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 trials^{152,207,208,209} 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:

• The 500 patients will be a mixture of post MI, revascularisation, angina, and heart failure patients, with post MI and revascularisation patients predominating.
• All patients with be suitable for some form of rehabilitation, with 250 (50%) opting for group exercise training, 150 (30%) preferring a home-based programme, and 100 (20%) not interested in any rehabilitation.
• Patients attending Phase 3 group classes and those who undertake home-based programmes will each have a formal assessment of functional capacity at the beginning and end of their programmes.
• Group exercise classes will run twice a week for eight weeks and will accommodate 12-15 patients at any one time. It follows that six separate classes will be required each week
• The population served will be predominantly urban, arbitrarily defined as 80% of patients living within 10 miles of a district general or teaching hospital. For Health Boards with a significant rural population, costs are likely to be higher because of smaller class sizes and longer travelling times.
• The first point of contact for patients with psychological distress will be a nurse therapist with training in cognitive behavioural therapy, rather than a clinical psychologist. A smaller number of clinical psychologist hours will then be required to help those patients whose anxiety or depression does not resolve with the advice and treatment provided by their nurse therapists.

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:

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.