Cardiac rehabilitation: we should all be doing it

Correspondence to Cardiac Cardiac rehabilitation: we should all be doing it

Dear Sirs

Varghese and Flint’s editorial highlights the patchy and poor provision of cardiac rehabilitation services in the UK and the need for improvement.¹ The authors state that home-based rehabilitation appears to be of much less benefit. This is based on two surveys. Firstly, a national audit which demonstrated that only 21% of English Cardiac Networks provided home-based cardiac rehabilitation and, secondly, a survey conducted by Pollard and Sutherland, which reported that 66/91 (73%) people who did not attend a rehabilitation programme said that they would ‘probably or definitely not have attended cardiac rehabilitation sessions if they were held in their own home’.²

We believe that the evidence from two recent UK-based randomised controlled trials lend ample support to the benefits of home-based cardiac rehabilitation for patients at low/moderate cardiac risk. Both CHARMS³ and BRUM⁴ have demonstrated that outcomes are similar for participants who follow a home-based rehabilitation programme compared to those who attend groups in centre-based classes. Moreover, health economic evaluations conducted as part of these trials showed that there was little difference in the cost of the home- and centre-based interventions^4,5 and there was evidence of superior adherence to home-based rehabilitation.

The latest commissioning guidance from the National Institute for Health and Clinical Excellence (NICE)⁶ on cardiac rehabilitation released in 2008 advocates that patients are offered alternative methods such as home-based rehabilitation.

Conflict of interest

None declared.

Yours faithfully

Hasnain Dalal
General Practitioner

Lower Lemon Street, Truro Cornwall TR1 2LZ

Jenny Wingham
Research Nurse

R&D Directorate, Royal Cornwall Hospital, Truro

Kate Jolly
Senior Lecturer in Public Health

University of Birmingham

Rod Taylor
Associate Professor

Peninsula Medical School, Exeter

References

1. Varghese A, Flint, J. Cardiac rehabilitation: we should all be doing it. Br J Cardiol 2009; 16:211–12.
2. Pollard M, Sutherland C. Cardiac rehabilitation: are we putting our hearts into it?” Br J Cardiol 2009; 16:247–9.
3. Dalal HM, Evans PH, Campbell JL et al. Home-based versus hospital-based rehabilitation after myocardial infarction: A randomized trial with preference arms – Cornwall Heart Attack Rehabilitation Management Study (CHARMS). Int J Cardiol 2007; 119:202–11.
4. Jolly K, Lip GY, Taylor RS et al. The Birmingham Rehabilitation Uptake Maximisation study (BRUM): a randomised controlled trial comparing home-based with centre-based cardiac rehabilitation. Heart 2009; 95:36–42.
5. Taylor RS, Watt A, Dalal HM et al. Home-based cardiac rehabilitation versus hospital-based rehabilitation: a cost effectiveness analysis. Int J Cardiol 2007;119:196–201.
6. NICE. http://www.nice.org.uk/usingguidance/commissioningguides/cardiacrehabilitationservice
   /CardiacRehabilitationService.jsp.

The authors’ reply

Thank you for your response highlighting the encouraging trial evidence in support of a home-based option for cardiac rehabilitation. In our original editorial, we included data from the 2007 Network Survey of Cardiac Rehabilitation Development. Repeat audit findings from 2008 are now available, and were presented to the Cardiac Rehabilitation National Priority Project, National Clinical Leads, and British Association for Cardiac Rehabilitation in October 2009. These showed that 29% of Networks had increased uptake of home options during the previous year, although only two Networks made it a majority activity for almost all their patients. Although only 21% of Networks appeared to be offering any significant home-based option in 2007, around two-thirds of Networks did suggest they had at least some activity in this area. These figures are not only compatible with those in the National Audit of Cardiac Rehabilitation (NACR) but do give some indication of positive change.

Professor Bob Lewin, Chair of the NACR Steering Group, has supported the need to be offering genuine choice of group programme or home-based options to all patients, and we would fully endorse this key aspect of rehabilitation services. The revisiting of cardiac rehabilitation pathways with the trend towards earlier percutaneous coronary intervention (PCI) and roll-out of primary PCI improved from 10% to 32% between 2007 and 2008 surveys. It is hoped this will improve further in our imminent 2009 survey, as we hope will the strength of commissioning links which were viewed as static during the first audit cycle. The National Priority Project has addressed many of these issues, and Networks are learning how to impact upon cardiac rehabilitation services and consider quite radical review in some instances.

Jane Flint
National Clinical Advisor for Cardiac Rehabilitation to NHS Improvement

Muhammad Shahid
Clinical Fellow in Cardiology

The Dudley Group of Hospitals NHS Foundation Trust

Anitha Varghese
SpR Cardiology West Midlands’ Training Programme

University of Birmingham NHS Foundation Trust