Cardiac rehabilitation services
This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg40
1 Commissioning cardiac rehabilitation services
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Cardiac rehabilitation is a structured set of services that enables people with coronary heart disease (CHD) to have the best possible help (physical, psychological and social) to preserve or resume their optimal functioning in society.
The World Health Organization has defined cardiac rehabilitation as:
'the sum of activities required to influence favourably the underlying cause of the disease, as well as the best possible, physical, mental and social conditions, so that they (people) may, by their own efforts preserve or resume when lost, as normal a place as possible in the community. Rehabilitation cannot be regarded as an isolated form or stage of therapy but must be integrated within secondary prevention services of which it forms only one facet'.
Cardiac rehabilitation is recommended in NICE clinical guideline 48 on myocardial infarction (MI): secondary prevention as an appropriate intervention for people following a hospital admission for MI. This supports the National service framework for coronary heart disease which sets the standard that:
'NHS Trusts should put in place agreed protocols/systems of care so that, prior to leaving hospital, people admitted to hospital suffering from coronary heart disease have been invited to participate in a multidisciplinary programme of secondary prevention and cardiac rehabilitation. The aim of the programme will be to reduce their risk of subsequent cardiac problems and to promote their return to a full and normal life'.
The National service framework for coronary heart disease established a goal that every hospital should ensure that more than 85% of people discharged from hospital with a primary diagnosis of acute MI or after coronary revascularisation are offered cardiac rehabilitation. It is also recommended in NICE clinical guideline 94 on unstable angina and non-ST-segment-elevation MI (NSTEMI). NICE clinical guideline 108 on chronic heart failure published in 2010 makes a new recommendation supporting cardiac rehabilitation for people with chronic heart failure.
There is evidence that exercise-based cardiac rehabilitation:
is effective in reducing total and cardiovascular mortality and hospital admissions in people with coronary heart disease
reduces all-cause and cardiovascular mortality rates in patients after MI when compared with usual care provided when it includes an exercise component
significantly reduces hospitalisation for chronic heart failure and significantly improves quality of life and exercise tolerance for people with heart failure.
Traditionally the provision of cardiac rehabilitation has been described using phases 1 to 4 as mentioned in the National Service Framework for coronary heart disease (chapter 7). A more recent approach within the Department of Health's commissioning pack on cardiac rehabilitation describes cardiac rehabilitation along a best practice care pathway using stages 0 to 6 to reflect core stages in the cardiac rehabilitation pathway (see section 2 of this guide).
Cardiac rehabilitation should be offered as a comprehensive package, including exercise, education and psychological support. It should not be regarded as an isolated form or stage of therapy, but be integrated within secondary prevention services. Cardiac rehabilitation services are no longer exclusively hospital based; emphasis is placed on helping patients become active self-managers of their condition. This can involve hospital-, home- and community-based cardiac rehabilitation programmes. Evidence suggests that home- and centre-based cardiac rehabilitation appear to be equally effective in improving the clinical and health-related quality of life outcomes in acute MI and revascularisation patients. Collaboration between primary and secondary care services is vital in order to achieve the best cardiac rehabilitation outcomes.
Currently, many people who might benefit do not receive adequate cardiac rehabilitation. The National Audit of Cardiac Rehabilitation 2010 indicates that referral to cardiac rehabilitation was almost entirely restricted to people in one of three diagnostic groups: those who had sustained a heart attack (MI, 39%), elective angioplasty (percutaneous coronary intervention [PCI], 28%) or coronary artery bypass surgery (CABG, 76%). Only 1% of patients recorded in the audit had a diagnosis of heart failure. The extent, nature and cost of provision varies dramatically around the country, with some services developing in a haphazard way with no core funding and relying on charitable donations and time 'borrowed' from various hospital departments.
There are also marked inequalities in the way people access the available services. Women, minority ethnic groups, the elderly and people with more severe CHD are all under-represented among users of rehabilitation services. Furthermore, in many parts of the country those that are ready to start a rehabilitation programme may have to wait for several weeks.
Commissioners should refer to NICE clinical guideline 48 on MI: secondary prevention, NICE clinical guideline 94 on unstable angina and NSTEMI and NICE clinical guideline 108 on chronic heart failure and the NICE quality standard for chronic heart failure when commissioning services which contribute to delivering the following NHS outcomes (2011/12):
preventing people from dying prematurely
enhancing the quality of life for people with long-term conditions
helping people to recover from episodes of ill health or following injury
ensuring that people have a positive experience of care
Key clinical and quality issues in providing effective cardiac rehabilitation are:
actively identifying all people potentially eligible for cardiac rehabilitation and encouraging them to take part in cardiac rehabilitation
improving referral, uptake and completion of cardiac rehabilitation programmes
comprehensive assessment of an individual, including their need for cardiac rehabilitation
developing individualised plans to a person's needs in line with NICE guidance and the British Association for Cardiac Rehabilitation document Standards and core components for cardiac rehabilitation
offering hospital-, community- or home-based programmes in line with NICE guidance and evidence-based national programmes
providing core components of the programme in line with the British Association for Cardiac Rehabilitation document Standards and core components for cardiac rehabilitation, including exercise, education, risk factor management and social and psychological support
providing the best possible outcomes for individual people/patients, their carers and local communities
providing a quality assured service (see section 6 within this guide).
 World Health Organisation (1993) Needs and action priorities in cardiac rehabilitation and secondary prevention in patients with CHD. Geneva: World Health Organization. Available from http://whqlibdoc.who.int/euro/-1993/EUR_ICP_CVD_125.pdf
 Heran BS, Chen JM, Ebrahim S et al. (2011) Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews Issue 7: CD001800
 National Collaborating Centre for Primary Care (2007) Post myocardial infarction: secondary prevention in primary and secondary care for patients following a myocardial infarction (full guideline). London: Royal College of General Practitioners
 National Clinical Guideline Centre for Acute and Chronic Conditions (2010) Chronic heart failure: national clinical guideline for diagnosis and management in primary and secondary care. London: Royal College of Physicians
 Taylor RS, Dalal H, Jolly K et al. (2010) Home-based versus centre-based cardiac rehabilitation. Cochrane Database of Systematic Reviews Issue 1: CD007130
 Department of Health (2000) National service framework for coronary heart disease: modern standards and service models (chapter 7: cardiac rehabilitation). London: Department of Health
 British Heart Foundation (2010) The national audit of cardiac rehabilitation. York: British Heart Foundation