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SIGN GUIDELINE 57: Cardiac Rehabilitation
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7.1 Statement of intent
This guideline is not intended to be construed or to serve as a standard of medical care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. The ultimate judgement regarding a particular clinical procedure or treatment plan must be made in light of the clinical data presented by the patient and the diagnostic and treatment options available.
7.2 Implementation
Implementation of national clinical guidelines is the responsibility of each NHS Trust and is an essential part of clinical governance. It is acknowledged that every Trust cannot implement every guideline immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed.
Standards for cardiac rehabilitation for NHS Scotland are given in the Clinical Standards Board for Scotland (CSBS) recommendations for coronary heart disease, which have focused initially on secondary prevention in a hospital setting.203 The CSBS peer review visits have included an examination of the provision of cardiac rehabilitation, which has highlighted the key role played by the cardiac rehabilitation team in the collection of data required to show that a Trust is meeting the standards. Essentially similar standards for cardiac rehabilitation are given in the National Service Framework for Coronary Heart Disease for England and Wales.204
Given the variation in provision of cardiac rehabilitation services in Scotland it would be prudent to have an initial focus on ensuring comprehensive and high quality services for MI survivors and those undergoing revascularisation. In particular, the inclusion of women and older patients should be addressed. As evidence of the cost benefit of extending services to other groups emerges, services can be extended in an incremental fashion. Managed Clinical Networks may prove to be the best way of ensuring the effective delivery and coordination of cardiac rehabilitation across primary and secondary care.205
7.3 Resource implications of implementing the guideline
The review of the cost effectiveness literature carried out for this guideline considered economic evaluations of comprehensive cardiac rehabilitation based on three observational studies,44,167,206 four randomised controlled trials152,207,208,209 and three reworkings of previously published data.210,211,212 The most methodologically rigorous economics study examined the costs incurred and quality of life gained in a randomised trial of cardiac rehabilitation in moderately anxious or depressed patients.207 Estimated survival benefit was determined from an earlier meta-analysis.135 The best estimates for cost-effectiveness and cost-utility were $21,800 per life year gained and $6,800 per quality adjusted life year (QALY) respectively (1991 prices). The most up-to-date conversions of this analysis for the UK estimated that the cost per life year gained was approximately £6,400 and the cost per QALY £2,700 (1999 prices).211
The process of ensuring that rehabilitation programmes are best placed to deliver maximum health gain may not be resource neutral. However, cardiac rehabilitation does compare favourably in cost-effectiveness terms with other cardiovascular interventions such as treatment of hypertension, hyperlipidaemia, thrombolysis for inferior myocardial infarction and angioplasty for patients with severe angina and single vessel disease.213 Viewed in this way, expenditure on cardiac rehabilitation services may be considered a worthwhile use of scarce health care resources.
The guideline development group have developed an estimate of the staff resources required to deliver multidisciplinary cardiac rehabilitation to patients with a wide range of needs. These represent the staff likely to be required to rehabilitate 500 patients per year. The following assumptions have been made:
These assumptions allow the following estimates of whole time equivalent (WTE) staff requirements to be made for Health Boards with and without a significant rural population:
|
Staff |
WTE |
|
|
|
|
G Grade nurse |
3.0 |
|
Senior 1 Physiotherapist |
2.0 |
|
Senior 1 Dietitian |
0.3 |
|
D grade Pharmacist |
0.2 |
|
Clinical Psychologist (Grade A) |
0.2 |
|
Audit and Clerical (Grade 3) |
0.5 |
|
Rural supplement |
|
|
|
|
|
G Grade nurse |
0.5 |
These estimates reflect the likely requirement for cardiac rehabilitation if the targets set by the Clinical Standards Board for Scotland are to be met. Health Boards may wish to vary the amount spent on cardiac rehabilitation according to local needs and priorities. The cost of providing cardiac rehabilitation services in Scotland has also been considered by the Scottish Needs Assessment Programme (SNAP).20
A review of the cost-effectiveness literature and details of the derivation of these staffing requirements, together with an estimation of the associated costs is provided on the SIGN website: www.sign.ac.uk.
7.4 Audit
If audit of cardiac rehabilitation is to be efficient and ongoing, audit data will need to fall out of routinely collected clinical data. The use of stand alone IT systems for audit requires double entry of data, which is time consuming and should be discouraged. Recommended minimum data fields (in addition to the CHD Task Force minimum data set) for the implementation of this guideline are detailed below. These have been designed primarily to meet the requirements of both the Clinical Standards Board for Scotland and the CHD Task Force, and are not intended to limit or restrict in any way those who wish to collect and audit additional data fields.
| INITIATING EVENT FOR CARDIAC REHAB | |||
| Angina | Y/N/NR | Valve surgery | Y/N/NR |
| Myocardial infarction | Y/N/NR | Heart failure | Y/N/NR |
| Bypass surgery | Y/N/NR | Internal cardiac defibrillator | Y/N/NR |
| Angioplasty | Y/N/NR | Other | Y/N/NR |
| HOSPITAL | |||
| Seen by Rehab Nurse | Y/N/NR | ||
| Rehab programme | Exercise only | Education only | Comprehensive CR |
| Invited | Y/N/NR | Y/N/NR | Y/N/NR |
| Started | Y/N/NR | Y/N/NR | Y/N/NR |
| Completed (>= 75%) | Y/N/NR | Y/N/NR | Y/N/NR |
| HOME | |||
| Heart Manual issued | Y/N/NR | ||
| Heart Manual completed | Y/N/NR | ||
| ENTRY
TO PROGRAMME Day/Month/Year |
EXIT
FROM PROGRAMME Day/Month/Year |
||
| REASONS FOR NOT COMPLETING AT LEAST ONE FORM OF REHAB | |||
| Patient not interested | Undergoing investigations | ||
| No transport | Return to work | ||
| Too far to travel | Physical incapacity | ||
| Holidaymaker | Mental incapacity | ||
| Died | Other | ||
| ASSESSMENTS | |||
| HAD score before discharge | A=/D=/Refused/NR | ||
| Follow up HAD score (for values 8 or more) | A=/D=/NI/Refused/NR | ||
| Functional capacity before training programme | Y/N/NR | ||
| Functional capacity after training programme | Y/N/NR | ||
| ADVICE | |||
| Cardiac misconceptions | Y/N/NR | ||
| Written information given | Y/N/NR | ||
| Video viewed | Y/N/NR | ||
| Carers seen | Y/N/No carer/NR | ||
| Basic life support discussed with carer | Y/N/NR | ||
| REFERRAL | |||
| Secondary prevention clinic | Y/N/NI/NR | ||
| BACR Phase 4 exercise | Y/N/NI/NR | ||
| Self help group | Y/N/NI/NR | ||
| Cardiology clinic | Y/N/NI/NR | ||
| Dietitian | Y/N/NI/NR | ||
| Occupational therapist | Y/N/NI/NR | ||
| Physiotherapy | Y/N/NI/NR | ||
| Psychology | Y/N/NI/NR | ||
| Smoking cessation | Y/N/NI/NR | ||
| Exercise physiologist | Y/N/NI/NR | ||
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Scottish Intercollegiate Guidelines Network,
Elliott House, 8-10 Hillside Crescent,
Edinburgh EH7 5EA
Tel. 0131 623 4720 Fax. 0131 623 4503 Web contact duncan.service@nhs.net
Last modified
6/05/11
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