1. Cardiac Rehabilitation – The Evidence Base & Implications for Practice Rod Taylor MSc, PhD Dept of Public Health & Epidemiology University of Birmingham Bisperbjerg Hospital, Copenhagen 11 th & 12 th 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 Loye’s 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 Oldridge 1988 O’Connor 1989 Cochrane I 2000 Cochrane II 2003* DiagnosisMI CHD RCTs (n)10223448 CCR/Ex only--20/1430/19 Patients (n)4,3474,5547,9968,940 OutcomesMortality Risk factors HRQL Mortality Risk factors HRQL Sub-group analysis *Taylor et al, Am J Med 2004 [in press]

5. Making policy decisions…

6. Whose getting rehab?

7. What’s the overall impact of CR on events? Relative Risk 0.500.751.01.25 Need for PTCA N=12 trials Need for CABG N=23 trials Non fatal MI N=33 trials Cardiac Mortality N=31 trials Total mortality N=41 trials FAVOURS REHABILITATION

8. Impact of CR – Risk Factors Mean Reduction (95% CI) Blood Pressure Systolic blood pressure (mmHg) [9 trials] Diastolic blood pressure (mmHg) [6 trials] -0.5 (-6.5 to 5.5) -0.6 (4.5 to 2.8) Blood Lipids Total cholesterol (mmol/l) [19 trials] HDL cholesterol (mmol/l) [14 trials] LDL cholesterol (mmol/l) [14 trials] Triglycerides (mmol/l) [13 trials] -0.34 (-0.56 to -0.11) 0.03 (-0.06 to 0.11) -0.32 (-0.55 to -0.10) -0.28 (-0.49 to -0.06) Relative Risk (95% CI) Smoking [13 trials] 0.77 (0.62 to 0.94)

9. Do we improve patient’s 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 Rx’s – how do we compare? Relative reduction in all cause mortality Reduction in all cause mortality per 1000 per year ß-blockers Freemantle, 1999 31 trials [24,974] 23% (15% to 31%) 12 (6 to 17) ACE inhibitors NofE Gudelines, 2001 22 trials [102,476] 17% (2% to 11%)4 (1 to 6) Statins La Rosa, 1999 3 trials [17,617] 23% (15% to 30%) 4 (2 to 6) Antiplatelets Antiplatelet trialists, 1994 11 trials [18,773] 24% (16% to 32%) 7 (1 to 3) Cardiac rehab Cochrane, 2003 44 trials [~9,000] 16% (4% to 27%)9 (15 to 116)

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 (1)Baseline risk (2) Inclusion of other Ix’s [esp HF] (3) Inclusion of other Dx’s (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 > 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 – VO 2 max

18. 2 “The drug itself has no side effects - but the number of health economists needed to prove its value may cause dizziness and nausea”

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 (95%CI: £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? AuthorSettingCurrency year Cost Effectiveness Lowensteyn (2000) Canada1996<$15,000 per LYG Ades (1997)US1995$4,950 per year of life Oldridge (1993) Canada1991$9,200 per QALY $21,800 per LYG

21. Comparative Cost Effectiveness

22. Can we (effectively) deliver in alternative settings? difference in exercise capacity METS -.7908251.20199 Combined Carlson (33) ) Sparks (29) Miller (8,9,11) Bell (17)

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