Provision, uptake and cost of cardiac rehabilitation programmes: improving services to under-represented groups.
OBJECTIVES: To estimate UK need for outpatient cardiac rehabilitation, current provision and identification of patient groups not receiving services. To conduct a systematic review of literature on methods to improve uptake and adherence to cardiac rehabilitation. To estimate cost implications of increasing uptake of cardiac rehabilitation. DATA SOURCES: Hospital Episode Statistics (England). Hospital Inpatient Systems (Northern Ireland). Patients Episode Database for Wales. British Association for Cardiac Rehabilitation/British Heart Foundation surveys. Cardiac rehabilitation centres. Patients from general hospitals. Electronic databases. REVIEW METHODS: The study analysed hospital discharge statistics to ascertain the population need for outpatient cardiac rehabilitation in the UK. Surveys of cardiac rehabilitation programmes were conducted to determine UK provision, uptake and audit activity, and to identify local interventions to improve uptake. Data were also examined from a trial estimating eligibility for cardiac rehabilitation and non-attendance. A systematic review of interventions to improve patient uptake, adherence and professional compliance in cardiac rehabilitation was conducted. Estimated costs of improving uptake were identified from national survey, systematic review and sampled cardiac rehabilitation programmes. RESULTS: In England, Wales and Northern Ireland nearly 146,000 patients discharged from hospital with primary diagnosis of acute myocardial infarction, unstable angina or following revascularisation were potentially eligible for cardiac rehabilitation. In England in 2000, 45-67% of these patients were referred, with 27-41% attending outpatient cardiac rehabilitation. If all discharge diagnoses of ischaemic heart disease were considered, nearly 299,000 patients would be potentially eligible and in England rates of attendance and referral would be 22-33% and 13-20% respectively. Rates of referral and attendance were similar in Wales, but somewhat lower in Northern Ireland. It was found that referral and attendance of older people and women at cardiac rehabilitation tended to be low. It was also suggested that patients from ethnic minorities and those with angina or heart failure were less likely to be referred to or join programmes. A wide range of local interventions suggested awareness of the problem of uptake. In an NHS-funded randomised controlled trial, possibly representing more optimal protocol-led care, medical and nursing staff identified 73-81% of patients with acute myocardial infarction as eligible for cardiac rehabilitation. Excluded patients tended to be older with more severe presentation of cardiac disease. Experiences of patients suggested that uptake may be improved by addressing issues of motivation and relevance of rehabilitation to future well-being, co-morbidities, site and time of programme, transport and care for dependents. Systematic review of studies supported the use of letters, pamphlets or home visits to motivate patients and the use of trained lay visitors. Self-management techniques showed some value in promoting adherence to lifestyle changes. Studies examining professional compliance found that professional support for practice nurses may have value in the coordination of postdischarge care. Average costs in 2001 of cardiac rehabilitation to the health service per patient completing a cardiac rehabilitation programme were about GBP350 (staff only) and GBP490 (total). If services were modelled on an intermediate multidisciplinary configuration with three to five key staff, approximately 13% more patients could be treated with the same budget. Depending on staffing configuration an approximate 200-790% budget increase would be required to provide cardiac rehabilitation to all potentially eligible patients. CONCLUSIONS: Provision of outpatient cardiac rehabilitation in the UK is low and little is known about the capacity of cardiac rehabilitation centres to increase this provision. There is an uncoordinated approach to audit data collection and few interventions aimed at improving the situation have been formally evaluated. Motivational communications and trained lay volunteers may improve uptake of cardiac rehabilitation, as may self-management techniques. Experience of low-cost interventions and good practice exists within rehabilitation centres, although cost information frequently is not reported. Increased provision of outpatient cardiac rehabilitation will require extra resources. Further trials are required to compare the cost-effectiveness of comprehensive multidisciplinary rehabilitation with simpler outpatient programmes, also research is needed into economic and patient preference studies of the effects of different methods of using increased funding for cardiac rehabilitation. An evaluation of a range of interventions to promote attendance in all patients and under-represented groups would also be useful. The development of standards is suggested for audit methods and for eligibility criteria, as well as regular and comprehensive data collection to estimate the need for and provision of cardiac rehabilitation. Further areas for intervention could be identified through qualitative studies, and the extension of low-cost interventions and good practice within rehabilitation centres. Regularly updated systematic reviews of relevant literature would also be useful.