally regarded as value for money for the NHS

7. Safety in the exercise component of comprehensive cardiac rehabilitation • There is no evidence that stable patients are harmed by the exercise component of cardiac rehabilitation • Exercise training does not appear to endanger stable patients with left ventricular dysfunction • Otsuka et al 2003: 3 months of exercise training,no incidence of heart failure or cardiac death • Giannuzzi et al 1997: 6 months exercise training, improvement in unfavourable remodelling response • Dubach et al 1997: 2 months exercise training, increased exercise capacity • Limited evidence on safety of exercise component of cardiac rehabilitation in older people (studies recruit patients with mean age 55 years)

8. Psychological and social support • Psychological intervention as part of a cardiac rehabilitation programme (e.g. risk factor counselling / theory behaviour change) reduces the risk of depression, anxiety and non-fatal MI • Rees et al 2004 systematic review • Social isolation or lack of a social support network associated with increased mortality and morbidity • Mookadam et al 2004 systematic review • There is limited evidence (based on three studies of married couples) that involving spouses may have beneficial effects on family anxiety • Van Horn et al 2002 systematic review

9. Education and information provision • Education and stress management programmes reduce cardiac mortality and MI recurrence in post MI patients • Dusseldorp et al 1999 systematic review • Education and stress management programmes may aid in return to work, and reduce anxiety at 3 months following an MI • Petrie et al 2002 randomised controlled trial • Mayou et al 2002 randomised controlled trial

10. Patient engagement in cardiac rehabilitation • Uptake improved by motivational communication (e.g. written letters / pamphlets / conversation with a healthcare professional) • Adherence (e.g. formal patient commitment / family involvement / education / aids to self-management / psychological interventions) • few studies of sufficient quality to make specific recommendations • most promising approach: use of self-management techniques based around individualised assessment, problem-solving, goal-setting and follow up • Based on Beswick et al 2004 Health Technology Assessment

11. Groups requiring specific consideration • Ethnic minority groups • Patients living in socially deprived areas • Patients living in rural areas • Women • Older patients • No randomised controlled trial evidence found of interventions to improve either uptake or adherence to cardiac rehabilitation

12. Cost effectiveness of methods for increasing uptake • The use of letters, or telephone calls plus a visit from a healthcare professional to improve uptake of cardiac rehabilitation was found to be cost effective • Based on economic model requested by GDG (Leo Nherera, using effectiveness data from Beswick at al 2004) • Letters: estimated incremental cost effectiveness ratio was about £8000 compared with usual care per quality adjusted life year • Telephone calls plus health professional visit: ratio was about £8500 compared with letters • These ratios are considered value for money for the NHS

13. Summary of evidence • Comprehensive cardiac rehabilitation has a significant positive effect on survival in post MI patients and is cost effective • Methods to improve uptake are cost effective • Further studies in patients requiring special consideration and also in adherence to cardiac rehabilitation programmes are warranted

14. Key provisional recommendations from the Post MI guideline stakeholder consultation draft: August 2006 • All patients (regardless of their age) should be given advice about and offered a cardiac rehabilitation programme with an exercise component • Comprehensive cardiac rehabilitation programmes should include health education and stress management components • Reminders such as letters or telephone calls in combination with contact from a healthcare professional should be used to improve uptake of cardiac rehabilitation Expected publication date: 23rd May 2007

15. The post MI Guideline Methods Team Clinical Advisor – Dr Jane Skinner Chairman – Prof Gene Feder SHSRF – Dr Angela Cooper Health Economist – Leo Nherera Information Scientist – Gill Ritchie Guideline Lead – Nancy Turnbull Project Manager – Meeta Kathoria

16. The post MI guideline development team Patient representatives – David Thomson, John Walsh BHF Cardiac specialist nurse – Anne White Consultant cardiologist – Dr Adam Timmis General Practitioners – Dr Keith MacDermott, Dr Rubin Minhas Pharmacist – Helen Williams Physiotherapist – Helen Squires Public health consultant – Dr Chris Packham

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