Cardiac rehabilitation:Cardiac rehabilitation:

2010 and beyond!

P f P t i k D h tProf Patrick Doherty and Julie Harries 

NHS Improvement

h f h hi d hiThe NSF for CHD has achieved great things

• Huge investment and effort that has directly reduced the rate of• Huge investment and effort that has directly reduced the rate of premature death from CHD earlier than anticipated but...

• The quality of life of survivors has not seen similar investment andThe quality of life of survivors has not seen similar investment and uptake to cardiac rehabilitation is unacceptably low

• CR is a proven intervention that will, on average, reduce prematureCR is a proven intervention that will, on average, reduce premature death by 26% in cardiac patients within three years and improve QoL  within weeks

• CR can reduce the burden on NHS services in terms of waiting times, LOS and the management of co‐morbidity

• Associated with one quarter reduction in hospital readmissions for heart failure patients

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Drivers for Cardiac rehabilitation  and secondary prevention• NSF CHD 2000 

– Chapter 6 ‐ Heart Failure

– Chapter 7 ‐ Cardiac Rehabilitation– Chapter 7 ‐ Cardiac Rehabilitation

– Chapter 8 Arrhythmia and Sudden Cardiac Death (2006)

• The Long‐term Conditions (NSF) March 2005

• BACR standards (2007)

• NICE  Post MI Guidance (2007)

• NICE CR service commissioning guides (2008)g g ( )

• SIGN cardiac rehabilitation guidelines (57), (2003, 2009) • Better Heart Disease  & Stroke Care Action Plan (2009)CMO R t (2005) At l t fi k• CMO Report (2005) At least five a week 

• JBS2 guidelines (2006) and future JBS3 (2010/11)• NICE (2005) physical activity• HDA (2005) Physical activity in adults• DH (2005): Choosing health: physical activity plan• BHF: Heart failure programmes and CVCBHF: Heart failure programmes  and CVC

• Cochrane reviews on CR and exercise (2000, 2004, 2010)

What is cardiac rehabilitation?What is cardiac rehabilitation?“Cardiac rehabilitation services are comprehensive, long‐term 

programs involving medical evaluation, prescribed exercise, p g g , p ,cardiac risk factor modification, education, and counselling. These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or re‐infarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process and enhancestabilize or reverse the atherosclerotic process, and enhancethe psychosocial and vocational status of selected patients”

AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation, J. Am. Coll. Cardiol. 2007;50;1400‐1433. 

Target population: 

Revasc, Post MI, Heart failure,  ICD and unstable anginaf g

St d d d CStandards and Core  Components for CR

Core components include:• Lifestyle:Lifestyle:

– Physical activity and exercise

Di t d i ht t– Diet and weight management

– Smoking cessation• Education

• Risk factor management

• Psychosocial

• Cardio protective drug therapy and implantable devices

• Long‐term management strategy including return to workDate of Preparation: September 2009OMA567

CR is effective and value for moneyCR is effective and value for money• 48 RCTs showing 26% reduction in cardiac mortality 

• Fidan et al 2007 Cost per life year gained  in the UK 2000 to 2010: IMPACT CHD model for number of life‐years gained

– Aspirin and beta blockers for secondary prevention < £1000– CR £1957– ACE (£3398)– Statins for secondary prevention (£4246)– CABG (£3239–£4601 )CABG (£3239 £4601 ) – Angioplasty (£3845–£5889)– Primary angioplasty for MI (£6054–£12 057 under 60 minutes) 

Statins for primary prevention (£27 828 £69 373)– Statins for primary prevention (£27 828–£69 373)

Fidan D, Unal B, Critchley J, et al. Economic analysis of treatments reducingcoronary heart disease mortality in England and Wales 2000–2010 QJMcoronary heart disease mortality in England and Wales, 2000–2010. QJM2007;100:277–89.

NICE clinical guideline CG048 ‘MI: secondary prevention d ti i i d d– secondary prevention in primary and secondary care 

for patients following a myocardial infarction’

Cardiac rehab and lifestyle:

• Key priorities for implementationKey priorities for implementation– Assessment

– Regular physical activity and exercise with an aim to increasingRegular physical activity and exercise with an aim to increasing exercise capacity (60 to 70% intensity)

– Meet CMO guidelinesMeet CMO guidelines

– Quit smoking

– Mediterranean style dietMediterranean style diet

– Drug management of risk factors

– Preventative approachPreventative approachhttp://www.nice.org.uk/guidance/index.jsp?action=download&o=30493

Prevention is also very importantPrevention is also very important

• Sedentary behaviour is a real challenge

• Motivational engagement is essential toMotivational engagement is essential to success

A i d h l lf• A sustained approach to long term self management is needed

• The scale of the prevention problem shouldn’t be underestimatedbe underestimated

The challenge of prevention!  UK adult Stats HSE 2009 NHS IC2009: NHS IC

~60% sedentary y(< 1 session/wk)

35% meet CMO35% meet CMO guidance

4% fit & high levels of exercise

1% athletic

Should we take a population orIndividual approachIndividual approach in setting targets?

It’s not just a European problem!

Buckley and Doherty 2008

Objective:  To examine how change in level of physical activity after 

Lyberg et al. BMJ 2009; 338: b688, DOI 10.1136/bmj.b688

middle age influences mortality and to compare it with the effect of smoking cessation.Design Pop lation based cohort st d ith follo p o er 35 earsDesign Population based cohort study with follow‐up over 35 years. Setting Municipality of Uppsala, Sweden.

Participants: 2205 men aged 50 in 1970‐3 who were re‐examined at ages 60, 70, 77, and 82 years. Main outcome measure Total (all cause) mortality

Conclusions: Increased physical activity in middle age is eventuallyConclusions: Increased physical activity in middle age is eventually followed by a reduction in mortality to the same level as seen among men with constantly high physical activity. This reduction isamong men with constantly high physical activity. This reduction is comparable with that associated with smoking cessation.

Now lets get back to cardiac rehabilitation!

CR uptake nationally

• NACR is the best available source for a national picture of CR • The median ait time as three eeks for MI patients a month for PCI

nationally

• The median wait time was three weeks for MI patients, a month for PCI patients and six weeks for CABG patients: across all three groups there was a reduction of ten days from the previous year A th th ti PCI ti t h d th t t i ti (f• Across the three nations, PCI patients had the greatest variation (from 9% to 32%) 

• Only 1% heart failure, 4% for angina and less than 1% for those having i d i l t d di d ireceived an implanted cardiac device

• Women, particularly older women,  are under‐represented in CR• Lack of referral to CR is a serious issue and service design is one of the g

ways of addressing this

NACR and CR uptakep

Multi disciplinary team from the CR national audit 340 programmes

Uptake, outcome and cost of CR are influenced by the extent of co-morbidity:Zoghbi GJ, Sanderson B, Breland J, Adams C, Schumann C, Bittner V. Optimizing risk stratification in cardiac rehabilitation with inclusion of a comorbidity index J Cardiopulm Rehabilstratification in cardiac rehabilitation with inclusion of a comorbidity index. J Cardiopulm Rehabil. 2004;24:8–13.Richardson LA, Buckenmeyer PJ, Bauman BD, Rosneck JS, Newman I, Josephson RA. Contemporary cardiac rehabilitation: patient characteristics and temporal trends over the past p y p p pdecade. J Cardiopulm Rehabil. 2000;20:57–64.Suaya JA, Shepard DS, Normand SL, et al. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation 2007;116:1653–62.

It’s all about choice: the menu of options should be comprehensivethe menu of options should be comprehensive

Home‐based versus centre‐based CRHome based versus centre based CR• Taylor RS, Dalal H, Jolly K, Moxham T, Zawada A. Home‐based versus 

centre‐based cardiac rehabilitation. Cochrane Database of Systematiccentre based cardiac rehabilitation. Cochrane Database of Systematic Reviews 2008 , Issue 2 . Art. No.: CD007130.  

A. Twelve studies (1,938 participants) met the inclusion criteria. B. Lower risk patient following an acute (MI) and revascularisation.

Main results1. There was no difference in outcomes of home- versus centre-based cardiac

rehabilitation in mortality risk ratio (RR) was1.31 (95% confidence interval

2. (C) 0.65 to 2.66), cardiac events, exercise capacity standardised mean difference

(SMD) -0.11 (95% CI -0.35 to 0.13), as well as in modifiable risk factors

3. There was no consistent difference in the healthcare costs of the two forms of

cardiac rehabilitation.

NACR CR cost

Impact of the financial crisis on the NHSp

• CR has a very strongest clinical and cost effectiveness evidence base but in 2010 this is not enough!!

• Billions of savings required from the NHS over 3 yearsg q y

• The case for CR could not come at a worse time

Lots of evidence but very little new cash to fund new– Lots of evidence but very little new cash to fund new activity

A h i d d d i i l• A new approach is needed and it involves commissioning best practice CR

National Priority Projects inNational Priority Projects inCardiac Rehabilitation

Prof. Patrick Doherty ‐ National Clinical Lead

Dr Jane Flint – National Clinical Advisor

Julie Harries – Director NHS Improvement

Linda Binder ‐ National Improvement LeadLinda Binder   National Improvement Lead

Wh t did hi ?What did we achieve?• Redesigned clinical pathways• Redesigned clinical pathways 

• Decreased waiting times and increased uptake 

• Improved quality – greater equity, safety, flexibility & choice

• Production of service specifications and business cases

• Commissioning and procurement guidance and supportCommissioning and procurement guidance and support

• New and innovative service models for instance nurse led 

discharge and community heart failure rehab

• And many more QIPP orientated outcomes• And many more QIPP orientated outcomes.......

More work to do “unfinished business” and aMore work to do  unfinished business  and a new trail blazing opportunity!

• Joint development of a CR Commissioning Pack with the  DH Strategic Commissioning Development Unit (SCDU) 

ll l d l ll h• NHS Improvement will lead  national projects to roll‐out the Commissioning Pack from autunm2010 and will work with commissioners and Networks to:commissioners and Networks to:– Improve quality and productivity of existing services

– to increase the numbers of patients receiving a quality cardiac rehab p g q yservice

– provide the business case and commissioning support to establish CR as a value for money part of revascularisation and heart failure pathwaysvalue for money part of revascularisation and heart failure pathways

– Commissioning tool and not a clinical guideline

• Why CR? Clinically effective and cost effective but also capable ofWhy CR? Clinically effective and cost effective but also capable of saving PCTs money in the longer term

D f H l h S i C i i iDept of Health: Strategic Commissioning Development Unit (SCDU):

Following extensive consultation, consideration of further packs includes:

Cardiac Rehab Hips (esp. 24-hr)COPD

Stroke Rehab End of Life

Detailed clinical and economic analyses will be conducted to underpin the business case for each pack.

Diabetes

CR commissioning working groupCR commissioning working group

• A reference group of 25 experts in cardiology & rehabilitation drawn from the academic & clinical community

• Joint leadership from SCDU and NHS Improvement

• Support from the DH pricing team, economists, PbR & IC

• Five reference groups meetings and we have completed an evidence based clinical pathway

• Pricing and service specification is nearly complete for a late summer publication

• The economic case is working on reducing LOS and hospital d i ireadmissions

CR Commissioning pack highlightsCR Commissioning pack highlights

• The following slides are a draft version of the CR pack specification which are likely to p p yundergo change before the final publication

Overview of Cardiac Rehabilitation PathwayOverview of Cardiac Rehabilitation Pathway

DRAFT v0.2 29

CR core Ongoing long term management and self management components

Stage 4 – Deliver comprehensive cardiac rehabilitation programme

Stage 6 – Transition to long term self management

Conclusion• Cardiac rehabilitation is clearly effective and value for money and can be delivered to more patients for nomoney and can be delivered to more patients for no extra cost

• Uptake can be improved through a menu of best• Uptake can be improved through a menu of best practice approaches run by a skilled MDT

N i l h i b t! It’ ll b t i• No single approach is best! It’s all about genuine evidence based choices for patients

• The future requires clinical and commissioning  leadership

• The new DH commissioning packs have the potential to make a real difference

Thank you for listening!

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