Cardiac rehabilitation services

3.1 Hospital episode statistics data

The 'Hospital episode statistics' (HES) database contains details of all admissions to NHS hospitals in England. It includes private patients treated in NHS hospitals, patients who were resident outside England and care delivered by treatment centres (including those in the independent sector) funded by the NHS.

The analysis of the data from HES suggests that in 2009/10 0.22% or 220 per 100,000 population were discharged alive following an acute admission for an MI and could therefore be given advice about and offered a cardiac rehabilitation programme with an exercise component.

HES analysis in 2009/10 for other patient groups that may be suitable for referral for cardiac rehabilitation following admission to hospital suggests that:

People who had multiple admissions in the year and people who had more than one of the procedures and/or diagnoses were counted just once.

3.2 Current practice

Patients with unstable angina and chronic heart failure may be suitable for cardiac rehabilitation; however, patients with these conditions are underrepresented in the uptake of cardiac rehabilitation.

IMS disease analyzer, a sample of GP practice databases, shows that the annual incidence of newly diagnosed cases of unstable angina – that is, the detection rate of new cases – is 0.03% per year for patients aged 18 years or over in England. This is likely to be an underestimate of the need among this group, as many people with unstable angina will not have been previously offered cardiac rehabilitation.

The 2010 National Audit of Cardiac Rehabilitation revealed that only 1% of the patients referred to cardiac rehabilitation were referred because of chronic heart failure^[8]. A quarter of cardiac rehabilitation programmes still routinely exclude people with chronic heart failure and nearly a fifth exclude people with an implanted cardiac defibrillator or angina.

Other groups that may benefit from an expanded cardiac rehabilitation service include people who have received heart transplants. The rate of heart transplants in the population is small – around 100 transplants per year in the UK^[9]. There is also a small number, less than 100 per year, of hospital procedures for the implant or removal of ventricular assist devices (VAD)^[10].

Patients who have undergone cardiac resynchronisation therapy (CRT) or valve surgery for reasons other than myocardial infarction or chronic heart failure may also be considered for cardiac rehabilitation.

3.3 Expert clinical opinion

The consensus opinion of the topic advisory group was:

The estimates on the take-up and referral of cardiac rehabilitation provided by the topic advisory group are based on best practice and are the proportions that could be achieved given optimal service design.

3.4 Published research

Poor referral, take-up and attendance have been identified as problems facing cardiac rehabilitation services in the UK^[11],^[12]. There are several reasons for the lower than expected levels of participation. These include a lack of engagement (people not invited to attend cardiac rehabilitation), low levels of referral, scarcity of service provision, and poor take-up due to practical reasons (for example, location and time of the session).

The health technology assessment Provision, uptake and cost of cardiac rehabilitation programmes: improving services to under-represented groups suggested that take-up of cardiac rehabilitation could be improved by addressing the barriers to take-up (also see Specifying a cardiac rehabilitation service).

It is assumed that optimal service design would lead to an increase in take-up and attendance in cardiac rehabilitation, and that those services with current high levels of take-up and attendance may be operating closer to optimal service design. Optimal uptake and referral are examined further in table 3.

3.5 Published guidance

Cardiac rehabilitation is recommended in:

This is explored further in section 4.

NICE clinical guideline 126 on the management of stable angina contains no recommendations on cardiac rehabilitation. The guideline suggests that this is an area that requires further research.

Table 1 below sets out priority conditions for a cardiac rehabilitation service and table 2 sets out the conditions not considered within the benchmark.

Table 1 Priority conditions for cardiac rehabilitation

Table 2 Conditions not considered within benchmark

Once trusts have an effective system for identifying, treating and following up people who have survived an MI, who have undergone coronary revascularisation or who have a diagnosis of chronic heart failure, commissioners may wish to consider extending cardiac rehabilitation services to include conditions suggested within the Department of Health's commissioning pack on cardiac rehabilitation, as detailed below.

The Department of Health's commissioning pack on cardiac rehabilitation (2010) advocates prioritising cardiac rehabilitation for people with a primary diagnosis of:

The Department of Health's commissioning pack states that people who have undergone surgery for ICD or cardiac resynchronisation therapy (CRT) or heart valve replacement and have a primary diagnosis of ACS or heart failure should also be included as high priority.

The Department of Health's commissioning pack states that as cardiac rehabilitation services develop and are successful with the high priority patients, services should be extended to include:

See also the National Service Framework for coronary heart disease (chapter 7).

3.6 Conclusion

Based on the epidemiological data and other information outlined above, it is concluded that 0.3% of the population would be suitable for referral to a cardiac rehabilitation service. This is based on the following assumptions (see also table 3):

Table 3 Assumptions used in the population benchmark for cardiac rehabilitation based on 2009/10 hospital activity data and expert clinical opinion

Therefore the population benchmark for a cardiac rehabilitation service is estimated to be 0.3%.

Commissioners should use their local needs assessment to determine optimum levels for local service provision. Commissioners should note that the benchmark rates do not represent NICE's view of desirable, or maximum or minimum, service levels.

Commissioners should use this benchmark and local data to facilitate local discussion on optimum service levels. There is considerable variation in the prevalence and identification of people requiring a cardiac rehabilitation service. This is influenced by the social, economic and demographic profile of the local population; therefore commissioners are encouraged to consider local assumptions.

Use the cardiac rehabilitation commissioning and benchmarking tool to determine the level of service that might be needed locally and to calculate the cost of commissioning the service using the indicative benchmark and/or your own local data.