Guideline 57 - Supporting Material

Cardiac rehabilitation

1 SIGN guidelines and health economics

The development process for this guideline included explicit consideration of economic issues. This was a two stage process involving a review of the economics literature with a view to informing guideline recommendations. Since there was not sufficient literature to shape recommendation setting, the second stage gave consideration to the possible economic implications of the guideline recommendations. The aim of considering health economic aspects as an integral part of guidelines is to ensure the efficient use of health care resources.

2 Glossary

2.1 COST EFFECTIVENESS ANALYSIS

A form of economic evaluation where the alternatives under consideration are compared in terms of respective costs and outcomes as measured in a common natural unit such as life years gained, cases detected etc. A cost-consequence analysis is a disaggregated form of cost-effectiveness analysis where cost and benefit are presented but not combined in an overall ratio of cost to effect.

2.2 COST UTILITY ANALYSIS

This method of analysis compares the costs of different procedures with their outcomes measured in 'utility based units' i.e. units that relate to a person's level of well-being such as QALYs (quality adjusted life years). QALYs are calculated by estimating the total life years gained associated with each intervention and weighting each year to reflect quality of life in that year.

2.3 COST ANALYSIS

A study comparing two or more services or interventions in terms of their costs. Outcomes are not assessed.

3 Cost-effectiveness of comprehensive cardiac rehabilitation

The review of cost-effectiveness literature considered economic evaluations of comprehensive cardiac rehabilitation based on three observational studies^1,2,3 four randomised-controlled trials^4,5,6,7 and three reworkings of previously published data.^8,9,10

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.⁴ Estimated survival benefit was determined from an earlier meta-analysis.¹¹ The best estimates for cost-effectiveness and cost-utility were $21,800 per life year gained and $6,800 per QALY respectively (1991 prices). The most up-to-date conversions of this analysis for the estimated that the cost per life year gained was approximately £6,400 and the cost per QALY £2,700 (1999 prices).⁸

These estimates of cost-effectiveness refer to comprehensive cardiac rehabilitation in a particular setting and patient population. In practice, the current 'menu-based' approach to cardiac rehabilitation will result in many different packages of care being implemented following an individual assessment of need. Given this heterogeneity, there is likely to be a continuum of cost-effectiveness ratios achievable in local practice around the point estimates given in the literature.

3.1 COST EFFECTIVENESS OF DIFFERING FORMS OF REHABILITATION

There is only limited information from the literature as to the relative cost- effectiveness of different modes of cardiac rehabilitation or rehabilitation in different patient groups. A randomised trial compared a modified form of cardiac rehabilitation aimed at encouraging independent exercise with a traditional protocol.⁵ During the six-month follow-up, the modified protocol cost $830 less per patient then the conventional rehabilitation and was able to demonstrate significantly improved process outcomes (exercise adherence and number of exercise sessions) with physiologic outcomes at least equal to the traditional program.

A cost-consequence analysis compared costs and outcomes in coronary artery disease patients randomised to a six week programme of either high or low frequency rehabilitation.⁶ Only the costs of providing each rehabilitation programme were included but this indicated that the high frequency group cost almost double the low frequency group. However, set against this incremental cost, some physiological outcomes and quality of life indicators were significantly better in the high frequency group.

No evidence was found comparing hospital- and home- based rehabilitation. Intuitively however, if evidence exists to show that low-cost home based programmes are of equal efficacy, then they could be presumed to be comparatively cost-effective on cost-minimisation grounds.

3.2 COST EFFECTIVENESS IN HIGH RISK AND OTHER SUB-GROUPS

One non-randomised study aimed to examine the economic implications of cardiac rehabilitation in the elderly.² This study did not incorporate a full economic evaluation but did present results to indicate that in post MI patients over 65, comprehensive cardiac rehabilitation leads to significantly lower hospital and emergency room visits compared with patients who did not attend. No other published evaluations were found specifically pertaining to cost-effectiveness of cardiac rehabilitation in women, heart failure patients or post-transplant/valve surgery patients.

3.3 PSYCHOLOGICALLY DISTRESSED PATIENTS

Cost analyses conducted in North America suggest that post MI patients who exhibit signs of psychological distress or depression are likely to incur significantly higher health care costs.^3,12 Specific cost-effectiveness studies evaluating the impact of the psychological therapy component of rehab programmes are limited. A trial conducted in the Netherlands found that the addition of relaxation and breathing training to exercise- only rehabilitation resulted in significantly lower resource use over a five year period in post MI patients.⁷ Another study investigated whether a home based rehabilitation programme based on the Heart Manual could reduce psychological distress. The results indicated that in addition to improved psychological adjustment with the intervention, the number of hospital admissions and GP contacts were significantly reduced over 6 months and 1 year respectively. ¹³ It should also be borne in mind that the commonly cited economic study by Oldridge was conducted in a population of patients who were moderately anxious or depressed. As such, the cost-effectiveness ratios cited in section 7.3 would apply to cardiac rehabilitation in psychologically distressed patients.

4 Costs to patients

A cost-consequence analysis in a non-randomised Swedish population examined the 5-year costs and effects of cardiac rehabilitation.¹ A particular feature of this study was the distribution of costs: the health service and other agencies incurred lower costs as a result of patients attending rehabilitation, whereas the patients incurred additional costs over usual care. Whilst conducted in another health care system, it does raise awareness that patients may bear a costs.

5 Conclusions

Whilst the existing economics literature would support comprehensive cardiac rehabilitation as a relatively cost- effective intervention, there is insufficient evidence from the economics literature to identify the most cost-effective ways of providing services. The cost-effectiveness of cardiac rehabilitation will vary depending on the setting, patient population and methods of intervention employed. Against an increasing trend towards provision of menu based cardiac rehabilitation, the task of isolating the relative costs and benefits of different components of the rehabilitation process is likely to prove difficult.

6 Resource implications

6.1 RESOURCE IMPLICATIONS OF IMPLEMENTATION

Studies published in the mid-1990s indicated that the pattern of cardiac rehabilitation provision across Scotland showed considerable variation.^14,15 Estimating the resource implications of the guideline recommendations and commenting on whether or not they can be met within existing resources will therefore vary according to local circumstances. Whether or not the total resource impact of guideline implementation can be absorbed within existing allocations will be dependent on local factors such as the current provision of staff, facilities and existing (spare) capacity.

For some cardiac rehabilitation services, specific resource impacts will arise due to changes in the patient population, the programme duration or prescribing costs associated with providing menu-based cardiac rehabilitation. For example, recommending that cardiac rehabilitation be offered to women, the elderly and patients with angina is likely to represent an expansion in the potential patient numbers currently seen by some rehabilitation services. Secondly, it is recommended that all exercised based programmes should last for a minimum of eight weeks and since this may not be current practice in all areas of Scotland, moving to this standard has the potential to increase the workload of some departments. Thirdly, there may be a potential impact on drug budgets as a result of ensuring that patients are on optimal secondary prevention medications. Lastly, any additional training and development of cardiac rehabilitation staff is also likely to require resource input.

6.2 IMPACT ON OUTCOMES OR RESOURCE USE IN DIFFERENT AREAS OF THE NHS

Implementation of the guideline is likely to have an impact on primary care and specialist services such as psychology or smoking cessation. Primary care providers are likely to be affected as a result of providing long-term follow up care for patients with coronary heart disease. In recommending referral to specialist services where clinically indicated, there are likely to be resource implications if the provision of care cannot be met within existing facilities. Securing appropriate staffing levels to provide a menu-based rehabilitation service may impact upon physiotherapy, dietetics and pharmacy departments since they are likely to provide key inputs into the rehabilitation package. Increased sessional input from psychologists was identified as being a particularly scarce resource in this respect. There may also be an impact on clinical audit departments as a consequence of recommending regular audit of cardiac rehabilitation services.

6.3 IMPACT ON OUTCOMES AND RESOURCE USE IN PARTNER ORGANISATIONS

Groups currently involved in providing self-help support or Phase 4 community-based rehabilitation may experience increased demand due to the guideline recommendations.

6.4 IMPACT ON OUTCOMES AND RESOURCE USE IN THE FUTURE

Ensuring that patients continue to be followed up at primary care level is likely to result in on-going resource use. It is also possible that future resource use will be affected as a consequence of improved health outcomes giving rise to changes in the use of health care services.

6.5 COSTS TO PATIENTS

Patients attending cardiac rehabilitation may incur private costs such as travel expenses and the cost of purchasing appropriate clothing and footwear. Ensuring that patients take optimal medications such as aspirin, statins, ace inhibitors and beta-blockers may result in patients facing additional prescription charges. Participation in on-going rehabilitation may also require the opportunity cost of the patient's time to be considered: patients may require additional time off work or may be unable to perform other roles such as caring for children or other family members.

7 Comparison with other health care interventions

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, thrombolytics for inferior myocardial infarction and angioplasty for patients with severe angina and single vessel disease.¹⁶ Viewed in this way, expenditure on cardiac rehabilitation services may be considered a worthwhile use of scarce health care resources.

References

1 Levin LA, Perk J, Hedback B. Cardiac Rehabilitation - a cost analysis. Journal of Internal Medicine 1991; 230: 427-434. [section 3] [section 4]

2 Bondestam E, Breikks A, Hartford M. Effect of early rehabilitation on consumption of medical care during the first year after acute MI in patients >65 years. American Journal of Cardiology 1995; 75: 767-771. [section 3] [section 3.2]

3 Allison TG, Williams DE, Miller TD, Pateen CA, Bailey KR, Squires RW, Gau GT. Medical and economic costs of psychological distress in patients with coronary artery disease. Mayo Clinic Proceedings 1995; 70: 734-42. [section 3] [section 3.3]

4 Oldridge N, Furlong W, Feeny D et al. Economic evaluation of cardiac rehabilitation soon after acute myocardial infarction. American Journal of Cardiology 1993; 72: 154-61.

5 Carlson J.J, Johnson J.A, Franklin BA et al. Program participation, exercise adherence, cardiovascular outcomes and program cost of traditional versus modified cardiac rehabilitation. American Journal of Cardiology 2000; 86: 17-23. [section 3] [section 3.1]

6 Nieuwland W, Berkhuysen M, van Veldhuisen D et al Differential effects of high-frequency versus low-frequency exercise training in rehabilitation of patients with coronary artery disease Journal of the American College of Cardiology 2000; 36: 202-207.

7 van Dixhoorn JJ, Duivenvoorden HJ. Effects of relaxation therapy on cardiac events after myocardial infarction: a five year follow up study Journal of Cardiopulmonary Rehabilitation 1999; 19: 178-185.[section 3] [section 3.3]

8 Taylor R, Kirby B. Cost implications of cardiac rehabilitation in older patients. Coronary Artery Disease 1999; 10: 53-56.

9 Taylor R, Kirby B. The evidence base for the cost effectiveness of cardiac rehabilitation. Heart 1997; 78: 5-6.

10 Ades PA, Pashkow FJ, Nestor JR. Cost-effectiveness of cardiac rehabilitation after myocardial infarction. Journal of Cardiopulmonary Rehabilitation 1997; 17: 222-231.

11 Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction. Combined experience of randomised clinical trials. JAMA 1988; 260: 945-50.

12 Frasure-Smith N, Lesperance F, Gravel G et al. Depression and health care costs during the first year following myocardial infarction. Journal of Psychosomatic Research 2000; 48: 471-478.

13 Lewin B, Robertson IH, Cay EL et al. Effects of self help post myocardial infarction rehabilitation on psychological adjustment and use of health services. Lancet 1992; 339: 1036-1040.

14 Campbell NC, Grimshaw JM, Ritchie LD, Rawles JM. Outpatient cardiac rehabilitation: are the potential benefits being realised? J R Coll Physicians Lond 1996; 30: 514-519.

15 Campbell NC, Grimshaw JM, Rawles JM, Ritchie LD. Cardiac rehabilitation in Scotland: is current provision satisfactory? J Public Health Med 1996; 18: 478-80.

16 Oldridge NB. Cardiac rehabilitation and risk factor management after myocardial infarction- clinical and economic evaluation. Wien Klin Wochenschr 1997; 109 Suppl 2: 6-16.