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Cardiac Rehabilitation The Evidence Base

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Diastolic blood pressure (mmHg) [6 trials] Mean Reduction (95% CI) ... also other patient groups [revascularisation, angina and heart failure patients] ... – PowerPoint PPT presentation

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Title: Cardiac Rehabilitation The Evidence Base


1
Cardiac Rehabilitation The Evidence Base
Implications for Practice
  • Rod Taylor MSc, PhD
  • Dept of Public Health Epidemiology
  • University of Birmingham
  • Bisperbjerg Hospital, Copenhagen
  • 11th 12th December 2003

2
Presentation
  • Update on the Cochrane systematic reviews of
    exercise-based CR?
  • What are implications for current CR practice
    future?

3
Acknowledgements
  • Judy Jolliffee - St Loyes School of Health
    Studies, Exeter, UK
  • Karen Rees - Department of Social Medicine,
    University of Bristol, UK
  • Canadian Coordinating Centre for Health
    Technology Assessment (CCOHTA)

4
Exercise Based CR - Meta Analyses
Taylor et al, Am J Med 2004 in press
5
Making policy decisions
6
Whose getting rehab?
7
Whats the overall impact of CR on events?
Relative Risk
Total mortality N41 trials
Cardiac Mortality N31 trials
Non fatal MI N33 trials
Need for CABG N23 trials
Need for PTCA N12 trials
0.50
0.75
1.0
1.25
FAVOURS REHABILITATION
8
Impact of CR Risk Factors
9
Do we improve patients quality of life?
  • Nine trials (20) assessed HRQoL using either
    validated measures or measures that covered 3
    domains physical, psychological and social well
    being
  • Range of both generic (SF-36, NHP, Karolinska,
    QWB, TTO) and disease specific HRQoL measures
    were used (QLMI).
  • Although all RCTs studies improvement in HRQoL
    with CR, few studies reported improvements in
    excess of usual care

10
Other Cardiac Rxs how do we compare?
11
Comparative effects of cardiac treatments
  • Trials demonstrate similar magnitude of total
    mortality benefit across drug, surgical and
    rehabilitative treatments for post MI patients
  • Caveats in making such comparisons
  • I. Potential differences between trials other
    than therapies
  • Baseline risk (2) Inclusion of other Ixs esp
    HF
  • (3) Inclusion of other Dxs (e.g. ß-blockers
    ACE)
  • II. Other outcomes side effects/HRQoL

12
Are effects of CR additive?
  • Rationale Recent CR trials (1990 beyond)
    patients will have had access to more active
    medical management (e.g. thrombolysis, statins,
    ACE)
  • Expect Effect size of CR trials before 1995 gt
    Effect size of CR trials 1995 after

13
Subgroups?
14
Are we effective in the long-term?
  • Three CR RCTs assessed CR outcomes for ? 10-years
  • Bethall et al (1999) 11 yr fu
  • Hamalanien et al (1989 1995) 10 15 yr fu on
    Kallio trial
  • Dorn et al (1999) 19 yr fu on NEDHP trial
  • None report a significant reduction in mortality
  • Implication
  • Importance of maintenance of lifestyle changes

15
NEDHP survival curve
16
Heart Failure - Mortality
17
Heart Failure VO2max
18
The drug itself has no side effects - but the
number of health economists needed to prove its
value may cause dizziness and nausea
2
19
How much does CR cost?
  • Gray et al (1997)
  • Random selection of 16 UK CR centres
  • Detailed collection of health service salary
    (1994) costs
  • Centre cost per programme/year - 33K (95 CI
    28K to 38K)
  • Patient cost per/year - 223 (95CI 262 to
    332)
  • Predictors of cost
  • ? - No. of patients/centre, no. of patient hrs
  • X - No. of assessments, equipment available, drop
    out rate range of indications

20
Is CR Cost Effective?
21
Comparative Cost Effectiveness
22
Can we (effectively) deliver in alternative
settings?
Bell (17)
Miller (8,9,11)
Sparks (29)
Carlson (33))
Combined
-.790825
1.20199
difference in exercise capacity METS
23
Conclusions
  • Updated review of Cochrane systematic review of
    RCTs confirms medium term mortality and risk
    factor benefits of exercise-based CR
  • Increasing evidence of these benefits not only in
    post MI patients but also other patient groups
    revascularisation, angina and heart failure
    patients

24
Conclusions cont
  • Remains relatively little RCT evidence of CR in
    women and older individuals
  • Positive impact of CR on quality of life remains
    unclear
  • Limited evidence for the equivalence of
    home/community-based CR compared to traditional
    hospital-based programmes

25
Future Research
  • Need good quality evidence for.
  • Clinical cost effectiveness of alternative
    models of CR/secondary prevention provision (e.g.
    primary care based nurse specialists)
  • Impact of CR on patient HRQoL
  • Effectiveness of strategies to enhance the uptake
    of CR in poorly represented population women,
    older individuals, ethnic groups
  • Effectiveness of strategies to enhance the
    short-term long-term compliance to CR/secondary
    prevention
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