1. National Collaborating Centre for Primary Care 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 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. National Collaborating Centre for Primary Care 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. National Collaborating Centre for Primary Care 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. National Collaborating Centre for Primary Care 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. National Collaborating Centre for Primary Care 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. National Collaborating Centre for Primary Care 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. National Collaborating Centre for Primary Care 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. National Collaborating Centre for Primary Care 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. National Collaborating Centre for Primary Care 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. National Collaborating Centre for Primary Care 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. National Collaborating Centre for Primary Care 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. National Collaborating Centre for Primary Care 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. National Collaborating Centre for Primary Care 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: 23 rd May 2007

15. National Collaborating Centre for Primary Care 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. National Collaborating Centre for Primary Care 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. National Collaborating Centre for Primary Care 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