Provision, uptake and cost of cardiacrehabilitation programmes: improvingservices to under-represented groups
AD Beswick, K Rees, I Griebsch, FC Taylor, M Burke, RR West, J Victory, J Brown, RS Taylor and S Ebrahim
Health Technology Assessment 2004; Vol. 8: No. 41
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October 2004
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HTA
Provision, uptake and cost of cardiacrehabilitation programmes: improvingservices to under-represented groups
AD Beswick,1 K Rees,1 I Griebsch,2 FC Taylor,3
M Burke,1 RR West,4 J Victory,5 J Brown,2
RS Taylor6 and S Ebrahim1*
1 Department of Social Medicine, University of Bristol, UK2 MRC Health Services Research Collaboration, Department of Social
Medicine, University of Bristol, UK3 Bristol Heart Institute, University of Bristol, UK4 Wales Heart Research Institute, University of Wales College of Medicine,
Cardiff, UK5 United Bristol Healthcare NHS Trust, UK6 Department of Public Health and Epidemiology, University of
Birmingham, UK
* Corresponding author
Declared competing interests of authors: none
Published October 2004
This report should be referenced as follows:
Beswick AD, Rees K, Griebsch I, Taylor FC, Burke M, West RR, et al. Provision, uptakeand cost of cardiac rehabilitation programmes: improving services to under-representedgroups. Health Technol Assess 2004;8(41).
Health Technology Assessment is indexed in Index Medicus/MEDLINE and Excerpta Medica/EMBASE.
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Objectives: To estimate UK need for outpatientcardiac rehabilitation, current provision andidentification of patient groups not receiving services.To conduct a systematic review of literature onmethods to improve uptake and adherence to cardiacrehabilitation. To estimate cost implications ofincreasing uptake of cardiac rehabilitation.Data sources: Hospital Episode Statistics (England).Hospital Inpatient Systems (Northern Ireland). PatientsEpisode Database for Wales. British Association forCardiac Rehabilitation/British Heart Foundationsurveys. Cardiac rehabilitation centres. Patients fromgeneral hospitals. Electronic databases.Review methods: The study analysed hospitaldischarge statistics to ascertain the population need foroutpatient cardiac rehabilitation in the UK. Surveys ofcardiac rehabilitation programmes were conducted todetermine UK provision, uptake and audit activity, andto identify local interventions to improve uptake. Datawere also examined from a trial estimating eligibility forcardiac rehabilitation and non-attendance. A systematicreview of interventions to improve patient uptake,adherence and professional compliance in cardiacrehabilitation was conducted. Estimated costs ofimproving uptake were identified from national survey,systematic review and sampled cardiac rehabilitationprogrammes.Results: In England, Wales and Northern Ireland nearly146,000 patients discharged from hospital with primarydiagnosis of acute myocardial infarction, unstable anginaor following revascularisation were potentially eligiblefor cardiac rehabilitation. In England in 2000, 45–67%of these patients were referred, with 27–41%
attending outpatient cardiac rehabilitation. If alldischarge diagnoses of ischaemic heart disease wereconsidered, nearly 299,000 patients would bepotentially eligible and in England rates of attendanceand referral would be 22–33% and 13–20%respectively. Rates of referral and attendance weresimilar in Wales, but somewhat lower in NorthernIreland. It was found that referral and attendance ofolder people and women at cardiac rehabilitationtended to be low. It was also suggested that patientsfrom ethnic minorities and those with angina or heartfailure were less likely to be referred to or joinprogrammes. A wide range of local interventionssuggested awareness of the problem of uptake. In anNHS-funded randomised controlled trial, possiblyrepresenting more optimal protocol-led care, medicaland nursing staff identified 73–81% of patients withacute myocardial infarction as eligible for cardiacrehabilitation. Excluded patients tended to be olderwith more severe presentation of cardiac disease.Experiences of patients suggested that uptake may beimproved by addressing issues of motivation andrelevance of rehabilitation to future well-being, co-morbidities, site and time of programme, transport andcare for dependants. Systematic review of studiessupported the use of letters, pamphlets or home visitsto motivate patients and the use of trained lay visitors.Self-management techniques showed some value inpromoting adherence to lifestyle changes. Studiesexamining professional compliance found thatprofessional support for practice nurses may have valuein the coordination of postdischarge care. Averagecosts in 2001 of cardiac rehabilitation to the health
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Abstract
Provision, uptake and cost of cardiac rehabilitation programmes:improving services to under-represented groups
AD Beswick,1 K Rees,1 I Griebsch,2 FC Taylor,3 M Burke,1 RR West,4 J Victory,5
J Brown,2 RS Taylor6 and S Ebrahim1*
1 Department of Social Medicine, University of Bristol, UK2 MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol, UK3 Bristol Heart Institute, University of Bristol, UK4 Wales Heart Research Institute, University of Wales College of Medicine, Cardiff, UK5 United Bristol Healthcare NHS Trust, UK6 Department of Public Health and Epidemiology, University of Birmingham, UK* Corresponding author
service per patient completing a cardiac rehabilitationprogramme were about £350 (staff only) and £490(total). If services were modelled on an intermediatemultidisciplinary configuration with three to five keystaff, approximately 13% more patients could betreated with the same budget. Depending on staffingconfiguration an approximate 200–790% budgetincrease would be required to provide cardiacrehabilitation to all potentially eligible patients. Conclusions: Provision of outpatient cardiacrehabilitation in the UK is low and little is known aboutthe capacity of cardiac rehabilitation centres to increasethis provision. There is an uncoordinated approach toaudit data collection and few interventions aimed atimproving the situation have been formally evaluated.Motivational communications and trained lay volunteersmay improve uptake of cardiac rehabilitation, as mayself-management techniques. Experience of low-costinterventions and good practice exists withinrehabilitation centres, although cost information
frequently is not reported. Increased provision ofoutpatient cardiac rehabilitation will require extraresources. Further trials are required to compare thecost-effectiveness of comprehensive multidisciplinaryrehabilitation with simpler outpatient programmes, alsoresearch is needed into economic and patientpreference studies of the effects of different methodsof using increased funding for cardiac rehabilitation. Anevaluation of a range of interventions to promoteattendance in all patients and under-representedgroups would also be useful. The development ofstandards is suggested for audit methods and foreligibility criteria, as well as regular and comprehensivedata collection to estimate the need for and provisionof cardiac rehabilitation. Further areas for interventioncould be identified through qualitative studies, and theextension of low-cost interventions and good practicewithin rehabilitation centres. Regularly updatedsystematic reviews of relevant literature would also beuseful.
Abstract
iv
Health Technology Assessment 2004; Vol. 8: No. 41
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List of abbreviations .................................. vii
Executive summary .................................... ix
1 Background ................................................ 1Cardiac rehabilitation ................................ 1Effectiveness in patients with coronary heart disease ............................................... 1Effectiveness in specific patient groups ..... 2Uptake of cardiac rehabilitation ................ 2Under-representation in cardiac rehabilitation .............................................. 2Barriers to uptake and adherence ............. 4Economic aspects of cardiac rehabilitation .............................................. 5Conclusions ................................................ 6
2 Objectives .................................................. 7
3 Population need for cardiac rehabilitation in the UK .................................................... 9Objectives ................................................... 9Background ................................................ 9Methods ...................................................... 9Results ........................................................ 10Discussion ................................................... 11Conclusions ................................................ 12
4 Provision and uptake of cardiac rehabilitation in the UK: national survey of UK cardiac rehabilitation services ........ 13Objective ..................................................... 13Methods ...................................................... 13Results ........................................................ 13Conclusions ................................................ 15
5 Audit of cardiac rehabilitation in England:National Service Framework for CoronaryHeart Disease recommendations .............. 17Objective ..................................................... 17Background ................................................ 17Methods ...................................................... 17Results ........................................................ 17Discussion ................................................... 19Conclusions ................................................ 20
6 Uptake and adherence in a randomisedcontrolled trial of cardiac rehabilitation after myocardial infarction ........................ 23Objective ..................................................... 23
Introduction ............................................... 23Methods ...................................................... 23Results ........................................................ 23Discussion ................................................... 26Conclusions ................................................ 27
7 Systematic review of interventions to improve uptake, adherence and professional compliance with cardiacrehabilitation .............................................. 29Definitions .................................................. 29Objective ..................................................... 29Methods ...................................................... 29
8 Systematic review of interventions to improve uptake of cardiac rehabilitation .............................................. 31Background ................................................ 31Results ........................................................ 31Discussion ................................................... 34Conclusions ................................................ 38
9 Systematic review of interventions to improveadherence to cardiac rehabilitation .......... 39Background ................................................ 39Results ........................................................ 39Discussion ................................................... 45Conclusions ................................................ 48
10 Systematic review of interventions to improve professional compliance with cardiac rehabilitation ................................. 49Background ................................................ 49Results ........................................................ 49Discussion ................................................... 52Conclusions ................................................ 53
11 Health service costs of cardiac rehabilitation in the UK ............................. 55Objectives ................................................... 55Health service costs associated with cardiac rehabilitation ................................. 55The national budget attributable to cardiac rehabilitation ................................. 58Discussion ................................................... 60Conclusions ................................................ 63
12 Conclusions ................................................ 65What is the population need for cardiacrehabilitation? ............................................ 65
Contents
Contents
Who is not receiving cardiac rehabilitation? ............................................ 65What is the effectiveness of different methods of improving uptake and ofdifferential targeting of cardiac rehabilitation? ............................................ 66What is the potential budget impact of increasing uptake of cardiacrehabilitation using different uptakeinterventions? ............................................. 68
13 Key findings ................................................ 71Implications for healthcare ........................ 71
Acknowledgements .................................... 73
References .................................................. 75
Appendix 1 Need for cardiac rehabilitation in the UK ............................. 83
Appendix 2 Need for and estimated level of cardiac rehabilitation provision in the UK .................................................... 87
Appendix 3 British Association for CardiacRehabilitation additional postal questionnaire .............................................. 91
Appendix 4 Literature search strategies ..................................................... 95
Appendix 5 Inclusion/exclusion form ....... 97
Appendix 6 Data extraction form ............. 99
Appendix 7 Flow diagram of the systematicreview of interventions to improve uptake ofcardiac rehabilitation (QUOROM statementflow diagram) ............................................. 103
Appendix 8 Studies evaluating interventions to improve the uptake of cardiac rehabilitation .............................................. 105
Appendix 9 Studies excluded from the review of interventions to improve uptake of cardiac rehabilitation .............................................. 113
Appendix 10 Flow diagram of the systematicreview of interventions to improve adherenceto cardiac rehabilitation (QUOROM statement flow diagram) ............................ 115
Appendix 11 Studies evaluating interventionsto improve adherence to cardiac rehabilitation .............................................. 117
Appendix 12 Studies excluded from the review of methods to improve adherence tocardiac rehabilitation ................................. 129
Appendix 13 Flow diagram of the systematicreview of interventions to improve professional compliance with cardiacrehabilitation (QUOROM statement flowdiagram) ..................................................... 131
Appendix 14 Studies evaluating interventions to improve professionalcompliance with cardiac rehabilitation ...... 133
Appendix 15 Studies excluded from the review of interventions to improve professional compliance with cardiacrehabilitation .............................................. 139
Appendix 16 Estimates for unit costs fordifferent staff categories and grades .......... 141
Appendix 17 List of equipment ................ 143
Appendix 18 Staff input: average hours perweek ............................................................ 145
Appendix 19 Referral, uptake and completion rates for 30 randomly selected UK cardiac rehabilitation programmes in 2000 ....................................................... 149
Appendix 20 Average cost estimates for cardiac rehabilitation (detailed table) ........ 151
Health Technology Assessment reportspublished to date ....................................... 153
Health Technology Assessment Programme ................................................ 163
vi
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AMI acute myocardial infarction
BACR British Association for CardiacRehabilitation
BHF British Heart Foundation
CABG coronary artery bypass graft
CHD coronary heart disease
CI confidence interval
CR cardiac rehabilitation
HES Hospital Episode Statistics(England)
HF heart failure
HIS Hospital Inpatient Systems(Northern Ireland)
ICD-10 International Classification ofDiseases-10
IHD ischaemic heart disease
IQR interquartile range
MI myocardial infarction
NSF-CHD National Service Framework forCoronary Heart Disease
OR odds ratio
PEDW Patient Episode Database forWales
PTCA percutaneous transluminalcoronary angioplasty
QUOROM quality of reporting of meta-analyses
RCT randomised controlled trial
RR relative risk
SD standard deviation
UA unstable angina
VAT value added tax
List of abbreviations
All abbreviations that have been used in this report are listed here unless the abbreviation is well known (e.g. NHS), or it has been used only once, or it is a non-standard abbreviation used only in figures/tables/appendices in which case the abbreviation is defined in the figure legend or at the end of the table.
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BackgroundThe National Service Framework for CoronaryHeart Disease (NSF-CHD) identifies patients withacute myocardial infarction and following coronaryrevascularisation as eligible for outpatient cardiacrehabilitation. However, rehabilitation uptakeremains low, particularly in some specific patientgroups. While many barriers to patientparticipation have been described, theeffectiveness of interventions to improve uptakeand adherence has not been assessed by systematicreview. Furthermore, the cost implications ofinterventions to improve uptake and adherenceand of increasing overall provision to meet totalpopulation need have not been estimated.
Objectives� To estimate UK population need and update
estimates of cardiac rehabilitation provision.� To identify patient groups not receiving cardiac
rehabilitation.� To review effectiveness of methods to improve
uptake and adherence to cardiac rehabilitation.� To estimate cost implications of increasing
uptake of cardiac rehabilitation.
Methods� Analysis of hospital discharge statistics to
ascertain the population need for outpatientcardiac rehabilitation in the UK.
� Surveys of cardiac rehabilitation programmes todetermine UK provision, uptake and audit activity,and to identify local interventions to improveuptake. Estimation of eligibility for cardiacrehabilitation and non-attendance in a recent trial.
� Systematic review of interventions to improvepatient uptake, adherence and professionalcompliance in cardiac rehabilitation.
� Assessment of costs of improving uptakeidentified from national survey, systematic reviewand sampled cardiac rehabilitation programmes.
ResultsPopulation need and provisionIn England, Wales and Northern Ireland nearly
146,000 patients discharged from hospital with aprimary diagnosis of acute myocardial infarction,unstable angina or following revascularisation werepotentially eligible for cardiac rehabilitation. InEngland in 2000, 45–67% of these patients werereferred, with 27–41% attending outpatient cardiacrehabilitation. If all discharge diagnoses of ischaemicheart disease (including angina pectoris and heartfailure) were considered, nearly 299,000 patientswould be potentially eligible, with rates of referraland attendance of 22–33% and 13–20%, respectively.Rates of referral and attendance were similar inWales, but somewhat lower in Northern Ireland.
Patient uptakeReferral and attendance of older people andwomen at cardiac rehabilitation tended to be low.There was a suggestion that patients from ethnicminorities and those with angina or heart failurewere less likely to be referred to or joinprogrammes. A wide range of local interventionssuggested awareness of the problem of uptake.
The survey of cardiac rehabilitation centres inEngland identified an uncoordinated approach toaudit, with variations in methods and contentdespite guidelines and the NSF requirements.
In an NHS-funded, multicentre, randomisedcontrolled trial, possibly representing moreoptimal protocol-led care, medical and nursingstaff identified 73–81% of patients with acutemyocardial infarction as eligible for cardiacrehabilitation. Excluded patients tended to beolder with more severe presentation of cardiacdisease. Experiences of patients suggested thatuptake may be improved by addressing issues ofmotivation and relevance of rehabilitation tofuture well-being, co-morbidities, site and time ofprogramme, transport and care for dependants.
Systematic reviewA comprehensive search strategy identified studiesrelating to uptake, adherence or professionalcompliance with cardiac rehabilitation. Of 3261references identified, 957 were acquired aspotentially relevant. Reports were frequently notpublished in easily accessible form. The majorityof studies were small, of short duration and not ofhigh quality. Consequently, none of the findings
Executive summary
x
can be considered definitive. Few studies reportedcost implications.
Eight studies (three randomised) evaluatedmethods to improve patient uptake of cardiacrehabilitation. These supported the use of letters,pamphlets or home visits to motivate patients.Some encouragement was found for the use oftrained lay visitors. Fourteen studies (sevenrandomised) evaluated methods to improveoverall patient attendance or maintenance oflifestyle changes associated with cardiacrehabilitation. Self-management techniquesshowed some value in promoting adherence tolifestyle changes. Six studies (two randomised)evaluated methods to improve patient uptake andadherence to cardiac rehabilitation by improvingprofessional compliance with guidelines and goodpractice. Although no effective interventionsspecifically aimed at improving professionalcompliance were found, professional support forpractice nurses may have value in the coordinationof postdischarge care.
Healthcare costsAverage costs in 2001 of cardiac rehabilitation tothe health service per patient completing a cardiacrehabilitation programme were about £350 (staffonly) and £490 (total). It is estimated thatoutpatient cardiac rehabilitation represented anNHS cost of £15–24 million in the UK. Variationin cost per patient across centres was partlyexplained by the duration of rehabilitation andstaff-to-patient ratio. If services were modelled onan intermediate multidisciplinary configurationwith three to five key staff, approximately 13%more patients could be treated with the samebudget. If the most modest services were provided,40% more patients could be treated. Dependingon staffing configuration an approximate200–790% budget increase would be required toprovide cardiac rehabilitation to all potentiallyeligible patients.
ConclusionsImplications for healthcare� Provision of outpatient cardiac rehabilitation in
the UK is low, well below the NSF-CHD goal of85% of patients with acute myocardial infarctionand following revascularisation being offeredoutpatient cardiac rehabilitation.
� Information on referral to and uptake of cardiacrehabilitation is incomplete, with widely varyingestimates of provision, particularly in under-represented groups. Little is known about the
capacity of cardiac rehabilitation centres toincrease provision.
� There is an uncoordinated approach to auditdata collection.
� Reasons reported by patients for non-attendance are amenable to intervention, butfew interventions have been formally evaluated.
� Many interventions aimed at improving patientuptake, adherence and professional compliancewith guidelines and good practice have beenproposed, but few have been formallyevaluated.
� Motivational communications and trained layvolunteers may improve uptake of cardiacrehabilitation.
� Self-management techniques may help topromote lifestyle change associated with cardiacrehabilitation.
� Information on costs of interventions isfrequently not reported.
� Experience of low-cost interventions and goodpractice exists within rehabilitation centres.
� Increased provision of outpatient cardiacrehabilitation will require extra resources.
Recommendations for researchand development� Trials comparing the cost-effectiveness of
comprehensive multidisciplinary rehabilitationwith simpler outpatient programmes.
� Economic and patient preference studies of theeffects of different methods of using increasedfunding for cardiac rehabilitation, and evaluationsof the impact of any increased funding.
� Evaluation of a range of interventions(including self-management techniques,motivational communication and the use oftrained lay volunteers) to promote attendancein all patients and under-represented groups.
� Development of standardised audit methods inthe context of modern records systems,appropriate training for dedicated staff anddialogue between service contributors.Standardisation of criteria for patient eligibility,regular and comprehensive data collection toestimate the need for and provision of cardiacrehabilitation.
� Identification of further areas for interventionthrough qualitative studies.
� Extension of low-cost interventions and goodpractice within rehabilitation centres.
� Regular updated systematic review of literaturerelating to uptake and adherence to cardiacrehabilitation to include ‘grey’ literature andnon-UK studies.
Executive summary
Cardiac rehabilitationComprehensive cardiac rehabilitation offerspatients with coronary heart disease a long-termprogramme involving medical evaluation,‘prescribed’ exercise, cardiac risk factormodification, education and counselling.1 Inpartnership with a multidisciplinary team ofhealth professionals, patients with cardiac diseaseare encouraged and supported to achieve andmaintain optimal physical and psychosocialhealth.2
In the UK cardiac rehabilitation usually comprisesfour phases3 in which the themes of exercise,education, psychological support and counsellingare addressed to a level appropriate to the stage ofrecovery. Throughout, consideration is given tothe processes of explanation and understanding,4
and the overall aim of long-term maintenance of ahealthy lifestyle.
The first phase takes the form of counselling witha simple programme of education andpsychological support while in hospital.5 Physical,psychological and social needs for cardiacrehabilitation are assessed and advice is given oneveryday activities with encouragement to takelight exercise in the first few weeks at home, thesecond phase of rehabilitation. Home visiting andtelephone contact, and the use of educationalmaterials or a supervised self-help programme,provide support during this period. The thirdphase of rehabilitation is delivered in anoutpatient setting by appropriate healthprofessionals and lasts typically for 6–8 weeks. Keyprogramme elements are supervised exercise,education on secondary prevention and risk factormodification, and psychological approaches torecovery. Maintenance of healthy behaviours aftercompletion of the outpatient programme is thefourth phase of cardiac rehabilitation. Continuedexercise and adherence with lifestyle changes maybe mediated through a cardiac support group.
Effectiveness in patients withcoronary heart diseaseThe effectiveness of cardiac rehabilitation has
been the subject of several randomised trials andreviews.6–9 Most recently, a Cochrane systematicreview concluded that exercise-based cardiacrehabilitation is effective in reducing cardiacdeaths, cardiovascular morbidity and primary riskfactors in patients who have had myocardialinfarction.10 An earlier overview of the evidenceconducted by the NHS Centre for Reviews andDissemination stated that a combination ofexercise, psychological and educationalinterventions is the most effective form of cardiacrehabilitation,11 but the efficacy of combinationsand durations of different components of therehabilitation package remains uncertain. InEngland, the National Service Framework forCoronary Heart Disease (NSF-CHD) concludedthat there is scope for improving services so thatall those in need are offered rehabilitation.12
Evidence for the effectiveness of cardiacrehabilitation mainly derives from studies ofpatients with myocardial infarction and there areinsufficient data to stratify systematic reviews byindication.10 However, the inclusion in reviewedtrials of patients who have undergonerevascularisation, that is, coronary artery bypassgraft (CABG) or percutaneous transluminalcoronary angioplasty (PTCA), or who have hadangina pectoris or coronary artery disease definedby angiography suggests the possibility of benefitfor these groups. Furthermore, while there is noconclusive evidence that cardiac rehabilitationreduces mortality in patients with heart failure, arecent systematic review looking specifically atexercise interventions found physiological benefitsand positive effects on quality of life in selectedsubgroups.13
Guidelines recommend that outpatient cardiacrehabilitation should be available for patientsfollowing myocardial infarction, PTCA and CABG,and for patients with angina, heart failure14 andarrhythmia.15,16 The Fifth Report on the Provisionof Services for Patients with Coronary HeartDisease states that in the UK patients must haveaccess to rehabilitation when required, forexample after a heart attack, cardiac surgery andintervention.17 In England the NSF-CHDidentifies patients who have survived acutemyocardial infarction and those who have
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Chapter 1
Background
undergone CABG or PTCA as priorities forcardiac rehabilitation.12 When high-quality-cardiacrehabilitation is available to these patients theNSF-CHD recommends that services should beextended to patients with angina and heart failure.In Wales, cardiac rehabilitation should be providedfor all those who have had an episode of acutecoronary syndrome, some of whom will haveundergone a revascularisation procedure.18 TheCanadian Association for Cardiac Rehabilitationstates that cardiac rehabilitation should beconsidered standard, usual care for virtually allpatients with documented cardiovascular disease.19
Effectiveness in specific patientgroupsEvidence for the effectiveness of cardiacrehabilitation in older and female patients islimited, as participants in trials tend to be youngerand predominantly male. In the most recentsystematic review the mean age of patients inexercise only studies was 53 years (range of means50–70 years) and in trials of comprehensivecardiac rehabilitation 56 years (range of means47–63 years).10 Women comprised 4% of patientsin exercise-only and 11% of patients incomprehensive cardiac rehabilitation trials. Trialsshow a bias towards the inclusion of men and mostexcluded older people. However, systematicreviews provide no evidence to suggest that elderlyor female patients benefit less than younger ormale patients.10 Indeed, it is possible that thepatients who would benefit most from cardiacrehabilitation are those excluded from trials on thegrounds of age, gender or co-morbidity.20
In elderly patients the goals of cardiacrehabilitation may differ from those of youngerpatients, and include the preservation of mobility,self-sufficiency and mental function.21 Cardiacrehabilitation may represent an opportunity toprovide effective healthcare and achieve a highquality of life for older patients.22 Similarly, thefrequently lower level of fitness observed inwomen at the time of hospitalisation suggests agreater potential for health improvement withcardiac rehabilitation.23,24
In trials of cardiac rehabilitation the ethnicbackground of patients is seldom reported,10 but itis likely that trial participants are mainly whiteCaucasian. There is neither evidence nor amechanism to suggest lack of benefit in ethnicminority groups.11
Thus, evidence from randomised controlled trials(RCTs), as demonstrated in Figure 1, supports theeffectiveness of cardiac rehabilitation in a range ofcardiac diagnoses including post-myocardialinfarction, post-PTCA, post-CABG, anginapectoris and heart failure. To date, althoughpatients with different cardiac conditions, andfemale, elderly and non-white Caucasian ethnicgroups, have been poorly represented in trials ofcardiac rehabilitation there is no evidence tosuggest that outcomes are less favourable.
Uptake of cardiac rehabilitationAlthough it is considered effective in quickeningrecovery and improving prognosis, not all patientsparticipate in a cardiac rehabilitation programme.Several recent UK surveys have reported theuptake of cardiac rehabilitation by patients with adischarge diagnosis of coronary heart disease.25–29
These are summarised in Table 1.
Surveys in the UK show low levels of patientparticipation (14–43% after myocardial infarction)with similarly low attendance reported inAustralia,30 France,31 New Zealand32 and theUSA.33–35 Low patient participation is aconsequence of low levels of provision, referraland invitation, and of poor uptake by patients.
Under-representation in cardiacrehabilitationPatients participating in cardiac rehabilitationprogrammes have tended to be male, middle-agedand diagnosed with uncomplicated myocardialinfarction.36 Those who do not participate in aprogramme often have greater degrees offunctional impairment and are the patients mostin need of and most likely to benefit fromrehabilitation.20
Variation in referral rates for patients withdifferent cardiac diagnoses reflects the traditionalindication for cardiac rehabilitation services ofmyocardial infarction and CABG.37 CABG patientstend to be younger than those with myocardialinfarction and this may explain some of theincreased rehabilitation uptake seen after CABG(see Table 1).26 Patients admitted for PTCA are lesslikely to be invited or participate, probably as aconsequence of the short hospital stay and thelimited opportunities for recruitment. Also, theprocedure is less invasive and painful than CABG,with a quicker recovery and return to work and
Background
2
normal activities.38,39 Heart failure patients areless likely to be referred for cardiac rehabilitationthan other cardiac patients40 and the complexityof the medical condition is identified as a barrierto physician referral.41 In the UK few programmesrecruit heart failure patients, possibly reflectingthe perceived need for further evaluation ofeffectiveness and safety in this patient group.42 InEngland, provision for both heart failure andangina may be limited by the priorities identifiedin the NSF-CHD: “once Trusts have an effectivesystem recruiting people who have survived amyocardial infarction or who have undergone
coronary revascularisation to high quality cardiacrehabilitation, they should extend theirrehabilitation services to people admitted tohospital with other manifestations of coronaryheart disease, e.g. angina and heart failure.”12
Patients with chronic non-cardiac medicaldisorders may be excluded from cardiacrehabilitation.43 Medical reasons for non-invitationinclude impaired mobility, more severe angina andperipheral arterial disease,29 chronic obstructivepulmonary disease and asthma,39 arthritis andback problems,44 and alcohol addiction.45
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Review: Exercise-based rehabilitation for coronary heart diseaseComparison: 02 Exercise plus other rehabilitation versus usual care Outcome: 04 Pooled mortality, non-fatal MI, CABG, PTCA
Treatment Control Peto OR Weight Peto ORor subcatogoryStudy
n/N n/N 95% CI % 95% CI
Engblom 29/119 35/109 6.37 0.68 (0.38 to 1.22) WHO Balatonfured 16/80 9/80 2.93 1.93 (0.83 to 4.53) WHO Brussels 25/85 24/81 4.79 0.99 (0.51 to 1.92) WHO Bucharest 16/65 23/64 3.78 0.59 (0.28 to 1.24) WHO Budapest 38/101 29/99 6.18 1.45 (0.81 to 2.61) WHO Dessau 4/29 7/25 1.23 0.42 (0.11 to 1.58) WHO Erfut 13/63 15/56 2.97 0.71 (0.31 to 1.66) WHO Ghent 19/84 12/84 3.51 1.73 (0.80 to 3.77) WHO Helsinki 41/188 56/187 9.95 0.65 (0.41 to 1.04) WHO Kaunas 19/66 17/49 3.37 0.76 (0.34 to 1.68) WHO Prague 15/59 20/53 3.34 0.57 (0.26 to 1.26) WHO Rome 8/34 6/29 1.52 1.18 (0.36 to 3.83) WHO Tel Aviv 14/63 8/51 2.44 1.52 (0.60 to 3.85) WHO Warsaw 6/39 8/40 1.61 0.73 (0.23 to 2.31) Sivarajan 82 10/86 10/84 2.45 0.97 (0.38 to 2.47) Bengtsson 83 12/81 10/90 2.65 1.39 (0.57 to 3.40) Fridlund 91 26/87 39/91 5.73 0.57 (0.31 to 1.05) Oldridge 91 3/99 4/102 0.94 0.77 (0.17 to 3.46) PRECOR 6/60 11/61 2.03 0.52 (0.19 to 1.44) Bertie 92 1/57 4/53 0.66 0.27 (0.04 to 1.59) Schuler/Niebauer 20/56 25/57 3.77 0.71 (0.34 to 1.51) Heller 93 46/213 54/237 10.73 0.93 (0.60 to 1.46) Fletcher 94 3/41 4/47 0.90 0.85 (0.18 to 3.97) SCRIP 26/145 44/155 7.42 0.56 (0.33 to 0.95) Taylor 97 13/293 10/292 3.06 1.31 (0.57 to 3.01) Carlsson 98 CABG 0/33 0/34 Not estimable Carlsson 98 AMI 2/85 2/83 0.54 0.98 (0.14 to 7.05) Lifestyle Heart 14/53 24/40 3.07 0.25 (0.11 to 0.58) Bell 99 8/102 8/102 2.05 1.00 (0.36 to 2.77)
Total (95% CI) 2566 2535 100.00 0.81 (0.70 to 0.93)Total events: 453 (treatment), 518 (control)Test for heterogeneity: χ2 = 34.08, df = 27 (p = 0.16), I2 = 20.8%Test for overall effect: z = 2.88 (p = 0.004)
0.1 0.2 0.5 1 2 5 10
Favours treatment Favours control
FIGURE 1 RCTs of the effects of cardiac rehabilitation. Source: Jollife et al., 200210 with permission of The Cochrane Library. CI, confidence interval; MI, myocardial infarction; OR, odds ratios; WHO, World Health Organization.
Rehospitalisation, health deterioration andplacement in a nursing home are also associatedwith reduced participation in cardiacrehabilitation.46 Patients with communicationdifficulties including short-term memory loss andconfusion, poor cognitive functioning orneurological impairment may be less likely toparticipate in cardiac rehabilitation,39,46–48 and agreater dropout rate has been observed in patientswith symptoms of depression.49
Older patients may not receive the same amountof advice from physicians on cardiac risk reductionas younger patients.46 Invitation to cardiacrehabilitation is often lower in olderpatients.3,29,32,33,39,41,43,46,49–52 In a US survey olderpatients expressed a preference for home-basedprogrammes, whereas younger patients preferredcomprehensive clinic-based programmes.53
Women tend to be under-represented in cardiacrehabilitation.20,32,33,43,54 Referral rates may belower,33,43 possibly reflecting the increased age ofwomen presenting with cardiovascular disease55
and the presence of co-morbid conditions.20
Women may be reluctant to participate in formalcardiac rehabilitation56 and perceived as lessmotivated to attend structured programmes withstrenuous exercise.23 However, rehabilitationprofessionals may seem less helpful and lessencouraging in promoting cardiac rehabilitation
for women.57 Invitation to a predominantly maleexercise group may also serve to discourageparticipation by women.57
Participation rates of patients living in areas of highsocial deprivation are low, probably reflectingreduced uptake rather than referral.27,29,58,59
Patients with no paid employment may also be lesslikely to attend a cardiac rehabilitation programme.59
In a survey of Canadian cardiac rehabilitationprogrammes participation by non-English-speaking patients was seen to be considerablylower than by English-speaking patients.39 Nosimilar surveys have been published in the UK,but a retrospective hospital audit found lowattendance at cardiac rehabilitation amongpatients of South Asian origin.60 This wasattributed to poor access and inadequate use ofinterpreting services by patients and staff, and lackof translated written information.
Barriers to uptake and adherenceCardiac rehabilitation should be accessible andacceptable to patients. A balance must be achievedbetween a programme of sufficient intensity andduration to be effective, and the tendency of along programme to encourage dependence insome and dropout in others.61 Many patients
Background
4
TABLE 1 Uptake of cardiac rehabilitation in recent UK surveys
Author Year of Region Study design Total no. of Participation as survey eligible patients percentage of
eligible patients
Evans et al., 200225 2000 UK CR programme 208,080 total 17% MIsurvey compared (calculated from 44% CABGwith BHF statistics percentages) 6% PTCA
Bethell et al., 200126 1997 UK CR programme 150,000 total 14–23% MIsurvey compared 33–56% CABGwith BHF statistics 6–10% PTCA
Melville et al., 199927 1996 Nottingham CR enrolment lists 261 43% MIcompared with hospital discharge
Campbell et al., 199628 1994 Scotland CR programme 29,294 (calculated 17% CHDsurvey compared from 4980 = with CHD survival 17% of total)
Pell et al., 199629 1994 Glasgow CR department 887 21% MIlists compared (12% completed)with hospital discharge
BHF, British Heart Foundation; CHD, coronary heart disease; CR, cardiac rehabilitation.
make recommended lifestyle changes, but othersmake no change or find it difficult to maintainnew behaviours.62 The initial improvements inexercise tolerance and psychosocial well-beingobserved in some trials are not evident over thelonger term and this has been attributed toreductions in compliance.63 Patients and providershave identified numerous possible reasons for lowlevels of uptake, adherence and professionalcompliance with cardiac rehabilitation.64
Some patients show a lack of interest and arereluctant to change their lifestyle.14,41,46,59,65,66
Affective reactions to disease can lead tomaladaptive responses and fear.44,66,67 The patientmay not perceive that they will benefit fromparticipating in a programme or may receivecontradictory advice from other sources.41,51,68,69
Conversely, after a short period of rehabilitationpatients may be satisfied and choose to continueindependently.70 Patients may dislike classes or thehospital setting.34,51
Patterns of personal or family living can influenceparticipation in cardiac rehabilitation.71
Conflicting work or domestic commitments andtime conflicts are associated with reducedattendance at cardiac rehabilitation.24,51,66,70 Lackof family support may be a barrier to uptake ofcardiac rehabilitation services.44,66
In the USA, reimbursement issues and cost ofrehabilitation services limit attendance at cardiacrehabilitation.14,34 Patients with insurancecoverage for cardiac rehabilitation are more likelyto be referred and programme directors identifyfinancial issues as the major barrier forrehabilitation uptake.37 Fee-for-service patients aremore likely to receive cardiac rehabilitation thanhealth maintenance organisation patients.72 Arequirement for continuous ECG monitoringduring exercise sessions, physician evaluation oftraces and exercise prescription also limitsrehabilitation provision.73
Cardiologists may be more likely to refer patientsto cardiac rehabilitation than primary carephysicians.14,29,50,66 Differing rates of referral mayreflect professional scepticism or a poorknowledge base about the effectiveness of cardiacrehabilitation39,46,62 and it is possible thatphysicians recommend rehabilitation to youngerpatients or those expected to comply.46,74 Thesource of referral may also influence patientattendance at cardiac rehabilitation, with physicianreferral and in particular that of a cardiologistshown to improve uptake.29,39,40,75
The location, convenience and accessibility of acardiac rehabilitation programme influenceattendance.14,34,41,43,66,76 Patients living closer tothe programme are more likely to receive areferral and attend.37,52,65 Patients living in citiesor urban areas are more likely to attend cardiacrehabilitation.39,77 Inconvenient transportation,lack of and cost of transport, and parkingproblems are frequently cited as barriers toattendance at cardiac rehabilitation.34,51,70
Economic aspects of cardiacrehabilitationCosts of cardiac rehabilitation services vary byformat of delivery. The German approach tocardiac rehabilitation with 4–6 weeks of inpatientcare is estimated to cost about seven times that ofan outpatient service.78 Information on the directcosts of outpatient cardiac rehabilitation asprovided in the UK is limited. The results ofrecent UK costs studies25,79–82 are shown in Table 2.
Comparison of studies is difficult as the authorsused different methodologies and sources of costestimates. The most recent BACR/BHF surveysuggests that cost varies widely, with a range of£50–712 per patient treated depending on thelevel of staffing, the equipment used and theintensity of the programme.25 Staffing representsthe most important share, with estimates of64–80% of total direct costs.79,81
Barriers to uptake and adherence may besummarised as follows.
Patient factors:� lack of interest� reluctance to change lifestyle� depression� dislike of classes/hospitals� work or domestic commitments� lack of family support� rural residence.
Service factors:� cost and reimbursement � ECG monitoring requirement� location and accessibility� car parking
Professional factors:� knowledge and attitudes� referral� prejudice (age, race, gender).
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Little information is available on the costs ofestablishing or expanding a rehabilitation service.Previously, it was considered that the resourcesneeded to establish a cardiac rehabilitationprogramme were present in most districthospitals.3,83 With changes in healthcaremanagement and increasing demands on facilitiesand space this may not now be the case.
ConclusionsOutpatient cardiac rehabilitation should beavailable to patients with a range of cardiovasculardiagnoses and after revascularisation procedures.Previous surveys have suggested that uptake ofoutpatient cardiac rehabilitation services is low,with specific patient groups under-represented. Toquantify the shortfall in cardiac rehabilitationservice availability and uptake, estimates of currentUK need and provision are required.
Barriers to participation in outpatient cardiacrehabilitation have been identified, but theeffectiveness of interventions to improve uptakeand adherence has not been assessed by systematicreview. Such a review is needed to identifyappropriate methods for increasing service useand to suggest areas meriting further research.
Previous economic evaluations of cardiacrehabilitation services have given a wide range ofcost estimates and little information on costs otherthan those attributable to staffing. A thoroughassessment of current UK costs of services isneeded to include staff, overhead, equipment andcapital costs. Furthermore, if greater numbers ofpatients are to receive outpatient cardiacrehabilitation an estimate of the cost implicationsof increasing provision by the establishment ofnew or expansion of existing services is required.
Background
6
TABLE 2 Studies reporting costs of cardiac rehabilitation in the UK
Author Year Type of programme Costs considered Results
Evans et al., 200225 2000 Annual BACR/BHF survey: Staff costs, possibly some £50–712 per patient budget statements from allowances for stationery (median £256)37 centres (2000 prices)
Osika, 200182 1997/98 Based on four cardiac Staff costs, non-staff costs £292 per patient, range rehabilitation centres in (not specified) £250–375 (1997–98 prices)Gwent
Taylor and Kirby, 199981 1995 One UK centre with Staff costs, equipment £140 per patient12-week programme costs, capital costs, £6 per patient per session with two outpatient visits transport (1995 prices)
Gray et al., 199780 1994 Survey of 16 UK centres Staff costs £371 per patient (median with an average of 9.2 £223), £47 per patient per sessions per patient session (median £26) (10.2 hours per patient) (1994 prices)
Turner, 199379 1992 Based on ten cardiac Staff costs, overhead costs, £200 per patient rehabilitation programmes equipment costs, capital (1992 prices)in the Wessex region costs
BACR, British Association for Cardiac Rehabilitation.
The questions posed in this project are asfollows.
� What is the population need for cardiacrehabilitation?
� Who is not receiving cardiac rehabilitation?� What is the effectiveness of different methods of
improving uptake and of differential targetingof cardiac rehabilitation?
� What is the potential budget impact ofincreasing uptake of cardiac rehabilitation usingdifferent uptake interventions?
The questions will be tackled using the followingsources of information:
� population need for cardiac rehabilitation inthe UK from analyses of the English HospitalEpisode Statistics (HES) and equivalent nationaldatabases
� provision and uptake of cardiac rehabilitation inthe UK by means of a national survey of cardiacrehabilitation services, ad hoc surveys andaudits
� uptake and adherence to cardiac rehabilitationfrom a recent multicentre RCT
� a systematic literature review of interventions toincrease patient uptake, adherence andprofessional compliance with cardiacrehabilitation
� the costs associated with improving uptake anddifferential targeting of cardiac rehabilitationfrom the national survey, systematic review andcosting data from sampled cardiac rehabilitationprogrammes.
Improving uptake of cardiac rehabilitation was conceived in a series of related stages: need for rehabilitation (in terms of ability tobenefit from rehabilitation), coverage of existing services; pattern (i.e. by age, gender,ethnicity) of referral to services, and adherence in terms of both acceptance of invitation to attend services and completion of treatment.Interventions to improve uptake could beenvisaged for each of these stages. This process is shown schematically in Figure 2.
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Chapter 2
Objectives
Need for rehabilitation
Referral
Coverage
Uptake and adherenceAcceptance of invitation
+Completion of treatment
HES
National survey +economic
Adherence in RCT
Systematic review of literature
National survey
Economic appraisal
FIGURE 2 Improving the uptake of cardiac rehabilitation
Objectives� Determination of the population need for
cardiac rehabilitation in the UK by analysis ofthe English HES and similar national databases.
� Estimation of the level of uptake of cardiacrehabilitation by patients with a dischargediagnosis of coronary heart disease.
BackgroundThe NSF-CHD states that every hospital shouldensure that more than 85% of people dischargedfrom hospital with a primary diagnosis of acutemyocardial infarction or after coronaryrevascularisation are offered cardiacrehabilitation.12 When cardiac rehabilitation isavailable to these patients, the NSF-CHDrecommends that this service should be extended to patients with angina and heart failure. However, there is only limited information available on population need, that is, the total number of patients who maybenefit from cardiac rehabilitation and the currentnationwide level of service provision and patientuptake.
MethodsData from the HES for England and similarsources for Wales [Patient Episode Database(PEDW)] and Northern Ireland [HospitalInpatient Systems (HIS)] were used to estimate the need for cardiac rehabilitation, that is, thenumber of patients discharged from hospital whohave the capacity to benefit from this therapy.Scottish data were not available. Data fromEngland, Wales and Northern Ireland werecollected from 1 April 1999 to 31 March 2000 and provide a comprehensive picture of thenumber of patients discharged from hospitals with particular conditions. Information wascollected for all patients discharged alive fromhospital with a primary diagnosis of ischaemicheart disease [International Classification ofDiseases-10 (ICD-10) codes I20–I25].Furthermore, data for subcategories of thesepatients were collected:
1. acute myocardial infarction (ICD-10 code I21)2. heart failure (ICD-10 code I50)3. unstable angina (ICD-10 code I20.0)4. CABG (OPCS-4 codes K40–K46)5. PTCA (OPCS-4 codes K49–K50)6. CABG patients with one or more of the
following discharge diagnoses or procedurecodes: acute myocardial infarction, unstableangina, heart failure or PTCA
7. all other ischaemic heart disease cases.
Categories 1–7 are mutually exclusive, so thatpatients are only recorded once using eitherdiagnosis or procedure codes. In case of multipleevents with the same code each patient was onlycounted once. When a person was admitted morethan once in a year, each extra admission wasincluded.
The total number of patients eligible to receivecardiac rehabilitation was derived by adding thenumbers in categories 1–7. These data werestratified by gender and age groups. Populationstatistics84 were used to derive rates per 100,000individuals.
The uptake of cardiac rehabilitation by eligiblepatients was estimated. Data from the 2000BACR/BHF survey of cardiac rehabilitationservices and an additional short postalquestionnaire (as described in Chapter 4) wereused to obtain the number of services and toestimate the total number of patients referred andjoining outpatient cardiac rehabilitation inEngland, Wales, Scotland and Northern Ireland.In total, 284 centres were identified for the wholeof the UK in 2000 (220 centres in England, 36centres in Scotland, 18 centres in Wales and tencentres in Northern Ireland).
Of these, 191 (67%) responded to the additionalquestionnaire. Where a centre had not responded,a value relating to the upper interquartile range(IQR) derived from the responding centres wasimputed and added to the aggregated figures ofthe responding centres to estimate the upperrange of service provision for England. The lowerrange of service provision was similarly estimatedby imputing, where data were missing for centres,the lower IQR derived from the responding
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Chapter 3
Population need for cardiac rehabilitation in the UK
centres. Uptake was estimated from the number ofeligible patients (using different need criteriagiven above) and the estimated number ofpatients referred, joining and completing cardiacrehabilitation. These estimates were then linkedwith the population need data.
Analyses were undertaken to estimate the level ofuptake with different criteria of eligibility forcardiac rehabilitation:
� All patients with the above-mentioned dischargediagnoses and procedure codes were consideredeligible.
� Only patients with acute myocardial infarction,unstable angina, CABG and PTCA wereconsidered eligible.
� Only patients younger than 75 years wereconsidered eligible.
The last two analyses were conducted bytruncating the population data using thesespecified criteria.
ResultsBased on hospital discharge statistics it wasestimated that the total numbers of hospitaldischarged patients potentially eligible to receivecardiac rehabilitation in 2000 were as follows:England 266,833; Wales 17,560 and NorthernIreland 13,988. Total counts of discharged caseswith acute myocardial infarction, heart failure,
unstable angina, CABG and PTCA stratified bycountry, gender, age group and rates of dischargediagnoses and procedure code per 100,000 personsare presented in Appendix 1 (Tables 35–37).
Table 3 shows the estimated number of patientsreferred to and joining outpatient cardiacrehabilitation programmes by country. Moredetailed information is shown in Appendix 2(Tables 38–41). Age, gender and diagnosis-specificestimates of need could not be provided as only aminority of cardiac rehabilitation centres were ableto supply relevant information broken down by thevariables required to link estimates of need toservice supply.
Similar proportions of all eligible patients inEngland and Wales were referred to cardiacrehabilitation (between 22 and 36%). However, theproportion of referred patients in NorthernIreland was significantly less (12–17%). Theproportions of all eligible patients joining cardiacrehabilitation programmes in England and Waleswere also similar (13–21%), but joining was lesscommon in Northern Ireland (9–12%).
Using more limited criteria of need for cardiacrehabilitation considering only patients dischargedwith a diagnosis of acute myocardial infarction,unstable angina or a procedure code of CABG orPTCA as eligible, under-provision was lessmarked, with about 45–67% referred to and27–41% joining cardiac programmes in England(see Table 3 for other countries).
Population need for cardiac rehabilitation in the UK
10
TABLE 3 Estimated uptake of cardiac rehabilitation by patients with different manifestations of coronary heart disease
England Wales Scotland NorthernIreland
Estimated number of patients referred to CRa 59,400–87,200 4,600–6,400 5,800–9,100 1,700–2,400Estimated number of patients joining CRa 35,700–53,100 3,000–3,600 3,500–6,000 1,200–1,700
Eligibility criteria
All patients 266,800 17,700 NA 14,000% referred to CR 22–33% 26–36% NA 12–17%% joining CR 13–20% 17–21% NA 9–12%
Patients with AMI, unstable angina, CABG 131,100 7,900 NA 6,800and PTCA
% referred to CR 45–67% 59–81% NA 25–36%% joining CR 27–41% 38–46% NA 18–25%
Patients <75 years 202,000 12,700 NA 11,200% referred to CR 30–43% 36–50% NA 15–22%% joining CR 18–26% 24–29% NA 11–15%
a Numbers estimated by imputing the IQR for non-responding centres.AMI, acute myocardial infarction.
Provision was also estimated considering patientsunder age 75 years as eligible. This analysissuggests that 30–43% of patients were referredand 18–26% joined cardiac rehabilitation inEngland (see Table 3 for other countries). Adetailed summary of this analysis is displayed inAppendix 2 (Tables 38–41).
DiscussionThe objective of this analysis was to estimate thepopulation need for cardiac rehabilitation and toprovide up-to-date information about the level ofuptake of cardiac rehabilitation in the UK. Thisinformation should assist healthcare policy makersto improve the provision of cardiac rehabilitationservices to all patients who have the capacity tobenefit.
The analysis suggests that provision of cardiacrehabilitation at the inception of the NSF-CHDwas low. This was still apparent when consideringonly patients with acute myocardial infarction,unstable angina, PTCA and CABG as eligible or,in a second analysis, only patients younger than75 years.
There appears to be variation in service provisionacross the UK, with a higher proportion ofeligible patients referred to and joining cardiacrehabilitation programmes in England and Wales than in Northern Ireland. Since the needfor rehabilitation is substantially greater inNorthern Ireland (and Scotland), this represents a considerable mismatch between uptake andneed.
Although a different approach was used toestimate the level of service provision, the presentfindings are in concordance with previous researchexamining the relationship between need andsupply. Bethell and colleagues estimated thatbetween 14 and 23% of myocardial infarctionpatients, between 33 and 56% of CABG patients,and between 6 and 10% of PTCA patientsattended cardiac rehabilitation in 1997.26 Themost recent update provided by the same groupsuggests that 17% of all myocardial infarction, 44%of all CAGB and 6% of all PTCA patients receivedcardiac rehabilitation in 2000.25 It should beemphasised, however, that this estimate was basedon only 69% of all UK centres. The true level ofprovision may be higher if non-participatingcentres were providing a service with betterreferral and joining rates, but this seemsimprobable.
The analysis presented here illustrates the lack ofcomprehensive and reliable data to estimate thelevel of service provision and should beinterpreted with some caution. By using data fromthe HES a number of assumptions had to be madeto estimate need. Although patients managed athome or in the private sector will be missed, itmay be assumed that the HES are complete and aprimary diagnosis of ischaemic heart diseaseindicates a need for cardiac rehabilitation.Furthermore, it is assumed that each finishedconsultant episode for these diagnoses equates toone person; the ratio of spells to finishedconsultant episodes is generally around one.85
However, the number of discharge diagnoses maybe slightly higher than the number of patientsbecause in some instances myocardial infarctionpatients receive revascularisation procedures suchas CABG or PTCA within a few weeks. The timebetween these two distinctive admissions may notbe sufficient for enrolment in a rehabilitationprogramme after the first event. The estimatesassume that a patient suffering two or more eventsin a year represents a need for two (or more)courses of rehabilitation. This seems legitimate assuch patients may be considered to berehabilitation ‘failures’, and may have slippedthrough the net on earlier occasions.
Another potential limitation is the approachadopted to estimate the current level of serviceprovision. These estimates are based on a postalsurvey with a response rate of 67% of the samplingframe of all cardiac rehabilitation centres existingin 2000 in the whole of the UK. Approximately80% of these centres could provide data for thenumber of patients referred to and joining cardiacrehabilitation programmes and therefore theestimates are based on a sample of about 55% ofall UK centres. However, by imputing the IQR totake account of missing data, the resultingestimates should provide a fair estimate of thecurrent situation.
The apparent inability of centres to providecomprehensive activity data is possibly due to thelack of automated systems to extract these data,lack of audit facilities or centres being in theprocess of installing systems to collect audit datato satisfy the requirements of the NSF-CHD.Therefore, the current level of service provisioncould only be estimated indirectly by assumingthat all patients with a primary diagnosis ofischaemic heart disease are eligible. Some limitingcriteria of need were also used, namely restrictingthe eligibility for cardiac rehabilitation to certain
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groups of patients (acute myocardial infarction,unstable angina, CABG and PTCA patients, andall ischaemic heart disease patients younger than75 years). A more appropriate approach would beto obtain information on the number of patientsreferred to, joining and completing programmesstratified by gender, age and discharge diagnosisdirect from cardiac rehabilitation centres andrelate these to data that represent need, such asthe HES, or to information obtained fromhospitals in the catchment area of therehabilitation service by means of comprehensivecoronary heart disease registers.
It was not possible to assess the level of uptake ofcardiac rehabilitation by patients of ethnicminority groups for two reasons. First, nationalhospital data stratified by ethnicity were onlyavailable for England. These were not completely
coded for ethnicity, with about 30% missing data.Second, as reported in Chapter 4, the majority ofcentres in the BACR/BHF survey were not able toprovide data on the referral and uptake of cardiacrehabilitation by ethnic minority groups.
ConclusionsThe analysis suggests that the level of serviceprovision of cardiac rehabilitation during 2000 waslow. Therefore, the achievement of the NSF-CHDgoal of 85% of acute myocardial infarction andrevascularisation patients receiving cardiacrehabilitation is far from fulfilled. In addition, theshortcomings of this analysis clearly emphasise theneed for a more comprehensive data collection toestimate reliably the provision of cardiacrehabilitation services and its relationship to need.
Population need for cardiac rehabilitation in the UK
12
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Objective� Assessment of the provision and uptake of
cardiac rehabilitation in the UK by means of anational survey of cardiac rehabilitationservices.
MethodsBACR, with financial backing from the BHF, hasconducted several surveys of cardiac rehabilitationservices in the UK.25,26,86 The authors of thesereports have kindly provided this group with thedata that they collected, and contact details of allservices identified for the latest survey conductedin 2001, which included data from 1 January to 31 December 2000. This latest survey includedquestions concerning the total number of patientsreferred, joining and completing outpatient(phase 3) cardiac rehabilitation, the numbersbroken down by diagnosis of myocardial infarctionor cardiac surgery and by age groups and gender,time spent per week for each programme byvarious staff members, current funding andquestions relating to outcome measures.
For the purposes of the current project there wasalso a need to know the numbers of patients fromtraditionally under-represented groups (women,the elderly, people from ethnic minority groupsand people with heart failure or angina) referred,joining and completing cardiac rehabilitationprogrammes to be able to determine currentservice provision in these groups. There was alsoan interest in knowing how many services activelypromoted adherence to programmes in theseunder-represented groups, and details of whatinterventions were used to achieve this. In termsof the extent of coverage and level of serviceprovision, questions were asked for all patients andthe study also sought to determine whetherservices had spare capacity for additional patients.A short postal questionnaire was devisedspecifically addressing these issues and sent to allthose respondents of the 2000 BACR/BHF survey.
ResultsBy contacting the cardiac rehabilitation liaisonperson for each local health authority in the UK,284 cardiac rehabilitation services were identifiedin 2000. Of these, 242 services responded to theBACR/BHF questionnaire, giving a response rateof 85%. The additional short postal questionnairedevised for the purposes of the current project(see letter of request and questionnaire inAppendix 3) was then sent to those respondents ofthe original survey, asking for information duringthe same period (1 January to 31 December 2000)so that data from the two sets of questionnairescould be linked. The response rate to thisadditional questionnaire following telephoneprompting was 79% (191 questionnaires returned).Data returned were entered into a MicrosoftAccess database and transferred to STATA (Version7) for data cleaning and analysis. Data arepresented as proportions, medians, IQR andrange, or means and standard deviations (SD).
Numbers of patients referred to,joining and completing cardiacrehabilitation programmes in 2000Most services were able to provide this information,as shown by the relatively high number ofresponders in Table 4 (maximum n = 191). Of thetotal number of patients referred, two-thirds ofpatients actually joined cardiac rehabilitationprogrammes and only half of those referredcompleted the programme. The number ofpatients attending individual programmes variedwidely across the UK, as shown by the large ranges.
Capacity to increase provisionThirty-one of 191 centres (16.2%) stated that theyhad spare capacity within their service, and couldaccommodate a median of four (two to 20) extrapatients each week.
Level of service provision across the UKin 2000The content of outpatient cardiac rehabilitationprogrammes was determined by the duration and
Chapter 4
Provision and uptake of cardiac rehabilitation in the UK: national survey of UK cardiac
rehabilitation services
the number and length of sessions for each of thecomponent parts: exercise, health education andpsychological interventions (stress managementand relaxation).
The mean values across services have beenweighted by the number of patients joining eachprogramme. Again, there was a reasonableresponse rate to these questions, as shown by therelatively high numbers who provided data. Table 5highlights just how variable the programmecontent and intensity of each intervention is acrossthe UK. Overall, exercise is the dominantcomponent, with the total time spent by a patientalmost twice that of health education and fourtimes that of psychological interventions. Thisreflects the origins of cardiac rehabilitation, theweight of evidence for benefit from exercise-basedprogrammes and the expertise of the principalmembers of most rehabilitation programmes.
Under-represented groups: number ofreferrals, joiners and completersbroken down by age, gender, diagnosisand ethnicityResponse rates to questions on numbers ofpatients referred to, joining and completingprogrammes from under-represented groups weremuch poorer. Reported reasons included lack ofautomated systems and audit facilities, or thatcentres were in the process of installing systems tocollect audit data to satisfy the requirements of theNSF-CHD.12 The representativeness of Table 6should therefore be interpreted with some caution.The numbers of patients with heart failure orangina, or from ethnic minority groups, were sosmall that it was not possible to look at theproportions of those referred, joining andcompleting rehabilitation. Similar proportions ofjoiners and completers relative to those referredwere seen for postmyocardial infarction patients
Provision and uptake of cardiac rehabilitation in the UK: national survey of UK cardiac rehabilitation services
14
TABLE 4 Overall referral, uptake and completion rates for UK cardiac rehabilitation programmes in 2000
Median IQR Range No. of programmes % of referrals
No. referred per centre 271 164–424 2–1564 156No. joined per centre 172 101–254 2–1066 153 63%No. completed per centre 130 75–186 3–450 133 48%
TABLE 5 Level of service provision for cardiac rehabilitation programmes in 2000
Weighteda mean (SD) Range No.b of programmes providing data
ExerciseNo. of weeks 7.4 (2.1) 1–12 144No. of sessions per week 1.7 (1.5) 1–14 146Average length of sessions (h) 1.2 (0.4) 0.5–3 145Total time spent by patient (h)c 12.9 (1.7) 3–98 143Average no. of patients per session 15.7 (6.2) 1–50 139
Health educationNo. of weeks 6.2 (2.1) 1–12 141No. of sessions per week 1.3 (1.6) 0.25–14 141Average length of sessions (h) 1.0 (0.4) 0.25–3 139Total time spent by patient (h)c 7.0 (2.0) 0.75–98 139Average no. of patients per session 16.1 (6.8) 1–40 132
Psychological interventionNo. of weeks 5.0 (2.7) 1–12 126No. of sessions per week 1.3 (1.5) 1–7 123Average length of sessions (h) 0.8 (0.5) 0.17–2 122Total time spent by patient (h)c 3.2 (2.0) 0.5–16 119Average no. of patients per session 14.6 (6.1) 1–40 116
a Weighted by the size of the service (number of patients who joined). Data not normally distributed were transformedbefore weighting.
b Data were not provided for all questions by all services, so the numbers of respondents to each question are provided.c Calculated as the number of weeks multiplied by the number of sessions per week multiplied by the duration of the
session in hours.
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(not an under-represented group, here only forcomparison), the over 65-year-olds and malepatients, with slightly fewer women joiningrehabilitation programmes relative to thosereferred. The number of patients post-CABGreferred for cardiac rehabilitation shows relativelyhigher rates of completion than other groups.
Efforts to promote attendance inunder-represented groupsFinally each service was asked whether they madeany special efforts to promote adherence tocardiac rehabilitation programmes in each of theunder-represented groups, and to detail anyinterventions that they used to achieve this. Ofthose services (126/191, 66%) that indicated thatthey promoted attendance in at least one of theunder-represented groups, 46% stated that theypromoted attendance in women, 48% in theelderly, 55% in revascularisation patients, 34% inethnic minority groups, and 17% and 18% inpatients with heart failure and angina, respectively.
Of the 126 services that stated that they promotedattendance in under-represented groups, 97provided details of the interventions that theyused to achieve this. A member of the report teamwith extensive clinical experience of cardiac
rehabilitation delivery examined these free textresponses. Among the under-represented groupsthere emerged themes of a variety of interventionsthat were being, or could be used generically,across the different patient groups, and some thatwere definitely more specific to each of theparticular groups. These are presented in Table 7.The numbers in parentheses refer to the numbersof services which described each particularintervention. The majority of services that statedthat they promoted adherence did so in a way thatwould benefit most patient groups; for example,follow-up phone calls, free transport, home visitsand personalised invitations. Of those interventionsthat were specific to under-represented groups,individualised classes, appropriate ‘buddy’ systems,attendance of relative or spouse were among thosemost commonly stated. Direct referrals fromsurgery and specialist clinics were also used asmethods to ensure uptake and adherence.
ConclusionsAlthough it is feasible to obtain useful informationabout means of improving uptake and adherenceusing ad hoc postal questionnaires, routineelectronic audit data are likely to provide a more
TABLE 6 Under-represented groups: referral, uptake and completion rates for UK cardiac rehabilitation programmes in 2000
Median per IQR Range na % of referralscentre per year
No. of male patients referred 213 111–334 2–1066 83joined 118 66–185 2–747 84 55%completed 84 43–154 2–329 65 39%
No. of female patients referred 85 36–130 1–498 83joined 36 17–60 1–319 84 42%completed 27 12–45 0–140 65 32%
No. of patients aged >65 referred 142 61–228 0–887 66joined 72 37–152 0–596 71 51%completed 54 30–110 4–212 51 38%
No. of black/Asian patients referred 5 1–19 0–196 59joined 2 0–7 0–127 63completed
No. of post-MI patients referred 160 78–286 0–881 97joined 91 49–149 0–446 88 57%completed 66 31–103 0–425 69 41%
No. of CABG patients referred 86 47–142 0–563 91joined 50 22–99 0–407 83 58%completed 45 13–82 0–367 65 52%
No. of HF patients referred 0 0–2 0–28 61joined 0 0–1 0–12 59completed 0 0–1 0–9 46
No. of angina patients referred 6 0–27 0–200 71joined 1 0–8 0–134 70completed 0 0–5 0–73
a Data were not provided for all questions by all services, so the numbers of respondents to each question are provided.HF, heart failure.
comprehensive picture, and more accurate data onreferral and uptake.
Relative to post-myocardial infarction patients,older people and women tended to be less oftenreferred and were less likely to join a programme.Data on ethnic minorities and those with diagnosesof angina and heart failure were too sparse toevaluate formally. However, the low numbersreported indicate that these groups are veryunlikely to be referred or to join programmes.
Many different interventions are reported byservices, suggesting high levels of awareness of the general problem of uptake. Theseinterventions vary in complexity and cost; forthose that are either complex or costly, moreformal evaluation of their effects on uptake and adherence would be valuable. Examples of low-cost, sensible good practice (e.g. telephone call follow-ups) should be widelydisseminated and would not require formalevaluation.
Provision and uptake of cardiac rehabilitation in the UK: national survey of UK cardiac rehabilitation services
16
TABLE 7 Interventions used by cardiac rehabilitation programmes to improve uptake and adherence (number of programmes reportingindicated intervention)
Any intervention (97)
Generic interventionsFollow-up telephone call post-discharge (69)Preassessment clinic appointment and individualisedcoronary heart disease advice (58)Free organised transport (51)Home visit by specialist cardiac/BHF liaison nurse (43)Personalised invitation by letter or telephone to attend (42)Inpatient follow-up and verbal explanation (28)Non-attenders followed up and offered furtherappointments (26)Range and choice of menu options for classes (13)Community GP and practice nurse encourage attendance (5)Choice of sessions offered (venue/day/time) (5)Anxious patients met at the entrance of the venue (1)Travel grants and transport-sharing scheme (1)Invitation letter marketed and evaluated to encourageuptake of classes (1)
Specific interventions for womenWomen patients ‘buddy’ system (15)Individualised exercise plans (14) Separate classes for women (6) Encouragement of husband or friend to attend (6) Choice of community or hospital-site sessions (3)Female volunteer befriending service and help-line (3)Focus groups to assess women’s needs (2)Smaller exercise groups for women (1)Health benefits for women explained (1) Women’s changing facilities (1)Female-only staff to facilitate rehabilitation sessions (1)
Specific interventions for age > 65 yearsSeparate and smaller classes for the elderly/frail (6)Flexible start date if patient slow to recover (4)Elderly patients’ buddy system (3)Relative /spouse encouraged to attend (3)Lower impact exercise class (3)Choice of sessions offered (day and times) (3)Focus groups to assess elderly needs (2)Elderly volunteer befriending service and help-line (2)One-to-one exercise supervision (1)Elderly education sessions (1)Audiotapes of education sessions (1)
Specific interventions for ethnic minority groupsAsian relative/friend encouraged to attend (8)Coronary heart disease leaflets in Asian languages (5)Audiotapes of education sessions (3)Asian-speaking nurses for home visits (5), education andexercise (3)Involvement of Asian support groups (3) Community elders from voluntary sector supportingrehabilitation (3)Asian education programme (3)Asian patient buddy system (2)Provision of culturally sensitive classes (2)Regular Asian focus groups to assess need (1)Separate exercise class for Asian women (1)Encouragement to wear traditional dress (1)
Specific interventions for CABG/PTCASurgical tertiary centre referral system (13)Specific revascularisation programme led by arevascularisation rehabilitation nurse (12)Strong recommendation by surgeon/consultant (2) Theatre list referral system (1)Buddy system (1)Preangiogram talk about rehabilitation (1)Video about cardiac rehabilitation (1)
Specific interventions for anginaSpecific angina education sessions (5)No exclusion to attend (5)Direct referral from rapid-access chest pain clinic (2)Referral while awaiting CABG (1)Buddy system (2)Referral followed up by specialist angina nurse (1)
Specific interventions for heart failureSpecific heart failure programme (9)Community specialist heart failure nurse encouragesattendance (5)No exclusion to classes (4)Low-impact exercise classes (2)Buddy system (1)Community-based programme (1)Audiotapes of health education provided (1)One-to-one exercise supervision (1)
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Objective� Assessment of cardiac rehabilitation audit
activity by survey of rehabilitation centres.
BackgroundPatient uptake of outpatient cardiac rehabilitationservices is poor, particularly by under-representedgroups including women, the elderly and ethnicminorities.25,33,36 Although guidelines on provisionof services exist,2,4,87 audit of cardiac rehabilitationservices has previously been piecemeal and notroutinely undertaken and, where data exist,adherence to guidelines is poor.88 In England, theNSF-CHD has recognised the benefits ofcomprehensive cardiac rehabilitation and the needfor services to be extended.12 It states that everyhospital should ensure that more than 85% ofpatients discharged with a primary diagnosis ofacute myocardial infarction or after coronaryrevascularisation are offered access to cardiacrehabilitation. This has implications for clinicalgovernance and the need to audit cardiacrehabilitation services.
In view of the NSF stated objectives, the aim wasto ascertain the level of cardiac rehabilitation auditactivity in the south-west of England and areaswith high ethnic minority populations in Londonand the midlands.
MethodsCardiac rehabilitation centres in the south-west ofEngland, London and the Midlands werecontacted by telephone and asked to supply areport on their most recent audit. Information onany special efforts to improve attendance byspecific patient groups (e.g. women, the elderlyand ethnic minorities) was also requested. Centresreporting no available data were asked to providereasons for not undertaking audit. Centres withaudit data or a report available but that did not
submit a copy were contacted a second time bytelephone and subsequently by letter. The medicaldirector of the NHS trust was then contacted,asking the hospital trust to follow-up the request.
ResultsResponse rate
From January to July 2002, 51/57 (89%) of cardiacrehabilitation centres that were approached weresuccessfully contacted. Twenty-six centres (46%)responded to the first telephone request. Furthercontact by telephone and letter led to replies fromone (2%) and eight centres (14%), respectively.Finally, after written communication with medicaldirectors, replies were received from a further 16centres (28%). Audit data were received from 24(42%) centres, nine (16%) reported that an audithad been undertaken but did not send it, and 18(32%) stated that no audit had ever beenundertaken. Two centres supplied their audit asanonymous individual patient data and one centrewas only able to provide an audit report limited toa single ethnic group.
Audit methodsThe means of data collection varied betweencentres. It was not possible to determine themethod of data collection by 12 centres (50%). Ofthose where this was clear, six (50%) relied on a‘paper system’ with retrospective data extractionfrom patient notes and attendance registers, whilesix (50%) used regularly updated computeriseddatabases. Commenting on the collection of data,respondents regarded paper systems as time-consuming, tedious and unreliable, while centresusing computerised methods reported thatfrequently there was a lack of trained staff for datamanagement.
The mean length of audit was 10.4 months(SD 2.8, range 4–12 months). Times for datacollection also varied between centres. Mid-pointdates were in 2002 (two hospitals), 2001 (ten
Chapter 5
Audit of cardiac rehabilitation in England: National Service Framework for Coronary Heart
Disease recommendations
hospitals), 2000 (eight hospitals), 1999 (twohospitals) and 1998 (one hospital). One audit didnot provide dates. The main reasons cited for notcollecting audit data were: time constraints, lack ofadequate resources and computing facilities, lackof appropriate personnel to input data, limited orno audit training, or lack of informationtechnology support for the audit process.
National Service FrameworkThe number of centres collecting information asstated in the NSF-CHD for annual collection ispresented in Table 8. The audit with data on asingle ethnic group is not included.
Of importance is that data received were often notcomparable. Regarding age, only six (26%) centresprovided age information adequate for theassessment of attendance by age group. This wassimilarly the case with ethnicity, where only five(22%) provided information that permittedcomparisons of cardiac rehabilitation uptake byethnic groups. This information was more likely tobe collected by centres in areas with high numbersof patients from ethnic minorities. Eleven out of13 centres (85%) from areas with high ethnicminorities collected information on provision forspecific ethnic minority groups, but in only four(31%) could this be used to assess some feature ofuptake. In areas with relatively low numbers ofpatients from ethnic minorities limitedinformation was reported by five out of 10 centres(50%), with only one centre collecting adequateinformation to assess differences in attendancerates (10%).
Of the 19 centres supplying relevant information,12 (63%) provided rehabilitation for patients withmyocardial infarction, coronary bypass surgery,
angioplasty and heart failure. Six (32%) wereexclusively for myocardial infarction patients andone (5%) for surgical patients.
Audits also contained information not directlyrelevant to the objectives of the NSF. This issummarised in Table 9.
Numbers of patients per yearThe annual baseline mean number of patientsdischarged alive from hospital and eligible forcardiac rehabilitation and the numbers of patientsreferred to, attending and completing cardiacrehabilitation are presented in Table 10 for allcentres and for those providing services to a highproportion of ethnic minorities.
The proportion of discharged patients attendingrehabilitation was 35% (weighted by number ofpatients discharged, SD 12, range 14–54%) and ofthose referred or invited to cardiac rehabilitationattendance was 55% (weighted by number ofpatients invited, SD 12, range 35–80%). Seventy-
Audit of cardiac rehabilitation in England: National Service Framework for Coronary Heart Disease recommendations
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TABLE 8 Audit activity specified in NSF-CHD
Stated NSF-CHD recommendation No. of centres collectinginformation (%) (n = 23)
No. (%) of patients discharged from hospital after coronary revascularisation or with a 10 (43%)primary diagnosis of AMI
Documentation of arrangements for cardiac rehabilitation in discharge communication to GP 0 (0%)
Information on gender of patients 20 (87%)
Information on age of patients 18 (78%)
Information on ethnic group of patients 16 (70%)
No. recruited to cardiac rehabilitation 21 (91%)
Outcome information: 1 year after discharge, regular physical activity of at least 30 min 2 (9%)duration on average five times a week, not smoking, body mass index < 30 kg/m2
TABLE 9 Additional information included in audits
Additional information collected No. of centrescollectinginformation (%)(n = 23)
Patient reasons for non-attendance 12 (52%)Patient clinical history and risk factors 6 (26%)Secondary prevention outcomes 4 (17%)Patient opinions and satisfaction 2 (9%)Patient’s home postcode 2 (9%)Psychological morbidity 1 (4%)Exercise outcomes 1 (4%)Reasons for non-referral 1 (4%)Referrals by consultant 1 (4%)
seven per cent of patients (weighted by number ofpatients attending, SD 13, range 57–91%) attendinga programme subsequently completed it.
The proportion of patients discharged whocompleted a programme was 32% (weighted bynumber of patients discharged, SD 6, range28–42%). However, this was based on informationfrom only three centres.
In five centres providing a service to a highproportion of ethnic minorities the percentage ofdischarged patients referred was significantlylower than in three centres from other areassurveyed and which provided appropriate data(29% compared with 45%). Otherwise, theproportions of patients referred, attending andcompleting programmes were similar.
Measures reported to improve patientattendance at outpatient cardiacrehabilitationEight centres (35%) reported a variety of measuresto improve attendance and these are summarisedin Table 11. Three of these measures concentratedon the uptake of ethnic minorities, one on womenpatients, but none on the elderly. Regrettably,information evaluating the success of thesemeasures was not available.
DiscussionClinical governance incorporates audit to ensurethat clinical care is up to date and effective.89
However, a commitment to the accuracy,appropriateness, completeness and analysis of
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TABLE 11 Measures taken to improve attendance at cardiacrehabilitation
No. of centresreportingmeasures toimproveattendance (%)
Community, non-hospital-based 5 (22%)programme
Translator or interpreter 3 (13%)
Evening programme 2 (9%)
Community liaison or link worker 2 (9%)
Women-only programme 1 (4%)
Programme for specific ethnic group 1 (4%)
Programme on days appropriate to 1 (4%)religious beliefs
Satellite services in local hospitals 1 (4%)
Audio information for visually impaired 1 (4%)
TABLE 10 Numbers and proportions of patients discharged alive, referred/invited, attending and completing cardiac rehabilitationper year
Mean no. (SD) Proportion of Proportion of Proportion of of patients (range) dischargeda referred/inviteda attendeda
(no. of centres) (no. of centres) (no. of centres) (no. of centres)
All centresDischarged patients 390 (182)
(167–684) (n = 10)
Referred/invited for cardiac 308 (223) 59% (n = 7)rehabilitation (62–1066) (n = 18)
Attending cardiac rehabilitation 176 (110) 35% (n = 8) 55% (n = 16)(23–533) (n = 19)
Completing cardiac rehabilitation 148 (53) 32% (n = 3) 48% (n = 8) 77% (n = 7)(66–233) (n = 8)
Centres providing service to a high proportion of ethnic minoritiesDischarged patients 398 (184)
(167–620) (n = 6)
Referred/invited for cardiac 334 (262) 60% (n = 5)rehabilitation (62–1066) (n = 11)
Attending cardiac rehabilitation 189 (135) 29% (n = 5) 57% (n = 10)(23–533) (n = 11)
Completing cardiac rehabilitation 137 (58) (66–233) (n = 6) 37% (n = 2) 48% (n = 6) 79% (n = 5)
a For centres providing complete information.
healthcare information is required if judgementsabout clinical quality are to be made and theimpact of clinical governance is to be assessed.90
Major barriers to clinical audit are lack of resources,lack of expertise or support, and organisationaldifficulties.91 This survey highlighted that aminority of centres was able to provide informationon outpatient cardiac rehabilitation audit, with one-third of centres reporting that no audit wasavailable. Some centres reported that audit hadbeen conducted, but were not eager to disseminatethe information outside the hospital. This mayreflect the perceived disadvantages associated withclinical audit of diminished clinical ownership andhierarchical and territorial suspicions.91 Althoughthe medical directors of NHS trusts were contactedfuture studies should consider methods to improvesharing of audit information.
Nearly half of the audits provided some relevantinformation on clinical audit as specified in theNSF-CHD. However, information on potentiallyunder-represented groups was limited. To someextent the style and content of audit reportsprobably reflect local interests and concernsrelating to cardiac rehabilitation provision. Basicinformation on the initiating event in particular,and on referral, invitation, attendance andcompletion was collected in sporadic and non-standard ways. A few audit reports werecomprehensive, with comparison of total numbersof discharged patients and patient attendance andcompletion of outpatient cardiac rehabilitation. Toallow comparison of provision between centres andover time, a baseline figure of total initiatingevents is required, as well as information oninvitation to, and completion of, the programme.Examples of clinical audit tools have beenincluded in cardiac rehabilitation guidelines.2,4
However, with the exception of initiating event,these have been limited in their inclusion ofinformation on potential sources of under-representation. A more recent resource considersage, gender and ethnicity,92 and is currently underevaluation.93 Development and acceptance of acomprehensive, standard audit tool with flexibilityregarding local issues would be helpful for use infuture audits. It may be possible to merge this intoa hospital critical care pathway and routinelycollected Myocardial Infarction National AuditProject (MINAP)94 data. If the targets laid down inthe NSF-CHD are to be met and the healthoutcomes are to be successful then the challengelies in the development of an effective anduncomplicated audit tool that can be appliednationally to serve all cardiac populations.
A difficulty identified in several audits and fromcentres unable to provide information was thatpatients may be referred to a programme fromone or more hospitals or from one hospital toseveral different programmes. This complicatesthe audit of programmes in both urban and ruralsettings. In one city unable to provide auditinformation a group of hospitals reported theimminent introduction of a joint database.
Where available, audits of outpatient cardiacrehabilitation varied considerably in style andcontent. Some were thorough documents coveringmany aspects of audit, whereas other centres hadbeen unable to prepare a formal document butwere able to provide raw data. Some audits wereprepared by staff trained in clinical audit, whereasothers were by less experienced staff or werestudent projects. Other facilitating factors foraudit include modern medical records systems,effective training, dedicated staff, protected time,structured programmes, and a shared dialoguebetween purchasers and providers.91
Only a minority of centres was able to providecomplete information on numbers of patientsreferred (seven centres) and who attended cardiacrehabilitation (eight centres) in relation tonumbers discharged. There was a suggestion thatreferral and invitation of patients were similar incentres providing services in areas with highproportions of ethnic minorities compared withcentres in other areas. However, the proportion ofpatients attending a programme was lower inareas with high ethnic minority populations.Changes to services and interventions to improveuptake of cardiac rehabilitation by ethnic minoritygroups may be indicated.
A series of measures had been undertaken bycentres to help patients to participate inoutpatient cardiac rehabilitation. These rangedfrom holding classes in community settings and attimes to suit patients, to the establishment ofclasses dedicated to women or ethnic groups. Asinterventions may be of interest to other centres,evaluation by controlled trials or within areproducible audit framework would be valuablein determining their overall effectiveness inimproving attendance at outpatient cardiacrehabilitation.
ConclusionsThe findings from this more detailed survey ofaudit activity complement those obtained from the
Audit of cardiac rehabilitation in England: National Service Framework for Coronary Heart Disease recommendations
20
national survey of cardiac rehabilitation servicespresented in Chapter 4. The authors had hopedto be able to find interventions specific to under-represented groups by focusing on services locatedin areas with relatively high proportions of blackand ethnic minorities and with rather more agedpopulations (the south-west of England). However,the quality of audit, the reports and the datacollected were insufficient to support robustinterpretation of the performance of theseservices.
The findings highlight a national uncoordinatedapproach to audit data collection in England withlarge variations in methods and content despitethe standards set out in the NSF and cardiacrehabilitation guidelines. The use of modernmedical records systems, appropriate training fordedicated staff and dialogue between allcontributors to services is suggested. Developmentof a national and policy-driven standardised
audit tool would facilitate the identification ofpatients by cardiac event and the following of allpatients through the cardiac rehabilitation process.
Limited analysis of audit data suggests that uptakeof cardiac rehabilitation is particularly low in areaswith high proportions of ethnic minorities.Information on under-represented groups andlocal interests should be incorporated into auditdata collection in a standardised way so that futurecare can be targeted to the needs of the localcardiac population.
Some cardiac rehabilitation programmes haveattempted to improve attendance with measuresappropriate for all patients or for specific groups.Evaluation and dissemination of information oneffective and ineffective interventions may helpother programmes to improve services and useresources appropriately.
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Objective� To evaluate uptake and adherence using data
from a recent multicentre RCT.95
IntroductionIn the UK provision of rehabilitation for patientsfollowing acute myocardial infarction is arequirement of the NHS-CHD12 and comparableguidelines in Scotland and Wales.2,18 Beforedischarge all patients should be invited toparticipate in a multidisciplinary cardiacrehabilitation and secondary preventionprogramme. Some patient groups are not thoughtto benefit from the exercise component of cardiacrehabilitation after acute myocardial infarction.Patients with more severe cardiac illness and thosewith psychiatric conditions that may compromisesafety are considered ineligible.96 Pragmatically,patients with poor functional capacity, significantco-morbidity, frailty or confusion are not suitablefor outpatient-delivered rehabilitation.Consequently, these factors may influence referraland uptake in clinical practice.
The uptake and adherence achieved in a clinicaltrial setting was examined because this shouldreflect the best that can be achieved in optimalroutine clinical practice.95 It would certainly beunlikely that NSF targets representing a higherlevel of uptake and adherence than that seen in acontemporary trial would be feasible. Whereappropriate, data for all patients discharged aftermyocardial infarction were analysed. For issuesrelating to attendance only those patientsallocated to cardiac rehabilitation were considered.
MethodsPatients were recruited in 18 typical acute generalhospitals in England and Wales. The trial protocolplanned for all potentially eligible myocardialinfarction patients to be identified onconfirmation of diagnosis. At discharge ineligible
patients (significant co-morbidity, etc.) wereexcluded under protocol guidelines of minimalexclusions and reasons were recorded, usually by anominated coronary care unit nurse. Patientseligible for rehabilitation were advised of the trialin an introductory letter.
Each patient was visited by a research interviewerapproximately 1 week after discharge. Patientswere given full details of the trial and, after beingasked for informed consent, answered the baselinestructured interview. Following entry into the trialand central blind randomisation, the names ofpatients allocated to cardiac rehabilitation weregiven to rehabilitation teams for invitation,treatment and follow-up as normal practice for theprogramme.
There were two opportunities for patient selection:by hospital medical or nursing staff (before trialentry) according to criteria in protocol; or bycardiac rehabilitation staff (after randomisation).There were also three opportunities for refusal ofthe trial or rehabilitation by patients: whenadvised of the trial by hospital staff; after a fulldescription of the trial and informed consent bythe research interviewer; or when given the date,time and venue of their first rehabilitationappointment. Patients were interviewed after1 year and asked about their experiences ofcardiac rehabilitation.
ResultsThe collection of names of potentially eligiblepatients and recording of clinical summaries werenot complete in all hospitals. Some progressivelyreduced the flow of forms of excluded patients.Consequently, analyses were undertaken both for all hospitals and for those hospitals in whichrecord-keeping was thought to be nearly complete.
In total, 3264 potentially eligible patients wereidentified in the 18 hospitals. Of these, 1400 werein five hospitals with complete registration.
Chapter 6
Uptake and adherence in a randomised controlled trial of cardiac rehabilitation after
myocardial infarction
Figure 3 shows reasons for exclusion from the trialand overall eligibility for cardiac rehabilitation inthe hospitals with complete registration. Seventy-three per cent of patients had no medical reason(identified during hospital stay by medical ornursing staff) for not attending a programme ofcardiac rehabilitation. Thus, nearly three-quartersof patients discharged within 28 days followingmyocardial infarction were deemed eligible forcardiac rehabilitation.
Follow-up interviews were completed for 959patients randomised to rehabilitation atapproximately 1 year, by when 75 patients haddied. Attendance information for a further91 patients was provided by rehabilitationcoordinators.
Medical reasons for exclusion, identified duringthe hospital stay, are shown in Table 12. Some ofthese patients may have been eligible forrehabilitation at a later date or in a differenthospital (patients awaiting surgery, transferred toanother hospital, having extended hospital stay orbeing readmitted). Including these patients raiseseligibility from 73 to 81%.
Patients excluded from rehabilitation for medicalreasons tended to be older (mean age 71.9 yearscompared with 64.6 years for eligible patients,p < 0.0001) and were more likely to be female(36.5% versus 21.9% males excluded, p < 0.0001).Table 13 shows patient exclusion in males andfemales in different age groups. There was a trendfor increasing exclusion in both men and women
Uptake and adherence in a randomised controlled trial of cardiac rehabilitation after myocardial infarction
24
1400 patients identified with acute myocardial infarction
678 (48%) patients admitted to trial of cardiac rehabilitation
722 (52%) patients excluded from trial
151 (11%) patients chose not to participate in trial (trial and rehabilitation refusals and elective rehabilitation requests)
95 (7%) patients did not participate in the trial for practical reasons (could not speak English, lived outside area, living in nursing home)
103 (7%) patients excluded for reasons concerning the trial (previous attendance at cardiac rehabilitation, interviewer unable to contact)
373 (27%) patients excludedfor medical and relatedreasons
1027 (73%) of patients eligible forcardiac rehabilitation
FIGURE 3 Exclusions from trial hospitals reporting complete myocardial infarction registration
with age. In multivariate analysis the associationbetween gender and exclusion was not significantafter adjustment for age.
Excluded patients tended to have pre-existingcardiovascular disease (previous myocardialinfarction or angina) or more severe presentationof the index myocardial infarction (Table 14).However, previous hypertension was not associatedwith eligibility.
In total, 2144 patients were entered into the trial. Ofthese, 1100 were allocated to cardiac rehabilitation.Attendance figures are shown in Table 15.
Not all patients allocated by the trial torehabilitation were offered cardiac rehabilitation.At least 22% and possibly as many as 33% ofpatients considered eligible by medical or nursingstaff at time of discharge were not offeredrehabilitation by cardiac rehabilitation staff.Patients invited tended to be younger than thosenot invited (mean age 62.8 years compared with68.1 years) with a clear trend for non-invitation inolder age groups (Table 16).
There was a tendency for women to be overlookedmore often than men (31% compared with 22%).In less elderly patients (under 70 years), 18% ofwomen were overlooked compared with 13% ofmen. However, the trend was not significant inmultivariate analysis.
At interview, patients who had been invited tocardiac rehabilitation (n = 721) estimated thenumber of classes that they had attended and, ifappropriate, gave reasons for non-attendance ordropout. Overall, 78% of patients invited torehabilitation attended at least one session. Ofpatients aged 65 years or more 72% attended atleast one session compared with 82% of thoseyounger than 65 (p = 0.001). These data providesupport for the observation that older patients areless likely to attend cardiac rehabilitation thanyounger patients. There were no statisticallysignificant differences in initial uptake betweenmen and women (79% versus 74%).
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TABLE 12 Reasons for exclusion in hospitals with completepatient registration
No. of patients (%)
Admitted to trial 678 (48.4%)Practical, personal and trial exclusion 349 (24.9%)
Medical exclusion:Significant co-morbidity 75 (5.4%)Frail or confused 154 (11.0%)Transferred to other hospital 75 (5.4%)>28 days in hospital 13 (0.9%)Readmitted within 28 days 16 (1.1%)Awaiting surgery 5 (0.4%)Uncooperative 7 (0.5%)Other 28 (2.0%)
Total 1400
TABLE 13 Medical exclusions by age and gender (1349 patients with age and gender known)
Age at MI (years) Male exclusions Female exclusions All exclusions (% potentially eligible) (% potentially eligible) (% potentially eligible)
<45 14 (25%) 4 (44%) 18 (28%)45–54 21 (13%) 2 (5%) 23 (12%)55–64 38 (16%) 13 (19%) 51 (16%)65–74 50 (19%) 34 (27%) 84 (21%)75–84 53 (34%) 69 (47%) 122 (40%)85+ 18 (56%) 31 (67%) 49 (63%)All ages 194 (21%) 153 (35%) 347 (26%)
TABLE 14 Medical exclusions by previous cardiovascular disease and more severe sequelae of myocardial infarction
Eligible Medical exclusion p
MI previous to index event 16.50% 26.70% p < 0.0001Previous angina 30.50% 44.10% p < 0.0001Previous hypertension 31.70% 31.00% p = 0.441
MI with left ventricular failure 29.10% 49.60% p < 0.0001
MI with cardiogenic shock 1.60% 7.30% p < 0.0001
Patients with a history of cardiovascular diseasebefore the index myocardial infarction wereslightly less likely to attend rehabilitation: previoushypertension (27% versus 21%) and previousmyocardial infarction (30% versus 22%), but thesedifferences were not statistically significant.
If invited, patients who had suffered a more severemyocardial infarction (complicated with leftventricular failure or cardiogenic shock) were aslikely to attend as those without complications.Seventy-seven per cent of patients with left
ventricular failure attended compared with 78% ofthose without. For cardiogenic shock the numbersare small, but of 12 affected patients, 11 attendedrehabilitation (92%) compared with 78% of thosewithout.
Having attended one class, 79% of patientsattended five or more sessions. Women wereslightly less likely than men to attend five or moresessions (75% versus 80%), although this was notstatistically significant.
Reasons reported for not attending or attendingfewer than five sessions are shown in Table 17.
The main reasons given by patients at the 1-yearfollow up interview for non-attendance were lackof interest and perceived illness. However, 34%reported reasons for non-attendance or droppingout that might have been avoided withappropriate management. These includedtransport difficulties, returned to work, holidays,other appointments, administrative failure,dissatisfaction with course, dependent relative,considered unnecessary by department, attendedother course and taking part in another trial.
DiscussionThis analysis showed that some cardiacrehabilitation programmes used selection. Thismay reflect local provision issues or the lesserimportance assigned to rehabilitation of patientsfollowing acute myocardial infarction comparedwith cardiac surgery. Although the analysis ofreasons for exclusion is based on 1400 patientsfrom five hospitals, a less representative
Uptake and adherence in a randomised controlled trial of cardiac rehabilitation after myocardial infarction
26
TABLE 15 Patient attendance in trial rehabilitation groups
No. of patients (%)
Not offered/did not attend 238 (21.6%)Not known whether offered/did not attend 66 (6.0%)Offered/did not attend 162 (14.7%)Attended one class 45 (4.1%)Attended two to four classes 57 (5.2%)Attended five or more classes 454 (41.3%)Attended but number not known 18 (1.6%)Not known whether offered or attended 60 (5.5%)Total 1100
TABLE 16 Non-invitation by age group
Age group (years) Not invited
<45 7 (11.3%)45–54 21 (12.2%)55–64 50 (17.2%)65–74 87 (22.9%)75+ 73 (37.2%)Total 238
TABLE 17 Reasons for non-attendance or attendance at fewer than five sessions in patients offered cardiac rehabilitation
Reason for non-attendance No. of patients (%)
Not interested or lost interest 71 (23.6%)Too ill 62 (20.6%)Transport difficulties 43 (14.3%)Returned to work 18 (6.0%)Holiday or other appointments 15 (5.0%)Recommended not to by doctor or rehabilitation staff 13 (4.3%)Rehabilitation department administrative failure 9 (3.0%)Dissatisfaction with course (age group, male/female, content) 6 (2.0%)Taken ill at rehabilitation class 6 (2.0%)Looking after dependent relative 6 (2.0%)Rehabilitation staff thought unnecessary (fit enough) 3 (1.0%)Attending another rehabilitation course 2 (0.7%)On another trial 1 (0.3%)Not known 46 (15.3%)Total 301
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sample of hospitals than the 18 trial hospitals, asimilar pattern is observed in the whole sample.
It is not possible to differentiate trial refusals fromcardiac rehabilitation refusals. By refusing toparticipate in the trial, patients may be seekingcardiac rehabilitation or may be turning it down.However, in an audit of rehabilitation servicesboth these patient groups must be considered aseligible. Patients who were excluded from the trialfor methodological (trial) reasons may have beeneligible and contactable if given a definiteinvitation while in hospital. Patients excluded forthe practical reason of living outside the area mayhave been eligible for a cardiac rehabilitationprogramme local to their home. Indeed, it ispossible that these patients received rehabilitationelsewhere. At the time there were no specificinterventions to facilitate uptake by patients whospoke no English, in the study hospitals (specificprogrammes for non-English-speaking patientsmay have been introduced more recently). It isunlikely that they would have receivedrehabilitation elsewhere.
The reasons reported by patients for non-attendance at and for early dropout from a cardiac
rehabilitation programme suggest that uptake maybe improved by addressing issues of motivationand the perceived relevance of rehabilitation tofuture well-being, minor co-morbidities orperceived illness, site and timing of sessions,transport and arrangement of care fordependants.
ConclusionsMedical and nursing staff identified 73–81% ofpatients discharged from hospital after acutemyocardial infarction as being eligible for cardiacrehabilitation. Excluded patients tended to beolder, were more likely to have suffered fromangina or had a previous myocardial infarctionand showed more severe presentation ofcardiovascular disease. Reduced invitation andattendance of women was largely explained bytheir greater age at myocardial infarction. Theexperiences of patients invited to cardiacrehabilitation suggest that uptake may beimproved by addressing issues of motivation andthe perceived relevance of rehabilitation to futurewell-being, co-morbidities, site and time ofsessions, transport and arrangement of care fordependants.
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Chapters 7–10 present the methods andfindings for a series of related systematic
reviews. The issue of improving uptake was splitinto three major questions: how can recruitment tocardiac rehabilitation be improved; how canpatients’ adherence to cardiac rehabilitation andmaintenance of lifestyle changes be improved; and,how can professionals be encouraged to complywith guidelines and good practice? The sources ofdata to answer these questions may overlap, asresearchers will not necessarily have conceivedtheir questions in the same form as the presentgroup has. With awareness of this, it was ensuredthat each pair of reviewers dealing with a specificquestion read source material with a view toidentifying potential relevance to other questions.
Definitions� Uptake: patients attending any outpatient
cardiac rehabilitation (i.e. successfulrecruitment).
� Adherence: patients attending all or majority ofoutpatient programme, or maintaining lifestylechanges associated with cardiac rehabilitation.
� Professional compliance: healthcareprofessionals complying with guidelines or goodpractice regarding invitation and support ofpatients’ cardiac rehabilitation.
Objective� How effective are different methods for
improving uptake, adherence or professionalcompliance with cardiac rehabilitation?
MethodsA systematic review of interventions to increaseuptake, patient adherence and professionalcompliance with cardiac rehabilitation isdescribed. This was supported by members of the
Cochrane Heart Group (KR, MB) who assistedwith designing search strategies and identifyingreports.
Data sourcesA general search strategy was designed to identifyall studies relating to the uptake, adherence orcompliance with cardiac rehabilitation services.The choice of sources was intended to find bothpublished and unpublished studies (greyliterature). Details of terms used in the search aregiven in Appendix 4. The terms used were thosefor ‘heart disease’ together with terms for ‘cardiacrehabilitation’. A broad approach to rehabilitationterms was chosen to identify not only formalcardiac rehabilitation programmes but also non-traditional programmes that could contribute tocardiac rehabilitation. Studies identified werefurther searched for terms relating to uptake,adherence, compliance and costs. Studymethodology terms were not included, as theintention was to find all studies irrespective ofmethodology used. No language restrictions wereapplied.
The following databases were searched frominception (as appropriate) to June 2001:
� MEDLINE on Ovid� EMBASE on Ovid� the Cochrane Library (2001 Issue 2). This
includes the Cochrane Controlled TrialsRegister, Cochrane Database of SystematicReviews, Database of Reviews of Effectiveness(DARE), HTA Database and NHS EconomicEvaluation Database
� CINAHL on Ovid� PsycINFO on BIDS Silverplatter WebSPIRS� ISI Web of Science and ISI Proceedings� ECONLIT on Silverplatter WebSPIRS� British Library Inside � SIGLE (System for Information on Grey
Literature in Europe)� HMIC (Health Management Information
Consortium database)
Chapter 7
Systematic review of interventions to improve uptake, adherence and professional compliance with
cardiac rehabilitation
� COPAC (joint catalogue of CURL – theConsortium of University Research Libraries)
� National Research Register.
Additional searching of literature:
� The Journal of Cardiopulmonary Rehabilitation,1990–2001, was handsearched.
� Coronary Health Care, 1997–2001, washandsearched.
� Abstracts from conference proceedings werehandsearched:– American Association of Cardiovascular and
Pulmonary Rehabilitation (AACVPR)– American College of Cardiology (ACC)– British Cardiac Society (BCS)– British Association for Cardiac Rehabilitation
(BACR)– European Society of Cardiology (ESC)– International Network of Agencies for Health
Technology Assessment (INAHTA)– Society for Social Medicine (SSM)– World Congress of Cardiology (WCC).
� The reference lists of relevant studies andreviews were scanned.
� Expert opinion was sought.
Study selectionPreliminary literature searches suggested that onlya small number of RCTs would be found and thatnon-randomised studies would form an importantpart of the review. Consequently, all studiesreporting evaluations of interventions wereconsidered. A total of 3261 references wasidentified in the searches, and the title andabstract of each article were examined by at leastone reviewer. Articles were only rejected if thereviewer could determine from the title andabstract that the article was not a report of anintervention. When a paper could not be rejectedwith certainty, the full text of the article wasobtained for further evaluation. A total of 957references was identified as potentially relevantand acquired for more detailed consideration.
There was concern about publication bias andtherefore special efforts were made to identifystudies that might report negative findings bysearching the grey literature, and handsearchingabstracts of scientific meetings. Many of theidentified interventions were found in the greyliterature, which tends to include studies reportinglower effectiveness than those published injournals.97 No attempt was made to contactauthors of studies as a lower response rate wasanticipated for supplementary information fromauthors of conference abstracts and theses
compared with authors of published papers, whichwould tend to bias the information towards studieswith more favourable outcomes.
After the discarding of purely descriptive reportstwo reviewers (from AB, KR, SE, MB, IG, FT andRW) assessed articles using a three-questioninclusion/exclusion form (Appendix 5). A thirdreviewer (SE or KR) resolved disagreements overinclusion/exclusion.
Reports were included for data extraction if thefollowing criteria were met:
� evaluation of intervention to increase uptake,patient adherence or professional compliance tocardiac rehabilitation
� patients with myocardial infarction, CABG orPTCA, with heart failure or angina, or coronaryheart disease
� outcomes relevant to the reviews, specificallynumbers attending and patient adherence tocardiac rehabilitation and its exercise, educationand lifestyle components.
Data extractionOnce the decision had been made to includestudies in the review two reviewers independentlyabstracted the relevant data (data extraction formin Appendix 6). Data extracted included details ofpatients, intervention, study type, quality andresults. No attempt was made to contact authorsfor additional information.
The quality of non-randomised studies wasrecorded in accordance with recent reviews,specifically information relating to selection bias,power and analysis.98 No formal scale was used tocategorise quality, but features of individual studiesare presented in the results sections. The methodof group allocation, sample size, comparison ofgroup characteristics at baseline and concomitantservice changes independent of the interventionare used as the basis for quality assessment.
AnalysisThe systematic review takes the form of threequalitative overviews. No attempt was made topool study results as the number of trials was smalland the study designs and interventions varied.Studies are grouped by quality of evidence. Thebest evidence comes from RCTs while non-randomised and before-and-after study designsprovide less reliable evidence.99,100 Studies werecharacterised by type and size, participants,intervention, comparison group, principal andother outcomes, and authors’ conclusions.
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BackgroundBarriers to attendance at outpatient cardiacrehabilitation have been identified, but theeffectiveness of interventions to improve uptakehas not been assessed by systematic review. Such areview is needed to identify appropriate methodsfor increasing patient use of services and tosuggest areas meriting further research. For thereview uptake was defined as any patientattendance at outpatient cardiac rehabilitation (i.e. successful recruitment).
ResultsStudies included in review ofinterventions to improve uptake ofcardiac rehabilitationThe flow of articles through the review process isshown in Appendix 7 in accordance with Qualityof Reporting of Meta-analyses (QUOROM).101
Twenty-seven articles reporting 22 studies wereidentified as relevant to the review of methods toimprove uptake of cardiac rehabilitation and wereformally included in the review. Reading by tworeviewers (AB and RW) found eight studiesreporting evaluation of an intervention relating touptake by an appropriate patient group and with arelevant outcome.
A brief summary of each study is shown in Table 18, with detailed descriptions presented inAppendix 8. More than one report was identifiedfrom the trials of Jolly and colleagues102–104 andWyer and colleagues.105,106 The referenceproviding the main source of information for thesystematic review is cited in the tables and text.
Studies excluded from review ofinterventions to improve uptake ofcardiac rehabilitationSixteen papers describing 14 studies selected fordata extraction but not included in the review aresummarised in Appendix 9. One paper reportinga before-and-after study of an intervention to
improve uptake of cardiac rehabilitation by CABGpatients was published after June 2001.112 Eightstudies had either no outcome data113–119 or nocomparison group,120 or the study wasretrospective in design.121 In five studies theoutcomes were referral122,123 or commitment toparticipate,124 or the study was related tosecondary prevention.125–127
Methodological qualities of studiesincluded in review of interventions toimprove uptake of cardiacrehabilitationSix studies reported interventions with a specificobjective of increasing uptake of outpatient cardiacrehabilitation.41,82,104,106,110,111 Two papersdescribed interventions to improve uptake ofcommunity or voluntary services (cardiac or heartclubs) after discharge from inpatient cardiacrehabilitation.108,109 All studies were of patientswith myocardial infarction, and in two studiespatients with angina104 and following cardiacsurgery110 were included.
Three of the eight studies were RCTs, withrandomisation on an individual basis in two106,108
and by general practice in one.104 Methods ofrandomisation and blind outcome assessment wereclearly described for two of the three RCTs104,106
and intervention groups were similar at baseline inall three trials.
Five articles reported non-randomisedcomparisons.41,82,109,110,111 In one study a districtproviding an intervention was compared with adistrict with no intervention.82 The districts hadpopulations with similar demographics that wereserved by the same general hospital. The otherfour papers reported uptake of cardiacrehabilitation in periods before and afterimplementation of an intervention.41,109,110,111
Baseline characteristics of groups were notreported in these studies. One before-and-afterstudy reported percentage uptake but did notprovide patient numbers or tests of statisticalsignificance.110
Chapter 8
Systematic review of interventions to improve uptake of cardiac rehabilitation
Systematic review of interventions to improve uptake of cardiac rehabilitation
32
TABLE 18 Studies evaluating interventions to improve uptake of cardiac rehabilitation
Authors, year Study type and Intervention Findings relevant to Commentsand country patients uptake
RCTs
Wyer et al.,2001106
UK
RCT, 87 MIpatients
Letters based on the theoryof planned behaviour (Ajzen& Madden)107 designed toincrease attendance at CR
Uptake of outpatient CR was86% in the interventiongroup and 57% in thecontrol group (p < 0.0025)
Intervention open toalternativeinterpretation; lettersconveying a ‘fear’message
Non-randomised studies
Osika, 200182
UKComparison oftwo districts withdifferentprovision, 175 MIpatients
Weekly home visits bytrained lay volunteers andaccompaniment to first CRsession
In the district with layvolunteer visiting 71% ofpatients attended a firstappointment at outpatientCR compared with 47% inthe control district (p = 0.02)
Intensity of lay volunteervisiting comparable withtypical CR
Krasemann &Busch, 1988109
Germany
200 MI patientsattending indifferent periods
After completion of inpatientCR pamphlet given withinformation designed tomotivate patients to join anoutpatient heart group
66% of patients whoreceived the interventionattended a heart groupcompared with 31% in thecontrol group (p < 0.001)
No baseline groupcomparisons
Mosca et al.,199841
USA
Before-and-afterstudy, 199 MIpatients
Prompt for outpatient CR indischarge critical carepathway
Critical care pathwayassociated with a non-significant increase inoutpatient CR participation(OR 1.9, 95% CI 0.6 to5.5).a
No baseline groupcomparisons
Imich, 1997110
UKBefore-and-afterstudy, MI andcardiac surgery,patient numbernot reported
Nurse support, educationand counselling in thepostdischarge, preoutpatientCR period
Attendance at outpatient CRby invited patients increasedfrom 55% before to 75%after instigation of theprogramme
Patient numbers notreported, so notpossible to assessstatistical significance
Scott et al.,2000111
Australia
a Lower 95% CI estimated.
Before and afterstudy, 649 MIpatients
Dissemination of clinicalguidelines to hospital staffand GPs. Feedback on clinicalindicators
After intervention outpatientCR utilisation increased from24% to 54% (p = 0.003)
Baseline periodcorresponds to CRprogramme start-up
Hillebrand et al., 1995108
Germany
RCT, 94 MIpatients
Following inpatient CRpatients had four telephoneand at home conversationswith social worker over a 6-month period
57% of patients whoreceived the interventionattended a cardiac groupcompared with 27% ofcontrols (p < 0.005)
Outcome is cardiacgroup attendance afterinpatient CR
Jolly et al.,1999104
UK
Cluster RCT, 67general practices,597 MI andangina patients
Liaison nurse encouragespatients to see practice nurseafter discharge and supportspractice nurses. Patient-heldrecord card to prompt andguide follow-up
42% of patients in theintervention group attendedat least one outpatient CRsession compared with 24%of controls (p < 0.001)
Multifacetedintervention.Management of patientsin control practices notexplicit
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Themes identified from the review ofinterventions to improve uptake ofcardiac rehabilitationThe interventions identified in the systematicreview can be grouped into four themes:healthcare professional-led interventions at thepatient level, trained lay volunteers, coordination of postdischarge care at the service level, and written motivationalcommunications.
Healthcare professional-led interventions at thepatient levelThree studies were identified but nonesatisfactorily assessed the value of patient contactwith healthcare professionals in improving cardiacrehabilitation uptake.104,108,110 In the RCT ofHillebrand and colleagues108 attendance at acardiac group after inpatient rehabilitation wassignificantly increased in myocardial infarctionpatients who received regular contact with a socialworker. The social worker–patient contacts attimes relevant to improvements in uptake were avisit in hospital and a telephone call 4 weeks afterdischarge. The authors considered this to be amotivational intervention. In the before-and-afterstudy of Imich110 postdischarge at-home nursingsupport for myocardial infarction and cardiacsurgery patients was associated withimprovements in attendance at outpatient cardiacrehabilitation. However, little information relatingto study quality and conduct was reported. In thenursing intervention reported by Jolly andcolleagues,104 although patients saw a liaisonnurse in hospital before discharge theintervention was aimed mainly at professionalorganisation of care and is discussed in thatsection.
Trained lay volunteersOne study looked at an intervention with trainedlay volunteers.82 In the thesis, Osika82 describesincreased cardiac rehabilitation uptake associatedwith an intervention by trained lay volunteers.The study compared myocardial infarctionpatients in two districts with similar populationsserved by the same general hospital. In onedistrict patients were offered the assistance of apatient who had previously attended cardiacrehabilitation. Patients in the district with the layvolunteer intervention were significantly morelikely to attend the first session of the outpatientcardiac rehabilitation programme. In the absence of randomisation the author attempted to validate the method by reporting similarities in demographics and service access betweengroups.
Coordination of referral and postdischarge careat the service levelInterventions aimed at increasing uptake ofoutpatient cardiac rehabilitation by improving thecoordination of postdischarge care were reportedin three studies.41,104,111 Jolly and colleagues104
reported a cluster RCT of coordination of carebetween hospital and general practice by specialistcardiac liaison nurses for myocardial infarctionand angina patients. Attendance at one or morecardiac rehabilitation sessions was significantlyincreased in the intervention group. Theintervention consisted of three main elements:liaison nurse encouragement for patient to seepractice nurse, liaison nurse support for practicenurses, and prompts and guidance for patients bymeans of a personal record card. The study designdoes not allow the effect of components to beassessed individually. Mosca and colleagues41
compared patient participation before and afterthe introduction of a prompt for cardiacrehabilitation in a discharge critical care pathway.An improvement in participation in outpatientcardiac rehabilitation was observed, but this wasnot statistically significant. Group characteristicswere not reported and other factors may haveinfluenced levels of participation. In the study byScott and colleagues,111 patients admitted tohospital in three periods were compared. Thesewere before, during and after the dissemination ofclinical guidelines and feedback of clinicalindicators to health professionals. The cardiacrehabilitation programme was operational duringthe implementation period and this was used asthe baseline period for evaluation. A steadyincrease in utilisation of the outpatient cardiacrehabilitation service was observed during theimplementation period and the authors attributethis to the intervention. However, no comparisonsof patient characteristics were available for therelevant periods and, although the authors reportthat the new cardiac rehabilitation service was fullyoperational, an increase in uptake might beexpected with a new service.
Motivational communicationsOne study showed significantly increasedoutpatient cardiac rehabilitation uptake aftermotivational letters106 and two showed improvedattendance at an outpatient heart group aftermotivational pamphlets109 or conversations.108 Inthe RCT of Wyer and colleagues,106 motivationalletters were sent to patients at 3 days and 3 weekspostmyocardial infarction. The letters were basedon Ajzen and Madden’s theory of plannedbehaviour107 and designed to influence acceptanceand attendance, although the authors noted that
the intervention many have been interpreted as afear message. Krasemann and Busch109 describeda before-and-after study in which the interventiongroup received a pamphlet with motivationalinformation about outpatient heart groups as acontinuation of inpatient cardiac rehabilitation.Patients in both intervention and comparisongroups received the addresses of local outpatientheart groups. The patients receiving themotivational pamphlet were more likely to attendthe heart group, but no comparison of baselinecharacteristics of the patient groups was reported.The RCT of Hillebrand and colleagues108
evaluated regular contact between a social workerand patients starting at the end of an inpatientcardiac rehabilitation programme. A motivatingconversation predischarge and a telephone callafter 4 weeks were associated with improvedattendance at an outpatient heart group.
Another before-and-after study of an interventionto improve uptake of cardiac rehabilitation waspublished outside the review time-frame.112 Theintervention comprised a telephonecommunication about the benefits of cardiacrehabilitation plus assistance in the referralprocess. The authors reported an increase inenrolment, but the significance of this interventionis not clear, as other between-group comparisonswere not described.
Resource implications of interventionsto improve uptake of cardiacrehabilitationInformation provided on resource use associatedwith effective interventions from studies ofreasonable quality is summarised in Table 19. Theinterventions can be summarised into threecategories: home visits by trained lay volunteers,coordination of referral and postdischarge care bypaid liaison nursing staff; and motivationalcommunication letters or pamphlets distributed bypaid staff.
Studies provided limited information on theresource inputs required. None providedinformation on the costs associated with theseresource inputs. It was unclear from theinformation available whether interventions can beimplemented by existing staff or requireemployment of extra staff and, if so, how many.Osika82 does not specify the number of trained layvolunteers per patient population required tocarry out home visits in order to encouragepatients’ attendance for cardiac rehabilitation. Themain cost incurred by the health service is thatassociated with the one-off training programme
provided by the hospital for the lay volunteers. Acardiac rehabilitation coordinator, a counsellor, aresuscitation officer and a safety officer conductedthe training, which comprised seven 5-hoursessions. The specific time input of each staff type,however, was not clearly specified, nor was it clearhow many lay volunteers were trained over thisperiod. Lay volunteers were reimbursed mileagecosts to attend for training and home visits, butthese were not quantified.
Similarly, the staff implications of liaison nursecoordination of referral and postdischarge carewere unclear. The intervention evaluated by Jollyand colleagues104 comprised three cardiac liaisonnurses who coordinated the referral andpostdischarge care of 277 patients over 18months. This suggests that one nurse could beresponsible for coordinating the referral andpostdischarge care of 62 patients per annum. It isunderstood that these liaison nurses were newappointments. Although mentioned in the study,transport costs incurred by the liaison nursevisiting practices and by the practice nursesattending training and support groups were notquantified, nor was the resource input or cost oftraining the liaison and practice nurses.
The use of motivational letters and pamphletsmay require some initial preparation and printing,but at little additional resource input to thestandard programme invitation, as these are likelyto replace existing letters. Motivational telephoneconversations and home visits by social workerswill require staff time and transport costs, butthese were not quantified in the study byHillebrand and colleagues.108
Further interventions that may improveuptake of cardiac rehabilitationsuggested in the literatureThe literature review identified a number ofsuggested interventions for improving uptake ofcardiac rehabilitation. Although these potentialinterventions were not evaluated, the studiesprovided some evidence to suggest methodsmeriting further investigation. Examples ofinterventions excluded from the review at bothformal extraction and the earlier inclusion stage,but with possible value in improving uptake, aresummarised thematically in Table 20.
DiscussionFew studies aimed at improving uptake ofoutpatient cardiac rehabilitation were found. The
Systematic review of interventions to improve uptake of cardiac rehabilitation
34
source of studies was diverse with five paperspublished in peer-reviewed journals, two as theses(the paper by Wyer and colleagues106 waspublished after June 2001 but had previously beenwritten as a thesis) and one as a conferenceabstract. The systematic review identified studiesof four types of intervention aimed towardsimproving uptake of outpatient cardiacrehabilitation and heart groups: written or auralmotivational communications, healthcareprofessional-led interventions at the patient level,coordination of referral and postdischarge care atthe service level, and lay volunteers.
The evidence for benefits from motivationalcommunications was reasonably good, withimprovements in uptake of outpatient cardiacrehabilitation and heart groups shown in tworandomised trials106,108 and one before-and-afterstudy.109 Methods of communication used werewritten letters106 or pamphlets,109 or conversationwith a health professional.108
No conclusions can be drawn on the effectivenessof an intensive home-based nurse-led approach inpromoting outpatient cardiac rehabilitationuptake, owing to the limited information in theone report looking at this type of intervention.110
A multifaceted approach to the coordination oftransfer of care from hospital to general practiceincluding patient self-management was effective inimproving cardiac rehabilitation uptake in arandomised trial.104 Particular aspects of theintervention were not evaluated separately, and itis not possible to compare the relative importanceof inpatient nurse contact, professional support ofpractice nurses and self-empowerment of patientswith record cards. Issues relating to study qualitylimit further support from two non-randomisedtrials.41,111
Regular support and practical assistance from layvolunteers was effective in improving uptake ofoutpatient cardiac rehabilitation in a non-
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TABLE 19 Resource implications of interventions to improve uptake of cardiac rehabilitation (only considering period of interventionrelating to improving uptake)
Staff Equipment Consumables Notes
Lay volunteers
Home visits by trained lay volunteers andaccompaniment to firstCR session (Osika, 200182)
Multidisciplinary teamproviding 35 hourstraining per group ofvolunteers
Car mileage for sevenlocal visits per patient,training at hospital
Considerable timedemands on volunteers
Coordination of referral and postdischarge care
Liaison nurseencouragement to seepractice nurse. Supportfor practice nurses.Patient-held record card.(Jolly et al., 1999104)
Three cardiac liaisonnurses visit bothpatients and practicenurses
Telephone calls; trainingfor cardiac liaison nursesand practice nurses; carmileage allowance fortraining and supportmeetings
The study employedthree nurses managingthe care of 277 patientsin 18 months
Motivational communication
Telephone and at-homeconversations with socialworker (Hillebrand et al.,1995108)
Social worker visitspatients
Telephone calls; carmileage for one localvisit per patient
Motivational lettersdesigned to increaseattendance (Wyer et al.,2001106)
(Support staff; minimalrevision of normalpractice)
Letters and postage Letters substitute forexisting invitations
Pamphlet withinformation designed tomotivate patients to joinoutpatient heart groups(Krasemann & Busch,1988109)
(Support staff; minimalrevision of normalpractice)
Pamphlets
randomised trial of demographically similardistricts with different service provision.82
All authors reported benefit for interventions toimprove uptake of outpatient cardiacrehabilitation. This observation should be treated
with caution, as it is suggestive of positivepublication bias.141 However, the wide-rangingsearch of grey literature including conferenceabstracts and theses should have identified studiesconsidered of limited value for dissemination byauthors and publishers. Although it is reasonable
Systematic review of interventions to improve uptake of cardiac rehabilitation
36
TABLE 20 Further interventions that may improve uptake of cardiac rehabilitation suggested in the literature
Authors, date Intervention Description of report
Non-specificSuskin et al., 2000124 Physician endorsement RCT. Outcome is intent to
participate in CR
Caulin-Glaser & Education of health professionals Before-and-after study. Outcome Schmeizel, 2000123 is referral to CR
Kalayi et al., 1999122 Computerised referral pathway Before-and-after study. Outcomeis referral to CR
Cannistra et al., 1995128 Early social services involvement could improve social Prospective study comparing support and therefore uptake and adherence, by reducing black and white womenhome stress
Beach et al., 199671 Self-care limitations assessment may help to assess, plan and Longitudinal interviewsfacilitate healthy perceptions and behaviour post-MI and promote CR
Tack & Gilliss, 1990129 Early information and follow-up can improve recovery Prospective, longitudinal expectations, give support and promote healthy coping and interviewsCR uptake
Hershberger et al., Assessment of patient personality type could give a better Retrospective study1999130 indicator of compliance, uptake and adherence, and allow
professionals to target those most in need
Alternative methods of provisionDeBusk et al., 1985131 Home-based rehabilitation with ECG monitoring RCT. Comparison of methods of
delivery
Lewin et al., 1992132 Home-based rehabilitation RCT. Effectiveness
Shaw, 1999133 Physiologically monitored exercise and health education Reviewover the Internet
Ades et al., 2000134 Home-based telephone-monitored CR Trial: group allocation by distancefrom CR. Comparison ofmethods of delivery
Roitman et al., 1998135 Case-management and risk stratification Review
Bethell & Mullee, 1990136 Community-based CR: achieves high patient uptake RCT. Effectiveness
Pell & Morrison, 199851 Community-based CR: more patient friendly, improving Audituptake, particularly if run in socially deprived areas
Contractor et al., 2000137 Community-based CR: may increase accessibility of services RCT. Effectiveness
Interventions for womenRadley et al., 199857 Implementing a one-off women-only education session in a Retrospective study
CR programme may help to address gender-sensitive issues e.g. returning to sexual relations and housework
Moore, 1996138 Women-specific social support. Strategies to improve social Focus-group interviewssupport: better exercise variety and choice, and social opportunities during the programme
Brezinka et al., 1998139 Women-specific counselling and smaller exercise sessions Comparative semistructuredinterviews and questionnaires
Cannistra et al., 199224 Provision of childcare/home-help for women attending Prospective study comparing men outpatient CR and women
Toobert et al., 1998140 Women’s retreat could increase uptake by improving RCT. Effectivenessemotional social support and relationships with CR staff
to anticipate some improvement, it is not knownhow many similar or different interventions havebeen tried without success and, becauseunsuccessful, not reported. Similarly, equivocalresults relating to cardiac rehabilitation uptakemay not have been included in publications ofstudies with multiple findings. Three of the eightstudies included in the review reported substantialmaterial on other outcomes or observations, whichwould have merited full publication.
It would be inappropriate to draw firmconclusions relating costs to effectiveness of theinterventions described in the above studies. Theirresource use implications are not clearly described.However, order of magnitude costs may beinferred and these suggest a wide range in impliedcosts. Motivational interventions need not becostly, as they may replace the existing method ofinvitation. Individual home visits clearly add tothe costs of a service otherwise provided in anoutpatient setting. However, more visiting isbecoming part of postdischarge care and cardiacrehabilitation. The study by Jolly and colleagues104
was an evaluation of the introduction of liaisonnurses (which would certainly be more costly) andmay serve to define their role in supportingpatients and other healthcare professionals andcoordinating postdischarge care. Incorporation ofmotivational elements into home visiting may beappropriate, with little further implications forresources.
The literature contained many suggestedinterventions as facilitators of improved uptake ofcardiac rehabilitation, but with no relevantevaluation. At the service level, appropriateeducation of health professionals and use ofdischarge care pathways and case managementmay improve referral and subsequent attendanceat rehabilitation.122–124,135 In a similar vein to themotivational approach of Wyer and colleagues106
the form of the recommendation to attend may beimportant, with endorsement by a physician ofpossible value.124
Early support postdischarge by healthcareprofessionals may be appropriate in promotingcardiac rehabilitation and improving uptake.128,129
In addition, at an early stage the assessment ofpatients with regard to self-care limitations andpersonality type may be helpful in the targeting,planning and optimisation of postdischarge care,including rehabilitation.71,130
Home-based programmes are frequently used inthe period between hospital discharge and
attendance at outpatient cardiac rehabilitation.142
The home-based programme usually takes theform of a written booklet with an exerciseschedule, psychosocial interventions andeducation relating to risk factor managementappropriate for the early stages of recovery. Thismay serve to maintain patient motivation tolifestyle change in a period with limited contactwith health professionals and hence promote lateruptake of outpatient rehabilitation services. Thismerits further evaluation.
Home-based cardiac rehabilitation has also beenpromoted as a substitute for attendance at anoutpatient programme.131,132 Trials have shownsimilar effectiveness in risk factor managementand patient quality of life after home-based andoutpatient methods. Appropriately delivered andassessed home-based cardiac rehabilitation may bea safe and effective form of provision for low- tomoderate-risk patients. However, application ofthe home-based approach as a means to improvethe reach of cardiac rehabilitation services shouldreplicate the methods used in the trials ofeffectiveness and include frequent nurse visits,multidisciplinary input, psychological evaluationand thorough assessment. Patient acceptance of ahome-based package does not equate to uptake ofcardiac rehabilitation and the demonstration ofcomparability with an existing service may merelybe observation of similar natural recovery in thepatient groups. Consequently, home-basedrehabilitation is not an appropriate substitute foroutpatient services in patients with more severedisease or those with low motivation or lack ofinterest. It may have value in motivated low- tomoderate-risk patients, particularly those livingdistant from current services. If there is arequirement for monitoring and assessment thiscould be undertaken using telemedicineapproaches, including ECG monitoring andtelephone contact during exercise sessions.131,133,134
An alternative approach to cardiac rehabilitationprovision outside the hospital setting is the use offacilities in the community.51,136,137 The serviceprovided can be identical to the outpatientprogramme in content and multidisciplinarynature but avoid features associated with reducedattendance at hospital, including accessdifficulties. Similarly, factors limiting the uptake ofhome-based cardiac rehabilitation may be avoided,including reduced reliance on patient self-motivation. Cardiac rehabilitation in a communitysetting merits evaluation as a method forimproving patient uptake and may be particularlyvaluable in socially deprived areas.51
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Systematic review of interventions to improve uptake of cardiac rehabilitation
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The need to adapt cardiac rehabilitation servicesto suit female patients has been acknowledged byseveral authors.57,128,138–140 Many female patientshave a higher level of psychosocial impairmentand lower level of physical function than men, andtherefore need gender-specific approaches torehabilitation.139 Suggested interventions toimprove uptake include a women-only educationsession,57 appropriate exercise choices,138 specificcounselling,139 strategies to improve socialsupport,138 provision of childcare and home-help,24 and a women’s retreat.140
There are numerous reports of reasons for non-attendance and under-representation in outpatientcardiac rehabilitation, so it is surprising that thesystematic review of published literature identifiedso few evaluations of interventions to improveuptake. All those found were generic interventionsapplicable to all patients. The effectiveness ofsimple targeted interventions to facilitateattendance is not reported in the literature. Noevaluations of interventions were reported toaddress the frequently cited patient reasons fornon-attendance of perceived illness, transportdifficulties, inconvenient timing or dependentrelatives. Transport schemes, non-hospital settings,programmes for specific patient groups (singlegender, elderly, ethnic minority groups) andprovision of respite care for dependants have beensuggested, but not evaluated as possible measuresfor improving service uptake. It is possible that
some programme coordinators have recogniseddeficits and the need for improvement in services and implemented changes: provision ofservices for a patient group previously nottargeted for rehabilitation is likely to show initial improvement in uptake; but this is aHawthorne effect which may not be sustained.However, the lack of evidence for benefit foundfor the use of critical care pathways and thelimited evidence for other interventionsdemonstrate the requirement for good qualityRCTs of new methods.
ConclusionsThe systematic review of the literature suggeststhat approaches aimed at motivating patients maybe of value in improving the uptake of cardiacrehabilitation. The content of invitation letters,pamphlets and home visits may be used as avehicle for motivational messages. Someencouragement was also found for use of trainedlay visitors in facilitating patient attendance atcardiac rehabilitation. The implied costs ofinterventions varied widely.
Overall, few trials aimed at improving uptake ofcardiac rehabilitation were identified. The needfor trials of interventions applicable to all patientsand targeting specific under-represented groups issuggested by observational studies.
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BackgroundFollowing successful recruitment of patients to acardiac rehabilitation programme it is importantto promote patient adherence to the programmeand to maintain associated lifestyle changes. Thissystematic review aims to assess the effectiveness ofmethods for increasing patient adherence tocardiac rehabilitation and to suggest areas forfurther research. For the review adherence wasdefined as patient attendance at all or the majorityof a programme, or maintenance of lifestylechanges associated with cardiac rehabilitation.
ResultsStudies included in the review ofinterventions to improve adherencewith cardiac rehabilitationIn Appendix 10 the flow of articles through thereview process is shown in accordance withQUOROM.101 Thirty-eight articles reporting 37studies identified as relevant to the review ofmethods to improve adherence to outpatientcardiac rehabilitation and its components wereformally included in the review. A broad definitionof adherence was applied, with included studiesreporting attempts to improve overall programmeattendance or compliance with aspects of cardiacrehabilitation. In-depth reading by two reviewers(KR and AB) found 14 studies reportingevaluation of an intervention relating toadherence in an appropriate patient group andwith a relevant outcome. Only studies with anexplicit statement in their objectives that theintervention under evaluation was designed topromote adherence or those studies withobjectives that were explicitly to examine theeffects of an intervention on adherence wereincluded in the review.
Studies were characterised by study design andsize, the study participants, nature of theintervention, comparison group, principal andother outcomes, and authors’ conclusions.
A brief summary of studies is presented in Table 21, with further details in Appendix 11. Tworeports were identified describing the study ofMiller and colleagues.143,144
Studies excluded from the review ofinterventions to improve adherence to cardiac rehabilitationPapers not included in the review are summarisedin Appendix 12. Nine out of 23 studies excludedfrom the review looked at the effectiveness ofdifferent rehabilitation formats: home-basedcardiac rehabilitation,73,131,134,158 differentintensities or duration of exercise training, 159–161
group counselling162 or structured teaching.163
These were not included in the review as theyreported effectiveness of interventions with nospecific aim at improving patient adherence tocardiac rehabilitation. Thirteen studies had eitherno relevant outcome126,164–172 or no comparisongroup.173–175 One study presented retrospectivedata with no indication of how patients came toreceive an intervention.121
Methodological qualities of studiesincluded in the review of interventionsto improve adherence to cardiacrehabilitationFourteen studies were identified, of which halfwere RCTs145–151 and half were non-randomisedstudies.143,144,152–157 One randomised147 and onenon-randomised study156 reported two distinctinterventions. In the non-randomised studiespatients were designated to groups by alternateallocation,143,144,152 before and afterimplementation of an intervention154,156,157 and byrandom allocation with some non-randomallocation aimed at increasing numbers in theintervention group.153 In two studies the allocationto groups was not clearly described.155,156
In six studies patients with one specific diagnosiswere included and in eight studies less specificselection was applied. Patients represented weremyocardial infarction (nine studies), CABG (eightstudies), angina (three studies), PTCA (three
Chapter 9
Systematic review of interventions to improve adherence to cardiac rehabilitation
Systematic review of interventions to improve adherence to cardiac rehabilitation
40
TABLE 21 Studies evaluating interventions to improve adherence to cardiac rehabilitation
Authors, year Study type and Intervention Outcome relevant to Commentsand country patients adherence
RCTs
Oldridge &Jones, 1983145
Canada
RCT, 120 MI,CABG and anginapatients
Self-management: agreementto participate in exerciserehabilitation programmesigned by patient andcoordinator; self-report diarywith monitoring of heartrates; questionnaires of dailyactivities; weight loss andsmoking diaries. Progressdiscussed with coordinator atregular intervals
Attendance at >60% ofexercise sessions was 54% inthe intervention group and42% in the control group(not statistically significant)
Daltroy, 1985146
USARCT, 174 MI,CABG, PTCA andangina patients
Persuasive telephoneeducation intervention toimprove patient adherenceto exercise regimens. Oralcommitment to attend.Spouse telephone counselling
Attendance at exercisesessions by patients was63.8% in the interventiongroup and 62.2% in thecomparison group (notstatistically significant)
Mahler et al.,1999147
USA
RCT with twointerventiongroups and onecontrol group,215 CABGpatients
Post-CABG surgeryvideotape. (1) Mastery:depicts patients as calm andconfident, making steadyprogress with relative ease.(2) Coping: recoveryportrayed as steady forwardprogression of ups anddowns
Exercise complianceimproved with bothinterventions compared withcontrols (p < 0.02 to p < 0.05). Reduction indietary cholesterol andsaturated fat at 1 month inboth intervention groupscompared with controls (p < 0.05) but not at 3 months
Aish & Isenberg, 1996148
Canada
RCT, 104 MIpatients
Nursing intervention ofnutritional self-care. Foodhabits assessed andsuggestions for changes givenwith patient commitment.Follow-up telephone calls
Total dietary and saturatedfat significantly reduced inthe intervention group (p < 0.01). Also significantimprovements in food habits(p < 0.05)
Ashe, 1993149
USAAllocation byform in sealedenvelope, 41 MI, CABG,angina, valveproblem patients
Motivational relapseprevention during the CRprogramme: identification offactors interfering withadherence; goals forprogramme; coping withslips; stressors affectinglifestyle. Also stressmanagement, exercise andrelaxation procedure
Total adherence to themaximum number ofexercise sessions was 90% inthe intervention group and89% in the control group(not significant)
continued
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TABLE 21 Studies evaluating interventions to improve adherence to cardiac rehabilitation (cont’d)
Authors, year Study type and Intervention Outcome relevant to Commentsand country patients adherence
Hopper,1995150
USA
RCT, 80 MI,CABG,angioplastypatients
Monthly telephone contactby a cardiac nurse orexercise physiologist topromote exercise, healthydiet, medication usage, riskfactor knowledge andidentification of symptoms
No difference betweengroups in exercise habit orintention to exercise.Conditions that facilitated theperformance of exercisewere improved in theintervention group comparedwith control (p < 0.05)
Losses to follow-up of45% in the interventiongroup and 47% incontrols
Duncan et al.,2001151
USA
RCT, eight heartfailure patients
Behavioural feedbackintervention on dietarysodium intake. Discussion ofproblem-solving strategies toreduce sodium intake
Sodium intake wassignificantly less in theintervention group (1569 vs2836 mg, p < 0.05)
Small feasibility study,four patients in eachgroup
Leslie &Schuster,1991152
USA
Alternateallocation, 30 MI,CABG,angioplasty,coronary diseasepatients
Written exercise contractnegotiated with the patient.On completion of thecontract patients received areward
No significant difference inattendance in intervention(90%) and control (89%).Significant increase inexercise knowledge in theintervention group
Miller et al.,1988,143
1989144
USA
Alternateallocation, 115 MI patients
Nurse intervention toimprove medical regimen. (1) Assessment: attitudes andregimen compliance. (2) Problem identification. (3) Goal setting
No significant differences inhealth behaviour and attitudescales
Repeated self-evaluationquestionnaires and visitsmay have acted asintervention in controlgroup
Lack, 1985153
USA Part random, partnon-randomised,48 CHD, MI,CABG patients
Insight-orientated grouppsychotherapy. Supportive,cooperative and goaldirected. Highlight andpromote change in non-compliance with physicianrecommendations
Self-report measures ofcompliance 2.57 forintervention and 2.37 controlgroups (not significant).Intervention group attended88.4% of the prescribedexercise sessions comparedwith 75.7% in the controlgroup (p < 0.05)
Marshall et al.,1986154
USA
Patients seen indifferent periods,60 CABGpatients
Nurse-led structuredteaching programme toincrease patients’ knowledgeand compliance tomedication, diet, smokingcessation and exercise
Overall compliance scoreassessed by self-report was86.8 in the interventiongroup, and 79.5 in thecontrol group (p < 0.05).Compliance better inintervention than controlgroup for activity (15.6 vs 7blocks walked, p < 0.005)
Huerin et al.,1998155
Argentina
Non-randomisedstudy, 509 CHDpatients
Adherence strategy withsigned commitment torehabilitation, familyinvolvement, sports,recreational activities andtalks
Attendance at ≥ 66%sessions. RR 2.3 (95% CI 1.8to 2.9) at 12 weeks, 2.9 (2.3to 3.7) at 24 weeks, 4.25(3.2 to 5.6) at 52 weeks (log-rank test between strategies,p < 0.001)
No information ongroup allocation
Non-randomised studies
continued
studies), heart failure (one study), valvereplacement (one study) and non-specific coronaryheart disease (four studies).
In eight studies (two randomised) the outcome wasattendance at exercise sessions.145,146,149,152,153,155–157
In six studies (four randomised) the outcome wasquestionnaire assessment of diet or exercisebehaviours to determine compliance with lifestylechanges.143,144,147,148,150,151,154
The method of randomisation was described intwo of the seven RCTs145,146 and blind outcomeassessment in one randomised study.146 None ofthe seven non-randomised studies reported blindoutcome assessment. Baseline characteristics ofintervention and comparison groups weredescribed in three randomised trials,146,148,150 andin one trial patients were stratified by factorspredictive of dropout from cardiacrehabilitation.145 In five non-randomised studiesbaseline characteristics of patients werereported.143,144,152–155 Eight studies providedinformation on losses to follow-up.143–147,149,150,152,153 In one randomised study lossto follow-up was particularly high at 45–47%.150
Themes identified from the review ofinterventions to improve adherence tocardiac rehabilitationInterventions to improve adherence to cardiacrehabilitation or elements of the rehabilitationprocess were varied and frequently multifaceted.
However, five general themes are apparent: formalpatient commitment, spouse or familyinvolvement, strategies to aid self-management,education, and psychological intervention. Studieswith more than one component are included ineach appropriate theme.
Formal patient commitmentIn four studies an agreement between the patientand the programme staff was a key element of theintervention.145,146,152,155 In the trial of Leslie andSchuster152 the intervention was solely a writtencontingency contract with rewards for successfulcompletion of attainable exercise behaviours.Patients were allocated alternatively to interventionand comparison groups, which were reasonablywell matched. Attendance rates at exercise sessionswere similar in the two groups, although patientsin the contract group showed a significant increasein exercise knowledge compared with controls.Overall participation at exercise sessions wasnotably high (90%). In the RCT of Oldridge andJones,145 a self-managed adherence promotingstrategy incorporating signed commitment wasassociated with a non-significant improvement inattendance at an exercise rehabilitationprogramme. Huerin and colleagues155 reported asignificant increase in cardiac rehabilitationattendance in patients receiving an adherence-promoting strategy with signed agreement, butlittle information was presented on the allocationof patients to groups. Daltroy146 reported an RCTin which oral commitment was included in a
Systematic review of interventions to improve adherence to cardiac rehabilitation
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TABLE 21 Studies evaluating interventions to improve adherence to cardiac rehabilitation (cont’d)
Authors, year Study type and Intervention Outcome relevant to Commentsand country patients adherence
McKenna et al.,1998156
UK
(1) Non-randomisedstudy. (2) MIpatientscompared withhistorical controls
(1) Low-intensity exercise forpatients unable to take partin standard exercise owing toco-morbidity. (2) Women-only groups
Attendance was 82% in thelow-intensity exercise groupand 34% in the standardrehabilitation comparisongroup. Significance notassessed as patient numbersnot reported. Attendance inthe women-only group was75%, compared with 6%historically
Patient numbers notreported. Themagnitude of changescannot be assessed
Erling &Oldridge,1985157
Canada
Before-and-afterstudy, 90 CHDpatients
Spouse support in outpatientCR. Compares baselinebefore spouse participation,patients with spouseparticipation and patientswith no spouse participation
Attendance increased from44% to 90% for programmewith spouse participation (p < 0.001), and 67% forprogramme with no spouseparticipation (p < 0.05)
RR, relative risk.
persuasive telephone intervention to improvepatient adherence to an exercise programme. Noimprovement in attendance was seen in patientsreceiving the intervention.
Spouse or family involvement Three studies included an intervention directed at the patient’s spouse or family.146,155,157 Erlingand Oldridge157 reported a before-and-after studyin which a spouse support programme wasassociated with significantly increased patientattendance at a cardiac rehabilitation programme.The authors showed no baseline comparisons ofthe two groups. In the RTC of persuasivetelephone education, Daltroy146 providedtelephone counselling to patient spouses. Noimprovement in attendance was associated withthe intervention. Family involvement was also acomponent of the adherence strategy of Huerinand colleagues.155 Improved outpatient cardiacrehabilitation attendance was observed, but lack ofinformation on group allocation limits the value ofthe study.
Strategies to aid self-management Five studies reported interventions based on self-management techniques.143–145,148,149,151 In theRCT of Oldridge and Jones,145 as well as signedagreement, patients completed and receivedfeedback on self-report diaries of heart rate, dailyactivities, weight loss and smoking habit. Theintervention was associated with a non-significantincrease in attendance at the exerciserehabilitation programme. Aish and Isenberg148
reported an RCT of nutritional self-care based onthe model of Orem,176 in which patients had foodhabits assessed and individualised nutritionalgoals set. Significant improvements in dietaryvariables were achieved in the self-care patients. Asimilar programme of assessment, problemidentification and goal setting was assessed in atrial by Miller and colleagues,143,144 in whichpatients were allocated alternatively tointervention and control after completion of acourse of inpatient rehabilitation. Regimencompliance measured by health behaviour andattitude scales did not differ between groups. Theauthors noted that the frequent completion of self-evaluation questionnaires and data collection visitsby nurses may have served as an effectiveintervention in the control group. In the thesis byAshe149 an apparently randomised approach wasused to evaluate a motivational relapse preventionprogramme, based on Marlatt and Gordon’smodel,177 for patients after an outpatient cardiacrehabilitation programme. Patients were allocatedto groups according to the forms contained in
sealed envelopes. As with other self-managementinterventions this included assessment, problemidentification and goal setting. Adherence toexercise was similar in the intervention andcontrol groups. However, it should be noted thatthe control patients received an interventionwhich, although not designed as a motivationalprogramme, did provide patients with anequivalent number of extra sessions of exerciseeducation. A small RCT described by Duncan andcolleagues151 applied self-management andbehavioural feedback methods to the control ofsodium intake. Heart failure patients attending acardiopulmonary rehabilitation programme wererandomised to receive an intervention withassessment of sodium intake, discussion ofproblem-solving strategies and follow-up. Patientsreceiving the intervention had a significantlyreduced sodium intake.
Educational intervention Four studies of educational interventions aimed atimproving adherence to components of cardiacrehabilitation were identified.146,147,150,154 TheRCT reported by Daltroy included an educationalintervention in the form of telephonecounselling.146 This was designed as a persuasivecommunication with emphasis on the benefits ofexercise, realistic expectations of recovery andcoping methods. Attendance at exerciseprogrammes was not improved in the group withthe educational intervention. In the RCT ofMahler and colleagues147 patients were showneducational videotapes before discharge fromhospital. The tapes provided informationregarding recovery delivered by a healthcareexpert. Compliance with exercise and dietaryadvice measured by questionnaire was increased inpatients receiving the intervention. The authorssuggest that presenting the information in aformat describing a realistic coping approach torecovery may be beneficial. Hopper150 describedan RCT of regular educational and supportivetelephone calls. Although no difference was shownin exercise behaviour between groups, thosepatients receiving the supportive educationalintervention did report improvement in conditionsfacilitating the performance of exercise. Marshalland colleagues154 compared the effect of nurse-ledstructured and non-structured postoperativeteaching in two consecutive groups of patients.Patient characteristics and risk factors were similarin the two groups. Measures of compliance basedon self-report of activity, smoking, and acomposite of activity, smoking, diet andmedications were improved in the structuredteaching group.
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Psychological intervention One intervention describing a specificallypsychological intervention was identified.153
Lack153 describes an insight-orientated grouppsychotherapy intervention in a partiallyrandomised study. The randomised group wasaugmented with non-randomised patients if therewere insufficient numbers to form an interventiongroup. For the intervention patients wereencouraged to communicate thoughts and feelingsand to promote changes in behaviours likely toaffect recovery. Self-report and physiologicalmarkers of compliance to exercise were littlechanged by the intervention. However, there was asignificantly higher attendance at exercise sessionsin the patients receiving the psychotherapyintervention.
Other interventions Two reports described interventions that did notfit into the above themes.155,156 McKenna andcolleagues156 reported that attendance wasincreased after implementation of women-onlyand low-intensity exercise programmes. Numbersin comparison groups and patient characteristicswere not reported. In the study by Huerin andcolleagues155 recreational activities and sports wereincluded in the adherence strategy. Again, thereporting precludes any assessment of value.
Resource implications of interventionsto improve adherence to cardiacrehabilitation Information provided on resource use associatedwith effective interventions from studies ofreasonable quality is summarised in Table 22. Theinterventions can be summarised into twocategories: strategies to aid self-management, and
educational interventions. Studies providedlimited information on the resource inputs and noinformation on the costs associated with theseresource inputs.
It is unclear whether the strategies to aid self-management can be implemented by existing staffor require the employment of extra staff and, if so,how many. The intervention described by Aish andIsenberg148 consisted of two interviews with anurse for dietary assessment and three follow-uptelephone calls by a nurse for each patient. Thefirst interview was conducted in hospital and thesecond at a home visit. Duncan and colleagues151
evaluated a similar intervention, but in their studyboth interviews were conducted during outpatientcardiac rehabilitation sessions. In both studiespatients were also required to complete a 3-daydietary intake log. The videotape intervention ofMahler and colleagues147 was provided in hospitalbefore discharge. After initial preparation ofeducational material the main resource input ofthe intervention would be the appropriateaudiovisual equipment.
Further interventions that may improveadherence to cardiac rehabilitationsuggested in the literatureThe literature review identified a number ofsuggested interventions for improving adherenceto cardiac rehabilitation. Although these potentialinterventions were not evaluated, the studiesprovided some evidence to suggest methodsmeriting further investigation. Examples ofinterventions excluded from the review at bothformal extraction and the earlier inclusion stage,but with possible value in improving uptake, aresummarised thematically in Table 23.
Systematic review of interventions to improve adherence to cardiac rehabilitation
44
TABLE 22 Resource implications of interventions to improve adherence to cardiac rehabilitation
Staff Equipment Consumables Notes
Strategy to aid self-management
Nursing intervention ofnutritional self-care (Aish & Isenberg, 1996148)
Nurse Telephone One visit in hospital andlocal visit; threetelephone calls perpatient; dietary records
Behavioural feedback ondietary sodium (Duncanet al., 2001151)
Nurse Two interviews duringoutpatient rehabilitation;dietary records
Educational intervention
Post-CABG surgeryvideotape (Mahler et al.,1999147)
Video recordingand player
Video shown in hospitalbefore discharge
DiscussionInformation came from journals (seven studies),theses (three studies) and conference abstracts(four studies). It was disappointing to find thatsome evaluations of potentially valuable methodsto improve adherence to outpatient cardiacrehabilitation and its components were only foundin the grey literature, with little chance of beingread by health professionals.
Systematic review of the literature identified fivemain intervention themes: formal patientcommitment, spouse or family involvement,strategies to aid self-management, education, andpsychological therapy.
The review of the literature gave little support tothe use of written and oral commitments topromote exercise adherence. The one studylooking exclusively at written contracting showed
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TABLE 23 Further interventions that may improve adherence to cardiac rehabilitation suggested in the literature
Authors, year Intervention Purpose of study
Non-specificMcGee & Horgan, 199254 Former patients as models may help to promote adherence Audit
Tooth & McKenna, Strategy to improve self-efficacy. Patient modelling on video Review1996178 and audiotape and in leaflets. Patients view other patients
(e.g. healthy meal preparation)
Koikkalainen et al., Social skill and taste-training may remove barriers to a Structured interviews1996179 healthy lifestyle
Knapp & Blackwell, Offering specific and practical assistance for spouses Review1985180 (e.g. menus and recipes) to help improve, lifestyle change
Edgren, 1998181 Hydrotherapy as part of the exercise component. To Generic case study and interviewsincrease self-training patients attend a gym and/or hydro session weekly
Lee et al., 1996161 Lower intensity exercise programme RCT of effectiveness
Oldridge, 1984182 Vary programme and include swimming and different Reviewexercise equipment
DeBusk et al., 1994183 Case management and risk stratification. A more RCT of effectivenessRoitman, et al., 1998135 individualised package of care may lead to improved Review
adherence
Hoepfel-Harris, 1980184 Provide classes at convenient times, including before work ReviewComoss, 1988185 and evenings ReviewEmery, 1995186 Review
Interventions for womenRadley et al., 199857 A one-off women-only education session may help to Retrospective study
address gender-sensitive rehabilitation issues
Moore & Kramer, 1996187 Women-specific social support, exercise variety and choice, Focus-group interviewsand social opportunities
Brezinka et al., 1998139 Women-specific counselling and smaller exercise sessions Comparative semistructuredinterviews and questionnaires
Toobert et al., 1998140 Women’s retreat to improve emotional social support and RCT of effectivenessrelationships with cardiac rehabilitation staff
Cannistra et al., 199224 Provision of childcare or home-help for women attending Prospective comparison study of cardiac rehabilitation men and women
Interventions for the elderlyAllen & Redman, 1996188 Awareness of elderly-specific hindrances. Shorter education Review
sessions with less information run at a slower pace
Interventions for ethnic groupsCaulin-Glaser & Take account of cultural and racial differences when Prospective observational studySchmeizel, 2000123 attempting to improve diet and exercise habits.
African–American males showed fewer improvements in diet than Caucasians
Eftekhari et al., 2000189 Translation and presentation of educational material for Programme descriptionAsian patients
no effect using a non-randomised design.152
Attendance in both intervention and controlgroups was high at about 90%. A randomised trialof a self-management programme incorporatingsigned agreement to participate as an adjunct toan exercise rehabilitation programme showed anon-significant improvement in attendance.145
The small benefit cannot be attributed entirely towritten communication as the interventionincluded several other self-managementapproaches. Similarly, in a study of persuasiveintervention by telephone with additional spousecounselling, oral commitment constituted one partof the intervention.146 No improvement inattendance was attributed to this package ofmeasures. One further study provided littlemethodological information to substantiate anobserved improvement in cardiac rehabilitationafter an adherence strategy incorporating signedcommitment.155 Overall, the value of formalcommitment in promoting adherence to cardiacrehabilitation is not supported by evidence fromthe literature. The identification of only one studylooking specifically at written agreement toparticipate, but in which attendance was uniformlyhigh in intervention and comparison groups maysuggest the need for more trials. However, it isprobable that the use of written and oralcommitment has better application in thepromotion of outpatient cardiac rehabilitationuptake rather than adherence.
Evidence for the benefit of spouse or familyinvolvement in increasing rehabilitation adherencewas limited by the designs of studies. One studylooking specifically at a spouse supportprogramme provided no information on baselinecharacteristics or group allocation.157 In anotherrandomised study telephone counselling forspouses was provided in addition to a moreintensive patient counselling intervention, but noimprovement in attendance was observed.146
Another study incorporated family involvementinto an adherence-promoting strategy, but littleinformation on the design or conduct of the studywas reported.155 None of these studies addressedspecifically the issue of spouse or familyinvolvement in promoting rehabilitationattendance in an adequately designed trial.Evidence for the effectiveness of counselling andsupport in helping spouses and families to copewith patient illness suggests that interventions mayhave value other than in promoting adherence tocardiac rehabilitation.144,190
Studies reporting strategies to aid self-management aimed at improving adherence to
rehabilitation goals give some suggestion ofbenefit. In a randomised trial of self-evaluationand information feedback on exercise and riskfactors a non-significant improvement inattendance at rehabilitation was observed.145 Inthis trial patients were also asked for writtencommitment. Another randomised trial reportedimprovements in dietary habits,148 and a small,randomised trial showed reduced sodium intakeafter individualised assessment and goal setting.151
However, two trials, one randomised149 and theother with non-random allocation to groups,143,144
suggested no benefit for assessment and goalsetting in improving health behaviours or exerciseadherence. The authors noted that controlpatients in these studies received regular self-evaluation questionnaires and nurse visits for datacollection143,144 or an educational interventionunrelated to self-management,149 which may haveaffected outcomes. In trials a repeatedlyadministered evaluation tool may act as anintervention. In conclusion, the uses of appropriatetechniques promoting self-management in specificareas of rehabilitation are at least worthy offurther study.
Studies of educational interventions to improveadherence to components of cardiac rehabilitationgave little encouragement. No benefits ofeducation and counselling on attendance at anexercise programme were seen in two RCTs usingtelephone interventions.146,150 A predischargevideotaped educational intervention was effectivein improving exercise and dietary compliance.147
Although this may be of benefit in the early phasesof rehabilitation it is likely to have limited value inthe promotion of adherence to outpatient cardiacrehabilitation. However, the study did suggest thatpresentation of information in a format describingrecovery based on a coping approach may be mosteffective. The importance of the method ofdissemination of educational information was alsosuggested by a before-and-after study showingbenefit for a structured teaching approach.154
One partially randomised study reported apsychological intervention aimed at improvingexercise adherence.153 Although no significantimprovement in self-reported exercise wasobserved, the patients receiving a 12-weekpsychotherapy intervention attended more cardiacrehabilitation exercise sessions. This improvedattendance may be a consequence of thepsychological features of the intervention or of theextra requirement to attend the rehabilitationcentre. The lack of an effect on self-reportedexercise tends to support the latter.
Systematic review of interventions to improve adherence to cardiac rehabilitation
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Two studies reported other approaches toimproving adherence. These were the inclusion ofrecreational activities and sports in theprogramme155 and the introduction of outpatientcardiac rehabilitation designed specifically forwomen.156 Little can be learned from either studyas insufficient information on patients and studymethods was reported.
Little information on the costs associated witheffective interventions can be inferred from thepublished reports. One can do little more thanguess the time commitment of nursing staff toundertake these extra tasks. Strategies to improvepatient self-management, such as dietaryassessments, could be incorporated into outpatientcardiac rehabilitation session and may thereforenot require home visits. Nurses would still requiretraining in the evaluation of diet and the analysisof questionnaire data, and this may serve toformalise assessment and procedures already inplace in cardiac rehabilitation.
With respect to the educational intervention,videos are frequently used to provide informationto patients before discharge, and presentation ofinformation in an alternative delivery formatwould not have resource implications. However,initial preparation or purchase of appropriateeducational videos would be required.
Outside those trials aimed at improving adherenceto cardiac rehabilitation several interventions havebeen suggested but not evaluated. These includemore approaches based around improvements inpatient self-efficacy. The inclusion in programmesof previous patients or representation on video ofbehaviour of model patients showing appropriatelifestyle change (e.g. relating to food preparation)may be a useful format for delivery ofinformation.54,178 Similarly, practical demonstrationthat a healthy diet can be palatable and enjoyablemay be a method to promote adherence to dietarychange.179 In these areas of intervention theinvolvement of spouses may be appropriate.180
Alternative forms of exercise, includingswimming,182 hydrotherapy181 and lower intensitytraining,161 may be worthy of evaluation inimproving adherence to rehabilitation.Programmes with lower exercise intensities may bemore likely to achieve maximum attendance,161
but an extended length programme may berequired to maintain benefits.144 Slower paced andless detailed sessions may be appropriate in theprovision of educational information to elderlypatients.188
Women patients may prefer different kinds ofexercise to men and be more likely to adhere torehabilitation other than treadmill and cycle.187
Other interventions that may improve adherenceby women patients suggested in the literatureinclude education, counselling and social supportaddressing issues specific to women’srecovery.57,139,187 Provision of childcare or home-help for women attending cardiac rehabilitationmay improve adherence.24
Taking into account cultural and racial differencesin the promotion of exercise and diet may help toimprove adherence by ethnic groups torehabilitation.123 Translation of educationalmaterials and presentation in an appropriate waymay improve adherence in ethnic minoritygroups.189
Other forms of rehabilitation based around riskstratification and case management are suggestedas methods to improve patient adherence,135,183
but the effectiveness of this approach comparedwith outpatient rehabilitation with appropriateoutcome measures is not known. Similarly,provision of support at a women’s retreat mayserve to promote lifestyle change, although itseffectiveness as an adjunct to outpatient care hasnot been evaluated.140
Providing classes at times to suit patients mayimprove adherence to cardiac rehabilitation.Patients may find it easier to attend classes timedbefore work and in the evening.184–186
The systematic review of the literature found fewstudies of sufficient quality to make specificrecommendations of methods to improveadherence to outpatient cardiac rehabilitation andits components. The most promising approach wasthe use of self-management techniques basedaround individualised assessment, problemsolving, goal setting and follow-up. This is mostlikely to be effective in improving specific aspectsof rehabilitation, including exercise and diet.Further investigation of this approach may be bestcarried out by a systematic review of self-management interventions in less specific patientgroups than considered here. Patient commitmentto attend did not suggest benefit in the promotionof adherence to aspects of outpatient cardiacrehabilitation, but may be useful in improvinguptake of rehabilitation. Other interventionsidentified in the literature may already bestandard practice: use of educational video andclasses, and psychological support are features ofthe modern rehabilitation programme. Similarly,
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Systematic review of interventions to improve adherence to cardiac rehabilitation
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spouse and family support may be provided as anadjunct to a rehabilitation programme for reasonsunrelated to patient adherence.
Perhaps the most disappointing outcome of thereview is the dearth of literature reporting theevaluation of simple interventions aimed atimproving adherence to cardiac rehabilitation forall patients or specific groups of patients. Nointerventions were reported to address thefrequently cited patient reasons for non-adherenceof perceived recovery, illness, transport difficulties,inconvenient timing or care of dependentrelatives. Similarly, no evaluations were identifiedof programmes designed to improve adherencefor specific patient groups frequently under-represented in outpatient cardiac rehabilitation(including women, the elderly and ethnic minoritygroups). The lack of published studies may reflectan under-appreciation by both rehabilitation staffand journal editors of the value of trials inevaluating new interventions to improveadherence to cardiac rehabilitation. Surveys andaudits suggest that programme coordinators mayrecognise deficits and the need for improvementsin services and implement changes to provisionwithout formal evaluation. The ineffectiveness ofseveral types of intervention to improve adherenceto cardiac rehabilitation identified in thissystematic review demonstrates that innovations inservices should be tested in well-designed studies.
ConclusionsThe systematic review identified few studies ofsufficient quality to assess the effectiveness ofinterventions to improve adherence to cardiacrehabilitation. Half of the studies found were insources outside the mainstream of medicalliterature.
Self-management techniques suggested somevalue in the promotion of specific aspects oflifestyle change and a further review in a broadercontext of health and disease may be appropriate.Educational interventions aimed at improvingadherence gave equivocal results and suggest thatthe format of the intervention merits furtherstudy.
Observational studies identify many areas whereinterventions may serve to improve patientadherence to cardiac rehabilitation, and surveysand audits show that interventions have alreadybeen implemented. The systematic review of theliterature suggests that, before implementation,interventions should be evaluated in well-conducted studies with economic assessment, andthe results disseminated widely and reviewedregularly.
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BackgroundBarriers to attendance at and adherence withoutpatient cardiac rehabilitation associated withservice factors have been identified. However, theeffectiveness of interventions to improveprofessional compliance with the provision ofcardiac rehabilitation has not been assessed bysystematic review. This systematic review aims toassess the effectiveness of methods for increasingprofessional compliance with cardiac rehabilitationand to identify areas meriting further research.The review includes interventions to encouragehealthcare professionals to comply with guidelinesor good practice regarding invitation and supportof patients’ cardiac rehabilitation.
ResultsStudies included in the review ofinterventions to improve professional compliance with cardiacrehabilitationEighteen articles reporting 17 studies wereidentified as relevant to the review of methods toimprove professional compliance with cardiacrehabilitation and were formally included in thereview. Reading by three reviewers (SE, FT andAB) found six studies reporting evaluation of anintervention relating to an appropriate patientgroup and with a relevant outcome. The flow ofarticles through the review process is shown inaccordance with QUOROM in Appendix 13.101
Studies were characterised by type and size,participants, intervention, comparison group,principal and other outcomes, and authors’conclusions.
A brief summary of studies is presented in Table 24,with further details in Appendix 14. More thanone report was identified from the trial of Jollyand colleagues102–104 and the reference providingthe main source of information for the systematicreview is cited in the tables and text.
Studies excluded from the review ofinterventions to improve professional compliance with cardiacrehabilitationEleven studies selected for data extraction but notincluded in the review are summarised inAppendix 15. More than one report was identifiedfrom the trial of Campbell and colleagues.125,126
The excluded studies either had no relevantoutcome data,116,117,125–127,164,171,191 provided onlydescriptions of services with no outcomes119,175,192
or were retrospective in design.116
Methodological qualities of studiesincluded in the review of interventionsto improve professional compliancewith cardiac rehabilitationSix studies were identified that evaluatedinterventions to improve professional compliancewith cardiac rehabilitation. Two reported RCTs. Inone trial randomisation was on an individualbasis,124 but no other information on the methodof randomisation, blind outcome assessment orbaseline characteristics of groups was reported. Inthe other trial patients were randomised bygeneral practice.104 The authors of this trialdescribed methods of randomisation, blindoutcome assessment and baseline characteristics ofgroups. Loss to follow-up was low in this study.None of the other studies reported loss to follow-up. Four studies described outcomes in periodsbefore and after implementation of anintervention.41,111,122,123 Baseline groupcharacteristics for appropriate periods were notreported in any of these studies.
In three studies the outcome wasattendance,41,104,111 in two referral122,123 and inone patient commitment to attend cardiacrehabilitation.124 Four studies included onlymyocardial infarction patients.41,111,122,124 Onestudy included myocardial infarction and anginapatients104 and another only post revascularisationpatients.123
Chapter 10
Systematic review of interventions to improve professional compliance with cardiac rehabilitation
Themes identified from the review ofinterventions to improve professionalcompliance with cardiac rehabilitationThree themes of interventions were identified inthe systematic review: improvement of the referralprocess, coordination of transfer of care, andphysician endorsement.
Improvement of referral process Four studies were identified that evaluatedmethods to improve the referralprocess.41,111,122,123 In a study comparing periodsbefore and after the introduction of an electronic
referral pathway Kalayi and colleagues122 observeda significant increase in patient referral to cardiacrehabilitation. The intervention was initiated witha referral section on the electronic patient recordof patients discharged with a diagnosis ofmyocardial infarction. Subsequently, feedback onreferral was given to ward staff. No information ongroup characteristics before and after interventionwas provided and large differences betweenmonthly and longer term referral rates suggest thepresence of other sources of referral variability.Mosca and colleagues41 compared patientparticipation before and after the introduction of a
Systematic review of interventions to improve professional compliance with cardiac rehabilitation
50
TABLE 24 Studies evaluating interventions to improve professional compliance with cardiac rehabilitation
Authors, year Study type and Intervention Findings relevant to Commentsand country patients uptake
RCTs
Jolly et al.,1999104
UK
Cluster RCT, 67general practices,597 MI andangina patients
Liaison nurse supportspractice nurses andencourages patients to seepractice nurse afterdischarge. Patient-heldrecord card to prompt andguide follow-up
42% of patients in theintervention group attendedat least one outpatient CRsession compared with 24%of controls (p < 0.001)
Multifacetedintervention.Management of patientsin control practices notexplicit
Non-randomised studies
Kalayi et al.,1999122
UK
Before-and-afterstudy, 561 MIpatients
Electronic referral pathwaywith feedback to ward staffon referral rates
After intervention referralincreased from 194/298(65%) to 208/263 (79%) (p = 0.0002)
Disparity between long-term and short-termreferral rates
Mosca et al.,199841
USA
Before-and-afterstudy, 199 MIpatients
Prompt for outpatient CR indischarge critical carepathway
Critical care pathwayassociated with a non-significant increase inoutpatient CR participation(OR 1.9, 95% CI 0.6 to 5.5)
No baseline groupcomparisons
Caulin-Glaser &Schmeizel,2000123
USA
Before-and-afterstudy. Post-revascularisationpatients. Patientnumbers notspecified
Educational intervention forhealthcare providers on thecomprehensive nature andbenefits of CR. Instructionsfor nurses to discuss CR withpatients and encouragediscussion of referral withphysicians
In-hospital referral increasedby 50% (p < 0.05). Physicianoffice referral increased by61% (p < 0.05)
Abstract only
Scott et al.,2000111
Australia
Before-and-afterstudy, 649 MIpatients
Dissemination of clinicalguidelines to hospital staffand general practitioners.Feedback on clinicalindicators
After intervention outpatientCR utilisation increased from24% to 54% (p = 0.003)
Baseline periodcorresponds to CRprogramme start-up
Suskin et al.,2000124
Canada
RCT, 50 patients Attending physician provideswritten endorsement
62% of patients in theintervention group gavecommitment to participate inCR compared with 38% inthe control group (p = 0.08)
Abstract only
prompt for cardiac rehabilitation in a dischargecritical care pathway. An improvement inparticipation in outpatient cardiac rehabilitationwas observed, but this was not statisticallysignificant. Group characteristics were notreported and other factors may have influencedlevels of participation. Caulin-Glaser andSchmeizel123 reported the implementation of aneducational intervention for healthcare providers.Information on cardiac rehabilitation, including itscomprehensive nature and benefits, was given tomedical and nursing staff and on health outcomesand cost-effectiveness to members of the clinicalcardiology council. After the intervention both in-hospital and physician office referral weresignificantly increased. Again, no baselineinformation to assess comparability of patientgroups was provided. In the study of Scott andcolleagues111 patients admitted to hospital in threeperiods were compared. These were before, duringand after the dissemination of clinical guidelinesand feedback of clinical indicators to healthprofessionals. The cardiac rehabilitationprogramme was operational during theimplementation period and this was used as thebaseline period for evaluation. A steady increase inutilisation of the outpatient cardiac rehabilitationservice was observed during the implementationperiod and the authors attribute this to theintervention. However, no comparison of patientcharacteristics was available for the relevantperiods and, although the authors report that thenew cardiac rehabilitation service was fullyoperational, an increase in uptake might beexpected with the new service.
Coordination of postdischarge care Jolly and colleagues104 reported a cluster RCT ofcoordination of care of myocardial infarction andangina patients between hospital and generalpractice by specialist cardiac liaison nurses.Attendance at one or more cardiac rehabilitationsessions was significantly increased in theintervention patients. The intervention consistedof three main elements: liaison nurse support forpractice nurses, liaison nurse encouragement for
patients to see the practice nurse, and promptsand guidance for patients by means of a personalrecord card. The study design does not allow theeffect of components to be assessed individually.
Physician endorsement Suskin and colleagues124 conducted an RCTcomparing attending physician cardiacrehabilitation endorsement with a genericendorsement. The intervention was associatedwith a non-significant increase in patient-reportedintent to participate in cardiac rehabilitation. Nobenefit was observed for in-person delivery of theendorsement. Little information on the conduct ofthe trial or patient characteristics was reportedand the outcome of intention to attend issomewhat removed from actual attendance atcardiac rehabilitation.
Resource implications of intervention toimprove professional compliance withcardiac rehabilitationInformation provided on resource use associatedwith the only effective intervention of reasonablequality is summarised in Table 25. As describedearlier, in the study by Jolly and colleagues104
three liaison nurses were employed withresponsibility for the coordination of postdischargecare of 277 patients over 18 months, a yearlyaverage of 62 patients per nurse. Transport costsincurred by liaison nurses visiting practices and bythe practice nurses attending training and supportgroups were not quantified, nor was the resourceinput or cost of training liaison and practicenurses.
Further interventions that may improve professional compliance withcardiac rehabilitation suggested in theliteratureThe literature review identified a number ofsuggested interventions for improving professionalcompliance with cardiac rehabilitation. Althoughthese potential interventions were not evaluatedthe studies provided some evidence to suggestmethods meriting further investigation. Examples
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TABLE 25 Resource implications of intervention to improve professional compliance with cardiac rehabilitation
Staff Equipment Consumables Patient costs
Coordination of postdischarge care
Liaison nurse support forpractice nurses (Jolly et al., 1999104)
Three cardiac liaisonnurses
Training for cardiacliaison nurses andpractice nurses
The study employedthree nurses involving atotal of 277 patients in18 months
of interventions excluded from the review at bothformal extraction and the earlier inclusion stage,but with possible value in improving professionalcompliance, are summarised thematically in Table 26.
DiscussionThe healthcare professional has a pivotal role inrecruitment of patients to cardiac rehabilitation,and their contribution is dependent on education,compliance with guidelines and coordination ofservices. Few studies aimed at improvingprofessional compliance with outpatient cardiacrehabilitation were found. Three studies werepublished in peer-reviewed journals and three asconference abstracts.
Evaluations of three types of intervention wereidentified by systematic review: improvement ofthe referral process, coordination of postdischargecare, and physician endorsement of cardiacrehabilitation.
None of the four studies reporting interventionsto improve the referral process included adequatemethodological information. The use of a before-and-after study design might have provided someevidence on the effectiveness of interventions, butthe lack of group comparisons and programmefactors influencing patient attendance precludes
this. This is disappointing, as the inclusion ofcardiac rehabilitation in a critical care pathwayeffective in promoting discharge medication isappealing. Similarly, improving referral bydissemination of clinical guidelines andsubsequent feedback of clinical indicators tohealth professionals merits further evaluation.
A multifaceted approach to the coordination oftransfer of care from hospital to general practiceincluding liaison nurse support for practice nurseswas effective in improving cardiac rehabilitationuptake in a randomised trial. Particular aspects ofthe intervention were not evaluated separately,and it is not possible to compare the relativeimportance of professional support of practicenurses, in-hospital nurse–patient contact and self-empowerment of patients with record cards. Thepossibility of referral of patients from generalpractice suggests that the involvement of practicenurses may be of particular value in the referral ofangina patients who have not been admitted tohospital.
The value of physician endorsement inencouraging patient participation in cardiacrehabilitation was not confirmed. However, somesupport for further evaluation is suggested by therandomised trial of Suskin and colleagues,124 wherea non-significant tendency for increased patientcommitment was seen in patients who had receivedan endorsement from an attending physician.
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TABLE 26 Further interventions that may improve professional compliance with cardiac rehabilitation suggested in the literature
Authors, year Intervention Purpose of study
Parks et al., 200032 Appointment of CR programme director to lead, audit and Auditcommission appropriate resources
Parks et al., 200032 Programme run in accordance with national guidelines Audit
Young & Kahana, 198946 Physicians and insurers educated on benefits for patient Retrospective observationalBittner et al., 199937 groups Retrospective observational
Comoss 1988185 Referring physicians involved in programme Review
Stokes, 2000193 Education for CR coordinators and staff Review
Parks et al., 200032 Explicit criteria for CR eligibility Audit
King & Teo, 1998194 Streamlining of referral Review
Parks et al., 200032 Centralised CR attendance and contact records Audit
Levknecht et al. 1997116 Clinical pathway and clinical quality improvement tool Programme description
Cannistra et al., 1995128 Early social services involvement to improve social support Prospective comparisonand hence uptake of CR
Effron et al., 1986195 CR commenced earlier Retrospective observational
Roitman et al., 1998135 Removal of time restriction for start of programme Review
Systematic review of the literature did not identifyany well-evaluated methods specifically aimed atimproving professional compliance to cardiacrehabilitation. One multifaceted approachsuggested benefit, but the importance of theintervention relating to improvement inprofessional compliance could not be distinguishedfrom other patient-directed aspects of theintervention. The resource and therefore costimplications of this intervention are also unclear.
All interventions identified were aimed atimproving overall cardiac rehabilitationattendance. It was surprising that no evaluationsof interventions targeted at service improvementsfor specific patient groups were reported.Frequently under-represented patient groupsinclude women, the elderly, ethnic minorities andpatients with more severe presentation of diseaseor co-morbidity.
Although few trials were found with the intentionof improving cardiac rehabilitation uptake andadherence by improving professional compliance,several areas for intervention are suggested in theliterature. Many may already be regular practice,but some may have application in the provision ofservices to under-represented groups.
Uptake of rehabilitation services is influenced bythe knowledge and enthusiasm of the physicianand providers in the referral process.46,62,194
Consequently, education of physicians andproviders on the benefits of cardiac rehabilitationmay help to improve referral and uptake.37,46 Thismay be accomplished best by the involvement ofreferring physicians in the programme.185 Acoherent approach to the education of programmecoordinators and staff on the benefits of cardiacrehabilitation and its application in patient groupsmay lead to better understanding of patienteligibility and thus wider invitation.193
Appointment of a programme director to lead,audit and commission appropriate resources forcardiac rehabilitation may lead to improvementsin service management and provision.32 This mayfacilitate the running of programmes inaccordance with national guidelines, which mayhelp to improve provision.32
Although none of the studies included in thesystematic review was of adequate quality tosuggest that the use of clinical pathways may be ofvalue in the management of cardiac rehabilitationreferral, this approach may merit furtherinvestigation. The use of clinical pathways with
explicit criteria for patient eligibility may be anappropriate way to manage and streamlinereferral and invitation.32,116,194
Flexibility in timing of care and support may beimportant in improving uptake of services. Visits athome by healthcare professionals may serve toprovide continuity of care and improve uptake ofcardiac rehabilitation.128 The provision of cardiacrehabilitation early after discharge may coincidewith the time of patients’ greatest need forsupport and greatest motivation, and earlyinvitation and provision may be rewarded byincreased uptake.195 Some patients may not find aparticular date for commencing rehabilitationsuitable, and flexibility and removal of timerestrictions may lead to an increase in uptake.135
The general scarcity of evaluated methods mayreflect an under-appreciation of the value of trialsin evaluating new interventions. Programmecoordinators may recognise deficits and the needfor improvements in services and implementchanges without formal evaluation. For example, itmay be assumed that incorporation of a promptfor referral in a discharge summary would be aneffective way of ensuring referral. However, thisdoes not necessarily mean that the crucialoutcome of increased patient uptake andattendance at cardiac rehabilitation will beachieved. The systematic review of the literaturesuggests that well-designed studies are required totest interventions aimed at improving professionalcompliance with cardiac rehabilitation.
ConclusionsLittle research has been conducted aimed atimproving professional compliance with cardiacrehabilitation. The systematic review identified fewstudies that specifically looked at improvingpatient uptake and adherence by intervening atthe level of healthcare professional activities.
The conduct of the healthcare professional iscentral in the recruitment of patients to cardiacrehabilitation and their contribution is dependenton education, compliance with guidelines andcoordination of services. Changes within cardiacrehabilitation services aimed at improving patientuptake and adherence should be evaluated in well-designed studies and the results disseminated andreviewed; otherwise, ineffective and inappropriatemethods may become routine clinical practice.
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Objectives� To estimate the health service costs associated
with cardiac rehabilitation programmes in theUK.
� To estimate the national budget attributable tooutpatient cardiac rehabilitation in the UK.
� To explore how coverage could be increased ifdifferent configurations of service wereprovided within the existing budget.
� To explore how coverage could be increasedwith additional funding.
Health service costs associatedwith cardiac rehabilitation MethodsThe costs associated with the provision of cardiacrehabilitation services from the health serviceperspective were estimated by considering thestaff, overheads, building capital and equipmentcosts. The costs borne by patients such as travelcosts or expenses for special clothing were notincluded, but it was recognised that these couldhave important implications if patients perceivedthem to be large enough to deter their attendance.
The BACR/BHF survey, described in Chapter 4,provided information on the typical number ofhours per week by broad staff categories spent inoutpatient (phase 3) cardiac rehabilitationprogrammes. The additional questionnaireprovided information on the number of patientsreferred, joining and completing cardiacrehabilitation, the total number of sessions, andnumber and length of sessions per week.
Centres that responded to the short questionnaireand provided information on staff input (n = 186;
65% of all UK centres identified by BACR/BHF)were stratified by a criterion of multidisciplinarityof staff input. This was based on the assumptionthat a greater variety of staff input is a proxy forhigher service quality. The following professionalcategories were considered to be relevant to anoutpatient cardiac rehabilitation programme(hereafter referred to as ‘key staff ’):
� physician (GP, cardiologist, general physician)� nurse� physiotherapist/sport scientist� occupational therapist� psychologist� dietitian� pharmacist.
Three groups were defined according to thenumber of different types of key staff: group 1having more than five different types of key staff,group 2 having three to five types of key staff, andgroup 3 having two or fewer. The total number ofcentres in each of these groups is shown in Table 27. Ten centres within each group werechosen at random to conduct a more detailedcosting study.
Staff costsAll 30 centres in the random sample werecontacted between April and June 2002 andprovided more detailed information on the gradesof staff working in 2000 (the year of theBACR/BHF survey). Staff costs were estimated bymultiplying the average numbers of hours perweek worked for each grade of staff by the hourlypay for that grade. Hourly pay rates werecalculated by dividing the midpoint of the relevantpay scale by the numbers of hours of expectedwork per annum, excluding annual leave, bankholidays, and training/study and sickness days. All
Chapter 11
Health service costs of cardiac rehabilitation in the UK
TABLE 27 Stratification of cardiac rehabilitation centres (n = 186) by number of different types of key staff
Group No. of different types of key staff No of centres %
1 >5 38 20.42 3–5 135 72.63 ≤ 2 13 7.0
pay scales were those prevailing on 1 April 2001and included employers’ on-costs (employers’contribution to national insurance plus 4% ofsalary contribution to superannuation).196
Salaries information was taken fromwww.nhscareers.nhs.uk.197 A detailed summary ofunit cost estimates for different staff categoriesand grades is shown in Appendix 16.
Non-staff-related costsNon-staff-related costs refer to the overheads,building capital and equipment costs associatedwith running cardiac rehabilitation services. Mostcardiac rehabilitation services tend to use anumber of different facilities to deliver thedifferent components of the programme and donot have these figures readily available. Hence,allowances for indirect overheads (the costs of thesupport services such as human resources, financeand estates required to carry out the services main functions) and building capital (the costsassigned to treatment and non-treatment space)
relative to the midpoint of the relevant pay scalewere based on Netten and colleagues196 (seeAppendix 16).
The required equipment was based on currentrecommendations from the BACR (see Appendix17). The unit costs were obtained from thecoordinator of the cardiac rehabilitation team ofthe Bristol Royal Infirmary. An equivalent annualcost was estimated by using an annuity factor of6% and assumed lifespan of 5 years. Annual costsaccounted for approximately £861 [value addedtax (VAT) included].
Direct overheads, that is, the costs associated withlighting, heating and cleaning, were assumed to be11% of the sum of staff costs, indirect overheads,building capital and equipment costs. This wasbased on previous studies carried out in hospitalsettings where the direct overheads were found toaccount for 4–18% (midpoint 11%) of totalcosts.198–200
Systematic review of interventions to improve professional compliance with cardiac rehabilitation
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TABLE 28 Average hours per week by staff category
Staff grade Group 1a Group 2b Group 3c
(n = 10) (n = 10) (n = 10)
Nurse grade:B 0.95E 7.2F 11.38 12.75 3G 21.40 16.15 9.25H 13.05 5.75 0.4
Physiotherapist:Helper 2Basic 0.20Senior I 10.05 5.4 2.7Senior II 1.4 1.2Superintendent III 2.6Superintendent IV 0.6
Sport scientist 1.9Exercise physiologist 3.8 0.4Occupational therapist:
Basic 0.8Senior 2.7 0.05 0.3Head 0.6
Dietitian 0.47 0.18Senior dietitian 0.58 0.46
Pharmacist 0.46 0.35Physician 0.38 0.75Clinical psychologist 0.67 0.3Cardiac technician 0.7 2 0.5Social worker 0.1Secretary 4.2 5.04 0.3Total (SD) 74.7 (5.8) 62.6 (4.7) 18.0 (2.9)
a Centres with more than five key staff.b Centres with three to five key staff.c Centres with two or fewer key staff.
The total cost of cardiac rehabilitation wasestimated for each centre, and the cost per patientreferred, joined and completed estimated. Thecost per hour was also estimated, taking the costper patient completing the programmes as thedenominator. The costs of each centre within agroup were then averaged. A weighted averagecost was also estimated, using the proportion ofcentres nationally falling within each group (seeTable 27).
Results Information on the weekly staff input by staffcategory and grade for each centre in the randomsample is shown in Table 28 (a detailed summaryof staff resource data for each centre is given inAppendix 18). Group 1 had higher levels ofweekly staff input (75 hours) than centres ingroups 2 (62 hours) and 3 (18 hours).
The average duration of the programmes bygroup is shown in Table 29. Centres that employmore than five different key staff (group 1) providethe most intensive service per patient, with anaverage duration of 29 hours per patient. Thiscompares to 24 hours per patient for group 2centres and 20 hours for group 3 centres (detailsgiven in Appendix 19). Table 29 also gives, bygroup, the absolute number of patients referred,
joining and completing cardiac rehabilitationprogrammes. This varied widely, with the highestaverage numbers being in group 2.
The average staff costs and average total costs ofcardiac rehabilitation are presented for each groupin Table 30 (more details shown in Appendix 20).There was a considerable difference in the cost ofan average centre and in the average cost perpatient between each group. The total averagecost per patient completing the programme was£542 for group 1, £317 for group 2 and £186 forgroup 3. Staff costs accounted for 73% of the totalcosts for centres in groups 1 and 2, and 70% forcentres in group 3 (based on cost per centre).
Figure 4 illustrates that nursing costs are the mostimportant share of total staff costs, accounting forabout 62% of total staff costs in group 1 centres,67% in group 2 and 71% in group 3.Physiotherapy costs are the second most importantshare of total costs, accounting for about 23% ingroup 1 and group 3 centres, and for about 14%in group 2 centres.
Weighted average staff and total costs are shown inTable 30. The weighted average cost per patientcompleting a cardiac rehabilitation programmewas £354 (staff costs only) and £486 (total costs).
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TABLE 29 Service provision, referral, uptake and completion rates for 30 UK cardiac rehabilitation centres in 2000 (stratified by staff mix)
Group 1 Group 2 Group 3(n = 10) (n = 10) (n = 10)
Mean Median Mean Median Mean Median
Hours per patient 29.0 27 24 215 20 17.5No. referred 282.4 289 352.5 255 170.7 150No. joined 157.3 148 194.3 172 97.9 104
% of referrals 56 51 55 67 57 69No. completed 126.3 104 158 150 89 92
% of referrals 45 36 45 59 52 62
TABLE 30 Average cost estimates for cardiac rehabilitation (2000/01 prices)
Costs (£) Group 1 Group 2 Group 3 Weighted costs
Staff Total Staff Total Staff Total Staff Total costs costs costs costs costs costs costs costs
Per year/centre 53,100 72,700 42,100 57,400 12,400 17,600 42,300 57,700Per patient referred 243 330 137 186 127 249 157 220Per patient joined 421 571 236 320 174 324 269 371Per patient completed 542 738 317 429 186 344 354 486Per hour 20 27 14 20 14 30 15 22
The national budget attributableto cardiac rehabilitationMethodsThe budget attributable to outpatient (phase 3)cardiac rehabilitation was estimated separately forEngland, Wales, Scotland and Northern Irelandusing data from the BACR/BHF survey and theadditional questionnaire (as described in Chapter4). The total number of patients completing acardiac rehabilitation programme was estimatedfor each country. Where centres did not providedata, the IQR derived from responding centres forthat country was used to calculate total numbers.
The budget for each country was estimated bymultiplying the number of patients (reported aslower and upper bound) completing a cardiacrehabilitation programme by the weighted totalaverage costs per patient completing cardiacrehabilitation (£486; see Table 30).
These estimated budget figures were then used toexplore how coverage could be increased if adifferent configuration of cardiac rehabilitationservices were provided. An estimate was made ofthe number of patients that could be treated ifrehabilitation services were entirely provided incentres with three to five key staff (as in group 2,see above) or in a different scenario, in centreswith two or fewer key staff (as in group 3). In
addition, an estimate was made of the necessarybudget increase to provide cardiac rehabilitationto all potentially eligible patients using data fromthe analysis presented in Chapter 3. Thisestimation was undertaken by assuming that, first,cardiac rehabilitation would be uniformly providedin group 2 centres and, second, cardiacrehabilitation would be uniformly provided ingroup 3 centres.
This study also explored how additional fundingcould increase coverage. If unit costs per patientfall as the number of patients completing therehabilitation programme rises (i.e. centresexperience economies of scale), additional fundingwill imply that the number of extra patientstreated is higher than proportionate. A possibleassociation between staffing costs per patient andthe number of patients treated was, therefore,examined. First, the log-transformed costs andlog-transformed numbers of patients were plotted,as both variables have a log-normal distribution.Secondly, a simple log-linear regression model wasused to estimate the relationship between costs perpatient, as the dependent variable, and the annualnumber of patients completing the rehabilitationprogramme, as the independent variable. Anadditional model was estimated, controlling fornumbers of staff employed on cardiacrehabilitation. The regression coefficient fornumber of patients in these log-linear regression
Systematic review of interventions to improve professional compliance with cardiac rehabilitation
58
0
10
20
30
40
50
60
70
80
90
100
1 2 3
Group
Prop
ortio
n of
tota
l cos
ts (%
)
Others
Physician
Psychology
Dietetics
Pharmacy
Occupational therapy
Physiotherapy
Nursing
FIGURE 4 Proportion of total staff costs attributable to staff categories
models measures the elasticity of the cost perpatient with respect to the number of patientscompleting the programme, that is, thepercentage change in costs for a given percentagechange in number of patients.
Results The estimated budgets attributable to cardiacrehabilitation by country are shown in Table 31.The current budget was estimated to beapproximately £12.5–19.0 million in England,£1.2–2.3 million in Scotland, £1.0–1.7 million inWales and £0.4–0.7 million in Northern Ireland.Overall, this would result in a budget estimate of£15.2–23.6 million for outpatient cardiacrehabilitation for the whole of the UK.
Table 32 shows the estimated impact of a change inservice configuration for two different scenarios bycountry. It was estimated that approximately 5,300
more patients across the UK could be treated ifthe service were provided in cardiac rehabilitationcentres with the staffing level of those in the‘group 2’ sample. This corresponds to a 13%increase in coverage compared with the currentsituation. If services were provided with cardiacrehabilitation centres with low staffing levels(group 3), approximately 16,490 more patientscould be treated, corresponding to a 41% increasein coverage compared with the current situation.
As shown in Chapter 3, around 266,800 patientswere potentially eligible for cardiac rehabilitationin England in 2000. Assuming that group 2services were uniformly provided, an annualbudget of approximately £115 million would berequired for the provision of cardiac rehabilitationto all patients. This represents a 630% increase inthe estimated current budget attributable tocardiac rehabilitation.
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TABLE 31 Estimated budget attributable to cardiac rehabilitation by country (2000/01 prices)
England Wales Scotland Northern Ireland
Estimated no. of patients completing 25,700–39,000 2,100–3,500 2,500–4,700 1,000–1,400outpatient cardiac rehabilitationa
Estimated budget attributable to outpatient £12,513,000– £1,018,000– £1,222,000– £487,000–cardiac rehabilitation 18,975,000 1,683,000 2,276,000 658,000
a Numbers were estimated by using information form the BACR/BHF survey for 2000. Data for non-responding centreswere imputed by IQR for the relevant country.
TABLE 32 Estimated impact of a change in service configuration given current budget
England Wales Scotland Northern Ireland
Estimated no. of patients completing outpatient 25,700–39,000 2,100–3,500 2,500–4,700 1,000–1,400cardiac rehabilitation in 2000 (current service provision)
Estimated no. of patients able to be treated 26,100–44,200 2,400–3,900 2,800–5,300 1,100–1,500with a group 2 type service (i.e. three to five key staff) without expanding budget
Estimated no. of additional patients if all treated 4,300 400 500 200with a group 2 type service (based on the midpoint of the ranges reported above)
% increase in coverage 13 13 13 13
Estimated no. of patients able to be treated 36,400–55,100 3,000–4,900 3,600–6,600 1,400–1,900with a group 3 type service (i.e. two or fewer key staff) without expanding budget
Estimated no. of additional patients if all treated 13,400 1,100 1,500 500with a group 3 type service (based on the midpoint of the ranges reported above)
% increase in coverage 41 41 41 41
Using a more limited criterion of need, namely,considering only patients with acute myocardialinfarction, unstable angina, CAGB and PTCA aseligible, an annual budget of approximately £56million would be required for the provision ofcardiac rehabilitation, an increase of 260% in thecurrent budget.
By extending the provision of cardiacrehabilitation using staffing configurations ofgroup 3 services, an approximate annual budgetof between £45 and £92 million would be requiredfor treating all potentially eligible patients. Thisrepresents a 200–500% increase in the currentannual budget attributable to cardiacrehabilitation.
Figure 5 shows the relationship between annualnumbers of patients completing cardiacrehabilitation and the staff costs per patients. Itsuggests that the costs fall as the annual patientthroughput increases. Figure 6 shows the samerelationship but stratified by group.
The simple regression showed no significantrelationship between staff costs per patient andnumbers of patients completing cardiacrehabilitation (Table 33).
Further exploration of the data, making allowancefor the differing staffing patterns in groups 1–3,showed a clear relationship between costs andnumbers completing cardiac rehabilitation withineach group. The results of this model includinggroup as an independent dummy variable are
shown in Table 34. The equations for predictingthe staff costs per patient completing cardiacrehabilitation are as follows:
Group 1: ln (cost per patient) = 7.33 – 0.245 ln (number of patients)
Group 2: ln (cost per patient) = 7.33 – 0.245 ln (number of patients) –0.733
Group 3: ln (cost per patient) = 7.33 – 0.245 ln (number of patients) –1.489
This suggests that cardiac rehabilitation centresexperience economies of scale when different levelsof multidisciplinarity of staff input, as in ourdefined groups, are taken into account. The costper patient falls as the annual number of treatedpatients rises, although this was dependent oncontrolling for the multidisciplinarity of staffrunning the programme. Roughly, a 1% increase inthe number of patients completing the programmeleads to a 0.245% fall in the staff cost per patientcompleting the programme. This means thatincreasing patient throughput, by increasedfunding, may result in greater opportunity toincrease coverage than might be expected.
DiscussionThe results of this analysis suggest a weightedaverage staffing cost of £354 and a weighted totalaverage cost of £486 per patient successfullycompleting a cardiac rehabilitation programme(2000/01 prices). Although previous studies havepresented figures for the cost of cardiac
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TABLE 33 Regression model for staff costs per patient completing cardiac rehabilitation (ln costs)
� SE 95% CI p
Constant 5.97 0.643 4.647 to 7.286 <0.0001ln no. of patients –0.10 0.143 –0.94 to 0.193 0.49
R2 = 0.02, n = 30, F = 0.49, p = 0.49
TABLE 34 Regression model for staff costs per patient completing cardiac rehabilitation (ln costs), controlling for group
� SE 95% CI p
Constant 7.33 0.592 6.11 to 8.55 <0.0001ln no. of patients –0.245 0.117 –0.488 to –0.002 0.048Group 1 – – – –Group 2 –0.733 0.335 –1.422 to –0.042 0.038Group 3 –1.489 0.340 –2.190 to –0.788 <0.0001
R2 = 0.44, n = 30, F = 6.66, p < 0.002
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50
200
400
800St
aff c
osts
per
pat
ient
(log
sca
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100 200 400Annual no. of patients completing CR (log scale)
FIGURE 5 Relationship between size (as measured by annual throughput of patients) and unit cost (staff costs) of cardiacrehabilitation programmes (all centres)
50
200
400
800
100 200 400
100 200 400 200 400
Group 3
Annual no. of patients completing CR (log scale)
Group 1 Group 2
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Staf
f cos
ts p
er p
atie
nt (l
og s
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)
100
FIGURE 6 Relationship between size (as measured by annual throughput of patients) and unit cost (staff costs) of cardiacrehabilitation programmes by group
Systematic review of interventions to improve professional compliance with cardiac rehabilitation
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rehabilitation in the UK, they have been lesscomprehensive in their cost estimates.Nonetheless, the present findings are consistentwith their findings, which suggested an averagecost of cardiac rehabilitation per treated patient inthe region of £200–£400.25,79–82
For example, Gray and colleagues80 estimated acost of £371 per patient completing a cardiacrehabilitation programme (median £223; 1994prices). This was based on a sample of 16 cardiacrehabilitation centres in England and Wales, buttheir estimate excluded non-staff costs andcontributions by non-specifically funded staff.Average staff costs of £350–425 (2001 prices) wereestimated by the Scottish Intercollegiate GuidelinesNetwork (SIGN) guideline development group,assuming 500 referred patients per year and a 90%uptake.2 Based on the funding information givenby 37 centres in the most recent BACR/BHFsurvey, Evans and co-workers25 reported a cost of£50–712 (median £256) per patient completingcardiac rehabilitation.
By using information from the BACR/BHF surveyand an additional questionnaire, all staffcontributions could be measured and valued. Theanalysis shows that centres with higher levels of staffmix provide a more expensive service per patienttreated than centres that employ fewer types of keystaff. This is due to a longer duration of cardiacrehabilitation programmes offered by centres ingroup 1 (29 hours per patient) compared with theaverage duration of programmes offered by centresin group 2 (24 hours) and group 3 (20 hours), aswell as the higher weekly staff input intoprogrammes offered by centres with more types ofkey staff. This did not correspond with highernumbers of patients entering and completing theprogrammes. Thus, patients treated in centres witha higher level of multidisciplinarity received themost intense rehabilitation programme in terms ofthe duration of the programme and staff/patientratio. Although the heterogeneity of cardiacrehabilitation services has long been acknowledged,evidence is lacking to suggest that programmeswith a higher level of multidisciplinarity offerimproved patient outcomes. Such services may noteven represent higher service quality; for example,adherence was lower in the most multidisciplinaryand intensive services.
This analysis has some limitations. Ideally,information on non-staff related costs such as directoverheads and capital costs should have beenobtained from each rehabilitation centre in thesample. From a practical point of view, this was not
feasible. The advantage of this study is the size ofthe sample, which allowed the cost differences dueto different staff configurations to be explored indetail.
The costs of equipment were also included, basedon current recommendations from the BACR.However, this list did not include equipment forundertaking ECG-exercise testing. Cardiacrehabilitation centres may carry out exercise testingbefore and after cardiac rehabilitation to assesspatients and will, therefore, incur higher costs.Annual costs of equipment (treadmills, consumablesfor ECG, etc.) have been estimated to account forapproximately £25,000 (Sally Turner, Alton CardiacRehabilitation Centre: personal communication, 2 December 2002).
Some extrapolations had to be made to calculatethe total numbers of patients completing aprogramme, because not all centres replied to thesurvey and provided comprehensive activity data.This is possibly due to their lack of automatedsystems to extract these data, lack of audit facilitiesor being in the process of installing systems tocollect audit data to satisfy the requirements of theNSF-CHD. However, the authors believe that theirestimate of an annual budget attributable to cardiacrehabilitation of £15.2–23.6 million for the whole ofthe UK is a refined update of previous budgetestimates, for example, £8–34 million by Taylor andKirby81 based on a converted US cost estimate.
The results of the simple budget analysis show thatby providing a service as offered in group 3 centres,the overall service provision could be increased byapproximately 40% with current funding. Providingcardiac rehabilitation as offered in group 2 centres,which represents the average cardiac service in theUK, could lead to an approximately 13% increasein coverage. This could be of importance givenlimited resources and the large extent of unmetneed, as shown in Chapter 3.
The resource implications for extending cardiacrehabilitation to a greater proportion of eligiblepatients and to other groups of patients asrecommended by the NSF-CHD are not clear.Only a minority of centres, as reported in Chapter4, state that they have spare capacity. It is also notobvious whether the difference between thenumber of referred and enrolled patientsrepresents spare capacity, as many centres havewaiting lists that restrict the number of patientsreceiving treatment. Therefore, the extension ofcardiac rehabilitation may require extra resources.The costs of these resources will be dependent on
local factors such as current provision of staff, theopportunity costs of extending the role of existingstaff employed in other areas, existing (spare)capacity and facilities and, if not available, thecosts of hiring facilities, for example in communitysport centres.
This study confirms the finding that cardiacrehabilitation centres experience economies ofscale, as first reported by Gray and colleagues.80
However, this was only apparent whenmultidisciplinarity of staff input, as defined by thethree groups, was explicitly taken into account. Thisfinding suggests that any budget increase couldlead to a more than proportionate improvement incoverage of cardiac rehabilitation services.
This analysis considers only the direct costs ofcardiac rehabilitation. Future assessments of thecost-effectiveness of cardiac rehabilitation need toconsider the future savings associated withreduced subsequent healthcare utilisation relatedto cardiac disease. The inclusion of future costsrelated to successfully rehabilitated patients livinglonger and requiring health services unrelated tocardiac disease is more controversial. Also to beconsidered are the future productivity gainsassociated, for example, with earlier return towork. The inclusion of costs incurred by patientssuch as expenses for travelling and specialclothing will depend on the perspective fromwhich the costs analysis is conducted. A fulleconomic evaluation requires the comparison ofthe resource use changes with improved healthconsequences, that is, the effectiveness of cardiacrehabilitation.
ConclusionsThe average costs of cardiac rehabilitation to thehealth service per patient successfully completing
a cardiac rehabilitation programme are about£350 (staff costs only) and £490 (total costs) perpatient. Outpatient cardiac rehabilitationrepresents an NHS cost of between £15.2 and 23.6million in the UK. Cost variation across centres ispartly explained by a higher dose of interventionin terms of duration and staff/patient ratio. Thereis a need to quantify the heterogeneity of servicesin terms of benefits. Trials comparing complexmultidisciplinary rehabilitation with simplerregimens require evaluation of their costs andeffectiveness.
If all services were modelled on the most commonconfiguration of staffing (group 2), approximately13% more patients could be treated with the sameannual budget, but if the simpler group 3 serviceswere to be uniformly provided, 40% more patientscould be treated. The levels of need for cardiacrehabilitation, using the more modest criteria ofneed (see Chapter 3), suggest that, at best, fewerthan 30–43% of eligible patients are referred and,of these, about half join cardiac rehabilitationprogrammes. This suggests that the capacity toincrease provision by 40% within current budgetswould meet between 42 and 60% of thepopulation need for treatment.
Higher funding would be needed to increaseprovision to match need and to meet NSF-CHDtargets. An approximate 260–630% increase in theannual current budget is required, to treat allpotentially eligible patients depending on thestaffing configurations of the cardiac rehabilitationprogramme. However, increased spending couldlead to a more than proportionate increase incoverage. Further work is required to examine thebest ways of using any increased funding, as it islikely that the potential of different services toincrease capacity will vary markedly, and theassociated costs will differ if, for example, newcapital schemes are required.
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Outpatient cardiac rehabilitation should beavailable to patients with a range of
cardiovascular diagnoses and afterrevascularisation procedures, but previous studieshave shown that uptake is low, particularly in somespecific patient groups. While many barriers toparticipation have been described, theeffectiveness of interventions to improve uptakeand adherence has not been assessed by systematicreview. Furthermore, the cost implications ofinterventions to improve uptake and adherenceand of increasing overall provision to meet totalpopulation need have not been estimated.Conclusions presented here are based around theobjectives set in Chapter 2.
What is the population need forcardiac rehabilitation?Population need for cardiac rehabilitation in theUK in 1999–2000 was assessed from hospitaldischarge statistics in England, Wales andNorthern Ireland. The researchers were unable touse equivalent data for Scotland.
Two criteria for eligibility for cardiac rehabilitationwere considered: patients with acute myocardialinfarction, unstable angina or following arevascularisation procedure; and all patientsdischarged alive with a primary diagnosis ofischaemic heart disease or followingrevascularisation. The former, more conservativeestimate of need, identified nearly 146,000patients per year as eligible for cardiacrehabilitation in England, Wales and NorthernIreland. The latter gives a considerably largerestimate of 299,000 patients per year, but includespatients with chronic ischaemic heart disease,some of whom may be considered eligible forparticipation in some programmes and who maybenefit from rehabilitation. Although thesepatients are not currently specified as immediatepriorities for cardiac rehabilitation, for example inthe NSF-CHD, many may be deserving ofrehabilitation or appropriate lifestyle advice andmodification as services develop.
Who is not receiving cardiacrehabilitation?To estimate the level of cardiac rehabilitationprovision, data from the 2000 BACR/BHF surveyof cardiac rehabilitation centres were combinedwith hospital discharge statistics. The overallresponse rate of survey centres was 67% and IQRswere imputed for non-responders. This gave arange of estimates of numbers of patients referredto and joining a cardiac rehabilitation programme.
It was estimated that in England about 53% (range45–67%), in Wales about 72% (range 59–81%) andin Northern Ireland about 30% (range 25–36%) ofacute myocardial infarction, unstable angina andrevascularisation patients were referred to cardiacrehabilitation in 2000. The proportions of patientsjoining a programme were about 33% (range27–41%), 40% (range 38–46%) and 22% (range18–25%), respectively. As this considers only thelimited eligibility criteria as the denominator itreflects an overestimate if centres providedservices to other patient groups. Applying the lessinclusive eligibility criteria of any ischaemic heartdisease or revascularisation, it was estimated thatin England about 26%, in Wales about 32% and inNorthern Ireland about 14% of patients werereferred to cardiac rehabilitation in 2000. Thecorresponding figures for patients joining aprogramme were 16%, 18% and 11%, respectively.A survey of rehabilitation centres suggested thatan average of about 63% of all patients referredjoined a programme and that about 48% ofreferrals completed a course.
There appeared to be variation in serviceprovision across the UK, with a higher proportionof eligible patients referred to and joining cardiacrehabilitation programmes in England and Walesthan in Northern Ireland. Since the need forrehabilitation is substantially greater in NorthernIreland (and Scotland), this represents aconsiderable disparity between uptake and need.
The data demonstrate that many eligible patientswho may derive benefit are not referred or invited,
Chapter 12
Conclusions
do not respond to invitation, or do not adhere tocardiac rehabilitation. Some of the shortfall inreferral and invitation may be explained by theclinical eligibility criteria used in selecting patientsas appropriate for cardiac rehabilitation. Thisselection is mainly by health status beforedischarge. From the clinical exclusion data in anRCT with minimal exclusions, about 81% ofpatients were identified as eligible forrehabilitation after myocardial infarction and,although slightly lower than the 85% stated in theNSF-CHD, this is a reasonable overall estimate.The remaining 19% of patients were consideredunsuitable for outpatient rehabilitation, mainly onthe basis of co-morbidity or frailty. This is not tosay that these patients may not gain materiallyfrom secondary prevention or individually selectedcomponents of cardiac rehabilitation. Indeed,many eligible and included patients may only besuited to, and gain benefit from, specific aspects ofrehabilitation.
The definition of eligibility is important. In anRCT setting with minimal exclusions andappropriate documentation the eligibility criteriaare clearly defined. In a non-trial setting thepossibility arises that eligibility can be flexible andtake on a role in rationing services. This may, inpart, explain the extra tier of exclusion observedwithin the randomised trial context in that, afterreferral, coordinators tended to exclude olderpatients and those with more severe presentationof coronary heart disease from outpatient cardiacrehabilitation, possibly on the basis of an exercisetest. Clearly, frail, elderly people and those withco-morbidity are capable of benefiting fromrehabilitation, as shown by trials of geriatricassessment and rehabilitation units, and everydaypractice within the NHS. The nature ofrehabilitation for such patients may be lessintensive than for other patients and may involveattendance at a day hospital. Some linkagebetween cardiac rehabilitation and health servicesfor elderly people would be desirable to ensurethat appropriate rehabilitation is available to all,regardless of age.
Under-represented groupsIn the national survey and in the RCT, uptake ofcardiac rehabilitation tended to be lower in olderpatients than in younger age groups. However,having attended one class there was no evidenceto suggest that older patients were more likely todrop out of rehabilitation. Women were less likelyto attend in both settings, but in the trial this waslargely explained by the increased age of womenat presentation. It is not possible to draw firm
conclusions about the attendance of black or Asiangroups as national database data were incompletefor coding of ethnicity, and in the survey ofrehabilitation centres numbers referred to andattending cardiac rehabilitation tended to be low.
Accessibility of informationGathering data on patient need, eligibility andrehabilitation activity was problematic. To simplifythe process and make estimates more precise,national analysis of audit data would be preferableto ad hoc surveys. Unfortunately, audit was foundto be underdeveloped in cardiac rehabilitation.The survey in England showed an uncoordinatedapproach to data collection and audit, withconsiderable variation in methods and content.With the standards set out in the NSF-CHD,reproducible and comparable methods should bein place, but little evidence was found to suggestthat this was so. The use of modern medicalrecords systems and gathering of data with anational and policy-driven standardised tool aredesirable. This would allow assessment of allstages of the rehabilitation process, starting withthe original coronary heart disease diagnosis orprocedure, and would include information onpossible causes of under-representation.
Some programme coordinators reported thatdirect referral systems from surgery and clinicswere in place aimed at improving uptake ofcardiac rehabilitation. The use of methods topromote direct referral suggests that audit canbridge the gap between inpatient care andoutpatient cardiac rehabilitation.
What is the effectiveness ofdifferent methods of improvinguptake and of differentialtargeting of cardiac rehabilitation?Barriers to participation in outpatientcardiac rehabilitationInterviews with patients randomised to attendrehabilitation in a trial confirmed commonlyperceived reasons for non-attendance at cardiacrehabilitation. The main reasons for non-attendance or dropout were: lack of interest,illness, transport difficulties, scheduling and careof dependants. These responses suggest that someaspects of non-attendance are amenable tointervention by addressing issues of motivation,perceived relevance of cardiac rehabilitation tofuture well being, co-morbidities, the site and timeof sessions, transport and arrangement of care fordependents.
Conclusions
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Interventions used in cardiacrehabilitation centresThe survey of cardiac rehabilitation coordinatorsfound a high level of awareness of the problem oflow uptake. Sixty-six percent of services thatresponded indicated that they had implementedmeasures to improve attendance. Interventionsappropriate to all patients included follow-uptelephone calls, personalised invitation, homevisits and free transport. More specificinterventions for under-represented groups(women, the elderly, ethnic minorities, patientswith heart failure or angina) includedindividualised classes, buddy systems and inclusionin the programme of a spouse or relative.
Many interventions were reported and somerepresent the application of common-sensemethods. Nevertheless, studies to show thesustainable effectiveness of interventions arenecessary if the long-term benefits of interventionsare to be confirmed and the value of interventionsdisseminated more widely. The possibility existsthat a common-sense intervention may have anegative effect on attendance. For example,patients collected last and returned home firstmay value free hospital transport as part of theoverall rehabilitation package, whereas patientssubjected to an extended journey and long transittimes may find this an inconvenience thatinfluences subsequent participation.
Although the RCT represents the gold standard inthe evaluation of new interventions, this may beconsidered inappropriate by a cardiacrehabilitation professional attempting to provideservices to all patients. As a possible alternative toRCTs, improvement in uptake attributable to anintervention may be identified by audit. However,reproducible audit procedures need to be in placefirst.
Systematic review of the literatureTo identify studies of interventions with the aim ofimproving uptake and adherence to cardiacrehabilitation, three systematic reviews werecarried out. The issue of improving uptake andadherence was split into three major questions:how can recruitment to cardiac rehabilitation beimproved (uptake); how can patients’ adherence tocardiac rehabilitation and maintenance of lifestylechanges be improved; and how can professionalsbe encouraged to comply with guidelines andgood practice? These were designed to identifyinterventions to improve all aspects of referral andinvitation, uptake and adherence to cardiacrehabilitation.
The comprehensive systematic review of literaturecovered a large range of databases andhandsearches. Studies identified were published injournals, theses and conference abstracts. It wasdisappointing to find that nearly half of thestudies reporting potentially valuable methods topromote cardiac rehabilitation were found only inthe grey literature, with little opportunity foraccess by interested healthcare professionals.Sharing of information is essential if effectivemethods are to be implemented. Of the studiesidentified, a minority were RCTs.
Although some studies that looked at alteringpatient behaviour were identified, there was verylittle literature on interventions aimed atencouraging healthcare professional compliancewith guidelines or good practice regardinginvitation and support of patients’ cardiacrehabilitation. As the conduct of the healthcareprofessional is central in the recruitment ofpatients to cardiac rehabilitation it seems logical tostudy interventions relating to professionaleducation, compliance with guidelines andcoordination of services. In one RCT amultifaceted approach to transfer of care fromhospital to general practice was associated withincreased cardiac rehabilitation uptake. However,the relative importance of one specific aspect ofthe intervention directly concerning professionalcompliance could not be evaluated.
The systematic literature review identified someinterventions to help improve patient uptake ofcardiac rehabilitation. Invitation letters,pamphlets, telephone calls and home visits may beused to convey a motivational message. Trainedlay volunteers providing support to patients in theperiod before an outpatient programme mayfacilitate subsequent attendance at cardiacrehabilitation.
Following successful recruitment of patients tocardiac rehabilitation it is important that patientsadhere to the programme and maintain anyassociated lifestyle changes. Methods based onimprovements in self-efficacy and behaviouralfeedback showed promise in improving andsustaining risk factor management.
Possible interventions suggested in the literature,but which have not been evaluated in trials, wereidentified as areas for future research. These werebased on observations in trials, reviews and patientinterviews. Interventions relating to professionalcompliance include education of healthcareprofessionals on the benefits of cardiac
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rehabilitation, appointment of a programmedirector, use of clinical pathways with explicitpatient eligibility criteria, flexibility in programmestart dates, flexibility in programme times, andhome visiting to provide continuity of care.Suggested interventions to improve uptake includeearly support and planning postdischarge byhealthcare professionals, adaptation of services forunder-represented groups, use of communityfacilities, provision of services in a communitysetting, and for motivated patients withappropriately supervised delivery, home-basedmethodologies. Unevaluated interventions toimprove adherence include further approachesbased on self-efficacy, including demonstrations ofbehaviours by previous patients, which may be ofparticular value in promoting dietary change.Alternative forms of exercise or diet modificationmay help to improve adherence, and this may beespecially useful for women, elderly people andminority ethnic groups. The use of different formsof rehabilitation such as home-based programmesmay be acceptable in highly motivated patientswith less severe coronary heart disease.
The identification of so many interventions inneed of evaluation suggests that there is value inthe study of factors determining attendance. Well-conducted qualitative studies in providers andparticularly in patients may be useful inidentifying the attitudes, beliefs and valuesassociated with successful cardiac rehabilitation.Since this review was completed, a qualitativestudy of factors influencing enrolment in cardiacrehabilitation has been published.201 This studysuggested that physician recommendation,encouragement from family and friends, andaccess to transportation are important factors inpromoting enrolment.
What is the potential budgetimpact of increasing uptake ofcardiac rehabilitation usingdifferent uptake interventions?Service duration and configurationThe effectiveness of different intensities andmultidisciplinarity of cardiac rehabilitation is notknown. Systematic reviews include a wide range ofinterventions both more and less intense thancurrent UK recommendations, but to date noattempt has been made to stratify effectiveness byservice model.
The BACR/BHF survey of cardiac rehabilitationacross the UK showed wide variations in intensity,
programme content and staffing. However, themean levels of service provision suggest that an 8-week programme with 2 hours per week ofexercise training, 1 hour per week of educationand half an hour per week of psychologicalintervention is typical.
In the UK, three service configurations wereidentified, based on numbers of different types ofkey staff. A service involving three to five key staffis most commonly provided, with 73% ofprogrammes reporting this configuration. Fewprogrammes had lower staffing levels, but 20% ofprogrammes had more than five key staff. Untilevidence is available on the effectiveness of moreintensive interventions it seems reasonable to baseprojections on the moderate service configurationwith its multidisciplinary structure.
Costs of cardiac rehabilitationThe average costs of cardiac rehabilitation to thehealth service per patient successfully completinga programme were estimated at about £350 (staffcosts only) and £490 (total costs) at 2000/01 prices.In the UK this equates to an NHS cost of between£15.2 and £23.6 million. This range representsthe uncertainty in identifying the total number ofpatients receiving cardiac rehabilitation in the UK.The lower figure is the number of patientscompleting a programme in centres whoresponded to the BACR/BHF survey, and thehigher figure is an extrapolation of identifiedservice levels to all known UK programmes. As theBACR/BHF database is an established and well-respected resource, it is likely that the non-responding centres are more recent and smallerprogrammes. Consequently, an overall UK costestimate greater than £15.2 million but less than£23.6 million is probable. Again, this highlightsthe importance of consistent national audit inguiding the provision of cardiac rehabilitation.
A minority of centres reported spare capacity andthis would have only a small potential impact onoverall provision. On the basis of unmet needidentified in the survey and applying theconservative eligibility criteria of acute myocardialinfarction, unstable angina and revascularisation,it was estimated that a budget increase ofapproximately 260% would be required,representing an overall annual budget of about£56 million at 2000/01 prices. Clearly, this wouldbe considerably greater if more than five key staffwere included in the programme and theeligibility criteria were extended to all patientswith a discharge diagnosis of coronary heartdisease or heart failure, or following
Conclusions
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revascularisation. This may imply a budgetincrease of up to 630% and an annual budget ofapproximately £115 million.
Other costs may be involved in the extension ofprovision, depending on local factors such ascurrent levels of staffing, the opportunity costs ofextending the role of existing staff, existing sparecapacity and facilities and, if not available, thecosts of hiring facilities, for example in communitysport centres. Conversely, economies of scale mayserve to reduce the extra budget required.
Additional costs of increasing uptakeand adherenceOrder of magnitude costs of interventions toimprove uptake and adherence with cardiacrehabilitation may be inferred and these suggest awide range of implied costs. Motivationalinterventions could replace existing methods of
invitation at minimal cost, and the incorporationof motivational elements into an establishedhome-visiting schedule may have little furtherimplication for resources. The use of layvolunteers in promoting uptake of cardiacrehabilitation is likely to be more costly, withextensive training requirements and travel costs.Similarly, the introduction of liaison nursecoordination of transfer of care would be costly ifrecruitment of new staff was required. However, itmay serve to define the role of the establishedliaison nurse in supporting patients and otherhealthcare professionals and coordination ofpostdischarge care. Strategies aimed at improvingself-management could be incorporated intooutpatient cardiac rehabilitation sessions, andtraining of rehabilitation staff in lifestyleevaluation may serve to formalise assessment andprocedures already in place in cardiacrehabilitation.
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Implications for healthcare� Provision of outpatient cardiac rehabilitation in
the UK is well below the NSF-CHD goal of 85%of patients with acute myocardial infarction andrevascularisation being offered outpatientcardiac rehabilitation.
� Information on referral to and uptake of cardiacrehabilitation is incomplete, with widely varyingestimates of provision, particularly in under-represented groups. Little is known about thecapacity of cardiac rehabilitation centres toincrease provision.
� There is an uncoordinated approach to auditdata collection.
� Reasons reported by patients for non-attendance are amenable to intervention, butfew interventions have been formally evaluated.
� Many interventions aimed at improving patientuptake, adherence and professional compliancewith guidelines and good practice have beenproposed, but few have been formallyevaluated.
� Motivational communications and trained layvolunteers may help to improve uptake ofcardiac rehabilitation.
� Self-management techniques may help topromote and sustain lifestyle changes associatedwith cardiac rehabilitation.
� Qualitative studies in providers and patientsmay identify attitudes, beliefs and valuesassociated with cardiac rehabilitation.
� Information on costs of interventions isfrequently not reported.
� Experience of low-cost interventions and goodpractice exists within many cardiacrehabilitation centres.
� Increased provision of outpatient cardiacrehabilitation will require additional resources.
Recommendations for research anddevelopment� Trials comparing the cost-effectiveness of
comprehensive multidisciplinary rehabilitationwith simpler outpatient programmes.
� Economic and patient preference studies of theeffects of different methods of using increasedfunding for cardiac rehabilitation, andevaluations of the impact of any increasedfunding.
� Evaluation of a range of interventions and goodpractice (including self-managementtechniques, motivational communication andthe use of trained lay volunteers) to promoteattendance in all patients and under-represented groups.
� Development of standardised audit methods inthe context of modern records systems,appropriate training for dedicated staff anddialogue between service contributors.Standardisation of criteria for patient eligibility,regular and comprehensive data collection toestimate the need for and provision of cardiacrehabilitation.
� Identification of further areas for interventionthrough qualitative studies.
� Extension of low-cost interventions and goodpractice in rehabilitation.
� Regular updated systematic review of literaturerelating to uptake and adherence to cardiacrehabilitation to include literature not readilyavailable to providers and non-UK studies.
Chapter 13
Key findings
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We are grateful to Judith Jolliffe, Jo Coast,Karl Karsch, David Thompson and Bob
Lewin for their involvement in the early phase ofthe project. We also thank Hugh Bethell and SallyTurner for allowing us access to the BritishAssociation for Cardiac Rehabilitation/BritishHeart Foundation survey data; Roy Maxwell andDavidson Ho (HES), Farzana Nadeem (PEDW)and Ciara Kennedy (HIS) for supplying data onpopulation need; and the staff of rehabilitationcentres that contributed additional survey data,audits and relevant information.
Contributors to survey of audit activityin UK cardiac rehabilitation centresWe are grateful for the assistance of rehabilitationand audit staff from the following centres: KatrinaCreedon (Birmingham Heartlands and SolihullNHS Trust), Claire Brereton-Worsman (BradfordHospitals NHS Trust), Gillian Matthews (CornwallPartnership NHS Trust), Ashley Davidson (EastSomerset NHS Trust), Mark Giles (GloucestershireHospitals NHS Trust), Alison Child (Guy’s and StThomas’ Hospital NHS Trust), Maureen Barry(Homerton Hospital NHS Trust), Judith Imich(Kings College Hospital NHS Trust), Pat Marley(The Lewisham Hospital NHS Trust), Sheila Ryan(Newham Primary Care Trust), Tony Andrews(North Devon Healthcare NHS Trust), ValerieNangle (North Middlesex University HospitalTrust), John Outhwaite and Julie Thompson(Plymouth Hospitals NHS Trust), Victoria Sievey(Royal Bournemouth and Christchurch NHSTrust), Alison Brown (Royal Cornwall NHS Trust),Alison Davey (Royal Free Hampstead NHS Trust),Margaret Wicks (Royal United Hospital Bath NHSTrust), Rosalind Leslie (Royal Wolverhampton
NHS Trust), Dee Hannah (St Mary’s NHS Trust),Maggie Kelly (Salisbury Health Care NHS Trust),Margaret Pritchard (Sandwell Healthcare NHSTrust), Suzy Young and Lynne Kilner (SouthDevon Healthcare NHS Trust), Petra Haig (SouthWarwickshire General Hospitals NHS Trust),Amanda Daniel (United Bristol Healthcare Trust),Mark Walsh (Walsall Hospitals NHS Trust), BrianColeman (Whipps Cross University Hospital NHSTrust) and Linda Barratt (Worcester AcuteHospitals NHS Trust).
Contributions of authorsAndrew Beswick (Research Associate) contributedto the systematic review, audit and RCT, andprepared the report. Karen Rees (Research Fellow)acted as project coordinator and contributed tothe systematic review and survey of UK provision.Ingolf Griebsch (Research Associate) preparedhealth service costs and population need. FionaTaylor (Public Health Specialist Trainee)contributed to the systematic review and auditsurvey. Margaret Burke (Trials Search Coordinatorfor the Cochrane Heart Group) carried out theliterature searches. Robert West (Reader inEpidemiology) contributed to the systematicreview and RCT attendance, design and planning. Jackie Victory (Cardiac RehabilitationSister) contributed to the audit survey and the UK survey of provision. Jacqueline Brown(MRC Senior Scientist) prepared health service costs. Rod Taylor (Senior Lecturer in Public Health and Epidemiology) worked on the UK survey of provision. Shah Ebrahim(Professor of Epidemiology and Ageing) workedon the systematic review and coordinated theproject.
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171. Senaratne MP, Griffiths J, Mooney D, Kasza L,Macdonald K, Hare S. Effectiveness of a plannedstrategy using cardiac rehabilitation nurses for themanagement of dyslipidemia in patients withcoronary artery disease. Am Heart J 2001;142:975–81.
172. Skof E, Span M, Keber I. Secondary prevention inpatients several years after myocardial infarction:comparison of an outpatient and an inpatientrehabilitation programme. J Cardiovasc Risk2001;8:119–26.
173. Baile WF, Engel BT. A behavioural strategy forpromoting treatment compliance followingmyocardial infarction. Psychosom Med 1978;40:413–19.
174. Stern MJ, Cleary P. National Exercise and HeartDisease Project. Psychosocial changes observedduring a low-level exercise program. Arch InternMed 1981;141:1463–7.
175. Starkey C, Michaelis J, de Lusignan S.Computerised systematic secondary prevention inischeamic heart disease: a study in one practice.Public Health 2000;114:169–75.
176. Orem D. Nursing concepts of practice. 4th ed. St. Louis, MO: Mosby; 1991.
177. Marlatt GA, Gordon JR, editors. Relapse prevention:maintenance strategies in the treatment of addictivebehaviors. New York: Guilford Press; 1985.
178. Tooth L, McKenna K. Contemporary issues incardiac rehabilitation: implications foroccupational therapists. British Journal ofOccupational Therapy 1996;59:133–40.
179. Koikkalainen M, Lappalainen R, Mykkanen H.Why cardiac patients do not follow thenutritionist’s advice: barriers in nutritional adviceperceived in rehabilitation. Disabil Rehabil1996;18:619–23.
180. Knapp D, Blackwell B. Emotional and behavioralproblems in cardiac rehabilitation patients. Journalof Cardiac Rehabilitation 1985;5:112–23.
181. Edgren L. Co-production – an approach to cardiacrehabilitation from a service managementperspective. J Nurs Manage 1998;6:77–85.
182. Oldridge NB. Compliance and dropout in cardiacexercise rehabilitation. Journal of CardiacRehabilitation 1984;4:166–77.
183. DeBusk RF, Miller NH, Superko HR, Dennis CA,Thomas RJ, Lew HT, et al. A case-managementsystem for coronary risk factor modification afteracute myocardial infarction. Ann Intern Med1994;120:721–9.
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Health Technology Assessment 2004; Vol. 8: No. 41
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© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 1
Need for cardiac rehabilitation in the UK
Appendix 1
84
TA
BLE
35
Nee
d fo
r car
diac
reha
bilit
atio
n in
Eng
land
Gen
der
Age
Po
pula
tion
Cou
nts
Rat
es p
er 1
00,0
00
grou
p(i
n 10
00s)
AM
IH
FU
AC
AB
GP
TC
AC
AB
Gp
Oth
ers
AM
IH
FU
AC
AB
GP
TC
AC
AB
Gp
Oth
ers
Fem
ale
35–4
43,
368.
427
115
442
4611
323
1,23
28.
00.
413
.11.
43.
40.
736
.645
–54
3,45
1.0
1,15
486
2,07
231
152
372
4,91
533
.42.
560
.09.
015
.22.
114
2.4
55–6
42,
398.
52,
585
261
4,00
588
61,
165
233
9,80
310
7.8
10.9
167.
036
.948
.69.
740
8.7
65–7
42,
253.
24,
586
808
6,14
81,
399
1,31
641
013
,777
203.
535
.927
2.9
62.1
58.4
18.2
611.
575
–84
1,60
1.2
4,76
71,
232
5,89
248
843
517
211
,105
297.
776
.936
8.0
30.5
27.2
10.7
693.
585
+73
7.5
1,97
373
21,
983
1218
24,
455
267.
599
.326
8.9
1.6
2.4
0.3
604.
1
Mal
e35
–44
3,45
0.0
1,76
888
1,58
735
966
791
3,92
351
.22.
646
.010
.419
.32.
611
3.7
45–5
43,
446.
35,
543
470
4,97
71,
951
2,53
142
014
,122
160.
813
.614
4.4
56.6
73.4
12.2
409.
855
–64
2,36
1.5
7,97
71,
138
8,32
54,
638
3,81
896
824
,906
337.
848
.235
2.5
196.
416
1.7
41.0
1,05
4.7
65–7
41,
949.
98,
568
1,75
29,
422
4,77
32,
625
1,08
324
,755
439.
489
.948
3.2
244.
813
4.6
55.5
1,26
9.6
75–8
41,
017.
85,
379
1,39
95,
711
1,05
863
837
112
,074
528.
513
7.5
561.
110
4.0
62.7
36.5
1,18
6.3
85+
265.
51,
156
356
1,07
419
234
2,24
743
5.3
134.
140
4.4
7.2
8.7
1.5
846.
2
Both
35–4
46,
818.
42,
040
103
2,03
140
578
011
45,
157
29.9
1.5
29.8
5.9
11.4
1.7
75.6
45–5
46,
897.
26,
698
557
7,05
22,
262
3,05
449
219
,043
97.1
8.1
102.
232
.844
.37.
127
6.1
55–6
44,
760.
010
,570
1,39
912
,336
5,52
44,
983
1,20
134
,731
222.
129
.425
9.2
116.
110
4.7
25.2
729.
665
–74
4,20
3.0
13,1
622,
562
15,5
776,
173
3,94
11,
493
38,5
6131
3.2
61.0
370.
614
6.9
93.8
35.5
917.
575
–84
2,61
9.0
10,1
562,
634
11,6
071,
546
1,07
354
323
,195
387.
810
0.6
443.
259
.041
.020
.788
5.6
85+
1,00
3.1
3,13
41,
089
3,06
431
416
6,71
331
2.4
108.
630
5.5
3.1
4.1
0.6
669.
3To
tal
26,3
00.7
45,7
608,
344
51,6
6715
,941
13,8
723,
849
127,
400
174.
031
.719
6.4
60.6
52.7
14.6
484.
4
Sour
ce: H
ES, E
ngla
nd. A
MI,
acut
e m
yoca
rdia
l inf
arct
ion;
HF,
hear
t fa
ilure
; CA
BG, c
oron
ary
arte
ry b
ypas
s gr
aft;
PTC
A, p
ercu
tane
ous
tran
slum
inal
cor
onar
yan
giop
last
y; U
A, u
nsta
ble
angi
na; C
ABG
p, C
ABG
with
AM
I or
HF
or P
TCA
or
UA
with
in o
ne a
dmiss
ion
episo
de; A
ll ot
hers
: all
patie
nts
who
hav
e be
enad
mitt
ed m
ore
than
onc
e an
d w
ith m
ore
than
one
disc
harg
e di
agno
sis.
Health Technology Assessment 2004; Vol. 8: No. 41
85
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
TA
BLE
36
Nee
d fo
r car
diac
reha
bilit
atio
n in
Wal
es
Gen
der
Age
Po
pula
tion
Cou
nts
Rat
es p
er 1
00,0
00
grou
p(i
n 10
00s)
AM
IH
FU
AC
AB
GP
TC
AC
AB
Gp
Oth
ers
AM
IH
FU
AC
AB
GP
TC
AC
AB
Gp
Oth
ers
Fem
ale
35–4
420
1.9
220
371
33
8610
.90.
018
.30.
51.
51.
542
.645
–54
197.
866
911
412
215
310
33.4
4.6
57.6
6.1
10.6
2.5
156.
755
–64
160.
820
532
258
4842
1566
212
7.5
19.9
160.
429
.926
.19.
341
1.7
65–7
414
4.2
374
6135
167
3825
998
259.
442
.324
3.4
46.5
26.4
17.3
692.
175
–84
108.
534
711
235
019
815
962
319.
810
3.2
322.
617
.57.
413
.888
6.6
85+
44.2
152
7697
00
040
634
3.9
171.
921
9.5
0.0
0.0
0.0
918.
6
Mal
e35
–44
203.
299
661
1517
720
848
.73.
030
.07.
48.
43.
410
2.4
45–5
419
6.5
408
3431
185
9831
916
207.
617
.315
8.3
43.3
49.9
15.8
466.
255
–64
156.
661
074
507
205
146
721,
657
389.
547
.332
3.8
130.
993
.246
.01,
058.
165
–74
125.
260
316
257
018
393
631,
614
481.
612
9.4
455.
314
6.2
74.3
50.3
1,28
9.1
75–8
469
.342
012
132
948
1422
938
606.
117
4.6
474.
769
.320
.231
.71,
353.
585
+15
.991
2265
01
021
157
2.3
138.
440
8.8
0.0
6.3
0.0
1,32
7.0
Both
35–4
440
5.1
122
698
1620
1029
430
.11.
524
.23.
94.
92.
572
.645
–54
394.
247
643
426
9711
936
1,22
612
0.8
10.9
108.
124
.630
.29.
131
1.0
55–6
431
7.4
816
106
765
253
188
872,
320
257.
133
.424
1.0
79.7
59.2
27.4
730.
965
–74
269.
497
822
392
225
013
188
2,61
236
3.0
82.8
342.
292
.848
.632
.796
9.6
75–8
417
7.9
768
233
680
6722
371,
903
431.
713
1.0
382.
237
.712
.420
.81,
069.
785
+60
.124
398
162
01
061
840
4.3
163.
126
9.6
0.0
1.7
0.0
1,02
8.3
Tota
l1,
624.
13,
403
709
3,05
368
348
125
88,
973
209.
543
.718
8.0
42.1
29.6
15.9
552.
5
Sour
ce: P
EDW
.
Appendix 1
86 TA
BLE
37
Nee
d fo
r car
diac
reha
bilit
atio
n in
Nor
ther
n Ire
land
Gen
der
Age
Po
pula
tion
Cou
nts
Rat
es p
er 1
00,0
00
grou
p(i
n 10
00s)
AM
IH
FU
AC
AB
GP
TC
AC
AB
Gp
Oth
ers
AM
IH
FU
AC
AB
GP
TC
AC
AB
Gp
Oth
ers
Fem
ale
35–4
412
0.1
263
192
70
8521
.62.
515
.81.
75.
80.
070
.845
–54
98.7
8211
102
1147
025
883
.111
.110
3.3
11.1
47.6
0.0
261.
455
–64
80.3
181
3618
931
950
550
225.
444
.823
5.4
38.6
118.
30.
068
4.9
65–7
467
.627
110
527
638
790
693
400.
915
5.3
408.
356
.211
6.9
0.0
1,02
5.1
75–8
446
.327
714
423
65
240
477
598.
331
1.0
509.
710
.851
.80.
01,
030.
285
+17
.594
5455
00
010
153
7.1
308.
631
4.3
0.0
0.0
0.0
577.
1
Mal
e35
–44
115.
910
86
7416
630
252
93.2
5.2
63.8
13.8
54.4
0.0
217.
445
–54
96.7
331
3527
074
247
181
934
2.3
36.2
279.
276
.525
5.4
1.0
846.
955
–64
75.6
468
117
514
183
358
31,
401
619.
015
4.8
679.
924
2.1
473.
54.
01,
853.
265
–74
54.1
478
171
494
126
227
11,
214
883.
531
6.1
913.
123
2.9
419.
61.
82,
244.
075
–84
28.4
249
138
215
2531
043
687
6.8
485.
975
7.0
88.0
109.
20.
01,
535.
285
+6.
140
4337
00
059
655.
770
4.9
606.
60.
00.
00.
096
7.2
Both
35–4
423
613
49
9318
700
337
56.8
3.8
39.4
7.6
29.7
0.0
142.
845
–54
195.
341
346
372
8529
41
1,07
721
1.5
23.6
190.
543
.515
0.5
0.5
551.
555
–64
155.
964
915
370
321
445
33
1,95
141
6.3
98.1
450.
913
7.3
290.
61.
91,
251.
465
–74
121.
774
927
677
016
430
61
1,90
761
5.4
226.
863
2.7
134.
825
1.4
0.8
1,56
7.0
75–8
474
.852
628
245
130
550
913
703.
237
7.0
602.
940
.173
.50.
01,
220.
685
+23
.613
497
920
00
160
567.
841
1.0
389.
80.
00.
00.
067
8.0
Tota
l80
7.3
2,60
586
32,
481
511
1,17
85
6,34
532
2.7
106.
930
7.3
63.3
145.
90.
678
6.0
Sour
ce: H
IS, N
orth
ern
Irel
and.
Health Technology Assessment 2004; Vol. 8: No. 41
87
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 2
Need for and estimated level of cardiac rehabilitation provision in the UK
Appendix 2
88 TA
BLE
38
Nee
d an
d es
timat
ed le
vel o
f pro
visio
n in
Eng
land
(to
tal n
umbe
r of c
ardi
ac re
habi
litat
ion
cent
res
n=
220
)
Mea
nSD
Med
ian
IQR
nSu
m o
f N
on-r
espo
ndin
g To
tal s
um o
f pat
ient
s al
l pat
ient
sce
ntre
s (n
)(r
espo
ndin
g pl
us n
on-
resp
ondi
ng c
entr
es)
Mea
nM
edia
nIQ
R
No.
of p
atie
nts
refe
rred
to
CR
349.
024
4.33
279.
018
0–45
011
740
,840
103
76,7
9369
,577
59,3
80–8
7,19
0N
o. o
f pat
ient
s jo
inin
g C
R20
8.6
141.
817
7.5
112–
277
114
23,7
8110
645
,893
42,5
9635
,653
–53,
143
Elig
ible
pat
ient
s (s
ourc
e: H
ES)
No.
of
Pro
port
ion
of p
atie
nts
refe
rred
to
Pro
port
ion
of p
atie
nts
join
ing
pati
ents
CR
(%
) D
ata
for
non-
resp
onde
rs
CR
(%
) D
ata
for
non-
resp
onde
rs
impu
ted
impu
ted
Mea
nM
edia
nIQ
RM
ean
Med
ian
IQR
All
patie
nts
with
prim
ary
diag
nosis
of I
HD
266,
833
2926
22–3
317
1613
–20
All
patie
nts
disc
harg
ed w
ith A
MI,
CA
BG, P
TCA
, UA
131,
089
5953
45–6
735
3327
–41
All
patie
nts
with
prim
ary
diag
nosis
of I
HD
<75
yea
rs
202,
001
3834
29–4
323
2118
–26
IHD
, isc
haem
ic h
eart
dise
ase.
Health Technology Assessment 2004; Vol. 8: No. 41
89
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
TA
BLE
39
Nee
d an
d es
timat
ed le
vel o
f pro
visio
n in
Wal
es (
tota
l num
ber o
f car
diac
reha
bilit
atio
n ce
ntre
sn
= 1
8)
Mea
nSD
Med
ian
IQR
nSu
m o
f N
on-r
espo
ndin
g To
tal s
um o
f pat
ient
s (r
espo
ndin
g pl
us n
on-r
espo
ndin
g al
l pat
ient
sce
ntre
s (n
)ce
ntre
s)
Mea
nM
edia
nIQ
R
No.
of p
atie
nts
refe
rred
to
CR
316.
717
0.7
311
180–
400
103,
167
85,
701
5,65
54,
607–
6,36
7N
o. o
f pat
ient
s jo
inin
g C
R18
5.4
93.0
150
119–
248
132,
410
53,
337
3,16
03,
005–
3,65
0
Elig
ible
pat
ient
s (s
ourc
e: P
EDW
)N
o. o
f P
ropo
rtio
n of
pat
ient
s re
ferr
ed t
o C
R (
%)
Pro
port
ion
of p
atie
nts
join
ing
CR
(%
) pa
tien
tsD
ata
for
non-
resp
onde
rs im
pute
dD
ata
for
non-
resp
onde
rs im
pute
d
Mea
nM
edia
nIQ
RM
ean
Med
ian
IQR
All
patie
nts
with
prim
ary
diag
nosis
of I
HD
17,6
5033
3226
–36
1918
17–2
1A
ll pa
tient
s di
scha
rged
with
AM
I, C
ABG
, PTC
A, U
A
7,87
872
7259
–81
4240
38–4
6A
ll pa
tient
s w
ith p
rimar
y di
agno
sis o
f IH
D <
75 y
ears
12,7
2845
4436
–50
2625
24–2
9
TA
BLE
40
Nee
d an
d es
timat
ed le
vel o
f pro
visio
n in
Nor
ther
n Ire
land
(to
tal n
umbe
r of c
ardi
ac re
habi
litat
ion
cent
res
n=
10)
Mea
nSD
Med
ian
IQR
nSu
m o
f N
on-r
espo
ndin
g To
tal s
um o
f pat
ient
s (r
espo
ndin
g pl
us n
on-r
espo
ndin
g al
l pat
ient
sce
ntre
s (n
)ce
ntre
s)
Mea
nM
edia
nIQ
R
No.
of p
atie
nts
refe
rred
to
CR
205.
510
1.9
196
141.
5–26
9.5
482
26
2,05
51,
998
1,67
1–2,
439
No.
of p
atie
nts
join
ing
CR
146.
560
.415
410
7–18
64
586
61,
465
1,51
01,
228–
1,70
2
Elig
ible
pat
ient
s (s
ourc
e: H
IS)
No.
of
Pro
port
ion
of p
atie
nts
refe
rred
to
CR
(%
) P
ropo
rtio
n of
pat
ient
s jo
inin
g C
R (
%)
pati
ents
Dat
a fo
r no
n-re
spon
ders
impu
ted
Dat
a fo
r no
n-re
spon
ders
impu
ted
Mea
nM
edia
nIQ
RM
ean
Med
ian
IQR
All
patie
nts
with
prim
ary
diag
nosis
of I
HD
13,9
8815
1412
–17
1111
9–12
All
patie
nts
disc
harg
ed w
ith A
MI,
CA
BG, P
TCA
, UA
6,
780
3030
25–3
622
2218
–25
All
patie
nts
with
prim
ary
diag
nosis
of I
HD
<75
yea
rs11
,248
1818
15–2
213
1311
–15
Appendix 2
90 TA
BLE
41
Estim
ated
leve
l of p
rovis
ion
in S
cotla
nd (
tota
l num
ber o
f car
diac
reha
bilit
atio
n ce
ntre
s n
= 3
6)
Mea
nSD
Med
ian
IQR
nSu
m o
f N
on-r
espo
ndin
g To
tal s
um o
f pat
ient
s (r
espo
ndin
g pl
us n
on-r
espo
ndin
g al
l pat
ient
sce
ntre
s (n
)ce
ntre
s)
Mea
nM
edia
nIQ
R
No.
of p
atie
nts
refe
rred
to
CR
207.
315
0.4
198.
565
–340
244,
975
127,
462
7,35
75,
755–
9,05
5N
o. o
f pat
ient
s jo
inin
g C
R13
2.2
101.
310
047
–218
212,
777
154,
761
4,27
73,
482–
6,04
7
Dear Cardiac Rehab Coordinator,
We have recently been funded by the NHS Health Technology Assessment Research & Developmentprogramme to look at the provision, uptake and adherence to cardiac rehabilitation programmes incurrently under-represented groups, which includes women, elderly people, Black and Asian groups, andpatients with diagnoses of angina, heart failure and post-revascularisation. As part of this work, we needan up-to-date picture of current service provision. We are aware that you have recently completed aquestionnaire for the BHF/BACR survey, and we are collaborating with Dr Bethell and Sally Turner to usethe data you have kindly provided. There are a few additional questions we need to ask that were notcovered in the recent survey. We know you are extremely busy people so we have put together a shortquestionnaire that complements the BHF/BACR survey, that should only take a few minutes to complete.Any data will be added to the main BHF/BACR database. To be consistent, we are asking for informationrelevant to the period 1st January to 31st December 2000. Please contact us if you have any queriesregarding this. Please could you return the completed questionnaire in the SAE or fax through to FAO K Rees.
Thank you so much for your help with this important work
Very best wishes
Dr Karen Rees, BHF Research Fellow
Health Technology Assessment 2004; Vol. 8: No. 41
91
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 3
British Association for Cardiac Rehabilitation additional postal questionnaire
Appendix 3
92
ID
ADDITIONAL SHORT QUESTIONNAIRE TO COMPLEMENT THE BHF/BACR
DATABASE OF UK CARDIAC REHABILITATION CENTRES 2001
1. How long is your supervised phase 3 programme for each patient? (please give an
average figure for each component of CCR, relevant to your programme)
Exercise component
Health education component (e.g. Healthy diet, smoking cessation)
Psychological component (e.g. Relaxation/stress management) if given
No. weeks Average no.
of sessions patients/session
Total for whole programme – if unable to break down into component sessions
No. sessions/week Average length
No. weeks Average no.
of sessions patients/session
No. sessions/week Average length
No. weeks Average no.
of sessions patients/session
No. sessions/week Average length
No. weeks Average no.
of sessions patients/session
No. sessions/week Average length
Health Technology Assessment 2004; Vol. 8: No. 41
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© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
2. Do you make any special efforts to promote attendance at rehab sessions for any
of the following groups? (TICK ANY THAT APPLY)
Women Patients with heart failure
People aged 65+ Patients with angina
Black and Asian groups Patients who have had
CABG/PTCA
Please provide details of the methods you use:
3. Do you have any spare capacity within your current service for
additional patients?
Yes No
If yes, please indicate the number of additional patients patients/
that could be included without any increase in resources: week
4. During the last year approximately how many patients were referred?
Total Male Female 65+ years post-MI CABG/PTCA
Heart Angina Black and Asian groups
Failure
Appendix 3
94
During the year how many patients joined the programme?
Total Male Female 65+ years post-MI CABG/PTCA
Heart Angina Black and Asian groups
Failure
Of these patients, how many (eventually) completed the programme?
Total Male Female 65+ years post-MI CABG/PTCA
Heart Angina Black and Asian groups
Failure
With many thanks for your help in completing this questionnaire. Please could you
post back in the envelope provided, or fax through (FAO K Rees)
by 31 st October 2001
CR Coordinator/contact.......................................................................................
CR Programme, where based................................................................................
Region.....................................................................................................................
Search terms for major databases are given.These terms were adapted appropriately for
other databases.
Search strategy for MEDLINE1 exp Heart diseases/2 coronary.tw.3 cardiac.tw.4 CABG.tw.5 myocardial.tw.6 angina.tw.7 heart failure.tw.8 heart disease$.tw.9 or/1-8
10 exp Rehabilitation/11 exp Rehabilitation centers/12 exp Rehabilitation nursing/13 rehabil$.tw.14 Aftercare/15 aftercare.tw.16 Convalescence/17 convalescen$.tw.18 recuperat$.tw.19 or/10-1820 9 and 1921 exp Heart diseases/rh [Rehabilitation]22 20 or 2123 Patient education/24 exp Counseling/25 exp Exercise therapy/26 Exercise/27 exp Psychotherapy/28 (patient adj2 educat$).tw.29 counsel$.tw.30 (behavi$ adj2 therap$).tw.31 psychosocial$.tw.32 ((lifestyle or life-style) adj2 intervent$).tw.33 ((exercise$ or fitness) adj5 (treatment or
intervent$ or program$)).tw.34 ((lifestyle or life-style) adj5 (intervent$ or
program$ or treatment$)).tw.35 Nurse practitioners/36 "nurse practitioner$".tw.37 or/23-3638 9 and 3739 (secondary adj5 prevent$).tw.40 Survival rate/41 (reduc$ adj5 (morbid$ or mortal$)).tw.
42 Patient readmission/43 rehospitali$.tw.44 ((improv$ or increase$ or decrease$) adj5
(recover$ or function)).tw.45 Disease management/46 (disease adj2 manage$).tw.47 Recovery of function/48 exp "Costs and cost analysis"/49 compliance.tw.50 adheren$.tw.51 non-compliance.tw.52 costs.tw.53 Patient compliance/54 or/39-5355 37 and 54 and 956 22 or 55
Search strategy for EMBASE1 exp Heart disease/2 coronary.tw.3 cardiac.tw.4 CABG.tw.5 myocardial.tw.6 angina.tw.7 heart failure.tw.8 heart disease$.tw.9 or/1-8
10 exp rehabilitation/11 exp rehabilitation center/12 rehabil$.tw.13 exp convalescence/14 convalescen$.tw.15 recuperat$.tw.16 or/10-1517 9 and 1618 exp Heart disease/rh19 Heart rehabilitation/20 or/17-1921 exp patient education/22 exp counseling/23 exp kinesiotherapy/24 exp exercise/25 exp psychotherapy/26 (patient adj2 educat$).tw.27 counsel$.tw.28 (behavi$ adj2 therap$).tw.29 psychosocial$.tw.30 ((lifestyle or life-style) adj5 (intervent$ or
Health Technology Assessment 2004; Vol. 8: No. 41
95
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 4
Literature search strategies
program$ or treatment$)).tw.31 ((exercise$ or fitness$) adj5 (treatment$ or
intervent$ or program$)).tw.32 Nurse practitioner/33 "nurse practitioner$".tw34 or/21-3335 9 and 3436 exp survival/37 (patient$ adj2 readmi$).tw.38 rehospitali$.tw.39 ((secondary or tertiary) adj5 prevent$).tw.40 (reduc$ adj5 (mortal$ or morbid$)).tw.41 ((improv$ or increase$ or decrease$) adj5
(recover$ or function$)).tw.42 (disease$ adj2 manag$).tw.43 exp aftercare/44 aftercare.tw.45 exp economic evaluation/56 costs.tw.57 Patient compliance/58 (compliance or non-compliance).tw.59 adheren$.tw.50 Patient satisfaction/51 or/36-5052 35 and 5145 20 or 52
The results of all searching were downloaded intoa reference management database and thensearched across all fields for the following terms:
AdherenceDropout*Drop-out*ComplyComplianceNoncomplianceParticipant*ParticipationReferral*Nonattend*Attend*Refusal*Patient attitude*Patient satisfaction*Barrier*Nonparticipant*Non-participant*Treatment refusalMotivat*CostCostsEconom*
Appendix 4
96
Health Technology Assessment 2004; Vol. 8: No. 41
97
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 5
Inclusion/exclusion form
Uptake and adherence tocardiac rehabilitation
Databasenumber
Date assessedExcluded? Included?First author
Uptake A AProf compliance B BAdherence C CAudits/descriptive I I
Source and date
Economic E E
Intervention toincrease uptake bypatients
Intervention toimproveprofessionalcompliance
Interventionto improveadherence
Reviewer (initials)
1. Is an interventionevaluated?
2. Patients:AMI, CABG, PTCA,Angina, Heart Failure,Other CVD (Specify)
3. Outcome:people attending,losses to follow up,adherence (medical advice,therapy, clinical events,rehospitalisation, costs)
If 1, 2 and 3 yes then include study
4. Reason for exclusion
Other information
5. Audit/descriptive information
6. Economic information
Health Technology Assessment 2004; Vol. 8: No. 41
99
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 6
Data extraction form
Appendix 6
100
Data extraction form – HTA SR of uptake, patient adherence and professional compliance
Reference:
Database ID: Date:
Reviewer: (initials)
Subject relevant to: (circle all that apply)
A – Intervention to increase uptake by patients
B – Intervention to improve professional compliance
C – Intervention to improve patient adherence
1. Data Source: (circle) Published only Unpublished only mixed
Country of publication/recruitment –
2. Study type: (circle)
Between group comparisons: RCT (adequate allocation concealment)
Quasi RCT (inadequate allocation concealment, e.g. alternate allocation, by hospital No., DoB etc.)
Non-randomised trial (e.g. Allocation to groups but no attempt at randomisation)
Before and after study (comparing outcomes in different groups of patients before and after an intervention)
Within group comparisons: Before and after study (comparing outcomes in the same patients before and after an intervention)
3. Quality of studies:
Creation of comparison groups
a) generation of random sequence method_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
b) concealment of allocation method_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
c) how allocation occurred (e.g. patient or doctor preference) detail _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
d) balance groups by design (e.g. matching) detail _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
e) within group comparisons (circle if applies)
Comparability of groups
a) Were comparison groups similar at baseline? Yes No Unclear
b) Were prognostic factors identified? Yes No Unclear
c) Was case-mix adjustment used to account for differences between groups? Yes No Unclear
d) (For within group comparisons only) — were only paired responses analysed? Yes No Unclear
Health Technology Assessment 2004; Vol. 8: No. 41
101
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Blinding of outcomes
a) Were outcomes assessed blind/independently of intervention? Yes No Unclear
Follow-up
a) Was there equal follow-up between groups? Yes No Unclear
b) What was the overall loss to follow-up? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Not reported
Sample
a) Prospective or retrospective sampling? Prospective Retrospective
b) Were inclusion and exclusion criteria specified? Yes No Unclear
c) Was the sample size planned (e.g. sample size calculation included)? Yes No Unclear
d) Is representativeness of the sample assessed? (add comments) Yes No Unclear
_ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4. Participants studied: (circle all that apply)
Diagnosis
Post MI CABG/PTCA Heart Failure (chronic / secondary to MI) Angina
Participants
Men Women Age limited (specify) Ethnic Minority Groups
For the whole sample:
Mean age (range) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Percentage men _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Case mix (specify, e.g. 100% MI or mixed diagnoses and proportions) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Percentage white (if known) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Inclusion/Exclusion criteria (if stated) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5. Intervention (investigator’s description in as much detail as possible, including theoretical basis,
intensity and duration, group or individual, setting, etc.)
A – Intervention to increase uptake by patients
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _
B – Intervention to improve professional compliance
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _
C – Intervention to improve patient adherence
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _
Appendix 6
102
Description of comparison group (treatment or usual care) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _
_ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ __
Duration of follow-up (not duration of intervention) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _
6. Outcomes: (circle all that apply)
Specified primary outcome (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _
Attendance rates Adherence to rehabilitation/medical advice/therapy(give criteria used) (give criteria used)
Clinical events Rehospitalisation Costs Changes in risk factors
Other (specify)
Number of follow-up measurement points (give time intervals, e.g. 6 months, 1 year)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _
7. Study comparisons: (if multiple time points, use longest duration of follow-up)
Characteristics Intervention/Before
Control/After
(additional columnfor 3 arm trial or 3time phase studies)
Baseline characteristics:Number randomisedAge (mean SD range)Sex (% male)Outcomes:Attendance Nos (%)Adherence to medication/therapy – Nos adhering (%)Adherence to medication/therapy – Nos adhering (%)Losses to follow-up Nos (%)Specified primary outcome: N(%)Clinical events: N(%)Total Mortality N(%)Cardiac Mortality N(%)Non-fatal MI N(%)Revascularisation N(%)CVD event (stroke/TIA) N(%)Other N(%)Hospitalisation/RehospitalisationNumber (%) of patientsNumber of occasionsCosts (specify what)Other outcomes:
8. Notes (what did the investigators find? Interesting features?)
Health Technology Assessment 2004; Vol. 8: No. 41
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© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 7
Flow diagram of the systematic review of interventions to improve uptake of cardiac
rehabilitation (QUOROM statement flow diagram)
Potentially relevant publications identifiedand screened for retrieval
3261
Publications retrieved for more detailedevaluation
957Publications excluded on the basis of titleand abstract:
No intervention evaluated 776
No outcome pertaining to uptakeof cardiac rehabilitation 154
Publications included for data extraction
27 (22 studies)
Studies included in review
8
Studies excluded from review:
Published after June 2001 1No outcome 6No comparison group 1Retrospective design 1Outcome is referral 2Outcome is patient commitment 1Outcome relates to secondaryprevention 2
__Total 14
Publications excluded on the basis of titleand abstract (clear evidence that sourcepaper did not describe intervention inappropriate patient group)
2304
Health Technology Assessment 2004; Vol. 8: No. 41
105
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 8
Studies evaluating interventions to improve theuptake of cardiac rehabilitation
Appendix 8
106 Stu
die
s ar
e li
sted
in
ter
ms
of
stu
dy
des
ign
an
d t
he
hie
rarc
hy
of
evid
ence
, w
ith
RC
Ts
firs
t.
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff gr
oup:
m
easu
re a
nd
outc
omes
au
thor
s’
coun
try
% m
en,
invo
lved
, int
ensi
ty,
deta
ils o
f re
sult
san
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
mea
n ag
e fo
llow
-up
peri
od fo
r us
ual c
are
inte
rest
ing
feat
ures
type
)(S
D),
ou
tcom
e as
sess
men
tet
hnic
ity
if st
ated
Wye
r et
al.,
2001
105,
106
UK
(jour
nal a
ndth
esis)
Para
llel
grou
p RC
T,87
pat
ient
sra
ndom
ised
Patie
nts
wer
e ha
nded
ase
aled
num
bere
den
velo
pe w
ith a
nom
inal
lett
er. H
alf o
f the
enve
lope
s al
so c
onta
ined
an in
terv
entio
n le
tter
.En
velo
pe c
onte
nts
know
n to
a r
esea
rch
assis
tant
onl
y an
d ha
dbe
en a
lloca
ted
toin
terv
entio
n or
con
trol
by r
ando
m n
umbe
ras
signm
ent.
Enve
lope
sgi
ven
to p
atie
nts
innu
mer
ical
ord
er. C
Rnu
rse
not
awar
e of
gro
upas
signe
d to
; how
ever
, no
proc
edur
e in
pla
ce t
ost
op p
atie
nts
telli
ngnu
rse
whi
ch le
tter
rece
ived
. Com
paris
ongr
oups
sim
ilar
at b
asel
ine
All
patie
nts
post
-MI.
Mea
nag
e 63
yea
rs,
87%
men
Lett
ers
base
d on
the
theo
ry o
f pla
nned
beha
viou
r (A
jzen
and
Mad
den,
198
6107 )
desig
ned
to in
crea
seat
tend
ance
at
outp
atie
ntC
R w
ere
give
n to
patie
nts
3 da
ys p
ost-
MI
and
sent
3 w
eeks
pos
t-M
I. T
he fi
rst
lett
er w
asde
signe
d to
influ
ence
acce
ptan
ce a
nd t
hese
cond
was
des
igne
d to
influ
ence
att
enda
nce.
Patie
nts
also
rec
eive
d a
nom
inal
lett
er o
f tha
nks
at 3
day
s an
d th
est
anda
rd le
tter
det
ailin
gco
urse
dat
es a
s se
nt t
oco
ntro
l pat
ient
s. A
fter
allo
catio
n to
gro
ups
the
CR
nurs
e sa
w a
ll pa
tient
sfo
r ro
utin
e as
sess
men
tan
d pe
rson
al in
vita
tion
toth
e pr
ogra
mm
e. F
orpa
tient
s w
ho d
eclin
edth
e of
fer
of a
pla
ce a
brie
f sec
ond
lett
er w
asse
nt w
ishin
g th
em w
ell
and
info
rmin
g th
em t
hat
they
wer
e st
ill w
elco
me
to c
onta
ct t
he t
eam
Nom
inal
lett
erof
tha
nks
give
nto
pat
ient
s at
3da
ys p
ost-
MI
and
the
stan
dard
lett
erde
taili
ngco
urse
dat
es
Upt
ake
defin
ed a
sat
tend
ance
at
the
outp
atie
nt C
Rpr
ogra
mm
e. U
ptak
ew
as 8
6% in
the
inte
rven
tion
grou
pan
d 57
% (a
utho
rsst
ate
59%
) in
the
cont
rol g
roup
(�2
=7.
91, d
f = 1
,p
< 0
.002
5)
Wom
en w
ere
less
like
ly t
oat
tend
the
prog
ram
me,
but
neith
erag
e no
rdi
stan
ce li
ved
from
the
prog
ram
me
pred
icte
dat
tend
ance
A s
igni
fican
tim
prov
emen
t in
upt
ake
of o
utpa
tient
CR
was
obse
rved
in t
he g
roup
that
rec
eive
d th
ele
tter
s de
signe
d to
influ
ence
acc
epta
nce
and
atte
ndan
ce. T
heau
thor
s no
te t
hat
the
inte
rven
tion
may
hav
ew
orke
d by
act
ing
as a
fear
mes
sage
(wor
ding
in le
tter
: “re
sear
ch h
assh
own
that
att
enda
nce
can
redu
ce t
hech
ance
s of
dyi
ng fr
oman
othe
r he
art
atta
ck”)
,ra
ther
tha
n th
roug
him
plem
enta
tion
ofth
eory
of p
lann
edbe
havi
our
cont
inue
d
Health Technology Assessment 2004; Vol. 8: No. 41
107
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff gr
oup:
m
easu
re a
nd
outc
omes
au
thor
s’
coun
try
% m
en,
invo
lved
, int
ensi
ty,
deta
ils o
f re
sult
san
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
mea
n ag
e fo
llow
-up
peri
od fo
r us
ual c
are
inte
rest
ing
feat
ures
type
)(S
D),
ou
tcom
e as
sess
men
tet
hnic
ity
if st
ated
Hill
ebra
ndet
al.,
1995
108
Ger
man
y(jo
urna
l)
Rela
tes
toat
tend
ance
at
outp
atie
nthe
art
grou
paf
ter
inpa
tient
CR
Para
llel
grou
p RC
T,94
pat
ient
sra
ndom
ised.
Resu
ltsre
port
ed
for
87(4
patie
nts
died
, thr
eere
fuse
dfo
llow
-up)
Met
hod
of r
ando
misa
tion
and
allo
catio
nco
ncea
lmen
t un
clea
r.C
ompa
rison
gro
ups
wer
e sim
ilar
at b
asel
ine
Post
-MI
patie
nts
atte
ndin
gin
patie
nt C
Rpr
ogra
mm
e.M
ean
age
52(3
3–60
) yea
rs,
89%
men
Spec
ial o
utpa
tient
car
epr
ogra
mm
e to
sup
port
blue
-col
lar
wor
kers
afte
rM
I to
join
cor
onar
ygr
oups
. The
pro
gram
me
cons
isted
of f
our
diffe
rent
con
vers
atio
nsbe
twee
n pa
tient
s an
d a
soci
al w
orke
r: a
t en
d of
reha
bilit
atio
npr
ogra
mm
e, t
elep
hone
cont
act
afte
r 4
wee
ks,
hom
e vi
sit a
fter
3 m
onth
s an
d te
leph
one
cont
act
afte
r 6
mon
ths
No
outp
atie
ntca
repr
ogra
mm
e
Att
enda
nce
at c
ardi
acgr
oup
afte
r12
mon
ths.
In t
hegr
oup
with
spe
cial
outp
atie
nt c
are
57%
of p
atie
nts
atte
nded
aca
rdia
c gr
oup
com
pare
d w
ith 2
7%of
con
trol
s (p
< 0
.005
)
The
aut
hors
not
e th
em
otiv
atin
g ef
fect
of a
nou
tpat
ient
car
epr
ogra
mm
e as
a li
nkbe
twee
n in
patie
nt C
Ran
d ca
rdia
c gr
oups
cont
inue
d
Appendix 8
108
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff gr
oup:
m
easu
re a
nd
outc
omes
au
thor
s’
coun
try
% m
en,
invo
lved
, int
ensi
ty,
deta
ils o
f re
sult
san
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
mea
n ag
e fo
llow
-up
peri
od fo
r us
ual c
are
inte
rest
ing
feat
ures
type
)(S
D),
ou
tcom
e as
sess
men
tet
hnic
ity
if st
ated
Jolly
et
al.,
1999
104
UK
(jour
nal)
Also
Bra
dley
et
al.,
199
7102
and
Jolly
et
al.,
1998
103
67 g
ener
alpr
actic
esra
ndom
ised
with
in s
trat
a(b
y fu
nd-
hold
ing
stat
us,
dist
ance
from
loca
lC
Rpr
ogra
mm
ean
d nu
mbe
rof
who
le-
time
part
ner
equi
vale
nts)
.27
7 pa
tient
sfr
omra
ndom
ised
inte
rven
tion
prac
tices
and
320
from
cont
rol
prac
tices
No
deta
ils o
fra
ndom
isatio
npr
oced
ure.
Fol
low
-up
ofpa
tient
s ca
rrie
d ou
t by
anu
rse
not
resp
onsib
le fo
rde
liver
ing
the
inte
rven
tion
to t
hepa
tient
’s p
ract
ice.
Pow
erca
lcul
atio
ns r
epor
ted
for
seru
m c
hole
ster
olch
ange
, dist
ance
wal
ked
and
smok
ing.
Com
paris
on g
roup
sw
ere
simila
r at
bas
elin
e.Lo
ss t
o fo
llow
-up
was
10%
in in
terv
entio
ngr
oup
and
9% in
con
trol
grou
p. A
naly
sis w
as b
yin
tent
ion
to t
reat
but
excl
uded
dea
ths
Patie
nts
regi
ster
ed w
ith67
gen
eral
prac
tices
in a
spec
ified
geog
raph
ical
area
. Pat
ient
sad
mitt
ed t
oho
spita
l with
MI (
71%
) or
with
ang
ina
ofre
cent
ons
et(<
3m
onth
s)se
en in
hos
pita
l(2
9%).
Patie
nts
wer
e ju
dged
wel
l eno
ugh
topa
rtic
ipat
e by
med
ical
and
nurs
ing
staf
f on
the
war
d or
incl
inic
Spec
ialis
t ca
rdia
c lia
ison
nurs
es c
oord
inat
ed t
hetr
ansf
er o
f car
e be
twee
nho
spita
l and
gen
eral
prac
tice.
The
liai
son
nurs
e sa
w p
atie
nts
inho
spita
l and
enc
oura
ged
them
to
see
the
prac
tice
nurs
e af
ter
disc
harg
e.Su
ppor
t w
as p
rovi
ded
topr
actic
e nu
rses
by
regu
lar
cont
act,
incl
udin
ga
tele
phon
e ca
ll sh
ortly
befo
re p
atie
nt d
ischa
rge
to d
iscus
s ca
re a
nd b
ook
a fir
st fo
llow
-up
visit
to
the
prac
tice.
Pra
ctic
enu
rses
wer
e en
cour
aged
to t
elep
hone
the
liai
son
nurs
e to
disc
uss
prob
lem
s or
to
seek
advi
ce o
n cl
inic
al o
ror
gani
satio
nal i
ssue
s.Ea
ch p
atie
nt w
as g
iven
apa
tient
-hel
d re
cord
car
dw
hich
pro
mpt
ed a
ndgu
ided
follo
w-u
p at
stan
dard
inte
rval
s
No
cont
act
betw
een
spec
ialis
tca
rdia
c lia
ison
nurs
es a
ndge
nera
lpr
actic
es. N
otex
plic
itly
stat
ed, b
utun
ders
tood
to
be n
ore
com
men
da-
tion
to s
eepr
actic
e nu
rse
and
no p
atie
nt-
held
rec
ord
Seru
m c
hole
ster
ol,
bloo
d pr
essu
re,
dist
ance
wal
ked
in 6
min
utes
and
sm
okin
gce
ssat
ion
did
not
diffe
r be
twee
ngr
oups
. Bod
y m
ass
inde
x w
as s
light
lylo
wer
in t
hein
terv
entio
n gr
oup.
Mor
e pa
tient
s in
the
inte
rven
tion
grou
pat
tend
ed a
t le
ast
one
outp
atie
nt C
R se
ssio
nco
mpa
red
with
cont
rols
(42%
vs
24%
, p<
0.0
01).
The
diffe
renc
e w
as m
ost
mar
ked
in a
ngin
apa
tient
s (4
2% v
s10
%)
The
pro
gram
me
prov
idin
g co
ordi
nate
dfo
llow
-up
care
by
spec
ialis
t ca
rdia
c lia
ison
nurs
es d
id n
ot im
prov
ehe
alth
out
com
es, b
utw
as e
ffect
ive
inpr
omot
ing
at le
ast
one
outp
atie
nt C
R se
ssio
nat
tend
ance
cont
inue
d
Health Technology Assessment 2004; Vol. 8: No. 41
109
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff gr
oup:
m
easu
re a
nd
outc
omes
au
thor
s’
coun
try
% m
en,
invo
lved
, int
ensi
ty,
deta
ils o
f re
sult
san
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
mea
n ag
e fo
llow
-up
peri
od fo
r us
ual c
are
inte
rest
ing
feat
ures
type
)(S
D),
ou
tcom
e as
sess
men
tet
hnic
ity
if st
ated
Osik
a, 2
00182
UK
(the
sis)
Non
-ra
ndom
ised
stud
y. O
nedi
stric
t w
ithin
terv
entio
n(9
8 pa
tient
s)an
d on
edi
stric
tw
ithou
t(7
7pa
tient
s)
Gro
ups
simila
r at
base
line
Post
-MI
patie
nts
invi
ted
to a
tten
d an
outp
atie
nt C
Rpr
ogra
mm
e.M
ean
age
72ye
ars,
78%
men
Hom
e vi
sitin
g by
lay
volu
ntee
rs. V
isito
rs w
ere
trai
ned
5 ho
urs
per
day
for
up t
o 7
days
. Pat
ient
sw
ere
visit
ed fo
rap
prox
imat
ely
30m
inut
es e
ach
wee
kfo
r 6
wee
ks. L
ayvo
lunt
eers
pro
vide
dad
vice
rel
atin
g to
reha
bilit
atio
n an
d of
fere
dto
acc
ompa
ny t
he p
atie
ntto
the
firs
t ou
tpat
ient
CR
appo
intm
ent
Dist
rict
with
no la
yvo
lunt
eer
visit
ing
Att
enda
nce
at fi
rst
outp
atie
nt C
Rap
poin
tmen
t. In
the
dist
rict
with
lay
volu
ntee
r vi
sitin
g 71
%of
pat
ient
s at
tend
ed a
first
app
oint
men
t at
outp
atie
nt C
R. In
the
cont
rol d
istric
t 47
%at
tend
ed (p
= 0
.02)
.N
o di
ffere
nce
inse
vera
l clin
ical
outc
omes
and
indi
cato
rs a
t fir
st C
Rat
tend
ance
The
lay
volu
ntee
rho
me
visit
ing
serv
ice
was
ass
ocia
ted
with
incr
ease
d up
take
of
outp
atie
nt C
R se
rvic
es
Kra
sem
ann
and
Busc
h, 1
98810
9
Ger
man
y(jo
urna
l)
Rela
tes
toat
tend
ance
at
an o
utpa
tient
hear
t gr
oup
afte
r an
inpa
tient
CR
prog
ram
me
Non
-ra
ndom
ised
tria
l.20
0pa
tient
sst
udie
d
Gro
ups
of p
atie
nts
atte
ndin
g in
diff
eren
tpe
riods
. No
info
rmat
ion
com
parin
g gr
oups
at
base
line.
156
pat
ient
sfo
llow
ed u
p. L
oss
tofo
llow
-up
22%
All
mal
epa
tient
s po
st-
MI
Afte
r co
mpl
etio
n of
an
inpa
tient
CR
prog
ram
me
patie
nts
wer
e gi
ven
apa
mph
let
with
info
rmat
ion
abou
tou
tpat
ient
hea
rt g
roup
sde
signe
d to
mot
ivat
epa
tient
s to
join
. The
book
let
cont
aine
dge
nera
l inf
orm
atio
nab
out
hear
t di
seas
e,in
clud
ing
nutr
ition
,ex
erci
se, r
elax
atio
n an
dm
edic
atio
n. P
atie
nts
wer
e al
so g
iven
the
addr
esse
s of
loca
lou
tpat
ient
hea
rt g
roup
s
Afte
rco
mpl
etio
n of
an in
patie
nt C
Rpr
ogra
mm
epa
tient
s w
ere
give
n th
ead
dres
ses
oflo
cal o
utpa
tient
hear
t gr
oups
Num
ber
of p
atie
nts
who
join
ed a
nou
tpat
ient
hea
rt g
roup
afte
r 6
mon
ths.
78
patie
nts
wer
efo
llow
ed u
p in
bot
hth
e in
terv
entio
n an
dco
ntro
l gro
ups.
66.
5%of
pat
ient
s w
hore
ceiv
ed t
hein
terv
entio
n at
tend
eda
hear
t gr
oup
com
pare
d w
ith 3
1.0%
in t
he c
ontr
ol g
roup
(�2
= 2
0, d
f = 1
, p
< 0
.001
)
The
aut
hors
rep
ort
that
the
info
rmat
ive
pam
phle
t us
ed t
om
otiv
ate
patie
nts
was
asso
ciat
ed w
ithin
crea
sed
atte
ndan
ceat
out
patie
nt h
eart
grou
ps. P
atie
nts
rank
ed s
ourc
es o
fin
form
atio
n: p
erso
nal
conv
ersa
tion
with
doct
or, p
amph
let,
lect
ures
, per
sona
l tal
ksw
ith c
arin
g pe
rson
san
d ta
lks
with
oth
erpa
tient
s
cont
inue
d
Appendix 8
110
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff gr
oup:
m
easu
re a
nd
outc
omes
au
thor
s’
coun
try
% m
en,
invo
lved
, int
ensi
ty,
deta
ils o
f re
sult
san
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
mea
n ag
e fo
llow
-up
peri
od fo
r us
ual c
are
inte
rest
ing
feat
ures
type
)(S
D),
ou
tcom
e as
sess
men
tet
hnic
ity
if st
ated
Mos
ca e
t al
.,19
9841
USA
(con
fere
nce
abst
ract
)
Befo
re-
and
afte
r-st
udy.
Com
paris
onof
out
patie
ntC
Rpa
rtic
ipat
ion
rate
s in
tw
o6-
mon
thpe
riods
with
a to
tal o
f19
9pa
tient
s
No
info
rmat
ion
onba
selin
e ch
arac
teris
tics
ofth
e tw
o gr
oups
All
patie
nts
post
-MI.
Mea
nag
e 61
yea
rs,
with
68%
men
Crit
ical
car
e pa
thw
aypr
ompt
ing
refe
rral
for
outp
atie
nt C
R
Befo
reim
plem
enta
tion
of c
ritic
al c
are
path
way
Ove
rall
part
icip
atio
nat
out
patie
nt C
R w
as54
%, a
s de
term
ined
by p
atie
nt s
elf-
repo
rt.
The
crit
ical
car
epa
thw
ay w
asas
soci
ated
with
a n
on-
signi
fican
t in
crea
se in
outp
atie
nt C
Rpa
rtic
ipat
ion
(OR
1.9,
95%
C
I 0.6
to
5.5)
The
aut
hors
con
clud
eth
at a
sys
tem
sap
proa
ch, i
nvol
ving
apr
ompt
for
outp
atie
ntC
R re
ferr
al a
s pa
rt o
f adi
scha
rge
criti
cal c
are
path
way
, may
pote
ntia
lly in
crea
sera
tes
of p
artic
ipat
ion
inC
R fo
r w
omen
Imic
h, 1
99711
0
UK
(jour
nal)
Befo
re-
and
afte
r-st
udy.
Com
paris
onof
12-
mon
thau
dit
perio
ds
No
info
rmat
ion
on t
henu
mbe
rs o
f pat
ient
s or
base
line
char
acte
ristic
s of
the
two
grou
ps
Post
-MI a
ndpo
stca
rdia
csu
rger
y pa
tient
s
Post
disc
harg
e, p
re-
outp
atie
nt C
R ho
me
visit
s by
tra
ined
com
mun
ity n
urse
s. F
orM
I pat
ient
s th
is w
as2–
3w
eeks
afte
rdi
scha
rge
and
for
hear
tsu
rger
y pa
tient
s4–
5w
eeks
. Visi
ts w
ere
aim
ed a
t: re
duct
ion
ofan
xiet
y le
vels,
ena
blin
gpa
tient
s to
mak
e an
dm
aint
ain
lifes
tyle
cha
nges
,id
entif
ying
pro
blem
s or
pote
ntia
l pro
blem
s, a
ndpr
ovid
ing
patie
nts
with
supp
ort,
educ
atio
n an
dco
unse
lling
. The
num
ber
and
freq
uenc
y of
hom
evi
sits
wer
e de
pend
ent
onin
divi
dual
req
uire
men
t
Patie
nts
disc
harg
edfr
om h
ospi
tal
befo
re t
henu
rse
hom
e-vi
sitin
gpr
ogra
mm
ew
as in
stig
ated
Patie
nt p
erce
ptio
n of
the
post
disc
harg
eho
me
visit
ing
serv
ice.
Att
enda
nce
atou
tpat
ient
CR
byin
vite
d pa
tient
sin
crea
sed
from
55%
befo
re t
o 75
% a
fter
inst
igat
ion
of t
hepr
ogra
mm
e. A
spa
tient
num
bers
are
not
give
n, t
hesig
nific
ance
of t
his
cann
ot b
e de
term
ined
Intr
oduc
tion
ofpo
stdi
scha
rge
hom
evi
sits
by t
rain
edco
mm
unity
nur
ses
repo
rted
to
beas
soci
ated
with
an
incr
ease
d at
tend
ance
at o
utpa
tient
CR cont
inue
d
Health Technology Assessment 2004; Vol. 8: No. 41
111
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff gr
oup:
m
easu
re a
nd
outc
omes
au
thor
s’
coun
try
% m
en,
invo
lved
, int
ensi
ty,
deta
ils o
f re
sult
san
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
mea
n ag
e fo
llow
-up
peri
od fo
r us
ual c
are
inte
rest
ing
feat
ures
type
)(S
D),
ou
tcom
e as
sess
men
tet
hnic
ity
if st
ated
Scot
t et
al.,
2000
1111
Aus
tral
ia(jo
urna
l)
Befo
re- a
ndaf
ter-
stud
y.C
ompa
rison
of c
linic
alin
dica
tors
inth
ree
perio
ds:
pre-
inte
rven
tion
(133
patie
nts)
,im
plem
ent-
atio
n of
inte
rven
tion
(271
patie
nts)
,an
d po
st-
inte
rven
tion
(245
pat
ient
s)
Pre-
and
post
inte
rven
tion
grou
psw
ere
simila
r at
bas
elin
e,bu
t no
info
rmat
ion
was
repo
rted
for
the
inte
rven
tion
perio
d.O
utpa
tient
CR
prog
ram
me
was
not
fully
oper
atio
nal i
n th
epr
eint
erve
ntio
n pe
riod.
Aut
hors
ass
umed
tha
tpa
tient
cha
ract
erist
ics,
diag
nost
ic m
etho
ds a
ndtr
eatm
ent
mod
aliti
esw
ould
rem
ain
esse
ntia
llyun
chan
ged
thro
ugho
utth
e st
udy
Post
-MI
patie
nts.
Pat
ient
char
acte
ristic
son
ly a
vaila
ble
for
pre-
and
post
inte
rven
tion
grou
ps. M
ean
age
66 y
ears
,66
% m
en
Diss
emin
atio
n of
evid
ence
-bas
ed c
linic
algu
idel
ines
for
the
man
agem
ent
of A
MI t
oho
spita
l sta
ff an
d G
Ps.
Info
rmat
ion
on c
linic
alin
dica
tors
was
fed
back
to a
ll ho
spita
l con
sulta
ntph
ysic
ians
, sen
ior
emer
genc
y st
aff,
med
ical
serv
ice
dire
ctor
s an
dse
nior
clin
icia
ns. A
s pa
rtof
the
feed
back
the
obse
rved
pro
port
ion
ofpa
tient
s re
ceiv
ing
the
trea
tmen
ts w
asco
mpa
red
with
a q
ualit
yth
resh
old
or m
inim
umle
vel o
f util
isatio
nin
dica
tive
of a
rea
sona
ble
stan
dard
of c
are.
Loc
alpr
ovid
ers
coul
d co
mpa
rean
d im
prov
e th
eir
own
prac
tice
Befo
redi
ssem
inat
ion
of e
vide
nce-
base
d cl
inic
algu
idel
ines
Clin
ical
indi
cato
rch
ange
s pr
e- t
opo
stin
terv
entio
n. N
och
ange
s w
ere
seen
in�
-blo
cker
, asp
irin
oran
giot
ensin
con
vert
ing
enzy
me
inhi
bito
r us
e.Li
pid-
low
erin
g dr
ugus
e in
crea
sed
from
23%
to
56%
(p<
0.00
3).
Out
patie
nt C
R se
rvic
ebe
cam
e op
erat
iona
l at
star
t of
inte
rven
tion
perio
d an
d sh
owed
ast
eady
incr
ease
inut
ilisa
tion
rate
from
24%
to
54%
(p=
0.00
3)
The
aut
hors
sug
gest
that
clin
ical
gui
delin
esco
mbi
ned
with
feed
back
of c
linic
alin
dica
tors
to
heal
thpr
ofes
siona
ls w
ere
usef
ul in
impr
ovin
gqu
ality
of c
are,
incl
udin
g ou
tpat
ient
CR
utili
satio
n in
MI
patie
nts.
How
ever
, the
impr
ovem
ent
may
be
due
to p
aral
lel c
hang
esin
leve
ls of
pro
visio
n
Health Technology Assessment 2004; Vol. 8: No. 41
113
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 9
Studies excluded from the review of interventions to improve uptake of cardiac rehabilitation
Authors, year Intervention Reason for exclusion
Campbell et al., 1998125,126 Nurse-led clinic giving secondary prevention Outcome: use of secondary assessment and advice prevention, not attendance at CR
Caulin-Glaser & Schmeizel, 2000123 Education of health professionals about CR Outcome: referral not attendance
Feder et al., 1999127 Leaflets promoting secondary prevention. Outcome: attendance at a general Also general practices received letters practice and drug prescribing, not summarising effective secondary prevention CR
Foresman, 1997120 Telephone invitation to CR programme No comparison group
Johnson, 2000118 Nurse telephone follow-up No data: descriptive
Kalayi et al., 1999122 Computerised referral pathway Outcome: referral not attendance
Keck et al., 1991,113 Keck & Comprehensive motivation programme Budde,1996114 integrated into CR to improve attendance No data: descriptive
at heart group after inpatient CR
Levknecht et al., 1997116 Outpatient clinical pathway No outcome data: descriptive
McCarney et al., 2000119 General practice database identifies patients No data: descriptivefor home visit by health visitor to improve secondary prevention
Mehta et al., 2000121 Quality improvement initiative: critical care Retrospective study. Allocation to pathway, patient education tool and staff groups according to physician education preference
Millar 1993115 Home visit by cardiac support worker No data: descriptive
Pasquali et al., 2001112 Telephone call describing CR benefits and Out of review periodassistance with referral
Suskin et al., 2000124 Physician endorsement Outcome: commitment toparticipate, not attendance
Tod et al., 1998117 Integration of primary and secondary care No outcome data: descriptive
Health Technology Assessment 2004; Vol. 8: No. 41
115
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 10
Flow diagram of the systematic review of interventions to improve adherence to cardiac
rehabilitation (QUOROM statement flow diagram)
Potentially relevant publications identifiedand screened for retrieval
3261
Publications retrieved for more detailedevaluation
957Publications excluded on the basis of titleand abstract:
No intervention evaluated 776
No outcome pertaining toadherence with cardiac rehabilitation 143
Publications included for data extraction
38 (37 studies)
Studies included in review
14
Studies excluded from review
Effectiveness of rehabilitationformats 9No outcome relating to adherence 10No comparison group 3Retrospective design 1
__Total 23
Publications excluded on the basis of titleand abstract (clear evidence that sourcepaper did not describe intervention inappropriate patient group)
2304
Health Technology Assessment 2004; Vol. 8: No. 41
117
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 11
Studies evaluating interventions to improve adherence to cardiac rehabilitation
Appendix 11
118 Stu
die
s ar
e li
sted
in
ter
ms
of
stu
dy
des
ign
an
d t
he
hie
rarc
hy
of
evid
ence
, w
ith
RC
Ts
firs
t.
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff gr
oup:
det
ails
m
easu
re a
nd r
esul
tsou
tcom
es
auth
ors’
co
untr
y %
men
, mea
n in
volv
ed, i
nten
sity
, of
usu
al c
are
and
resu
lts
conc
lusi
ons,
(p
ublic
atio
nag
e (S
D),
fo
llow
-up
peri
od fo
r in
tere
stin
g fe
atur
esty
pe)
ethn
icit
y if
stat
edou
tcom
e as
sess
men
t
Old
ridge
&Jo
nes,
198
3145
Can
ada
(jour
nal)
Para
llel g
roup
RCT.
120
patie
nts
rand
omise
d.Pa
tient
sst
ratif
ied
bysm
okin
gst
atus
,oc
cupa
tion,
leisu
re h
abits
and
num
ber
ofpr
ior
infa
rctio
nsbe
fore
rand
omisa
tion.
The
seva
riabl
es w
ere
show
n to
be
pred
icto
rs o
fdr
opou
t ba
sed
on p
revi
ous
expe
rienc
e of
this
grou
p
Patie
nts
rand
omise
dus
ing
a lis
t of
ran
dom
num
bers
. Met
hod
ofal
loca
tion
conc
ealm
ent
uncl
ear.
Blin
d as
sess
men
t of
outc
omes
unc
lear
.U
ncle
ar w
heth
erco
mpa
rison
gro
ups
wer
e sim
ilar
atba
selin
e. L
osse
s to
follo
w-u
p (d
efin
ed a
sno
n-at
tend
ance
at
eigh
t co
nsec
utiv
ere
habi
litat
ion
sess
ions
) wer
e sim
ilar
in t
he in
terv
entio
nan
d co
ntro
l gro
ups
(21%
and
16%
)
Mix
ed C
HD
patie
nts,
MI 7
3%,
CA
BG 1
6%,
angi
na 1
2%.
Mea
n ag
e 50
.5ye
ars,
all
men
Usu
al c
ompr
ehen
sive
card
iac
reha
bilit
atio
n pr
ogra
mm
e, p
lus
self-
man
agem
ent
tech
niqu
esin
clud
ing
an a
gree
men
t to
part
icip
ate
in t
he p
rogr
amm
efo
r 6
mon
ths
to b
e sig
ned
byth
e pa
tient
and
coo
rdin
ator
,an
d se
lf-re
port
dia
ries
toco
mpl
ete
and
be d
iscus
sed
with
the
coo
rdin
ator
at
regu
lar
inte
rval
s. D
iarie
s in
clud
edsix
grap
hs fo
r pl
ottin
g se
lf-m
onito
red
subm
axim
al h
eart
rate
s ea
ch m
onth
, at
33%
,50
% a
nd 7
5% o
f the
max
imum
pow
er o
utpu
t ac
hiev
ed in
the
prev
ious
exe
rcise
tes
t, an
d six
24-h
our
reca
ll qu
estio
nnai
res
ofda
ily a
ctiv
ities
on
a ra
ndom
lych
osen
day
to
be c
ompl
eted
each
mon
th. I
n ad
ditio
n, a
wei
ght
loss
dia
ry t
o fil
l in
each
wee
k w
as g
iven
to
thos
e w
hoin
itial
ly a
gree
d to
lose
wei
ght,
and
simila
r di
arie
s to
rec
ord
num
ber
of c
igar
ette
s sm
oked
each
day
. Fol
low
-up
at t
he e
ndof
the
inte
rven
tion
perio
d of
6m
onth
s
Usu
alco
mpr
ehen
sive
card
iac
reha
bilit
atio
npr
ogra
mm
e
Com
plia
nce
defin
ed a
sat
tend
ance
at
60%
or
mor
e of
the
sch
edul
ed 4
8su
perv
ised
card
iac
reha
bilit
atio
n se
ssio
ns. (
Ifan
y pa
tient
faile
d to
att
end
four
con
secu
tive
sess
ions
they
wer
e co
ntac
ted
byte
leph
one
and
urge
d to
cont
inue
.) D
ata
pres
ente
das
inte
ntio
n to
tre
at.
Com
plia
nce
rate
was
54%
in t
he in
terv
entio
n gr
oup,
and
42%
in t
he c
ontr
olgr
oup;
the
se r
ates
wer
eno
t st
atist
ical
ly s
igni
fican
t.A
tten
danc
e of
dro
pout
sw
as s
imila
r in
the
inte
rven
tion
and
cont
rol
grou
ps (2
1% v
s 16
%) a
ndw
as a
lso s
imila
r fo
rco
mpl
iers
(74%
vs
76%
).N
ot a
ll pa
tient
s in
the
inte
rven
tion
grou
p sig
ned
the
agre
emen
t to
part
icip
ate.
Com
plia
nce
was
sig
nific
antly
hig
her
inth
e 48
sub
ject
s w
ho s
igne
d(6
5%),
than
in t
he 1
5 w
hore
fuse
d (2
0%)
Ove
rall,
no
impr
ovem
ent
in c
ompl
ianc
e w
ithre
habi
litat
ion
sess
ions
was
seen
in p
atie
nts
rand
omise
d to
apr
ogra
mm
e of
sel
f-m
anag
emen
t te
chni
ques
,in
clud
ing
signe
dag
reem
ent
and
diar
ies.
Ina
subg
roup
ana
lysis
, the
auth
or fo
und
high
erco
mpl
ianc
e ra
tes
in t
hose
patie
nts
in t
hein
terv
entio
n gr
oup
who
signe
d th
e ag
reem
ent
topa
rtic
ipat
e th
an in
tho
sew
ho d
id n
ot, a
ndsu
gges
ted
the
need
for
furt
her
inve
stig
atio
n of
self-
man
agem
ent
com
plia
nce-
impr
ovin
gst
rate
gies
cont
inue
d
Health Technology Assessment 2004; Vol. 8: No. 41
119
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff in
volv
ed,
grou
p: d
etai
ls
mea
sure
and
res
ults
outc
omes
au
thor
s’
coun
try
% m
en, m
ean
inte
nsit
y, fo
llow
-up
peri
od
of u
sual
car
ean
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
age
(SD
),
for
outc
ome
asse
ssm
ent
inte
rest
ing
feat
ures
type
)et
hnic
ity
if st
ated
Dal
troy
, 198
5146
USA
(jour
nal)
Para
llel g
roup
RCT,
174
patie
nts
rand
omise
d
Met
hod
ofra
ndom
isatio
n an
dal
loca
tion
conc
ealm
ent
uncl
ear.
Out
com
eas
sess
ors
wer
ebl
ind
to g
roup
allo
catio
n, a
ndco
mpa
rison
grou
ps w
ere
simila
r at
bas
elin
e.N
o lo
sses
to
follo
w-u
pre
port
ed a
t 3
mon
ths,
the
perio
d at
whi
chm
ost
data
are
pres
ente
d. S
tudy
was
pow
ered
to
dete
ct a
14%
diffe
renc
e in
atte
ndan
ce o
ver
3m
onth
s
Mix
ed C
HD
patie
nts,
81%
MI,
63%
with
ahi
stor
y of
ang
ina,
17%
pos
t-C
ABG
.M
ean
age
53.8
year
s, 8
8% m
en,
95%
whi
te
Ora
l per
suas
ive
com
mun
icat
ion
and
educ
atio
n in
terv
entio
n to
impr
ove
patie
nt a
dher
ence
toex
erci
se r
egim
ens.
Inte
rven
tion
deve
lope
d fr
om in
terv
iew
s w
ithpr
evio
us p
atie
nts
and
thei
r sp
ouse
sto
elic
it th
e m
ost c
omm
on b
elie
fsof
ben
efits
and
dra
wba
cks
to th
eex
erci
se p
rogr
amm
e. P
atie
nts
inth
e in
terv
entio
n gr
oup
rece
ived
an
oral
per
suas
ive
com
mun
icat
ion
onth
e te
leph
one
in s
crip
ted
coun
selli
ng fo
rmat
to: c
onvi
nce
them
of t
he b
enef
its o
f reg
ular
exer
cise
, war
n th
em o
f lik
ely
draw
back
s so
that
exp
ecta
tions
wou
ld b
e re
alist
ic, a
cqua
int t
hem
with
met
hods
use
d by
oth
erpa
tient
s to
cop
e w
ith d
raw
back
s,an
d el
icit
an o
ral c
omm
itmen
t to
atte
nd a
t lea
st tw
o cl
asse
s pe
rw
eek
for
the
first
6 w
eeks
. In
addi
tion,
pat
ient
s re
ceiv
ed a
mai
led
writ
ten
pers
uasiv
e co
mm
unic
atio
nto
rei
nfor
ce th
ese
poin
ts. S
pous
esal
so r
ecei
ved
tele
phon
e co
unse
lling
to e
ncou
rage
the
patie
nt to
att
end
and
disc
uss
met
hods
that
oth
erpa
tient
s sp
ouse
s fo
und
usef
ul. A
writ
ten
com
mun
icat
ion
tore
info
rce
thes
e po
ints
was
also
sen
tto
the
spou
se to
incr
ease
the
spou
se’s
supp
ort.
Patie
nts
also
rece
ived
a p
amph
let w
ithin
form
atio
n on
ben
efits
and
draw
back
s of
exe
rcise
. All
com
mun
icat
ion
was
tailo
red
toin
divi
dual
pat
ient
s ba
sed
on d
ata
colle
cted
by
ques
tionn
aire
at
base
line
Com
paris
ongr
oup
patie
nts
and
spou
ses
rece
ived
the
sam
e pa
mph
let
with
info
rmat
ion
on t
he b
enef
itsan
d dr
awba
cks
of e
xerc
ise, a
sth
e in
terv
entio
ngr
oup.
Thi
s w
asdo
ne s
o al
lpa
tient
s w
ould
have
the
sam
ein
duce
men
t to
ente
r th
epr
ogra
mm
e. It
was
tho
ught
unlik
ely
that
thi
ssin
gle
inte
rven
tion
wou
ld p
rodu
cela
stin
gbe
havi
oura
lch
ange
Att
enda
nce
at e
xerc
isese
ssio
ns o
ver
3 m
onth
s.A
tten
danc
e fo
r pa
tient
s in
the
inte
rven
tion
grou
p w
as63
.8%
, and
62.
2% in
the
com
paris
on g
roup
.Su
bgro
up a
naly
sis r
evea
led
that
am
ong
the
inte
rven
tion
grou
p,at
tend
ance
was
gre
ater
amon
g be
tter
edu
cate
dpa
tient
s. S
pous
epa
rtic
ipat
ion,
age
, gen
der
and
occu
patio
n w
ere
not
asso
ciat
ed w
ith a
tten
danc
e,al
thou
gh t
he n
umbe
rs in
thes
e su
bgro
ups
are
likel
yto
be
too
smal
l to
draw
firm
con
clus
ions
Ove
rall,
no
signi
fican
tim
prov
emen
t in
atte
ndan
ce a
t ex
erci
sese
ssio
ns w
ith t
hein
terv
entio
n. T
here
isso
me
sugg
estio
n th
ated
ucat
iona
l lev
el is
afa
ctor
ass
ocia
ted
with
atte
ndan
ce
cont
inue
d
Appendix 11
120
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff in
volv
ed,
grou
p: d
etai
ls
mea
sure
and
res
ults
outc
omes
au
thor
s’
coun
try
% m
en, m
ean
inte
nsit
y, fo
llow
-up
peri
od
of u
sual
car
ean
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
age
(SD
),
for
outc
ome
asse
ssm
ent
inte
rest
ing
feat
ures
type
)et
hnic
ity
if st
ated
Mah
ler
et a
l.19
9914
7
USA
(jour
nal)
Para
llel g
roup
RCT,
tw
oin
terv
entio
ngr
oups
and
one
cont
rol
grou
p,21
5pa
tient
sra
ndom
ised
Met
hod
ofra
ndom
isatio
n an
dal
loca
tion
conc
ealm
ent
uncl
ear.
Blin
das
sess
men
t of
outc
omes
unc
lear
.U
ncle
ar w
heth
erco
mpa
rison
grou
ps w
ere
simila
r at
bas
elin
e,as
dem
ogra
phic
data
are
not
pres
ente
dse
para
tely
for
each
gro
up.
Ove
rall
loss
es t
ofo
llow
-up
at3
mon
ths
wer
e9%
Con
secu
tive
elec
tive
first
tim
eC
ABG
, mea
n ag
e61
.4 (3
.2ye
ars)
,86
.5%
men
,83
.3%
whi
te
Vide
otap
e in
terv
entio
npo
stsu
rger
y, s
hort
ly b
efor
edi
scha
rge
to e
nhan
ce c
ompl
ianc
ew
ith e
xerc
ise a
nd d
iet.
Two
vide
otap
e in
terv
entio
ns:
(1)M
aste
ry T
ape:
dep
icts
pat
ient
sas
cal
m a
nd c
onfid
ent
at t
he t
ime
of h
ospi
tal d
ischa
rge,
mak
ing
stea
dy p
rogr
ess
with
no
com
plic
atio
ns d
urin
g 6
mon
ths,
and
adju
stin
g to
the
rec
omm
ende
dex
erci
se a
nd lo
w-f
at d
iet
with
rela
tive
ease
; (2)
Cop
ing
Tape
:ed
ited
so t
he s
ame
patie
nts
men
tion
conc
erns
the
y ar
eex
perie
ncin
g ab
out
hosp
ital
rele
ase
and
cope
with
effo
rt, b
utsu
cces
sful
ly, w
ith a
var
iety
of
diffi
culti
es (e
.g. f
atig
ue, d
iet
chan
ges)
, so
the
reco
very
ispo
rtra
yed
as a
ste
ady
forw
ard
prog
ress
ion
of u
ps a
nd d
owns
.Ex
erci
se a
nd d
ieta
ry c
ompl
ianc
eas
sess
ed a
t 1
and
3 m
onth
spo
stdi
scha
rge
Stan
dard
disc
harg
epr
epar
atio
n fr
omon
e of
the
tw
oho
spita
ls w
here
recr
uitm
ent
took
plac
e. N
oat
tem
pt w
asm
ade
toin
terf
ere
with
this.
Con
siste
dal
mos
tex
clus
ivel
y of
advi
ce n
ot t
o lif
tto
o m
uch,
and
inst
ruct
ions
rega
rdin
g th
eim
port
ance
of
exer
cise
and
mai
ntai
ning
alo
w-f
at d
iet
Com
plia
nce
with
life
styl
ech
ange
s. E
xerc
iseco
mpl
ianc
e as
sess
ed w
ith a
simpl
e qu
estio
nnai
re o
fle
isure
-tim
e ex
erci
se (h
owm
any
times
in t
he p
ast
7da
ys t
hey
part
icip
ated
inlig
ht, m
oder
ate
and
stre
nuou
s ex
erci
se).
Die
tary
com
plia
nce
was
asse
ssed
from
the
chol
este
rol–
satu
rate
d fa
tsu
bsca
le o
f the
die
t ha
bit
surv
ey. A
t 3
mon
ths
exer
cise
com
plia
nce
was
impr
oved
with
bot
hin
terv
entio
ns (p
< 0
.05)
,bu
t im
prov
emen
ts w
ere
grea
test
for
the
Cop
ing
Tape
at
1m
onth
for
mod
erat
e ex
erci
se, a
nd a
t3
mon
ths
for
stre
nuou
sex
erci
se. B
oth
inte
rven
tion
grou
ps s
how
ed a
red
uctio
nin
die
tary
cho
lest
erol
and
satu
rate
d fa
t at
1 m
onth
(p<
0.0
5), b
ut n
odi
ffere
nces
wer
e se
en a
t3
mon
ths
Anx
iety
and
self-
effic
acy
belie
fs.
Hyp
othe
sised
that
the
sew
ould
affe
ctco
mpl
ianc
e
The
aut
hors
hyp
othe
sised
that
eith
er t
ape
wou
ldre
sult
in im
prov
edou
tcom
es c
ompa
red
with
cont
rol,
but
also
tha
t th
eC
opin
g Ta
pe w
ould
exhi
bit
the
high
est
self-
effic
acy
belie
fs a
ndgr
eate
st c
ompl
ianc
e. T
hey
conc
lude
d th
at v
iew
ing
eith
er t
ape
prov
ed t
o be
an e
ffect
ive
met
hod
for
incr
easin
g di
etar
y an
dex
erci
se c
ompl
ianc
edu
ring
the
first
3 m
onth
spo
stsu
rger
y
cont
inue
d
Health Technology Assessment 2004; Vol. 8: No. 41
121
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff in
volv
ed,
grou
p: d
etai
ls
mea
sure
and
res
ults
outc
omes
au
thor
s’
coun
try
% m
en, m
ean
inte
nsit
y, fo
llow
-up
peri
od
of u
sual
car
ean
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
age
(SD
),
for
outc
ome
asse
ssm
ent
inte
rest
ing
feat
ures
type
)et
hnic
ity
if st
ated
Aish
& Is
enbe
rg,
1996
148
Can
ada
(jour
nal)
Para
llel g
roup
RCT,
104
patie
nts
rand
omise
d
Met
hod
ofra
ndom
isatio
n an
dal
loca
tion
conc
ealm
ent
uncl
ear.
Com
paris
ongr
oups
wer
esim
ilar
at b
asel
ine.
Blin
d as
sess
men
tof
out
com
esun
clea
r. Lo
sses
to
follo
w-u
p no
tre
port
ed
MI p
atie
nts,
maj
ority
firs
t M
I.Pa
tient
s re
crui
ted
whi
le in
hos
pita
l.M
ean
age
62 (1
1)ye
ars,
60%
men
Nur
sing
inte
rven
tion
of n
utrit
iona
lse
lf-ca
re b
ased
on
Ore
m’s
theo
ry.17
6H
ome
visit
to
colle
ctba
selin
e 3-
day
diet
rec
ord,
ass
ess
food
hab
its a
nd p
rovi
dein
form
atio
n ab
out
nutr
ition
al g
oals
for
heal
thy
hear
ts, a
nd d
eter
min
ew
heth
er t
hese
wer
e be
ing
met
.Su
gges
tions
for
chan
ges
give
n an
da
com
mitm
ent
on t
he p
art
of t
hepa
tient
sou
ght
to m
ake
thes
ech
ange
s. T
hree
follo
w-u
pte
leph
one
calls
ove
r 6
wee
ks a
nda
furt
her
hom
e vi
sit t
o co
llect
3-
day
diet
rec
ord
and
asse
ss fo
odha
bits
at
7w
eeks
pos
tdisc
harg
e.D
ata
com
pare
d be
twee
n ba
selin
ean
d 7
wee
ks p
ostd
ischa
rge
Con
trol
gro
upre
ceiv
ed fo
llow
-up
tel
epho
neca
lls a
nd h
ome
visit
at
7w
eeks
to c
olle
ct d
ata
on3-
day
diet
ary
reco
rd a
ndas
sess
food
habi
ts. A
dvic
eab
out
diet
was
not
give
n un
less
the
patie
ntin
trod
uced
the
subj
ect
Adh
eren
ce t
o di
etar
yad
vice
ass
esse
d fr
omdi
etar
y re
cord
and
food
habi
ts q
uest
ionn
aire
. Tot
alfa
t an
d sa
tura
ted
fat
perc
enta
ge o
f cal
orie
s w
assig
nific
antly
red
uced
in t
hein
terv
entio
n gr
oup
(p<
0.01
). Si
gnifi
cant
impr
ovem
ent
on t
he fo
odha
bits
que
stio
nnai
re w
asse
en in
the
inte
rven
tion
grou
p (p
< 0
.05)
App
raisa
l of s
elf
care
and
eat
ing
habi
ts w
hich
show
edim
prov
emen
tw
ith t
hein
terv
entio
n,an
d se
lf-ef
ficac
yfo
r he
alth
yea
ting,
whi
chsh
owed
no
chan
ge w
ithth
ein
terv
entio
n
The
aut
hors
con
clud
e th
atth
is nu
rsin
g in
terv
entio
nw
as e
ffect
ive
atsu
ppor
ting
heal
thy
eatin
gan
d pa
tient
s’ s
elf-
care
agen
cy
cont
inue
d
Appendix 11
122
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff in
volv
ed,
grou
p: d
etai
ls
mea
sure
and
res
ults
outc
omes
au
thor
s’
coun
try
% m
en, m
ean
inte
nsit
y, fo
llow
-up
peri
od
of u
sual
car
ean
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
age
(SD
),
for
outc
ome
asse
ssm
ent
inte
rest
ing
feat
ures
type
)et
hnic
ity
if st
ated
Ash
e, 1
99314
9
USA
(PhD
the
sis)
Qua
si RC
T,41
pat
ient
sra
ndom
ised
Allo
catio
n to
grou
ps b
ypr
esen
ting
patie
nts
with
apa
cket
con
tain
ing
a fo
rm c
oded
Aor
B. B
lind
asse
ssm
ent
ofou
tcom
es u
ncle
ar.
Sim
ilarit
y of
grou
ps a
t ba
selin
eun
clea
r. O
vera
lllo
sses
to
follo
w-
up 2
2%
Subj
ects
rec
ruite
dfr
om a
pha
se 2
card
iac
reha
bilit
atio
npr
ogra
mm
e.M
ixed
car
diac
patie
nts
incl
udin
gM
I, C
ABG
, ang
ina
and
patie
nts
with
valv
e pr
oble
ms.
Mea
n ag
e 62
(ran
ge33
–77)
year
s,ge
nder
not
men
tione
d, 9
5%w
hite
Mot
ivat
iona
l rel
apse
pre
vent
ion
inte
rven
tion
rece
ived
dur
ing
the
cour
se o
f the
car
diac
reh
abili
tatio
npr
ogra
mm
e. T
he c
ardi
acre
habi
litat
ion
prog
ram
me
cons
isted
of th
ree
wee
kly
exer
cise
ses
sions
of 3
0–40
min
utes
ove
r 2–
3m
onth
s.T
he in
terv
entio
n w
as s
tart
ed a
fter
four
or
five
exer
cise
ses
sions
. The
inte
rven
tion
was
bas
ed o
n M
arla
ttan
d G
ordo
n’s
mod
el.17
7Pa
tient
sre
ceiv
ed in
divi
dual
ses
sions
, one
aw
eek
for
3 w
eeks
. Ses
sion
1: u
sing
pret
est i
nfor
mat
ion,
fact
ors
foun
dto
inte
rfer
e w
ith a
dher
ence
wer
ein
trod
uced
. Pat
ient
s di
scus
sed
thei
rpe
rcep
tions
on
the
valu
e of
exer
cise
, list
ed th
eir
goal
s fo
r th
epr
ogra
mm
e an
d an
ticip
ated
outc
omes
. Ses
sion
2: p
atie
nts
wer
ein
trod
uced
to d
ecisi
on-m
akin
gco
ncep
ts a
nd c
ogni
tive
inte
rfer
ence
fact
ors.
Disc
ussio
n w
ith r
egar
d to
copi
ng w
ith ‘s
lips’
and
intr
oduc
tion
to a
ppro
pria
te w
ays
to r
efra
me
pers
pect
ives
. Pat
ient
s fil
led
in d
aily
activ
ity s
heet
s. S
essio
n 3:
focu
sed
on th
e im
port
ance
of l
ifest
yle
bala
nce.
Pat
ient
s w
ere
aske
d to
refe
r to
dai
ly a
ctiv
ity s
heet
s to
intr
oduc
e co
ncep
ts o
f sho
ulds
and
wan
ts. S
tres
sors
wer
e id
entif
ied
that
may
impa
ct o
n lif
esty
le b
alan
cean
d di
scus
sed,
as
was
the
impo
rtan
ce o
f pos
itive
thin
king
and
use
of m
edic
atio
n. P
atie
nts
also
took
par
t in
a st
ress
man
agem
ent
exer
cise
and
rel
axat
ion
proc
edur
e
Dur
ing
the
cour
se o
f the
exer
cise
prog
ram
me
patie
nts
rece
ived
a ‘b
enig
n’ed
ucat
ion
inte
rven
tion,
whi
ch c
over
edba
sic e
xerc
iseco
ncep
ts,
guid
elin
es fo
rpr
oper
exe
rcise
part
icip
atio
n,ex
erci
se t
ips
and
hand
outs
, and
the
bene
fits
ofex
erci
se
Tota
l adh
eren
ce t
o th
em
axim
um n
umbe
r of
exer
cise
ses
sions
. Thi
s w
as90
% in
the
inte
rven
tion
grou
p an
d 89
% in
the
cont
rol g
roup
(not
signi
fican
t)
Vario
usps
ycho
logi
cal
mea
sure
s us
edto
det
erm
ine
rela
tions
hips
with
atte
ndan
ce
Man
y hy
poth
eses
tes
ted
with
rel
ativ
ely
smal
lnu
mbe
r of
pat
ient
s. T
heau
thor
s co
nclu
de t
hat
they
foun
d no
diff
eren
ces
betw
een
grou
ps o
nm
easu
res
of a
dher
ence
,se
lf-m
otiv
atio
n, s
elf-
effic
acy
or in
tern
al h
ealth
locu
s of
con
trol
cont
inue
d
Health Technology Assessment 2004; Vol. 8: No. 41
123
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff in
volv
ed,
grou
p: d
etai
ls
mea
sure
and
res
ults
outc
omes
au
thor
s’
coun
try
% m
en, m
ean
inte
nsit
y, fo
llow
-up
peri
od
of u
sual
car
ean
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
age
(SD
),
for
outc
ome
asse
ssm
ent
inte
rest
ing
feat
ures
type
)et
hnic
ity
if st
ated
Hop
per,
1995
150
USA
(PhD
the
sis)
Para
llel g
roup
RCT,
80
patie
nts
rand
omise
d
No
deta
ils o
fm
etho
d of
rand
omisa
tion
oral
loca
tion
conc
ealm
ent.
Blin
d as
sess
men
tof
out
com
esun
clea
r. G
roup
ssim
ilar
at b
asel
ine.
46%
loss
to
follo
w-u
p.
Mix
ed C
HD
patie
nts:
49%
MI,
16%
CA
BG, 3
%an
giop
last
y, 8
% M
Ian
d C
ABG
, 10%
MI a
nd a
ngio
plas
ty,
15%
MI,
CA
BGan
d an
giop
last
y.M
ean
age
58ye
ars,
83%
men
Dur
ing
the
12m
onth
s fo
llow
ing
card
iac
reha
bilit
atio
n pa
tient
sre
ceiv
ed m
onth
ly s
truc
ture
dte
leph
one
inte
rvie
ws
with
aca
rdia
c nu
rse
or a
n ex
erci
seph
ysio
logi
st fr
om t
he r
ehab
ilita
tion
team
. Int
ervi
ews
prov
ided
soc
ial
supp
ort
and
enco
urag
emen
t,la
sted
for
abou
t 15
min
utes
, and
addr
esse
d th
e ar
eas
of c
onsis
tent
exer
cise
, mai
nten
ance
of a
hea
lthy
diet
, con
siste
ncy
with
med
icat
ion,
know
ledg
e of
cur
rent
blo
odpr
essu
re a
nd c
hole
ster
ol le
vels,
and
sym
ptom
s th
at r
equi
red
med
ical
att
entio
n. H
ealth
prof
essio
nals
prov
ided
ass
istan
ce if
imm
edia
te c
are
was
req
uire
d.Po
stal
que
stio
nnai
re fo
llow
-up
12m
onth
s af
ter
com
plet
ion
of C
Rpr
ogra
mm
es
No
supp
ort
orte
leph
one
calls
afte
r C
R fr
omre
habi
litat
ion
staf
f
Exer
cise
hab
it, in
tent
ion
toex
erci
se a
nd c
ondi
tions
that
faci
litat
ed o
rdi
scou
rage
d th
epe
rfor
man
ce o
f exe
rcise
asse
ssed
by
self-
com
plet
edqu
estio
nnai
re. N
odi
ffere
nce
in e
xerc
ise h
abit
or in
tent
ion
to e
xerc
iseas
soci
ated
with
the
inte
rven
tion.
Con
ditio
nsth
at fa
cilit
ated
the
perf
orm
ance
of e
xerc
isew
ere
impr
oved
in t
hein
terv
entio
n gr
oup
com
pare
d w
ith c
ontr
ol(p
<0
.05)
Exer
cise
conf
iden
cesc
ale
(sel
f-ef
ficac
y),
pers
onal
attit
udes
sca
le(d
epre
ssio
n),
rest
ing
and
exer
cise
blo
odpr
essu
re, b
lood
lipid
s an
dgr
aded
max
imal
exer
cise
tes
t.N
o di
ffere
nces
betw
een
inte
rven
tion
and
cont
rol
The
aut
hor
conc
lude
s th
atpe
rson
al in
depe
nden
ce o
fpa
rtic
ipan
ts a
fter
a C
Rpr
ogra
mm
e ca
n be
impr
oved
by
mea
ns o
fte
leph
one
cont
act
cond
ucte
d af
ter
conc
lusio
n of
the
prog
ram
me
cont
inue
d
Appendix 11
124
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff in
volv
ed,
grou
p: d
etai
ls
mea
sure
and
res
ults
outc
omes
au
thor
s’
coun
try
% m
en, m
ean
inte
nsit
y, fo
llow
-up
peri
od
of u
sual
car
ean
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
age
(SD
),
for
outc
ome
asse
ssm
ent
inte
rest
ing
feat
ures
type
)et
hnic
ity
if st
ated
Dun
can
et a
l.,20
0115
1
USA
(con
fere
nce
proc
eedi
ngs)
Para
llel g
roup
RCT,
eig
htpa
tient
sra
ndom
ised.
Feas
ibili
tyst
udy,
hen
cesm
all
num
bers
No
deta
ils o
fm
etho
d of
rand
omisa
tion,
allo
catio
nco
ncea
lmen
t,bl
indi
ng o
fou
tcom
eas
sess
ors,
com
para
bilit
y of
grou
ps a
t ba
selin
eor
loss
es t
ofo
llow
-up
Hea
rt fa
ilure
patie
nts
who
wer
ecu
rren
tlypa
rtic
ipat
ing
in a
card
iac
reha
bilit
atio
npr
ogra
mm
e. N
ode
tails
of a
ge o
rge
nder
, mea
nej
ectio
n fr
actio
n24
%
Car
diac
reh
abili
tatio
n pl
usbe
havi
oura
l fee
dbac
k in
terv
entio
non
die
tary
sod
ium
inta
ke.
Feed
back
giv
en o
n a
3-da
y di
etar
ylo
g of
sod
ium
inta
ke, d
iscus
sion
ofpr
oble
m-s
olvi
ng s
trat
egie
s to
redu
ce fu
ture
sod
ium
inta
ke
Patie
nts
in t
here
habi
litat
ion
prog
ram
me
com
plet
ed t
he
3-da
y di
etar
y lo
gon
sod
ium
inta
ke
Repe
at o
f the
3-d
ay d
ieta
rylo
g of
sod
ium
inta
ke a
t th
een
d of
the
inte
rven
tion
perio
d, a
nd c
ompl
etio
n of
the
belie
fs a
bout
die
t in
stru
men
t(m
easu
re o
f ben
efits
and
barr
iers
rel
ated
to
diet
ary
sodi
um a
dher
ence
). So
dium
inta
ke w
as s
igni
fican
tly le
ss in
the
inte
rven
tion
grou
p (1
569
vs 2
836
mg,
p<
0.05
), an
dth
ese
patie
nts
iden
tifie
dsig
nific
antly
few
er b
arrie
rs t
oad
herin
g to
sod
ium
reco
mm
enda
tions
Very
sm
all f
easib
ility
stu
dyw
ith o
nly
four
pat
ient
sra
ndom
ised
to e
ach
grou
p. In
terv
entio
n of
beha
viou
ral f
eedb
ack
had
posit
ive
effe
cts
on s
odiu
min
take
and
att
itude
sto
war
ds a
dher
ence
to
reco
mm
ende
d so
dium
leve
ls
Lesli
e &
Sch
uste
r,19
9115
2
USA
(jour
nal)
Qua
si RC
T,30
pat
ient
sra
ndom
ised
Alte
rnat
eal
loca
tion
toin
terv
entio
n or
cont
rol.
Blin
das
sess
men
t of
outc
omes
unc
lear
.T
he c
ompa
rison
grou
ps w
ere
simila
r at
bas
elin
ein
ter
ms
of a
gean
d ge
nder
but
ther
e w
ere
mor
eC
ABG
and
few
erM
I pat
ient
s in
the
cont
rol g
roup
.T
here
was
a 7
%ov
eral
l los
s to
follo
w-u
p ov
er a
n8-
wee
k pe
riod
Mix
ed C
HD
patie
nt: M
I 25%
,C
ABG
43%
,an
giop
last
y 18
%,
othe
r co
rona
rydi
seas
e 14
%.
Mea
n ag
e55
.6ye
ars,
71%
men
Con
tinge
ncy
cont
ract
ing.
Con
trac
ting
in t
his
stud
y is
defin
edas
a w
ritte
n co
ntra
ct n
egot
iate
dw
ith t
he p
atie
nt, s
tatin
g ho
w lo
ngth
ey w
ill e
xerc
ise fo
r to
mai
ntai
nth
eir
hear
t ra
te a
t a
cert
ain
leve
l,on
how
man
y da
ys t
hat
wee
k, in
retu
rn fo
r a
rew
ard.
Pat
ient
sch
ose
rew
ards
tha
t w
ere
gene
rally
acce
ptab
le p
rovi
ding
the
y w
ere
not
dam
agin
g to
hea
lth. E
xam
ples
incl
uded
die
tary
rec
ipes
, T-s
hirt
sor
loan
of e
xerc
ise e
quip
men
t. A
llco
ntra
ctin
g do
ne b
y th
e ed
ucat
ion
coor
dina
tor
of t
he c
ardi
acre
habi
litat
ion
prog
ram
me,
with
sess
ions
last
ing
for
10 m
inut
esea
ch w
eek
for
8 w
eeks
. Con
trac
tbe
havi
ours
wer
e de
signe
d to
be
atta
inab
le, a
nd e
xerc
ise s
essio
nsw
ere
rout
inel
y sc
hedu
led
thre
etim
es a
wee
k. U
pon
com
plet
ion
ofth
e co
ntra
ct p
atie
nts
rece
ived
thei
r re
war
d. P
atie
nts
also
rece
ived
1ho
ur o
f for
mal
educ
atio
n ea
ch w
eek.
Fol
low
-up
asse
ssm
ent
at 8
wee
ks
Patie
nts
in t
heco
mpa
rison
grou
p re
ceiv
edth
e sa
me
1ho
urpe
r w
eek
offo
rmal
edu
catio
nas
the
inte
rven
tion
grou
p
Exer
cise
kno
wle
dge
test
and
adhe
renc
e to
exe
rcise
sess
ions
. The
re w
as a
signi
fican
t in
crea
se in
exe
rcise
know
ledg
e sc
ores
at
8 w
eeks
in t
he in
terv
entio
n gr
oup,
but
no d
iffer
ence
in a
tten
danc
era
tes
betw
een
the
inte
rven
tion
and
cont
rol
grou
ps (9
0% a
nd 8
9%,
resp
ectiv
ely)
The
re w
as n
o ef
fect
of
the
inte
rven
tion
onpr
ogra
mm
e at
tend
ance
.T
he a
utho
rs c
oncl
ude
that
the
incr
ease
in e
xerc
isekn
owle
dge
sugg
ests
tha
tth
e co
ntin
genc
yco
ntra
ctin
g pr
oces
sm
aybe
an
inte
rven
tion
wor
thy
of c
onsid
erat
ion
in a
dditi
on t
o tr
aditi
onal
grou
p le
ctur
es
cont
inue
d
Health Technology Assessment 2004; Vol. 8: No. 41
125
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff in
volv
ed,
grou
p: d
etai
ls
mea
sure
and
res
ults
outc
omes
au
thor
s’
coun
try
% m
en, m
ean
inte
nsit
y, fo
llow
-up
peri
od
of u
sual
car
ean
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
age
(SD
),
for
outc
ome
asse
ssm
ent
inte
rest
ing
feat
ures
type
)et
hnic
ity
if st
ated
Mill
er e
t al
.,19
8814
3
Mill
er, e
t al
.,19
8914
4
USA
(jour
nals)
Qua
si RC
T.11
5 pa
tient
sra
ndom
ised
Alte
rnat
eal
loca
tion
toin
terv
entio
n or
cont
rol.
Blin
das
sess
men
t of
outc
omes
unc
lear
.T
he c
ompa
rison
grou
ps w
ere
simila
r at
bas
elin
e.T
here
was
an
11%
ove
rall
loss
to fo
llow
-up
over
a 60
-day
per
iod,
and
30%
loss
to
follo
w-u
p at
1ye
ar
All
patie
nts
recr
uite
d fr
om in
patie
nt c
ardi
acre
habi
litat
ion
prog
ram
mes
(one
of t
hree
sim
ilar
prog
ram
mes
)fo
llow
ing
a fir
stun
com
plic
ated
MI.
Age
ran
ge30
–65
year
s, 8
1%m
en. D
ata
avai
labl
e fo
r on
lyth
ose
patie
nts
follo
wed
up,
not
all t
hose
rand
omise
d
All
patie
nts
had
10–1
5da
ys o
fca
rdia
c re
habi
litat
ion
in h
ospi
tal,
incl
udin
g ad
vice
on
diet
, act
ivity
,sm
okin
g an
d m
edic
atio
n. A
t 30
days
pos
tdisc
harg
e nu
rses
visi
ted
patie
nts
at h
ome
to d
eliv
er a
nin
terv
entio
n to
impr
ove
med
ical
regi
men
adh
eren
ce w
hich
cons
isted
of t
hree
ste
ps:
(1) A
sses
smen
t: da
ta o
btai
ned
onpa
tient
sel
f-as
sess
men
t of
att
itude
san
d pe
rcei
ved
belie
fs o
f oth
ers
tow
ards
reg
imen
com
plia
nce,
pers
onal
psy
chol
ogic
al a
nd s
ocie
tal
adju
stm
ents
, and
rep
orte
dre
gim
en c
ompl
ianc
e by
pat
ient
and
spou
se, p
redi
scha
rge
and
30da
yspo
stdi
scha
rge.
(2) P
robl
emid
entif
icat
ion:
dat
a fr
om s
tep
1w
ere
eval
uate
d by
the
pat
ient
,sp
ouse
and
nur
se. P
robl
em a
reas
wer
e de
fined
and
fact
ors
cont
ribut
ing
to n
on-c
ompl
ianc
ew
ere
disc
usse
d. (3
) Goa
l set
ting:
on t
he b
asis
of p
robl
ems
iden
tifie
d, a
ltern
ativ
e ac
tions
wer
edi
scus
sed
and
a he
alth
pla
n w
ithsp
ecifi
c go
als
was
dev
elop
ed.
Ass
essm
ent
of c
ompl
ianc
e w
ithm
edic
al r
egim
en a
t fo
llow
-up
hom
e vi
sits
at 6
0 da
ys a
nd 1
yea
r
All
patie
nts
had
10–1
5 da
ys o
fca
rdia
cre
habi
litat
ion
inho
spita
l,in
clud
ing
advi
ceon
die
t, ac
tivity
,sm
okin
g an
dm
edic
atio
n.Pa
tient
sin
terv
iew
edbe
fore
disc
harg
ean
d vi
sited
at
hom
e 30
day
spo
stdi
scha
rge
toco
llect
asse
ssm
ent
data
as fo
r th
ein
terv
entio
ngr
oup.
Ass
essm
ent
ofco
mpl
ianc
e w
ithm
edic
al r
egim
enat
follo
w-u
pho
me
visit
s at
60da
ys a
nd1
year
Com
plia
nce
with
med
ical
regi
men
, div
ided
into
die
t,sm
okin
g, a
ctiv
ity, s
tres
s an
dm
edic
atio
ns. V
ario
us h
ealth
beha
viou
r an
d at
titud
esc
ales
use
d to
ass
ess
this.
No
signi
fican
t di
ffere
nces
wer
e se
en b
etw
een
inte
rven
tion
and
cont
rol
grou
ps a
t 60
days
or
1ye
arpo
stdi
scha
rge
The
aut
hors
con
clud
e th
atno
diff
eren
ces
wer
efo
und
betw
een
the
inte
rven
tion
or c
ontr
olgr
oups
for
med
ical
regi
men
adh
eren
ce. T
heau
thor
s ob
serv
ed t
hat
attit
udes
and
per
ceiv
edbe
liefs
of o
ther
s w
ere
pred
ictiv
e of
adh
eren
cean
d sh
ould
be
incl
uded
inan
y re
habi
litat
ion
prog
ram
me.
Rep
eate
dse
lf-ev
alua
tion
ques
tionn
aire
s an
d nu
rse
visit
s m
ay h
ave
acte
d as
an in
terv
entio
n in
the
cont
rol g
roup
cont
inue
d
Appendix 11
126
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff in
volv
ed,
grou
p: d
etai
ls
mea
sure
and
res
ults
outc
omes
au
thor
s’
coun
try
% m
en, m
ean
inte
nsit
y, fo
llow
-up
peri
od
of u
sual
car
ean
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
age
(SD
),
for
outc
ome
asse
ssm
ent
inte
rest
ing
feat
ures
type
)et
hnic
ity
if st
ated
Lack
, 198
5153
USA
(P
hD t
hesis
)
Qua
si RC
T,48
pat
ient
sra
ndom
ised,
data
pres
ente
d fo
r34
com
plet
ers
Patie
nts
rand
omly
assig
ned
toin
terv
entio
n or
cont
rol a
s th
eypr
esen
ted
them
selv
es. O
noc
casio
ns w
here
ther
e w
ere
insu
ffici
ent
num
bers
to
form
an in
terv
entio
ngr
oup,
the
aut
hors
depa
rted
from
thei
r st
anda
rdra
ndom
isatio
n an
dpr
iorit
y w
as g
iven
to t
hein
terv
entio
ngr
oup,
hen
ce t
his
grou
p is
larg
er
(n=
22
vs
n=
12)
. Blin
ding
of o
utco
me
asse
ssor
s un
clea
r.C
ompa
rison
grou
ps w
ere
simila
r at
bas
elin
e.O
vera
ll lo
sses
to
follo
w-u
p 29
%
Patie
nts
refe
rred
to c
ardi
acre
habi
litat
ion.
Mix
ed C
HD
patie
nts:
62%
MI,
24%
CA
BG, 1
5%bo
th. M
ean
age
59(r
ange
28–7
2ye
ars)
,86
.8%
men
12-w
eek
psyc
hoth
erap
yin
terv
entio
n an
d its
impa
ct o
npa
tient
com
plia
nce
with
pres
crib
ed r
egim
en in
the
car
diac
reha
bilit
atio
n se
ttin
g. P
atie
nts
rece
ived
the
inte
rven
tion
whe
nth
ey fi
rst
star
ted
the
card
iac
reha
bilit
atio
n se
ssio
n. In
terv
entio
nco
nsist
ed o
f 90-
min
ute
sess
ions
once
a w
eek
for
3m
onth
s, o
r12
or 1
5 se
ssio
ns o
f ins
ight
-or
ient
ated
gro
up p
sych
othe
rapy
.T
he p
rimar
y fo
cus
was
to
help
the
grou
p to
com
mun
icat
e th
ough
tsan
d fe
elin
gs w
ith t
he a
ssoc
iate
daf
fect
s. T
he t
hera
pist
cre
ated
an
atm
osph
ere
that
was
sup
port
ive,
coop
erat
ive
and
goal
dire
cted
. The
seco
ndar
y fo
cus
was
to
high
light
and
prom
ote
chan
ge in
tho
sebe
havi
ours
and
sty
les
of r
elat
ing
that
ref
lect
ed a
mal
adap
tive
cont
rol o
rient
atio
n, e
.g. h
esita
ncy
or r
efus
al t
o co
mpl
y w
ith p
hysic
ian
reco
mm
enda
tions
, or
resis
tanc
e to
grou
p pa
rtic
ipat
ion.
Per
iod
offo
llow
-up
at e
nd o
f int
erve
ntio
npe
riod
of 3
mon
ths
Con
trol
gro
upre
ceiv
ed u
sual
card
iac
reha
bilit
atio
n
Phys
iolo
gica
l mar
kers
of
com
plia
nce
with
exe
rcise
(hea
rt r
ate
and
bloo
dpr
essu
re).
Att
enda
nce
atpr
escr
ibed
exe
rcise
sess
ions
, and
sel
f-re
port
of
exer
cise
at
hom
e: r
ated
as
poor
(onc
e a
wee
k fo
r le
ssth
an 2
0 m
inut
es o
r no
ne,
scor
e 0–
1), g
ood
(thr
eetim
es a
wee
k fo
r20
–30
min
utes
, sco
re 2
) or
exce
llent
(mor
e th
an t
hree
times
a w
eek
for
mor
eth
an 3
0 m
inut
es, s
core
3).
Mea
n sc
ores
for
self-
repo
rtm
easu
res
of c
ompl
ianc
ew
ere
2.57
and
2.3
7 fo
r th
ein
terv
entio
n an
d co
ntro
lgr
oups
, res
pect
ivel
y, o
ver
the
3m
onth
per
iod.
The
inte
rven
tion
grou
pat
tend
ed 8
8.4%
of t
hepr
escr
ibed
exe
rcise
sess
ions
, the
con
trol
gro
up75
.7%
(p<
0.0
5)
The
aut
hors
con
clud
e th
atth
e an
alys
es s
how
ed n
oef
fect
of t
heps
ycho
ther
apy
inte
rven
tion
on p
atie
ntco
mpl
ianc
e m
easu
red
byph
ysio
logi
cal o
r se
lf-re
port
mea
sure
s. T
hey
did,
how
ever
,de
mon
stra
te t
hat
patie
nts
rece
ivin
g th
e in
terv
entio
nat
tend
ed s
igni
fican
tlym
ore
pres
crib
ed e
xerc
isese
ssio
ns
cont
inue
d
Health Technology Assessment 2004; Vol. 8: No. 41
127
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff in
volv
ed,
grou
p: d
etai
ls
mea
sure
and
res
ults
outc
omes
au
thor
s’
coun
try
% m
en, m
ean
inte
nsit
y, fo
llow
-up
peri
od
of u
sual
car
ean
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
age
(SD
),
for
outc
ome
asse
ssm
ent
inte
rest
ing
feat
ures
type
)et
hnic
ity
if st
ated
Mar
shal
l et
al.,
1986
154
USA
(jour
nal)
Non
-ra
ndom
ised
tria
l,60
patie
nts
stud
ied
Dat
a w
ere
colle
cted
from
cont
rols
first
(n=
30) a
nd t
hen
inte
rven
tion
patie
nts
(n=
30).
Com
paris
ongr
oups
wer
esim
ilar
at b
asel
ine.
Sam
plin
g w
aspr
ospe
ctiv
e an
din
clus
ion
crite
riaw
ere
spec
ified
.Lo
sses
to
follo
w-
up n
ot r
epor
ted
CA
BG p
atie
nts.
Elec
tive
CA
BGpe
rfor
med
by
the
sam
e gr
oup
ofsu
rgeo
ns. M
ean
age
59 (r
ange
46–7
8ye
ars)
,70
% m
en
Stru
ctur
ed t
each
ing
prog
ram
me
toin
crea
se p
atie
nts’
kno
wle
dge
and
com
plia
nce
to m
edic
atio
n, d
iet,
smok
ing
cess
atio
n an
d ex
erci
sepo
st s
urge
ry. T
each
ing
guid
ede
velo
ped
by n
urse
s w
ithco
nsid
erab
le e
xper
ienc
e w
ith t
his
patie
nt g
roup
, and
use
d by
nur
ses.
Follo
w-u
p as
sess
men
t at
4–6
wee
ks p
osts
urge
ry
Rece
ived
teac
hing
by
unst
ruct
ured
met
hod
Com
plia
nce
with
die
t,m
edic
atio
n, s
mok
ing
cess
atio
n an
d ac
tivity
, and
know
ledg
e. C
ompl
ianc
eas
sess
ed b
y se
lf-re
port
.Pa
tient
s w
ere
assig
ned
asc
ore
on fo
llow
-up
visit
of
com
plia
nce
base
d on
indi
vidu
al r
isk fa
ctor
s.O
vera
ll co
mpl
ianc
e sc
ores
wer
e 86
.8 in
the
inte
rven
tion
grou
p, a
nd79
.5 in
the
con
trol
gro
up(p
<0.
05).
Com
plia
nce
was
bet
ter
in t
hein
terv
entio
n th
an in
the
cont
rol g
roup
for
activ
ity(1
5.6
vs 7
blo
cks
wal
ked,
p<
0.00
5). N
one
of t
hepa
tient
s in
the
inte
rven
tion
grou
p re
port
ed n
on-
com
plia
nce
with
any
of t
heris
k fa
ctor
s m
easu
red
Kno
wle
dge
scor
es p
ost
surg
ery
wer
esim
ilar
for
the
stru
ctur
ed a
ndun
stru
ctur
edte
achi
ng g
roup
s
The
aut
hors
con
clud
e th
atov
eral
l com
plia
nce
and
activ
ity le
vels
wer
esig
nific
antly
hig
her
post
surg
ery
in t
hest
ruct
ured
tea
chin
g gr
oup
Hue
rin e
t al
.,19
9815
5
Arg
entin
a(c
onfe
renc
epr
ocee
ding
s)
Non
-ra
ndom
ised
tria
l,50
9pa
tient
sst
udie
d,in
terv
entio
ngr
oup
n=
229,
cont
rol g
roup
n=
280
Com
paris
ongr
oups
wer
esim
ilar
at b
asel
ine
and
sam
plin
g w
aspr
ospe
ctiv
e. N
ofu
rthe
r de
tails
are
give
n
Patie
nts
with
CH
D. M
ean
age
56 (S
D 1
0) y
ears
,67
.5%
men
Trad
ition
al r
ehab
ilita
tion
and
anad
here
nce
stra
tegy
whi
ch in
clud
eda
signe
d co
mm
itmen
t to
reha
bilit
atio
n, fa
mily
invo
lvem
ent,
spor
ts a
nd r
ecre
atio
nal a
ctiv
ities
to
incr
ease
pat
ient
com
mitm
ent
and
invo
lvem
ent
in a
var
iety
of
activ
ities
, and
thr
ee w
eekl
y ta
lks
on C
HD
-rel
ated
top
ics.
Fol
low
-up
at 1
2, 2
4 an
d 52
wee
ks
Trad
ition
alre
habi
litat
ion
Com
plia
nce
expr
esse
d as
rela
tive
risks
, def
ined
as
atte
ndan
ce a
t 66
% o
rm
ore
sess
ions
. 12
wee
ks,
RR 2
.3 (9
5% C
I 1.8
to
2.9)
,24
wee
ks, R
R 2.
9 (2
.3 t
o3.
7), 5
2w
eeks
, RR
4.25
(3.2
to
5.6)
(log
-ran
k te
stbe
twee
n st
rate
gies
p<
0.00
1)
The
aut
hors
con
clud
e th
atat
eac
h tim
e-po
int,
the
adhe
renc
e st
rate
gy g
roup
show
ed s
igni
fican
tlybe
tter
com
plia
nce
with
card
iac
reha
bilit
atio
n
cont
inue
d
Appendix 11
128
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff in
volv
ed,
grou
p: d
etai
ls
mea
sure
and
res
ults
outc
omes
au
thor
s’
coun
try
% m
en, m
ean
inte
nsit
y, fo
llow
-up
peri
od
of u
sual
car
ean
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
age
(SD
),
for
outc
ome
asse
ssm
ent
inte
rest
ing
feat
ures
type
)et
hnic
ity
if st
ated
McK
enna
et
al.,
1998
156
UK
(con
fere
nce
proc
eedi
ngs)
Two
stud
yde
signs
: non
-ra
ndom
ised
tria
l, ex
erci
sevs
. sta
ndar
dre
habi
litat
ion,
and
anev
alua
tion
ofa
wom
en-o
nly
prog
ram
me
com
pare
dw
ith h
istor
ical
cont
rols.
No
info
rmat
ion
on p
atie
ntnu
mbe
rs
No
mor
e de
tails
pres
ente
d ab
out
how
the
stu
dies
wer
e co
nduc
ted
MI p
atie
nts,
mea
nag
e 62
yea
rs, 7
5%m
en. M
ean
age
ofth
e w
omen
-onl
ygr
oup
was
60ye
ars
Two
inte
rven
tions
exa
min
ed.
(1) L
ow-in
tens
ity e
xerc
ise t
oin
crea
se c
ompl
ianc
e, o
ffere
d to
patie
nts
who
wer
e pr
evio
usly
unab
le t
o ta
ke p
art
in s
tand
ard
exer
cise
ow
ing
to c
o-m
orbi
dity
.T
he c
ompa
rison
gro
up w
ere
stan
dard
reh
abili
tatio
n. (2
)W
omen
-onl
y gr
oups
: com
plia
nce
with
reh
abili
tatio
n. H
istor
ical
lyco
mpl
ianc
e in
wom
en w
ithst
anda
rd r
ehab
ilita
tion
was
6%
Stan
dard
reha
bilit
atio
nA
tten
danc
e at
car
diac
reha
bilit
atio
n. A
tten
danc
ew
as 8
2% in
the
low
-in
tens
ity e
xerc
ise g
roup
and
34%
in t
he s
tand
ard
reha
bilit
atio
n co
mpa
rison
grou
p. A
tten
danc
e in
the
wom
en-o
nly
grou
p w
as75
%
The
aut
hors
con
clud
e th
atta
ilore
d ex
erci
se fo
rdi
ffere
nt p
atie
nt g
roup
sin
crea
sed
com
plia
nce
with
the
exe
rcise
com
pone
nt o
f sta
ndar
dre
habi
litat
ion.
Pat
ient
num
bers
not
rep
orte
d.T
he m
agni
tude
of c
hang
esca
nnot
be
asse
ssed
Erlin
g &
Old
ridge
,19
8515
7
Can
ada
(con
fere
nce
proc
eedi
ngs)
Befo
re-
and
afte
r-st
udy
Pros
pect
ive
sam
plin
g, in
clus
ion
crite
ria n
otsp
ecifi
ed. N
oot
her
deta
ilsab
out
how
the
stud
y w
asco
nduc
ted
CH
D p
atie
nts.
No
othe
r de
tails
Spou
sal s
uppo
rt p
rogr
amm
e:sp
ousa
l par
ticip
atio
n in
car
diac
reha
bilit
atio
n. N
ot a
ll sp
ouse
sat
tend
ed, s
o co
mpa
rato
rs a
reba
selin
e be
fore
spo
use
part
icip
atio
n (n
= 3
0), s
pous
epa
rtic
ipat
ion
in c
ardi
acre
habi
litat
ion
(n=
30)
and
no
spou
se p
artic
ipat
ion
(n=
30)
.Fo
llow
-up
at 6
mon
ths
Patie
ntco
mpl
ianc
ebe
fore
intr
oduc
tion
ofth
e sp
ouse
supp
ort
prog
ram
me
Att
enda
nce
at c
ardi
acre
habi
litat
ion
sess
ions
defin
ed a
s th
ose
who
atte
nded
at
leas
t 50
% o
fth
e se
ssio
ns. B
efor
e th
esp
ousa
l int
erve
ntio
nat
tend
ance
was
44%
, afte
rth
e sp
ousa
l sup
port
prog
ram
me
whe
re t
hesp
ouse
par
ticip
ated
inre
habi
litat
ion
patie
ntat
tend
ance
was
90%
(p<
0.00
1), a
nd w
here
the
spou
se d
id n
ot a
tten
d th
isw
as 6
7%
The
aut
hors
con
clud
e th
atev
en fo
r pa
tient
s w
hose
spou
ses
did
not
atte
ndre
habi
litat
ion
ther
e w
ere
bene
ficia
l effe
cts
of g
roup
supp
ort
whe
n th
e sp
ousa
lpr
ogra
mm
e w
as r
unni
ngco
mpa
red
with
the
pres
pous
al p
rogr
amm
e
Health Technology Assessment 2004; Vol. 8: No. 41
129
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 12
Studies excluded from the review of methods to improve adherence to cardiac rehabilitation
Authors, year Intervention Reason for exclusion
Ades et al., 2000134 Home-based telephone-monitored Authors report on effectiveness of CR formats. Patients CR compared with outpatient CR were not randomised but allocated to home-based
telephone monitored CR if living in remote area orunable to attend outpatient CR due to work or timeconstraints
Baile & Engel 1978173 Follow-up of non-compliant No comparison groupcoronary care unit patients
Barnason & Postdischarge telephone follow-up No relevant outcomeZimmerman, 1995167 or group teaching
Blumenthal et al., 1988159 Comparison of high- and low- Comparison of rehabilitation intensities. Authors report intensity exercise training on effectiveness. RCT of patients representative of
most US CR programmes
Brubaker et al., 1996160 Comparison of standard and Comparison of rehabilitation duration. Authors report extended length CR benefit from continuing CR for >1 year. Retrospective
non-randomised comparison of patients who attended3 months or >1 year of CR
Campbell et al., 1998126 Nurse-run clinics in general practice No relevant outcome
Carlson et al., 200073 Comparison of traditional and partly Comparison of rehabilitation formats. Authors report home-based CR increased total exercise sessions with partly home-
based programme. Randomised trial
DeBusk et al., 1985131 Comparison of home and group Comparison of rehabilitation formats. Authors report exercise training on effectiveness. Randomised trial
Dracup et al., 1984162 Group counselling No relevant outcomes.
Gordon & Haskell, 1997168 Physician-supervised, nurse No comparison group. No relevant outcomescase-manager CR model
Labrador et al., 1998169 Physician-directed, nurse-supervised No relevant outcomescase-management programme
Lee et al., 1996161 Comparison of high- and low- Comparison of rehabilitation intensities. Authors report intensity exercise training on effectiveness. Randomised trial
Linde & Janz, 1979164 Postoperative teaching programme No relevant outcomes
Mehta et al., 2000121 Quality improvement initiative: Retrospective study. Allocation to groups according to critical care pathway, patient physician preferenceeducation tool and staff education
Penckofer & Llewellyn, Comparison of education by Comparison of education interventions. Authors report 1989163 structured and unstructured methods little extra benefit from structured teaching. Not
randomised
Senaratne et al., 2001171 Lipid management by cardiac Outside search period. No relevant outcomerehabilitation nurse
Skof et al., 2001172 Comparison of late outpatient and No relevant outcomeinpatient CR
continued
Appendix 12
130
Authors, year Intervention Reason for exclusion
Sparks et al., 1993158 Home-based telephone-monitored Comparison of rehabilitation formats. Authors report CR compared with outpatient CR on effectiveness. Randomised trial.
Starkey et al., 2000175 Computer-facilitated secondary No comparison groupprevention programme
Stern & Cleary, 1981174 Low-level exercise programme No comparison group
Unden et al., 1993165 Nurse support No relevant outcome
Vale et al., 2000170 Telephone coaching by dietitian No relevant outcome
van Elderen et al., 1994166 Group health education programme No relevant outcome
Health Technology Assessment 2004; Vol. 8: No. 41
131
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 13
Flow diagram of the systematic review of interventions to improve professional compliancewith cardiac rehabilitation (QUOROM statement
flow diagram)
Potentially relevant publications identifiedand screened for retrieval
3261
Publications retrieved for more detailedevaluation
957Publications excluded on the basis of titleand abstract:
No intervention evaluated 776
No outcome pertaining to professionalcompliance with cardiac rehabilitation 163
Publications included for data extraction
18 (17studies)
Studies included in review
6
Studies excluded from review:
No outcome 7No comparison group 2Retrospective design 1Descriptive only 1
__Total 11
Publications excluded on the basis of titleand abstract (clear evidence that sourcepaper did not describe intervention inappropriate patient group)
2304
Health Technology Assessment 2004; Vol. 8: No. 41
133
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 14
Studies evaluating interventions to improve professional compliance with cardiac rehabilitation
Appendix 14
134 Stu
die
s ar
e li
sted
in
ter
ms
of
stu
dy
des
ign
an
d t
he
hie
rarc
hy
of
evid
ence
, w
ith
RC
Ts
firs
t.
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff gr
oup:
m
easu
re a
nd
outc
omes
au
thor
s’
coun
try
% m
en,
invo
lved
, int
ensi
ty,
deta
ils o
f re
sult
san
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
mea
n ag
e fo
llow
-up
peri
od fo
r us
ual c
are
inte
rest
ing
feat
ures
type
)(S
D),
ou
tcom
e as
sess
men
tet
hnic
ity
if st
ated
Jolly
, et
al.,
1999
104
UK
(jour
nal)
Also
Bra
dley
etal
., 19
9710
2
and
Jolly
et
al.,
1998
103
67 g
ener
alpr
actic
esra
ndom
ised
with
in s
trat
a(b
y fu
nd-
hold
ing
stat
us,
dist
ance
from
loca
lC
Rpr
ogra
mm
ean
d nu
mbe
rof
who
le-
time
part
ner
equi
vale
nts)
,27
7 pa
tient
sfr
omra
ndom
ised
inte
rven
tion
prac
tices
and
320
from
cont
rol
prac
tices
No
deta
ils o
fra
ndom
isatio
npr
oced
ure.
Fol
low
-up
ofpa
tient
s ca
rrie
d ou
t by
anu
rse
not
resp
onsib
le fo
rde
liver
ing
the
inte
rven
tion
to t
hepa
tient
’s p
ract
ice.
Pow
erca
lcul
atio
ns r
epor
ted
for
seru
m c
hole
ster
olch
ange
, dist
ance
wal
ked
and
smok
ing.
Com
paris
on g
roup
sw
ere
simila
r at
bas
elin
e.Lo
ss t
o fo
llow
-up
was
10%
in in
terv
entio
ngr
oup
and
9% in
con
trol
grou
p. A
naly
sis w
as b
yin
tent
ion
to t
reat
but
excl
uded
dea
ths
Patie
nts
regi
ster
ed w
ith67
gen
eral
prac
tices
in a
spec
ified
geog
raph
ical
area
. Pat
ient
sad
mitt
ed t
oho
spita
l with
MI (
71%
) or
with
ang
ina
ofre
cent
ons
et(<
3 m
onth
s)se
en in
hos
pita
l(2
9%).
Patie
nts
wer
e ju
dged
wel
l eno
ugh
topa
rtic
ipat
e by
med
ical
and
nurs
ing
staf
f on
the
war
d or
incl
inic
Spec
ialis
t ca
rdia
c lia
ison
nurs
es c
o-or
dina
ted
the
tran
sfer
of c
are
betw
een
hosp
ital a
nd g
ener
alpr
actic
e. T
he li
aiso
nnu
rse
saw
pat
ient
s in
hosp
ital a
nd e
ncou
rage
dth
em t
o se
e th
e pr
actic
enu
rse
afte
r di
scha
rge.
Supp
ort
was
pro
vide
d to
prac
tice
nurs
es b
yre
gula
r co
ntac
t, in
clud
ing
a te
leph
one
call
shor
tlybe
fore
pat
ient
disc
harg
eto
disc
uss
care
and
boo
ka
first
follo
w-u
p vi
sit t
oth
e pr
actic
e. P
ract
ice
nurs
es w
ere
enco
urag
edto
tel
epho
ne t
he li
aiso
nnu
rse
to d
iscus
spr
oble
ms
or t
o se
ekad
vice
on
clin
ical
or
orga
nisa
tiona
l iss
ues.
Each
pat
ient
was
giv
en a
patie
nt-h
eld
reco
rd c
ard
whi
ch p
rom
pted
and
guid
ed fo
llow
-up
atst
anda
rd in
terv
als
No
cont
act
betw
een
spec
ialis
tca
rdia
c lia
ison
nurs
es a
ndge
nera
lpr
actic
es. N
otex
plic
itly
stat
ed, b
utun
ders
tood
to
be n
ore
com
men
d-at
ion
to s
eepr
actic
e nu
rse
and
no p
atie
nt-
held
rec
ord
Seru
m c
hole
ster
ol,
bloo
d pr
essu
re,
dist
ance
wal
ked
in 6
min
utes
and
sm
okin
gce
ssat
ion
did
not
diffe
r be
twee
ngr
oups
. Bod
y m
ass
inde
x w
as s
light
lylo
wer
in t
hein
terv
entio
n gr
oup.
Mor
e pa
tient
s in
the
inte
rven
tion
grou
pat
tend
ed a
t le
ast
one
outp
atie
nt C
R se
ssio
nco
mpa
red
with
cont
rols
(42%
vs
24%
, p<
0.0
01).
The
diffe
renc
e w
as m
ost
mar
ked
in a
ngin
apa
tient
s (4
2% v
s10
%)
The
pro
gram
me
prov
idin
g co
ordi
nate
dfo
llow
-up
care
by
spec
ialis
t ca
rdia
c lia
ison
nurs
es d
id n
ot im
prov
ehe
alth
out
com
es, b
utw
as e
ffect
ive
inpr
omot
ing
at le
ast
one
outp
atie
nt C
R se
ssio
nat
tend
ance
cont
inue
d
Health Technology Assessment 2004; Vol. 8: No. 41
135
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff gr
oup:
m
easu
re a
nd
outc
omes
au
thor
s’
coun
try
% m
en,
invo
lved
, int
ensi
ty,
deta
ils o
f re
sult
san
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
mea
n ag
e fo
llow
-up
peri
od fo
r us
ual c
are
inte
rest
ing
feat
ures
type
)(S
D),
ou
tcom
e as
sess
men
tet
hnic
ity
if st
ated
Susk
in e
t al
.,20
0012
4
Can
ada
(con
fere
nce
abst
ract
)
RCT,
50
patie
nts
rand
omise
d
No
info
rmat
ion
onra
ndom
isatio
n pr
oced
ure
or b
asel
ine
char
acte
ristic
s of
the
tw
opa
tient
gro
ups
Post
-MI
patie
nts.
76%
men
Writ
ten
endo
rsem
ent
byat
tend
ing
phys
icia
nG
ener
icen
dors
emen
tSe
lf-re
port
edco
mm
itmen
t to
part
icip
ate
in C
R w
as62
% in
tho
se w
hore
ceiv
ed t
he p
hysic
ian
endo
rsem
ent
com
pare
d w
ith 3
8%in
tho
se r
ecei
ving
age
neric
end
orse
men
t(p
= 0
.08)
No
effe
ct o
fm
etho
d of
deliv
ery
(in-
pers
on v
sno
t)
The
aut
hors
sug
gest
furt
her
stud
y re
quire
dto
eva
luat
e w
heth
erph
ysic
ian
endo
rsem
ent
impr
oves
CR
part
icip
atio
n
Kala
yi e
t al
.,19
9912
2
UK
(jour
nal)
Befo
re- a
ndaf
ter-
stud
y.C
ompa
rison
of C
Rre
ferr
al r
ates
befo
rein
terv
entio
n(2
98 p
atie
nts)
and
afte
rin
terv
entio
n(2
63 p
atie
nts)
No
info
rmat
ion
onba
selin
e ch
arac
teris
tics
ofth
e tw
o pa
tient
gro
ups
Post
-MI
patie
nts.
No
info
rmat
ion
onag
e or
gen
der
of g
roup
s
Elec
tron
ic r
efer
ral
path
way
with
feed
back
to w
ard
staf
f on
refe
rral
rate
s. T
he r
efer
ral
path
way
was
initi
ated
whe
n a
CR
refe
rral
scre
en w
as a
utom
atic
ally
flagg
ed u
p on
the
elec
tron
ic p
atie
nt r
ecor
dof
tho
se p
atie
nts
with
adi
scha
rge
diag
nosis
of M
I
Befo
reim
plem
enta
tion
of r
efer
ral
path
way
inte
rven
tion
Afte
r in
terv
entio
nre
ferr
al in
crea
sed
from
194
/298
(65%
)to
208
/263
(79%
) (p
= 0
.000
2)
Mon
thly
refe
rral
rat
eat
sta
rt o
fst
udy
15/3
7(4
0%).
With
in3
mon
ths
ofin
terv
entio
nm
onth
lyre
ferr
al 3
5/39
(90%
)
The
aut
hors
not
e th
atas
wel
l as
impr
ovin
gpa
tient
car
e th
e us
e of
elec
tron
ic r
efer
ral a
ndfe
edba
ck o
f ref
erra
lra
tes
was
of b
enef
it to
staf
f, sa
ving
tim
ere
ferr
ing
and
iden
tifyi
ng p
atie
nts
Mos
ca e
t al
.,19
9841
USA
(con
fere
nce
abst
ract
)
Befo
re-
and
afte
r-st
udy.
Com
paris
onof
out
patie
ntC
Rpa
rtic
ipat
ion
rate
s in
two
6-m
onth
perio
ds w
itha
tota
l of
199
patie
nts
No
info
rmat
ion
onba
selin
e ch
arac
teris
tics
ofth
e tw
o gr
oups
All
patie
nts
post
-MI.
Mea
nag
e 61
yea
rs,
68%
men
Crit
ical
car
e pa
thw
aypr
ompt
ing
refe
rral
for
outp
atie
nt C
R
Befo
reim
plem
enta
tion
of c
ritic
al c
are
path
way
Ove
rall
part
icip
atio
n at
outp
atie
nt C
R w
as54
%, a
s de
term
ined
by
patie
nt s
elf-r
epor
t. T
hecr
itica
l car
e pa
thw
ayw
as a
ssoc
iate
d w
ith a
non-
signi
fican
t inc
reas
ein
out
patie
nt C
Rpa
rtic
ipat
ion
(OR
=1.
9, 9
5% C
I 0.6
to 5
.5)
The
aut
hors
con
clud
eth
at a
sys
tem
sap
proa
ch, i
nvol
ving
apr
ompt
for
outp
atie
ntC
R re
ferr
al a
s pa
rt o
f adi
scha
rge
criti
cal c
are
path
way
, may
pote
ntia
lly in
crea
sera
tes
of p
artic
ipat
ion
inC
R fo
r w
omen co
ntin
ued
Appendix 14
136
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff gr
oup:
m
easu
re a
nd
outc
omes
au
thor
s’
coun
try
% m
en,
invo
lved
, int
ensi
ty,
deta
ils o
f re
sult
san
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
mea
n ag
e fo
llow
-up
peri
od fo
r us
ual c
are
inte
rest
ing
feat
ures
type
)(S
D),
ou
tcom
e as
sess
men
tet
hnic
ity
if st
ated
Cau
lin-G
lase
r&
Sch
mei
zel,
2000
123
USA
(con
fere
nce
abst
ract
)
Befo
re-
and
afte
r-st
udy.
Com
paris
onof
out
patie
ntC
Rpa
rtic
ipat
ion
rate
s in
tw
o5-
mon
thpe
riods
.Pa
tient
num
bers
not
spec
ified
No
info
rmat
ion
onba
selin
e ch
arac
teris
tics
ofth
e tw
o pa
tient
gro
ups
Post
-re
vasc
ular
isa-
tion
patie
nts.
No
info
rmat
ion
on a
ge o
rge
nder
of
grou
ps
Educ
atio
nal i
nter
vent
ion
for
heal
thca
re p
rovi
ders
on t
he c
ompr
ehen
sive
natu
re a
nd b
enef
its o
fC
R, w
ith p
artic
ular
emph
asis
on w
omen
.C
onsis
ted
of g
rand
roun
ds fo
r m
edic
al a
ndnu
rsin
g st
aff,
mon
thly
revi
ew o
f hea
lthou
tcom
es a
nd c
ost-
effe
ctiv
enes
s of
CR
with
clin
ical
car
diol
ogy
coun
cil,
plac
emen
t of
CR
info
rmat
ion
inex
amin
atio
n of
fices
, and
inst
ruct
ions
for
nurs
es t
odi
scus
s C
R w
ith p
atie
nts
and
enco
urag
e di
scus
sion
of r
efer
ral w
ithph
ysic
ians
Befo
reim
plem
enta
tion
of e
duca
tiona
lin
terv
entio
n
In-h
ospi
tal r
efer
ral
incr
ease
d by
50%
(p
< 0
.05)
. Phy
sicia
nof
fice
refe
rral
incr
ease
d by
61%
(p
< 0
.05)
. Mal
e an
dfe
mal
e re
ferr
al r
ates
incr
ease
d by
41%
(p
< 0
.05)
and
65%
(p<
0.0
5),
resp
ectiv
ely
The
aut
hors
con
clud
eth
at a
ppro
pria
tely
desig
ned
educ
atio
nal
inte
rven
tions
are
succ
essf
ul in
alte
ring
beha
viou
rs o
fhe
alth
care
per
sonn
elan
d im
prov
ing
refe
rral
to C
R
cont
inue
d
Health Technology Assessment 2004; Vol. 8: No. 41
137
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Aut
hors
, St
udy
type
Stud
y qu
alit
yPa
rtic
ipan
ts’
Inte
rven
tion
: det
ails
C
ompa
riso
n P
rinc
ipal
out
com
e O
ther
C
omm
ents
: ye
ar a
nd
and
size
case
-mix
, in
clud
ing
sett
ing,
sta
ff gr
oup:
m
easu
re a
nd
outc
omes
au
thor
s’
coun
try
% m
en,
invo
lved
, int
ensi
ty,
deta
ils o
f re
sult
san
d re
sult
sco
nclu
sion
s,
(pub
licat
ion
mea
n ag
e fo
llow
-up
peri
od fo
r us
ual c
are
inte
rest
ing
feat
ures
type
)(S
D),
ou
tcom
e as
sess
men
tet
hnic
ity
if st
ated
Scot
t et
al.,
2000
111
Aus
tral
ia(jo
urna
l)
Befo
re- a
ndaf
ter-
stud
y.C
ompa
rison
of
clin
ical
indi
cato
rs in
thre
e pe
riods
:pr
eint
erve
ntio
n(1
33pa
tient
s),
impl
emen
tatio
nof
inte
rven
tion
(271
pat
ient
s)an
d po
stin
ter-
vent
ion
(245
patie
nts)
Pre-
and
post
inte
rven
tion
grou
ps w
ere
simila
r at
base
line,
but
no
info
rmat
ion
was
repo
rted
for
the
inte
rven
tion
perio
d.O
utpa
tient
CR
prog
ram
me
was
not
fully
ope
ratio
nal i
n th
epr
eint
erve
ntio
npe
riod.
Aut
hors
assu
med
tha
t pa
tient
char
acte
ristic
s,di
agno
stic
met
hods
and
trea
tmen
tm
odal
ities
wou
ldre
mai
n es
sent
ially
unch
ange
d th
roug
hout
the
stud
y
Post
-MI
patie
nts.
Patie
ntch
arac
teris
tics
only
ava
ilabl
efo
r pr
e- a
ndpo
stin
ter-
vent
ion
grou
ps.
Mea
n ag
e66
year
s, 6
6%m
en
Diss
emin
atio
n of
evid
ence
-bas
ed c
linic
algu
idel
ines
for
the
man
agem
ent
of A
MI t
oho
spita
l sta
ff an
d G
Ps.
Info
rmat
ion
on c
linic
alin
dica
tors
was
fed
back
to a
ll ho
spita
l con
sulta
ntph
ysic
ians
, sen
ior
emer
genc
y st
aff,
med
ical
serv
ice
dire
ctor
s an
dse
nior
clin
icia
ns. A
s pa
rtof
the
feed
back
the
obse
rved
pro
port
ion
ofpa
tient
s re
ceiv
ing
the
trea
tmen
ts w
asco
mpa
red
with
a q
ualit
yth
resh
old
or m
inim
umle
vel o
f util
isatio
nin
dica
tive
of a
rea
sona
ble
stan
dard
of c
are.
Loc
alpr
ovid
ers
coul
d co
mpa
rean
d im
prov
e th
eir
own
prac
tice
Befo
redi
ssem
inat
ion
of e
vide
nce-
base
d cl
inic
algu
idel
ines
Clin
ical
indi
cato
rch
ange
s pr
e- t
opo
stin
terv
entio
n. N
och
ange
s w
ere
seen
in�
-blo
cker
, asp
irin
oran
giot
ensin
con
vert
ing
enzy
me
inhi
bito
r us
e.Li
pid-
low
erin
g dr
ugus
e in
crea
sed
from
23%
to
56%
(p<
0.00
3).
Out
patie
nt C
R se
rvic
ebe
cam
e op
erat
iona
l at
star
t of
inte
rven
tion
perio
d an
d sh
owed
ast
eady
incr
ease
inut
ilisa
tion
rate
from
24%
to
54%
(p
= 0
.003
)
The
aut
hors
sug
gest
that
clin
ical
gui
delin
esco
mbi
ned
with
feed
back
of c
linic
alin
dica
tors
to
heal
thpr
ofes
siona
ls w
ere
usef
ul in
impr
ovin
gqu
ality
of c
are,
incl
udin
g ou
tpat
ient
CR
utili
satio
n in
MI
patie
nts.
How
ever
, the
impr
ovem
ent
may
be
due
to p
aral
lel c
hang
esin
leve
ls of
pro
visio
n
Health Technology Assessment 2004; Vol. 8: No. 41
139
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Appendix 15
Studies excluded from the review of interventionsto improve professional compliance with
cardiac rehabilitation
Authors, year Intervention Reason for exclusion
Axtell et al., 2001191 Inclusion of pharmacist in MI care Outcome: use of medication
Campbell et al., 1998125,126 Nurse-led clinic giving secondary prevention Outcome: use of secondary assessment and advice prevention, not attendance at CR.
Feder et al., 1999127 General practices received letters with summary Outcomes: attendance at a generalof effective secondary prevention with reference practice and drug prescribing, not to local guidelines. Also prompts to patients CR
Hillert et al., 2000192 Risk factor management through physician No comparison groupeducation, participation and consensus development
Levknecht et al., 1997116 Outpatient clinical pathway No outcome data: descriptive
Linde & Janz, 1979164 Nurse training to master’s level in postoperative Inpatient programme. Outcome: teaching programme patient knowledge and follow-up.
Data not interpretable
McCarney et al., 2000119 General practice database identifies patients for No data: descriptivehome visit by health visitor to improve secondary prevention
Mehta et al., 2000121 Quality improvement initiative: critical care Retrospective study. Allocation to pathway; patient education tool and staff groups according to physician education preference
Senaratne et al., 2001171 Lipid management by cardiac rehabilitation nurse Outside search period. Outcome:lipid levels
Starkey et al., 2000175 Computer-facilitated secondary prevention No comparison groupprogramme
Tod et al., 1998117 Integration of primary and secondary care No outcome data: descriptive
Health Technology Assessment 2004; Vol. 8: No. 41
141
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Appendix 16
Estimates for unit costs for different staff categories and grades
Staff category Costs (£)
Salarya Salary Over- Capital Total Staff Total on-costs headsb costsc hours costs costs
worked per per per yearc hourd hour
Staff nurse B grade 11,820 1,507e 2,216 1,288 1,575 8 11Staff nurse E grade 18,222 2,323e 2,216 1,288 1,575 13 15Staff nurse F grade 21,010 2,679e 2,216 2,263 1,575 15 18Staff nurse G grade 23,948 3,053 2,216 2,263 1,575 17 20Staff nurse H grade 26,540 3,384e 2,216 2,263 1,575 19 22Physiotherapist helper 10,865 1,130 2,216 2,775 1,584 8 11Physiotherapist basic 17,202.50 2,193f 2,216 4,302 1,512 13 17Physiotherapist senior I 23,452 2,990 2,216 4,302 1,512 17 22Physiotherapist senior II 20,670 2,635f 2,216 4,302 1,512 15 20Physiotherapist superintendent III 25,832.50 3,294f 2,216 4,302 1,512 19 24Physiotherapist superintendent IV 23,452.50 2,990f 2,216 4,302 1,512 17 22Sport scientist 22,767.50 2,903f 2,216 4,302 1,512 17 21Exercise physiologist (MTO 3) 20,647 2,632f 2,216 4,302 1,512 15 20Occupational therapist basic 17,202.50 2,193g 2,216 4,302 1,512 13 17Occupational therapist senior I/II 21,785 2,778 2,216 4,302 1,512 16 21Occupational therapist head 26,467.50 3,375g 2,216 4,302 1,512 20 24Dietitian 21,785 2,778e 2,216 3,606 1,554 16 20Dietitian senior I/II 23,452.50 2,990e 2,216 3,606 1,554 17 21Pharmacist 32,983.50 4,205e 2,216 3,606 1,554 24 28GP NA NA NA NA NA 54 62Medical consultant 67,064 9,664 24,320 4,161 1,640 47 64Clinical psychologist 38,316 5,364 3,978 2,144 1,476 30 34Cardiac technician (MTO 4) 25,118 3,203e 2,216 4,302 1,512 19 23Social worker 19,951 2,709 3,399 2,007 1,554 15 18Secretary NA NA NA NA NA 10 13
a Salaries information from www.nhscareers.nhs.uk, March 2002.197 Salaries are based on the midpoint of the relevant scaleprevailing at 1 April 2001, except for GP, medical consultant, secretary and social worker (source: Netten et al., 2001196).All costs are given as 2000/01 values (overheads, capital overheads).
b Comprise estimates for indirect overheads (administrative services) (source: Netten et al.196). Indirect overheads for allother staff for which Netten et al.196 do not provide estimates are assumed to be the same as for staff in the same group.
c Based on Netten et al.196 Capital overheads for all other staff for which Netten et al.196 do not provide estimates areassumed to be the same as for staff in the same group.
d Comprises only salary and salary on-costs.e On-costs are estimated assuming the same on-costs/salary ratio as for staff nurse G grade. f On-costs are estimated assuming the same on-costs/salary ratio as for physiotherapist senior I. g On-costs are estimated assuming the same on-costs/salary ratio as for occupational therapist senior I/II. MTO, medical technical officer.
Costs of equipment for outpatient cardiac rehabilitation (phase 3), are shown below. (Source: cardiacrehabilitation programme, Bristol Royal Infirmary.) All prices include VAT.
Life Fitness upright cycle LC9100 £2770.65Cardiosport watches ‘Cardiosport Go’ (×15) £375.41Reebok step (×2) £78.00Physio Med Rehab Bouncer £57.57Yellow Theraband exercise roll (50 yards) £38.77York Probells in carry case (×2) £19.90Theraband exercise ball (Antiburst) (45 cm) (×2) £19.97Pro Fitness exercise mats (×15) £89.85Physio Med rehab support rails £46.94Theraband exercise ball (Antiburst) (55 cm) (×2) £27.02Duflex deluxe Gym Mate £82.19
–––––––––––––––––––––––––––––––Total: £3606.27 (VAT included)
Health Technology Assessment 2004; Vol. 8: No. 41
143
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Appendix 17
List of equipment
Health Technology Assessment 2004; Vol. 8: No. 41
145
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Appendix 18
Staff input: average hours per week
TABLE 42 Average hours per week by staff category for centres in group 1 (more than five key staff)
Staff category Centre Centre Centre Centre Centre Centre Centre Centre Centre Centre 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10
Nursing gradeBEF 20.0 37.5 18.5 37.5G 38.0 37.5 37.5 26.0 37.5 37.5H 37.5 37.5 18.0 37.5
PhysiotherapistHelperBasic 2.0Senior I 9.0 4.0 10.0 49.5 3.0 18.0 7.0Senior IISuperintendent III 26.0Superintendent IV 6.0
Sport scientist
Exercise physiologist 37.5 0.5
Occupational therapistBasic 1.0 7.0Senior 7.0 6.0 8.0 2.0Head 6.0
Dietician 4.0 0.32 0.33Senior dietitian 0.33 0.16 1.0 0.2 3.0 1.0 0.125
Pharmacist 0.5 0.16 1.0 0.16 1.0 0.12 0.16 1.0 0.125 0.33
Physiciana 0.15 0.2 0.41 3.0 0b
Clinical psychologist 0.75 4.0 0.16 0b 0.5 1.0 0.33
Cardiac technician 3.0 4.0
Social worker 1.0
Secretary 25.0 2.0 10.0 5.0
Total 70.4 122.8 83.5 67.2 95.0 67.6 39.5 103.0 41.8 56.5
a Includes cardiologists, consultants, clinical assistants and GPs.b Centres indicated the contribution of these staff groups in their questionnaire, but stated that their contribution was rather
advisory and did not include any time involvement.
Appendix 18
146
TABLE 43 Average hours per week by staff category for centres in group 2 (three to five key staff)
Staff category Centre Centre Centre Centre Centre Centre Centre Centre Centre Centre 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10
Nursing gradesB 9.5E 15.0 37.5 19.5F 22.5 75.0 30.0G 75.0 10.0 2.0 37.5 37.0H 37.5 20.0
PhysiotherapistHelper 6.0 14.0BasicSenior I 10.0 4.0 11.0 6.0 2.0 21.0Senior II 2.0 12.0Superintendent IIISuperintendent IV
Sport scientist 6.0 13.0
Exercise physiologist
Occupational therapistBasicSenior 0.5Head
Dietitian 0.25 0.25 0.15 0.16 1.0Senior dietitian 3.0 0.62 1.0
Pharmacist 0.25 1.0 0.25 0.5 0.32 0.04 1.0 0.16
Physiciana 0.5 7.01
Clinical psychologist 3.0
Cardiac technician 4.0
Social worker 16.0
Secretary 12.0 0.35 30.0 8.0
Total 33.0 90.0 123.0 23.5 5.3 39.7 72.0 75.3 64.0 100.5
a Includes cardiologists, consultants, clinical assistants and GPs.
Health Technology Assessment 2004; Vol. 8: No. 41
147
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TABLE 44 Average hours per week by staff category for centres in group 3 (two or fewer key staff)
Staff category Centre Centre Centre Centre Centre Centre Centre Centre Centre Centre3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10
Nursing gradeBEF 30.0G 4.0 52.5 21.0 2.0 12.0 1.0H 4.0
PhysiotherapistHelperBasicSenior I 14.0 6.0 2.0 1.0 4.0Senior II 4.0 2.0 6.0Superintendent IIISuperintendent IV
Sport scientist 4.0
Exercise physiologist
Occupational therapistBasicSenior 1.0 2.0Head
DietitianSenior dietitian
Pharmacist
Physiciana
Clinical psychologist
Cardiac technician 5.0
Social worker
Secretary 3.0
Total 18.0 53.5 32.0 6.0 6.0 21.0 4.0 1.0 1.0 38.0
a Includes cardiologists, consultants, clinical assistants and GPs.
Health Technology Assessment 2004; Vol. 8: No. 41
149
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Appendix 19
Referral, uptake and completion rates for30 randomly selected UK cardiac rehabilitation
programmes in 2000
Group 1a Group 2b Group 3c
(n = 10) (n = 10) (n = 10)
Hours per patient 29.0 (8.9) 24.0 (8.6) 20.0 (12.3)27.0 21.5 17.5
(21–48) (15–38) (6–48)
Patients referred to CR 282.4 (169.5) 352.5 (244.5) 170.7 (142.5)289.5 255.5 150
(84–578) (130–855) (3–400)
Patients joined CR 157.3 (97.6) 194.3 (104.7) 97.9 (73.3)148.0 171.5 103.5
(46–381) (73–429) (2–216)
% of referrals 55.7 55.1 57.351.1 67.1 69.0
Patients completed CR 126.3 (90.4) 158.1 (100.8) 88.8 (67.2)104.5 150.5 92.5
39–319 44–392 2–195
% of referrals 44.7 44.8 5236.0 58.9 61.6
Data are shown as mean (SD) and median (in italics) (range).a Centres with more than five key staff.b Centres with three to five key staff.c Centres with two or fewer key staff.
Health Technology Assessment 2004; Vol. 8: No. 41
151
© Queen’s Printer and Controller of HMSO 2004. All rights reserved.
Appendix 20
Average cost estimates for cardiac rehabilitation (detailed table)
Appendix 20
152
Cos
ts (
£)G
roup
1a
Gro
up 2
bG
roup
3c
(n=
10)
(n=
10)
(n=
10)
Staf
f cos
ts o
nly
Tota
l cos
tsSt
aff c
osts
onl
yTo
tal c
osts
Staf
f cos
ts o
nly
Tota
l cos
ts
Per
year
/cen
tre
53,0
87 (1
8,25
1)72
,676
(25,
485)
42,1
25 (2
4,05
9)57
,353
(32,
146)
12,3
83 (1
2,68
8)17
,638
(16,
752)
51,3
2369
,834
43,3
3758
,362
8,40
012
,797
(26,
658–
85,8
69)
(37,
183–
118,
299)
(3,6
07–7
8,52
6)(5
,932
–105
,763
)(7
14–3
8,15
7)(1
,888
–50,
886)
Per
patie
nt r
efer
red
243
(143
)33
0 (1
77)
137
(92)
186
(120
)12
7 (9
4)24
9 (2
43)
175
245
113
156
105
156
(88–
441)
(123
–587
)(2
8–35
7)(4
5–47
0)(1
0–25
4)(1
6–66
0)
Per
patie
nt jo
ined
421
(187
)57
1 (2
46)
236
(167
)32
0 (2
17)
174
(132
)32
4 (2
99)
466
639
212
293
118
192
(159
–777
)(2
21–9
48)
(36–
651)
(59–
856)
(26–
382)
(44–
944)
Per
patie
nt c
ompl
eted
542
(225
)73
8 (2
98)
317
(228
)42
9 (2
95)
186
(133
)34
4 (2
95)
553
750
259
354
139
230
(224
–846
)(3
14–1
118)
(48–
716)
(79–
947)
(26–
382)
(44–
944)
Per
patie
nt c
ompl
eted
/hou
r20
(9)
27 (1
2)14
(11)
20 (1
4)14
(15)
30 (4
1)20
2711
157
10(5
–33)
(7–4
5)(1
–38)
(2–4
9)(1
–40)
(1–1
10)
Dat
a ar
e sh
own
as m
ean
(SD
) and
med
ian
(in it
alic
s) (r
ange
).a
Cen
tres
with
mor
e th
an fi
ve k
ey s
taff.
bC
entr
es w
ith t
hree
to
five
key
staf
f.c
Cen
tres
with
tw
o or
few
er k
ey s
taff.
Health Technology Assessment 2004; Vol. 8: No. 41
163
Health Technology AssessmentProgramme
Prioritisation Strategy GroupMembers
Chair,Professor Tom Walley, Director, NHS HTA Programme,Department of Pharmacology &Therapeutics,University of Liverpool
Professor Bruce Campbell,Consultant Vascular & GeneralSurgeon, Royal Devon & ExeterHospital
Professor Shah Ebrahim,Professor in Epidemiology of Ageing, University of Bristol
Dr John Reynolds, ClinicalDirector, Acute GeneralMedicine SDU, RadcliffeHospital, Oxford
Dr Ron Zimmern, Director,Public Health Genetics Unit,Strangeways ResearchLaboratories, Cambridge
HTA Commissioning BoardMembers
Programme Director, Professor Tom Walley, Director, NHS HTA Programme,Department of Pharmacology &Therapeutics,University of Liverpool
Chair,Professor Shah Ebrahim,Professor in Epidemiology ofAgeing, Department of SocialMedicine, University of Bristol
Deputy Chair, Professor Jenny Hewison,Professor of Health CarePsychology, Academic Unit ofPsychiatry and BehaviouralSciences, University of LeedsSchool of Medicine
Dr Jeffrey AronsonReader in ClinicalPharmacology, Department ofClinical Pharmacology,Radcliffe Infirmary, Oxford
Professor Ann Bowling,Professor of Health ServicesResearch, Primary Care andPopulation Studies,University College London
Professor Andrew Bradbury,Professor of Vascular Surgery,Department of Vascular Surgery,Birmingham HeartlandsHospital
Professor John Brazier, Directorof Health Economics, Sheffield Health EconomicsGroup, School of Health &Related Research, University of Sheffield
Dr Andrew Briggs, PublicHealth Career Scientist, HealthEconomics Research Centre,University of Oxford
Professor Nicky Cullum,Director of Centre for EvidenceBased Nursing, Department ofHealth Sciences, University ofYork
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Professor Fiona J Gilbert,Professor of Radiology,Department of Radiology,University of Aberdeen
Professor Adrian Grant,Director, Health ServicesResearch Unit, University ofAberdeen
Professor F D Richard Hobbs,Professor of Primary Care &General Practice, Department ofPrimary Care & GeneralPractice, University ofBirmingham
Professor Peter Jones, Head ofDepartment, UniversityDepartment of Psychiatry,University of Cambridge
Professor Sallie Lamb, ResearchProfessor in Physiotherapy/Co-Director, InterdisciplinaryResearch Centre in Health,Coventry University
Professor Julian Little,Professor of Epidemiology,Department of Medicine andTherapeutics, University ofAberdeen
Professor Stuart Logan,Director of Health & SocialCare Research, The PeninsulaMedical School, Universities ofExeter & Plymouth
Professor Tim Peters, Professorof Primary Care Health ServicesResearch, Division of PrimaryHealth Care, University ofBristol
Professor Ian Roberts, Professorof Epidemiology & PublicHealth, Intervention ResearchUnit, London School ofHygiene and Tropical Medicine
Professor Peter Sandercock,Professor of Medical Neurology,Department of ClinicalNeurosciences, University ofEdinburgh
Professor Mark Sculpher,Professor of Health Economics,Centre for Health Economics,Institute for Research in theSocial Services, University of York
Professor Martin Severs,Professor in Elderly HealthCare, Portsmouth Institute ofMedicine
Dr Jonathan Shapiro, SeniorFellow, Health ServicesManagement Centre,Birmingham
Ms Kate Thomas,Deputy Director,Medical Care Research Unit,University of Sheffield
Professor Simon G Thompson,Director, MRC BiostatisticsUnit, Institute of Public Health,Cambridge
Ms Sue Ziebland,Senior Research Fellow,Cancer Research UK,University of Oxford
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Diagnostic Technologies & Screening PanelMembers
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Ms Norma Armston,Freelance Consumer Advocate,Bolton
Professor Max BachmannProfessor Health Care Interfaces, Department of Health Policy and Practice,University of East Anglia
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Professor Adrian K Dixon,Professor of Radiology,Addenbrooke’s Hospital,Cambridge
Dr David Elliman, Consultant in Community Child Health, London
Professor Glyn Elwyn,Primary Medical Care Research Group,Swansea Clinical School,University of WalesSwansea
Dr John Fielding,Consultant Radiologist,Radiology Department,Royal Shrewsbury Hospital
Dr Karen N Foster, ClinicalLecturer, Dept of GeneralPractice & Primary Care,University of Aberdeen
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Dr William Rosenberg, SeniorLecturer and Consultant inMedicine, University ofSouthampton
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Professor Lindsay WilsonTurnbull, Scientific Director,Centre for MR Investigations &YCR Professor of Radiology,University of Hull
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Chair,Dr John Reynolds, ClinicalDirector, Acute GeneralMedicine SDU, OxfordRadcliffe Hospital
Professor Tony Avery, Professor of Primary HealthCare, University of Nottingham
Professor Stirling Bryan,Professor of Health Economics,Health Services Management Centre,University of Birmingham
Mr Peter Cardy, ChiefExecutive, Macmillan CancerRelief, London
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Chair, Professor Bruce Campbell,Consultant Vascular andGeneral Surgeon, Royal Devon& Exeter Hospital
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Dr Aileen Clarke,Reader in Health ServicesResearch, Public Health &Policy Research Unit,Barts & the London School ofMedicine & Dentistry,Institute of Community HealthSciences, Queen Mary,University of London
Mr Matthew William Cooke,Senior Clinical Lecturer andHonorary Consultant,Emergency Department,University of Warwick, Coventry& Warwickshire NHS Trust,Division of Health in theCommunity, Centre for PrimaryHealth Care Studies, Coventry
Dr Carl E Counsell, SeniorLecturer in Neurology,University of Aberdeen
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Mr Jonothan Earnshaw,Consultant Vascular Surgeon,Gloucestershire Royal Hospital,Gloucester
Professor Martin Eccles, Professor of ClinicalEffectiveness, Centre for HealthServices Research, University ofNewcastle upon Tyne
Professor Pam Enderby,Professor of CommunityRehabilitation, Institute ofGeneral Practice and PrimaryCare, University of Sheffield
Mr Leonard R Fenwick, Chief Executive, Newcastleupon Tyne Hospitals NHS Trust
Professor David Field, Professor of Neonatal Medicine,Child Health, The LeicesterRoyal Infirmary NHS Trust
Mrs Gillian Fletcher, Antenatal Teacher & Tutor andPresident, National ChildbirthTrust, Henfield
Professor Jayne Franklyn,Professor of Medicine,Department of Medicine,University of Birmingham,Queen Elizabeth Hospital,Edgbaston, Birmingham
Ms Grace Gibbs, Deputy Chief Executive,Director for Nursing, Midwifery& Clinical Support Servs, West Middlesex UniversityHospital, Isleworth
Dr Neville Goodman, Consultant Anaesthetist,Southmead Hospital, Bristol
Professor Alastair Gray,Professor of Health Economics,Department of Public Health,University of Oxford
Professor Robert E Hawkins, CRC Professor and Director ofMedical Oncology, Christie CRCResearch Centre, ChristieHospital NHS Trust, Manchester
Professor F D Richard Hobbs, Professor of Primary Care &General Practice, Department ofPrimary Care & GeneralPractice, University ofBirmingham
Professor Allen Hutchinson, Director of Public Health &Deputy Dean of ScHARR,Department of Public Health,University of Sheffield
Dr Duncan Keeley,General Practitioner (Dr Burch& Ptnrs), The Health Centre,Thame
Dr Donna Lamping,Research Degrees ProgrammeDirector & Reader in Psychology,Health Services Research Unit,London School of Hygiene andTropical Medicine, London
Mr George Levvy,Chief Executive, MotorNeurone Disease Association,Northampton
Professor James Lindesay,Professor of Psychiatry for theElderly, University of Leicester,Leicester General Hospital
Professor Rajan Madhok, Medical Director & Director ofPublic Health, Directorate ofClinical Strategy & PublicHealth, North & East Yorkshire& Northern Lincolnshire HealthAuthority, York
Professor David Mant, Professor of General Practice,Department of Primary Care,University of Oxford
Professor Alexander Markham, Director, Molecular MedicineUnit, St James’s UniversityHospital, Leeds
Dr Chris McCall, General Practitioner, The Hadleigh Practice, Castle Mullen
Professor Alistair McGuire, Professor of Health Economics,London School of Economics
Dr Peter Moore, Freelance Science Writer,Ashtead
Dr Andrew Mortimore, Consultant in Public HealthMedicine, Southampton CityPrimary Care Trust
Dr Sue Moss, Associate Director, CancerScreening Evaluation Unit,Institute of Cancer Research,Sutton
Professor Jon Nicholl, Director of Medical CareResearch Unit, School of Healthand Related Research,University of Sheffield
Mrs Julietta Patnick, National Co-ordinator, NHSCancer Screening Programmes,Sheffield
Professor Robert Peveler,Professor of Liaison Psychiatry,University Mental HealthGroup, Royal South HantsHospital, Southampton
Professor Chris Price, Visiting Chair – Oxford, Clinical Research, BayerDiagnostics Europe, Cirencester
Ms Marianne Rigge, Director, College of Health,London
Dr Eamonn Sheridan,Consultant in Clinical Genetics,Genetics Department,St James’s University Hospital,Leeds
Dr Ken Stein,Senior Clinical Lecturer inPublic Health, Director,Peninsula TechnologyAssessment Group, University of Exeter
Professor Sarah Stewart-Brown, Director HSRU/HonoraryConsultant in PH Medicine,Department of Public Health,University of Oxford
Professor Ala Szczepura, Professor of Health ServiceResearch, Centre for HealthServices Studies, University ofWarwick
Dr Ross Taylor, Senior Lecturer, Department of General Practiceand Primary Care, University of Aberdeen
Mrs Joan Webster, Consumer member, HTA –Expert Advisory Network
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