Transcript Developing NICE Guidelines

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: [email protected]
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
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
National Collaborating Centre
for Primary Care
Cardiac rehabilitation
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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
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
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)
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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
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
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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)
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
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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
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
National Collaborating Centre
for Primary Care
Patient engagement in cardiac rehabilitation
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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)
•
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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
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
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)
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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
National Collaborating Centre
for Primary Care
Summary of evidence
 Comprehensive cardiac rehabilitation has a
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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
National Collaborating Centre
for Primary Care
Key provisional recommendations from
the Post MI guideline stakeholder
consultation draft: August 2006
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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
National Collaborating Centre
publication date:
for Primary Care
23rd May 2007
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
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
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: [email protected]
National Collaborating Centre
for Primary Care