Cardiac Rehabilitation Capacity Tools

National Public Health Service for Wales Need and Capacity For Cardiac Rehabilitation

Need and Capacity for Cardiac Rehabilitation

Authors: Nigel Monaghan, Deputy Director of Health and Social Care Quality

Date: 15/10/08 Version: 1a

Status: Final

Intended Audience: Cardiac Networks, LHB’s, Trusts

Purpose and Summary of Document:

This paper summarises advice from the NPHS on translation of information on need into capacity in line with NICE Commissioning Guidance on Cardiac Rehabilitation

Publication/Distribution:

Cardiac Networks

Publication in NPHS HSCQ Document Database

Link from NPHS e-Bulletin

Link from Stakeholder e-Newsletter

Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 1 of 34 Intended Audience: Cardiac

Networks/ NHS Wales (Intranet)


1 Background

On 29th February a letter was sent from the Welsh Assembly to LHB Chief Executives informing them of the need for local “cost and clinically effective cardiac rehabilitation services” as part of “an integral part of the package of care for people at risk of or who have cardiac disease”. The letter went on to request “each LHB in each of the 3 regions, working together through the Cardiac Network, must assess current cardiac rehabilitation provision against the requirements of the NSF Standards and submit a Network level action plan for the delivery of the NSF Standards to the relevant Regional Office by 31 December 2008.”

In addition to supporting the action plans the letter covered spending plans associated with existing projects funded by the Inequalities in Health Fund or the Big Lottery Fund, and the need for joint working with Stop Smoking Wales and the National Exercise Referral Scheme. £2 million of the 2008-09 LHB discretionary allocation was ring-fenced for these services matching existing Inequalities in Health and Big Lottery funding which had come to an end .

The letter indicated that a data collection exercise will be undertaken to ascertain the baseline investment in services, and any shortfall in the ring-fenced sum will be corrected during 2008-09.

A WAG project is seeking to develop exercise referral schemes to accept people participating in phase 4 cardiac rehabilitation. Thus the local cardiac rehabilitation plans need to incorporate phases 1 to 4 allowing for this anticipated change.

In support of the Cardiac Networks in co-ordinating these tasks the NPHS have been asked to provide advice related to need and demand for these services.

2 Evidence Base for Cardiac Rehabilitation

2.1 Policy Context

Cardiac rehabilitation is being promoted because it has the potential to prevent premature deaths. Cardiac rehabilitation whilst proven to be effective and cost-effective is not currently provided across the whole of Wales to a consistent minimum standard.

The Cardiac Network Co-ordinating Group submission to the Welsh Assembly Government proposing updates to the Wales National Service Framework for Coronary Health Disease and Arrhythmias recognises the need to be more flexible in delivery of cardiac rehabilitation to reflect the needs of individual patients.1 The classification now used by NICE for cardiac rehabilitation is phase 1 – inpatient, phase 2 – early post-discharge rehabilitation, phase 3 – definitive rehabilitation service, phase 4 – long term maintenance.2

Experience in Wales and elsewhere shows that even where it is offered cardiac rehabilitation is not always utilised for a range of reasons:




Poor referral, take-up and attendance have been identified as problems facing cardiac rehabilitation services in the UK. 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).2

Across the UK cardiac rehabilitation is currently delivered in a combination of home, community and hospital settings. As a general rule in Wales and in line with Designed for Life3 the expectation is that services will be provided as locally as possible consistent with provision of safe and effective services. There is no reason to assume that provision in a non-hospital setting should affect the outcomes of cardiac rehabilitation for suitable patients although there is some evidence to suggest that patients prefer to attend local non-hospital based sessions and that provision of such sessions increases uptake significantly.4 A reported reason for drop-off in attendance for hospital based cardiac rehabilitation is that patients dislike the hospital setting and find access difficult. Applying this to cardiac rehabilitation over the longer term with increasing experience and confidence we would expect to see a shift of rehabilitation from the hospital except for those patients where it is assessed that risks associated with the rehabilitation are large enough to necessitate this being provided in a hospital. Thus a shift may be indicated where there is limited hospital based rehabilitation, but some hospital based rehabilitation will still be required for high risk individuals. Whatever setting the rehabilitation is undertaken in it is important to review participation rates, completion rates, and user satisfaction among those who complete and do not complete rehabilitation alongside other outcome data.

Due to the difficulties associated with conducting randomised controlled trials of different models of care across most of healthcare there is only limited good quality scientific evidence to support decisions on a particular model of care over another. This is also true for cardiac rehabilitation. Conversely cardiac rehabilitation provided in hospital, community and home settings have all proven effective, for example home rehabilitation has been shown to provide similar benefits to hospital based rehabilitation and some patients prefer it.2 The key issues are to ensure all patients meeting guidance on need are offered cardiac rehabilitation, and to ensure uptake that they are offered a range of options which have the potential to meet their needs and circumstances. Given experiences across the UK these should arguably include hospital, community and home based options.

2.2 NICE Commissioning Guidance on Cardiac Rehabilitation

On March 20th 2008 NICE published a commissioning guide on cardiac rehabilitation (CR). The commissioning guide should be read in conjunction with the clinical guideline published in May 2007 MI: secondary prevention. Secondary prevention in primary and secondary care for patients following a myocardial infarction.

The prime aim of a cardiac rehabilitation programme is encouraging and supporting individuals at risk of further events associated with cardiac disease to achieve and maintain optimal physical and psychosocial health. This is tailored to the needs of each patient based on a comprehensive assessment of their cardiac risks. The set of services encompass a multidisciplinary team of health professionals employed by different bodies but acting in partnership. The NICE Commissioning Guide gives details of how to develop and




commission a high quality comprehensive cardiac rehabilitation group and emphasises the need to provide services tailored to the needs of the patient.

There are 4 sections to the commissioning guide:

Commissioning a cardiac rehabilitation service

Specifying a cardiac rehabilitation service

Ensuring Corporate and Quality Assurance

Determining local service levels for a cardiac rehabilitation service

2.2.1 POTENTIAL BENEFITS OF CARDIAC REHABILITATION

The commissioning guide lists a number of potential impacts on mortality and morbidity. These include greater survival for people with coronary heart disease who participate in comprehensive cardiac rehabilitation. There is evidence that cardiac rehabilitation reduces the risk of total and cardiac related mortality and reduces the occurrence of non-fatal MI .

Evidence also suggests that cardiac rehabilitation results in improving people’s ability to work, their physical capacity and perceived quality of life In addition it indicates improved exercise tolerance and quality of life for people with mild to moderate heart failure.

Participation in comprehensive cardiac rehabilitation can enable people to become active self managers of their condition, and this can assist in reducing unplanned hospital admissions. It also reduces the need for subsequent revascularisation for those undergoing vascular procedures.

Comprehensive rehabilitation also offers an opportunity to reduce inequalities associated with heart disease. Overall providing rehabilitation offers better value for money than not providing it.

CNS are able to organise prompt and timely admission to hospital when patients symptoms deteriorate in order to prevent adverse effects.

COMMISSIONING A CARDIAC REHABILITATION SERVICE

The NICE Commissioning Guidance on Cardiac Rehabilitation indicates that cardiac rehabilitation should not be regarded as an isolated form or stage of therapy but be integrated within secondary prevention services. Having said that, cardiac rehabilitation services are no longer exclusively hospital based. Emphasis is placed on helping patients become active self-managers of their condition and this can involve hospital, home and community based cardiac rehabilitation programmes, all of which are effective.

NICE estimate that the cost of cardiac rehabilitation varies enormously throughout the UK, from £17 to £2186 per patient, despite it being highly cost effective at their estimate of the mean cost of £550 per patient.

Based on their analysis of the evidence base NICE have indicated that those with the greatest potential to benefit from cardiac rehabilitation should be the priority until such time as there is Author: Nigel Monaghan Dep Dir HSCQ Date: 15/10/08 Status: FinalVersion: 1a Page: 4 of 34 Intended Audience: Cardiac



capacity to rehabilitate all those who could benefit. NICE suggest that once trusts have an effective system for identifying, treating and following up people who have survived an MI or who have undergone coronary revascularisation (coronary artery bypass graft and percutaneous coronary intervention) they should consider extending their rehabilitation services to people admitted to hospital with stable angina, heart failure, those having cardiac transplant and those receiving implantable cardiac defibrillators. NICE Commissioning Guidance on Cardiac Rehabilitation suggests that key clinical issues in providing an effective comprehensive cardiac rehabilitation service are:

actively identifying all people potentially eligible for cardiac rehabilitation and encouraging them to take part in cardiac rehabilitation prior to hospital discharge

assessing an individual’s risk and need for cardiac rehabilitation and developing individualised plans to meet those needs in line with NICE clinical guideline CG48 on MI: secondary prevention and the British Association for Cardiac Rehabilitation document ‘Standards and core components for cardiac rehabilitation’. The Quality requirements within standard 6 of the NSF detail these clinical components further.

providing a quality assured service.

NICE guidance does not make specific recommendations regarding patients with chronic CHD, or who had a past event.

2.2.2 SPECIFYING A CARDIAC REHABILITATION SERVICE

The 29th February 2008 letter from WAG indicated concerns that access to service in Wales is “patchy”. The NICE Guidance on Cardiac Rehabilitation indicates that where cardiac rehabilitation services have been adequately resourced and where they have systematically identified people and adopted a structured approach to their work, the numbers of people treated have increased.

Thus for Wales it is proposed that the key service components of a cardiac rehabilitation service are:

systematically identifying and actively engaging people potentially eligible for cardiac rehabilitation

developing a high-quality multidisciplinary comprehensive cardiac rehabilitation service in line with British Association for Cardiac Rehabilitation guidance.5

Structures and Processes

Local health boards, local authorities, NHS Trusts, and the voluntary sector should agree the range and availability of services that can be drawn on for cardiac rehabilitation. For example, local authority leisure centres, church halls or other easily accessible public venues may be appropriate for cardiac rehabilitation sessions, and appropriately trained local authority staff can play a useful role in supervising physical activity and supporting exercise referral schemes. Note that in the context of suitably trained staff there are specified skills and competencies for people supervising patients undertaking phase 3 and phase 4 cardiac




rehabilitation. Hospital staff and facilities will be required for those patients assessed as high risk.

There is no single model of delivery of cardiac rehabilitation which can be recommended from the evidence base and there is a need for many options to suit the circumstances of the patient. Following a comprehensive assessment patients should have access to services within the hospital, community and home. this would be dependant on their risk assessment, personal choice and access. From the viewpoint of patients hospital, community and home are all possible settings). From the viewpoint of participation and maximising the health gained from cardiac rehabilitation all of these options should ideally be offered across Wales. From the viewpoint of the taxpayer, the service should be effective and cost-effective. The vehicle options for delivering all of these include:

A highly detailed service specification covering all details of the service supported by details in individual patient records

A less detailed service specification indicating client groups, settings, hours of operation and outcomes supported by detailed protocols and individual patient records (which may or may not include care pathways).

The Cardiac Networks are better placed than the NPHS to decide how they wish to provide advice on service specifications and protocols.

Given that there are various models of delivery in operation in Wales, that these reflect to some degree local circumstances and that there is no good evidence to support one method of delivery over another the option of a less detailed service specification which operates in line with locally appropriate and more detailed local protocols would seem to be the more flexible approach.

Whichever combination of service specification/protocol/care pathway option is chosen it needs to cover:

the target groups currently served

the expected number of patients based on discharge data for the target groups (this should take into account how quickly any changes in service provision are likely to take place)

ease of access, service settings and hours of operation (commissioners should engage with service users and other relevant individuals and organisations locally and consider need for home, community and hospital based elements)

outcomes expected in terms of targets for clients offered cardiac rehabilitation, waiting times and number of clients waiting for access to cardiac rehabilitation, targets for clients choosing to participate in cardiac rehabilitation, targets for clients completing rehabilitation by phase, clinical outcomes expected and service user satisfaction with services; these will for the basis of service monitoring criteria

information, quality assurance and audit requirements, including IT support and infrastructure for all settings and phases




the required competencies of and training for, staff responsible for providing the service for all settings and phases

detailed information on service locations, hours of operation and contact details for all settings and phases

detail on the scope of the programme - balance of dietary, exercise, education, psychological and social etc and difference for different groups of patients – for all settings and phases

detail on how programme options are offered to patients and how programmes are tailored to each patient’s need

detail on number and length of sessions for each element of the programme

care and referral pathways for the individual can be described from the detail outlined above

protocols, equipment and training for the management of predictable medical emergencies appropriate to the hospital, community or home setting

planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times

Appendix 1 proposes a minimum content for service specifications in Wales. It is structured so that local data can be entered and local estimates of proportion of cases suitable for each setting for rehabilitation by phase can be entered.

Appendix 2 proposes minimum content for protocols which it is suggested should be setting and phase specific. If a decision is taken to have a single highly detailed service specification rather than a less detailed service specification indicating client groups, settings, hours of operation and outcomes supported by detailed protocols and individual patient records then it is suggested that the content in appendix 2 should also be included in the local protocol.

Appendix 3 is attached as a tool to assist local planning for provision of cardiac rehabilitation in hospital, domiciliary and community settings. It is structured to allow local data on expected hospital discharges to be combined with estimates to calculate capacity needed by phase of cardiac rehabilitation and by setting for each clinical indication. Factors affecting these estimates include risk assessment for rehabilitation in different settings, preferring rehabilitation in particular settings and proportions of those commencing completing each phase. NPHS has produced similar excel spreadsheets for each health community in Wales.

2.2.3 ENSURING CORPORATE AND QUALITY ASSURANCE

The NICE Commissioning Guidance on Cardiac Rehabilitation suggests that commissioners need to ensure they consider both the clinical and economic viability of the service, and any related services, and take into account patient’s and carer’s views and those of other stakeholders when planning these services. It also suggests that a clear specification is the starting point for monitoring and assuring quality in the service contract.




The NICE Commissioning Guide for Cardiac Rehabilitation lists the features of a cardiac rehabilitation service needs to ensure corporate and quality assurance and for local quality assurance they suggest the following:

Equipment: testing and calibration of exercise and monitoring equipment.

Health, safety and security: infection control, waste management, confidentiality procedures, legislative requirements.

Staff competencies: individual and team baseline requirements, monitoring and performance. See Implementation advice for NICE clinical guideline CG48 on MI: secondary prevention for recommendations on assessing training needs.

Accreditation requirements: for some or all elements of the service, the premises and/or staff.

Clinical quality criteria: appropriateness of referral, consenting procedures, clinical protocols.

Information requirements, including both patient-specific information (NHS number, referring GP, provision of high-quality information to patients/carers) and service-specific information (referral-to-treatment times, workload trends, number of complaints). Clinical governance arrangements, including incident reporting.

Audit arrangements: frequency of reporting, reporting route and format, and dissemination mechanisms; this should include auditing the proportion of eligible patients requiring cardiac rehabilitation who are provided with care, and monitoring of patient outcomes and complications. (See audit criteria for NICE clinical guideline CG48 on MI: secondary prevention, which includes recommendations to link with the national audit of cardiac rehabilitation which is also recommended within the Welsh Cardiac NSF).

Service and performance targets, including estimated activity levels and case mix, waiting and referral-to-treatment times (ensuring that patients and carers do not experience unnecessary delays), complaints procedures.

Patient outcomes: reduced risk of further cardiac problems, improved quality of life, reduction in hospital admissions, improved return to work rates, reduced blood pressure and cholesterol levels, improved patient knowledge and psychosocial well-being and reporting these outcomes to the ‘National audit of cardiac rehabilitation’ (see Appendix 3 for rationale).

Patient satisfaction: patient and carer perspective and perception of service provision, complaints.

Achieving targets associated with equalities legislation

The process for reviewing the service with stakeholders, including decisions on changes necessary to improve or to decommission the service.




3 Potential Need and Demand - Determining Local Service Levels for a Cardiac Rehabilitation Service

NICE used data to estimate that the standard benchmark rate for a cardiac rehabilitation service for all the conditions/procedures listed in the is 0.20%, or 200 per 100,000, population per year. The estimates used in these calculations of the benchmark for cardiac rehabilitation are provided by the topic-specific advisory group; they are based on best practice and are the proportions that could be achieved given optimal service design. Some clinicians have expressed concern that these numbers do not reflect the position in Wales.

The NICE assumptions used in estimating a population benchmark rate for new referrals into a cardiac rehabilitation service were based on the following sources of information:-

‘Hospital episode statistics’ and general practice data to establish the proportion of the population discharged alive per year following an acute admission for a myocardial infarction (MI) or heart failure; and after admission for revascularisation, heart transplant or implantable cardiac defibrillators; and the proportion of the population identified in the community with angina per year

published research on cardiac rehabilitation

expert clinical opinion of the topic-specific advisory group, based on experience in clinical practice and literature review

Table 1 Assumptions used in the population benchmark for cardiac rehabilitation based on 2006/7 hospital activity data and expert clinical opinion

Diagnosis/procedure

Percentage of population discharged alive in 2006/07

Percentage of discharged population suitable for cardiac rehabilitation referral

Percentage (optimal) of population suitable for referral who take up cardiac rehabilitation

Combination of referral and optimal take-up (percent) – that is, attendance

Percentage (optimal) of discharged population who take up cardiac rehabilitation based on 2006/7 data

Myocardial infarction

0.12 85 80 68 0.082

Percutaneous coronary intervention

0.02 100 85 85 0.017

Coronary artery bypass graft

0.04 100 85 85 0.034

Heart failure 0.07 75 70 53 0.037

Implant of a cardiac 0.004 100 85 85 0.0034




defibrillator

Table 2 NICE commissioning guidance estimates of percentage of whole population taking up cardiac rehabilitation

Year 2007 Percentage of whole population requiring rehabilitation for

Myocardial Infarction

Percutaneous Coronary

Intervention

Coronary Artery

Bypass Graft

Heart Failure

Implant of Defibrillator

0.082 0.017 0.034 0.037 0.0034AreaWales 2979975 2444 507 1013 1103 101Isle of Anglesey 69003 57 12 23 26 2Gwynedd 118374 97 20 40 44 4Conwy 111709 92 19 38 41 4Denbighshire 97009 80 16 33 36 3Flintshire 150537 123 26 51 56 5Wrexham 131911 108 22 45 49 4Powys 131963 108 22 45 49 4Ceredigion 77777 64 13 26 29 3Pembrokeshire 117921 97 20 40 44 4Carmarthenshire 179539 147 31 61 66 6Swansea 228086 187 39 78 84 8Neath Port Talbot 137376 113 23 47 51 5Bridgend 133917 110 23 46 50 5The Vale of Glamorgan 124017 102 21 42 46 4Cardiff 321000 263 55 109 119 11Rhondda, Cynon, Taf 233734 192 40 79 86 8Merthyr Tydfil 55619 46 9 19 21 2Caerphilly 171824 141 29 58 64 6Blaenau Gwent 69170 57 12 24 26 2Torfaen 91086 75 15 31 34 3Monmouthshire 88200 72 15 30 33 3Newport 140203 115 24 48 52 5

Calculated using NICE Commissioning Guidance for Cardiac Rehabilitation and the Mid-Year Population Estimates (2001 onwards), by local authority from Statistical Directorate, Welsh Assembly Government

Some concern has been expressed that these estimates based on NICE guidance may not be applicable for Wales. To address these concerns hospital discharge data for Wales has also been analysed and presented.

For a complete picture on hospital discharges alive for the procedures and diagnoses which NICE Commissioning Guidance recommends Cardiac Rehabilitation Appendix 4 provides data on the number of individuals discharged alive in each of the years from 2002 to 2006 at LHB, old Trust and new Trust levels. All Wales trends in diagnoses are not consistently reflected in 2006 data at LHB and Trust level. However at all Wales level there is a tendency to decrease in myocardial infarction in more recent years whereas there is an increased trend for provision of a range of cardiac procedures.




Given these trends the most recent data is presented in Tables 3 and 4. Table 3 provides LHB data on the number of individuals discharged alive in 2006 for each of the procedures listed in table 1. Note that in tables 3 and 4 the data on revascularisation includes that for coronary artery bypass grafts, for percutaneous coronary angioplasty and for stent placement combined.

Table 3 Discharges Alive for Selected Cardiac Diagnoses and Interventions by LHBMyocardial Infarction Revascularisation Heart Failure Transplant Defibrillator

Isle of Anglesey 96 140 239 0* 6

Gwynedd 179 198 444 0* 8

Conwy 257 255 494 0* 0

Denbighshire 183 166 403 0* 8

Flintshire 226 317 540 0* 17

Wrexham 205 221 457 0* 18

Powys 179 227 613 0* 0

Ceredigion 88 117^ 245 0* 0

Pembrokeshire 232 158^ 457 0* 0

Carmarthenshire 269 275 758 0* 0

Swansea 229 384^ 907 0* 0

Neath Port Talbot 249 284^ 678 0* 0

Bridgend 252 257^ 637 0* 0

Vale of Glamorgan 116 200 339 0* 0

Cardiff 227 484 807 0* 0

Rhondda Cynon Taff 353 257 754 0* 6

Merthyr Tydfil 103 88 202 0* 0

Caerphilly 287 270 543 0* 0

Blaenau Gwent 124 70 363 0* 0

Torfaen 154 120 326 0* 0

Monmouthshire 157 103 320 0* 0

Newport 249 190 395 0* 0* data still being analysed, number and Wales very low and typically 0 for most LHBs^plus an additional 0-4 stent placements

Table 4 provides similar data for the new Welsh Trusts. More detailed breakdown by old Welsh Trust is presented in Appendix 4.

Table 4 Discharges Alive for Selected Cardiac Diagnoses and Interventions by TrustMyocardial Infarction

Revascularisation

Stable Angina

Heart Failure Transplant Defibrillator

ABM 287 1543 ? 640 0 68Cardiff and Vale 0 0 ? 0 ?* 0

Cwm Taf 0 0 ? 0 0 0Gwent Healthcare 0 0 ? 0 0 0

Hywel Dda 0 0 ? 0 0 0

North Wales 0 0 ? 0 0 0

North West Wales 0 0 ? 0 0 0

Powys Teaching LHB 0 0 ? 0 0 0All English Providers 0 0 ? 0 ?* 0




Velindre 0 0 0 0 0 0

It should be noted that stable angina is not included in any of these tables or in the estimate rates in the NICE commissioning guidance. Although data on all angina codes is collected and within the codes used there is a specific diagnosis of unstable angina, it cannot be concluded that all patients with angina codes other than those for unstable angina have stable angina. It is likely that there may be a mix of stable and unstable angina cases among these codes. The diagnostic codes for angina are:

INC 10 Code 120 Angina pectoris I20.0 Unstable angina

Angina: o crescendo o de novo effort o worsening effort

Intermediate coronary syndrome Preinfarction syndrome

I20.1 Angina pectoris with documented spasm

Angina: o angiospastic o Prinzmetal o spasm-induced o variant

I20.8 Other forms of angina pectoris

Angina of effort Stenocardia

I20.9 Angina pectoris, unspecified

Angina: o NOS o cardiac

Anginal syndrome Ischaemic chest pain .

The identification of all patients admitted to hospital (not just those admitted with cardiac indication) with stable angina is a challenge and could be a useful audit topic.

Similarly NICE do not provide an estimate of the number of individuals receiving heart and lung or heart only transplants who are in another group for which rehabilitation is recommended when capacity allows. In Wales there are less than 5 transplants in a typical year. Thus the LHBs will normally have 0 cases per annum and the additional burden on an individual Trust service from cardiac transplants will also be small.




4 Capacity of Existing Services

The NPHS does not have access to data describing the current cardiac rehabilitation services in place in Wales. The Cardiac networks are in the process of auditing existing provision. This audit should facilitate a gap analysis identifying development needs for individual services.

The description of the number of cases per Trust and Per LHB summarised in Section 3 and use of the tool attached as Appendix Z should assist local discussion regarding the demands upon local rehabilitation services, the capacity which can be provided by local services and any opportunity to expand beyond the initial priority groups of those who have had MI or who have undergone coronary revascularisation recommended by NICE.

NPHS are exploring the possibility of making this tool available to LHBs and Trusts in a partially completed spreadsheet format.

5 References

1. Cardiac Network Co-ordinating Group (2007). Tackling Coronary Heart Disease and Arrhythmias in Wales – Update of the original Coronary Health Disease National Service Framework for Wales http://howis.wales.nhs.uk/sites3/Documents/338/Updated%20CHD%20NSF%20Final%20Submission%20to%20WAG%20March%202007%20%283%29.pdf (accessed 29/08/2008)

2. NICE (2007) Specifying a cardiac rehabilitation service. http://www.nice.org.uk/usingguidance/commissioningguides/cardiacrehabilitationservice/SpecifyingCardiacRehabilitationService.jsp?textonly=false (accessed 29/08/2008)

3. National Assembly for Wales (2005). Designed for Life - creating world-class health and social care for Wales in the 21st century http://www.wales.nhs.uk/documents/designed-for-life-e.pdf (accessed 29/08/2008)

4. Harris N (2007). Cardiac Rehabilitation in Westminster http://www.selcardiacnetwork.nhs.uk/files/NigelHarris.pdf (accessed 29/08/2008)

5. British Association for Cardiac Rehabilitation (2007). Standards and Core Components for Cardiac Rehabilitation http://www.bcs.com/documents/affiliates/bacr/BACR%20Standards%202007.pdf (accessed 29/08/2008)



http://www.bcs.com/documents/affiliates/bacr/BACR%20Standards%202007.pdf

http://www.nice.org.uk/usingguidance/commissioningguides/cardiacrehabilitationservice/SpecifyingCardiacRehabilitationService.jsp?textonly=false

http://www.nice.org.uk/usingguidance/commissioningguides/cardiacrehabilitationservice/SpecifyingCardiacRehabilitationService.jsp?textonly=false

http://howis.wales.nhs.uk/sites3/Documents/338/Updated%20CHD%20NSF%20Final%20Submission%20to%20WAG%20March%202007%20(3).pdf

http://howis.wales.nhs.uk/sites3/Documents/338/Updated%20CHD%20NSF%20Final%20Submission%20to%20WAG%20March%202007%20(3).pdf


Appendix 1

Suggested Minimum Content for Service Specification

Service Specification for Cardiac Rehabilitation

1 Background

The prime aim of a cardiac rehabilitation programme is to provide a set of services tailored to the needs of each patient based on a comprehensive assessment of their cardiac risks.

Cardiac rehabilitation associated with admission to hospital has four main phases: phase 1 – inpatient, phase 2 – early post-discharge discharge, phase 3 – definitive rehabilitation service, phase 4 – long term maintenance. This specification relates to cardiac rehabilitation across all 4 phases and encompasses a comprehensive programme as outlined in national guidelines (BACR) of assessment, risk stratification, goal setting, health education, structured exercise programmes, psychological assessment, support and review.

Cardiac rehabilitation provided in an effective and efficient way is a cost-effective intervention. The cost effectiveness is dependent upon putting in place effective systems for identifying, treating and following up clients.

2 Client Groups

Where capacity is an issue NICE have proposed that people who have survived an MI or who have undergone coronary revascularisation (coronary artery bypass graft and percutaneous coronary intervention) are those who gain the greatest benefit. They advice that when there is sufficient capacity locally rehabilitation services should also cover those people admitted to hospital with stable angina, heart failure, those having cardiac transplant and those receiving implantable cardiac defibrillators.

In [name of health community] each year approximately [number of] people are discharged from hospital as follows:

Need for Cardiac Rehabilitation

Diagnosis/procedureEstimated Discharges Alive Per Annum

Myocardial infarction

Percutaneous coronary intervention

Coronary artery bypass graft

Heart failure

Implant of a cardiac defibrillator




Locally cardiac rehabilitation should be offered to those who have survived an MI or who have undergone coronary revascularisation (coronary artery bypass graft and percutaneous coronary intervention) [add or delete from the following list according to local capacity: those people admitted to hospital with stable angina, heart failure, those having cardiac transplant and those receiving implantable cardiac defibrillators.]

3 Access – Settings and Hours of Operation

The evidence based for cardiac rehabilitation is strongest for those who have been recently admitted to hospital and this is the basis of the NICE guidance. This all patients admitted to hospital for conditions included in the client group section should be offered cardiac rehabilitation.

There is some evidence that offering rehabilitation in domicilary and community settings is effective and is preferred by many patients. Setting of rehabilitation is more commonly an issue for patients than hours of the service or language issues therefore all patients who are risk stratified as able to participate in rehabilitation outside a hospital setting should be offered domiciliary or community based rehabilitation in the latter phases.

Rehabilitation services should operate [according to hours agreed locally]. Data from patient surveys should be collected to inform decisions regarding future hours of operation.

4 Quality Assurance

Comprehensive routine data collection is the bedrock upon which a quality assured service is built. As different models of delivery of care may be in place in different settings it is important that for all phases and settings of cardiac rehabilitation that Protocols are developed and used to construct a range of patient care pathways. Data collected as protocols are followed will form the patient record and will usefully inform audit, and performance management.

Performance management data will examine the participation rates and completion rates for cardiac rehabilitation by setting and by phase. This data will also contribute to the NACR.

Service users views will be collected by setting and by phase. This work to be conducted as advised by the all Wales cardiac rehabilitation working group (AWCRWG).

In addition to the NACR local audit will be undertaken to target areas or service user concern and settings and phases where completion rates are poorest. The audits should be conducted as closely as possible to standards promoted by the AWCRWG and findings be reported back to the AWCRWG.




An annual report will draw on performance management findings, service users views and changes made as a result of audit.

5 Performance Indicators

The objective of cardiac rehabilitation is encouraging and supporting individuals at risk of further events associated with cardiac disease to achieve and maintain optimal physical and psychosocial health.

In the long term an ultimate objective is to enable individuals to live longer and live more complete lives than they would without cardiac rehabilitation. Thus potential outcome measures could include mortality and quality of life indicators. However these are indicators which take time to effect even a small change in at population level of statistical significance.

In the shorter term there are clinical indicators which may change as a result of participation in rehabilitation. These include reaching CHD risk targets, medication and psychological aspects. It is possible that future studies or audits may show benefits of one model of rehabilitation over other models where delivery is equally good but the actual model is better.

In the shorter term still and as part of the evaluation of the management and delivery is necessary to ensure that any comparisons of outcomes of models are grounded on similar levels of participation in cardiac rehabilitation.

Many clinical targets for cardiac rehabilitation (such as BMI changes or regular participation in exercise) are set at individual level.

There is debate as to whether an intended objective is for individuals to be ready to move to independent and regular exercise. The commissioners of services are unlikely to view participation in phase 4 Cardiac Rehabilitation as the end of the patient journey. Most if not all of them will expect patients to move from phase 4 into mainstream community or home based activity as the end point. Therefore this transition from completion of phase 4 into the community is likely to be an outcome of interest.

Certainly the satisfaction of users with a service may be a reason for participation or dropping out. This too is a key indicator of the quality of a patient centred service of interest for both those completing and those not completing expected programmes of rehabilitation.

As different models of care may be in place it is important to define the indicators on which the range of models may be compared and the data collected will need to separate differences due to the models of rehabilitation from how well they are managed and delivered. Thus the potential framework within which performance indicators could be identified by the cardiac networks include:




Mortality and Quality of Life

|

Clinical Indicators (e.g, blood pressure, BMI, psychological)

|

Participation indicators (e.g. completion rates for phases)

|

Satisfaction of those completing and not completing rehabilitation




Appendix 2

Suggested Content for Setting and Phase Specific Protocols

Protocols

It is assumed that protocols may be developed for a range of settings as follows:

Setting Phase1 Phase 2 Phase 3 Phase 4

Hospital √ √ √ √

Domiciliary √ √ √

Community √ √ √

An individuals care pathways will consist of their journey which could for example consist of:

Phase 1 in hospital

phase 2 & 3 at home

Phase 4 in the community.

Note that in a specific location some of these elements may not be necessary, for example hospital based phase 2 and phase 4 rehabilitation may not be required. In this case protocols will not be needed.




Appendix 3How To Use The Cardiac Rehabilitation Need To Capacity Tool

The following sheets are intended to be used with information on individuals discharges alive following specified cardiac procedures or on discharges alive associated with a specified chronic cardiac condition. This information should be entered into the appropriate box for phase 1.

There is variation in the length of various phases of cardiac rehabilitation iin different locations. The evidence base has not developed to the point of proving effectiveness of one model over another. Thus the best estimate of the length of the local phase 1 programme for the average patient should be entered into the appropriate box.

From the number of discharges per annum the total annual number of person-weeks of cardiac rehabilitation capacity can be calculated. When this is divided by 52 it indicates the mean weekly capacity required on the assumption that all patients progress once through each phase.

The percentage to complete phase 1 estimation should indicate the local percentage of individuals expected to complete this phase following one or more attempts. This percentage figure will assist in calculating the number to complete phase 1 which is the starting point for phase 2 calculations.

As phase 2 may be conducted in different settings there is a need to estimate the local percentage of individuals undertaking phase 2 in home and in hospital settings based on either local experience or that elsewhere. The resulting numbers can then be inserted into the phase 2 calculations similar to those used for phase 1. If rehabilitation in a phase is not provided in a setting then please enter 0% for that phase/setting cell.

At the end of phase 2 individuals will move into one of three settings. Again an estimate of the percentage moving to each is required to enable the phase 3 calculations to be completed. This process also needs to be repeated for phase 4.

Once all estimates have been inserted the number of individuals expected to complete phase 4 can be compared with the percentage discharged alive and entering the programme. The resulting target percentage figure can be used as a check that assumptions made are realistic. There is nothing to stop further copies of the tool being used with higher and lower estimates being entered to ensure that any conclusions drawn are reasonable and robust.




It is suggested that once these tables are completed and the resulting figures are agreed as sensible a final upward adjustment is made to the capacity calculation at each phase to reflect the number of individuals expected to repeat that phase on one or more occasions. These final figures estimate how the local need translates into cardiac rehabilitation capacity.




Service Capacity Calculations [Name of Health Community]

Sheet for (complete one set of sheets for each condition): Condition Myocardial

InfarctCoronary revascularisation

Stable angina

Heart failure

Cardiac transplant

Implantable cardiac defibrillators

(Tick one only)

Phase 1

Phase 1 – Hospital BasedDischarged Alive per Year

No of Weeks of Phase 1

Average Weekly Capacity = (No to complete phase x No. of weeks)/52

% to complete Phase 1

Number to complete Phase 1

Phase 1 to Phase 2 Transition

No. Completing Phase 1

% to Domiciliary Phase 2

No. to Domiciliary Phase 2

% to Hospital Phase 2

No. to Hospital Phase 2

%. to Community Phase 3

No. to Community Phase 3




Phase 2

Phase 2 – Domiciliary SettingNo. from Phase 1





Phase 2 – Hospital BasedNo. from Phase 1





Phase 2 – Community BasedNo. from Phase 1






No. Completing Domiciliary Phase 2







No. Completing Hospital Phase 2







No. Completing Community Phase 2







Total to Domiciliary Phase 3

Total to Hospital Phase 3

Total to Community Phase 3




Phase 3

















No. Completing Domiciliary Phase 3







No. Completing Hospital Phase 3







No. Completing Community Phase 3







Total to Domiciliary Phase 4

Total to Hospital Phase 4

Total to Community Phase 4




Phase 4
















Total completing Phase 4

% of discharges alive completing Phase 4




Appendix 4

Myocardial Infarction

LHB Data

Counts of individual patients with a primary diagnosis of myocardial infarction (ICD-10 I21, I22)during a spell of hospital care, by Local Authority of residence, 2002-06

Local Authority 2002 2003 2004 2005 2006 TotalIsle of Anglesey 107 125 104 92 96 524Gwynedd 160 179 155 174 179 847Conwy 211 217 214 260 257 1159Denbighshire 179 202 168 179 183 911Flintshire 229 249 218 236 226 1158Wrexham 236 199 213 200 205 1053Powys 179 199 199 190 179 946Ceredigion 93 109 96 104 88 490Pembrokeshire 253 262 240 261 232 1248Carmarthenshire 233 216 229 291 269 1238Swansea 351 347 285 244 229 1456Neath Port Talbot 257 314 276 253 249 1349Bridgend 264 256 231 257 252 1260The Vale of Glamorgan 178 186 138 152 116 770Cardiff 373 365 286 204 227 1455Rhondda Cynon Taff 386 316 339 331 353 1725Merthyr Tydfil 103 95 78 95 103 474Caerphilly 334 313 330 319 287 1583Blaenau Gwent 175 152 144 130 124 725Torfaen 173 184 186 168 154 865Monmouthshire 145 157 168 155 157 782Newport 289 254 267 237 249 1296

Wales 4908 4896 4564 4532 4414 23314




Trust Data

Counts of individual patients resident in Wales with a primary diagnosis of myocardial infarction (ICD-10 I21, I22) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06

2002 2003 2004 2005 2006 Total

Bro Morgannwg 474 502 505 527 484 2492

Swansea 532 569 366 325 335 2127

Cardiff and Vale 698 684 521 344 392 2639

Pontypridd and Rhondda 220 184 232 213 216 1065

North Glamorgan 240 216 177 247 249 1129

Gwent Healthcare 958 899 960 933 874 4624

Pembrokeshire and Derwen 210 221 217 235 211 1094

Ceredigion and Mid Wales 70 102 99 86 94 451

Carmarthenshire 230 210 238 309 264 1251

Conwy and Denbighshire 333 353 323 364 356 1729

North East Wales 346 298 323 293 315 1575

North West Wales 334 365 309 329 342 1679

Powys Teaching LHB 46 42 35 13 9 145

All English Providers 224 254 262 322 287 1349*annual totals do not match those in residence-based table above due to a small number of patients not having a valid local authority code recorded.

Counts of individual patients resident in Wales with a primary diagnosis of myocardial infarction (ICD-10 I21, I22) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06

2002 2003 2004 2005 2006 Total

ABM 1006 1071 871 852 819 4619

Cardiff and Vale 698 684 521 344 392 2639

Cwm Taf 460 400 409 460 465 2194

Gwent Healthcare 958 899 960 933 874 4624

Hywel Dda 510 533 554 630 569 2796

North Wales 679 651 646 657 671 3304

North West Wales 334 365 309 329 342 1679

Powys Teaching LHB 46 42 35 13 9 145

All English Providers 224 254 262 322 287 1349*annual totals do not match those in residence-based table above due to a small number of patients not having a valid local authority code recorded.




Atrial Fibrillation

LHB Data

Counts of individual patients with a primary diagnosis of atrial fibrillation (ICD-10 I48)during a spell of hospital care, by Local Authority of residence, 2002-06

2002 2003 2004 2005 2006Isle of Anglesey 116 124 120 137 163Gwynedd 190 191 162 182 195Conwy 227 240 227 268 239Denbighshire 147 183 180 178 203Flintshire 190 210 219 256 239Wrexham 173 185 186 177 222Powys 180 156 151 199 206Ceredigion 70 81 96 90 94Pembrokeshire 233 218 220 211 224Carmarthenshire 244 256 306 262 257Swansea 376 321 326 379 374Neath Port Talbot 215 194 175 252 242Bridgend 267 250 234 221 223The Vale of Glamorgan 183 209 186 181 189Cardiff 347 329 333 305 310Rhondda Cynon Taff 331 325 345 299 280Merthyr Tydfil 56 71 70 74 92Caerphilly 239 201 227 226 217Blaenau Gwent 101 82 88 91 74Torfaen 128 103 104 121 109Monmouthshire 102 111 135 139 114Newport 181 164 121 173 160




Trust Data

Counts of individual patients resident in Wales with a primary diagnosis of atrial fibrillation (ICD-10 I48) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06

2002 2003 2004 2005 2006Bro Morgannwg 482 446 392 457 434Swansea 478 425 424 484 493Cardiff and Vale 583 570 573 528 535Pontypridd and Rhondda 248 238 236 223 200North Glamorgan 136 160 169 164 200Gwent Healthcare 675 592 609 673 605Pembrokeshire and Derwen 214 194 192 188 195Ceredigion and Mid Wales 52 57 73 71 84Carmarthenshire 249 267 335 280 256Conwy and Denbighshire 314 353 329 385 397North East Wales 279 283 304 287 321North West Wales 349 357 338 381 404Powys Teaching LHB 44 40 23 27 28Velindre 1 2 1 0 0All English Providers 195 220 215 280 285

Counts of individual patients resident in Wales with a primary diagnosis of atrial fibrillation (ICD-10 I48) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06Current Trust 2002 2003 2004 2005 2006ABM 960 871 816 941 927Cardiff and Vale 583 570 573 528 535Cwm Taf 384 398 405 387 400Gwent Healthcare 675 592 609 673 605Hywel Dda 515 518 600 539 535North Wales 593 636 633 672 718North West Wales 349 357 338 381 404Powys Teaching LHB 44 40 23 27 28Velindre 1 2 1 0 0All English Providers 195 220 215 280 285




Heart Failure

LHB Data

Counts of individual patients with any mention of heart failure (ICD-10 I50) during a spell of hospital care, by Local Authority of residence, 2002-06Local Authority 2002 2003 2004 2005 2006Isle of Anglesey 214 216 216 258 239Gwynedd 359 356 389 407 444Conwy 483 496 470 508 494Denbighshire 395 467 410 451 403Flintshire 554 581 566 591 540Wrexham 456 457 437 425 457Powys 565 541 506 531 613Ceredigion 234 250 276 265 245Pembrokeshire 472 491 477 528 457Carmarthenshire 763 764 783 767 758Swansea 998 918 995 1022 907Neath Port Talbot 677 690 724 778 678Bridgend 750 664 655 647 637The Vale of Glamorgan 371 335 361 381 339Cardiff 727 642 801 829 807Rhondda Cynon Taff 836 784 824 884 754Merthyr Tydfil 231 248 225 202 202Caerphilly 639 630 650 600 543Blaenau Gwent 362 396 426 393 363Torfaen 333 340 329 317 326Monmouthshire 271 337 335 329 320Newport 424 424 398 398 395




Trust Data

Counts of individual patients resident in Wales with any mention of of heart failure (ICD-10 I50) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06

2002 2003 2004 2005 2006Bro Morgannwg 1259 1224 1204 1222 1155Swansea 1512 1326 1531 1579 1353Cardiff and Vale 1160 1011 1220 1268 1268Pontypridd and Rhondda 497 489 520 610 512North Glamorgan 576 588 572 511 492Gwent Healthcare 1858 1966 1943 1863 1739Pembrokeshire and Derwen 409 427 390 434 389Ceredigion and Mid Wales 187 197 219 241 216Carmarthenshire 739 789 761 736 721Conwy and Denbighshire 814 836 770 890 828North East Wales 757 755 690 662 626North West Wales 654 671 708 772 787Powys Teaching LHB 347 291 246 192 217Velindre 11 9 10 14 24All English Providers 350 452 477 538 616

Counts of individual patients resident in Wales with any mention of of heart failure (ICD-10 I50) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06Current Trust 2002 2003 2004 2005 2006ABM 2771 2550 2735 2801 2508Cardiff and Vale 1160 1011 1220 1268 1268Cwm Taf 1073 1077 1092 1121 1004Gwent Healthcare 1858 1966 1943 1863 1739Hywel Dda 1335 1413 1370 1411 1326North Wales 1571 1591 1460 1552 1454North West Wales 654 671 708 772 787Powys Teaching LHB 347 291 246 192 217Velindre 11 9 10 14 24All English Providers 350 452 477 538 616




Percutaneous Transluminal Coronary Angioplasty

LHB Data

Counts of individual patients with any mention of PTCA (OPCS codes K49, K50, K75) during a spell of hospital care, by Local Authority of residence, 2002-06Local Authority 2002 2003 2004 2005 2006Isle of Anglesey 38 52 44 67 62Gwynedd 56 63 94 89 82Conwy 52 50 72 85 107Denbighshire 33 42 66 67 61Flintshire 89 97 98 122 131Wrexham 84 107 99 91 84Powys 28 40 71 89 103Ceredigion 23 26 50 53 61Pembrokeshire 39 88 113 90 84Carmarthenshire 64 104 136 157 148Swansea 184 209 257 245 232Neath Port Talbot 69 115 153 159 168Bridgend 59 93 110 151 173The Vale of Glamorgan 48 70 76 103 122Cardiff 106 210 216 241 283Rhondda Cynon Taff 97 112 122 137 143Merthyr Tydfil 21 26 42 42 51Caerphilly 61 86 120 138 156Blaenau Gwent 21 40 32 24 37Torfaen 18 33 29 54 64Monmouthshire 24 27 25 39 53Newport 39 41 49 74 105

Trust Data

Counts of individual patients resident in Wales with any mention of PTCA (OPCS codes K49, K50, K75) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06

2002 2003 2004 2005 2006

ABM (Swansea) 475 650 842 896 910

Cardiff and Vale 397 626 682 806 968

All English Providers 377 446 545 612 629




Coronary Artery Bypass Graft

LHB Data

Counts of individual patients with any mention of CABG (OPCS codes K40 - K46) during a spell of hospital care, by Local Authority of residence, 2002-06Local Authority 2002 2003 2004 2005 2006Isle of Anglesey 51 36 31 22 21Gwynedd 86 67 43 44 51Conwy 58 51 56 39 48Denbighshire 47 48 34 29 46Flintshire 80 88 70 60 63Wrexham 81 58 58 60 55Powys 46 48 89 60 63Ceredigion 31 33 33 34 56Pembrokeshire 73 72 56 84 74Carmarthenshire 98 113 103 146 121Swansea 152 139 135 136 152Neath Port Talbot 79 116 108 125 116Bridgend 76 96 96 98 84The Vale of Glamorgan 68 67 75 52 58Cardiff 150 174 175 108 135Rhondda Cynon Taff 131 136 86 107 88Merthyr Tydfil 34 34 34 23 27Caerphilly 87 81 121 96 85Blaenau Gwent 36 18 44 26 25Torfaen 34 42 45 44 41Monmouthshire 41 41 37 49 35Newport 70 69 75 56 57

Trust Data

Counts of individual patients resident in Wales with any mention of CABG (OPCS codes K40 - K46) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06

2002 2003 2004 2005 2006

ABM (Swansea) 546 602 553 585 628

Cardiff and Vale 616 645 691 535 539

All English Providers 447 379 358 375 332




Implantable Defibrillators

LHB Data

Counts of individual patients with any mention of cardiac defibrillator implant (OPCS code K59) during a spell of hospital care, by Local Authority of residence, 2002-06Local Authority 2006Isle of Anglesey 6Gwynedd 8Conwy -Denbighshire 8Flintshire 17Wrexham 18Powys -Ceredigion -Pembrokeshire -Carmarthenshire -Swansea -Neath Port Talbot -Bridgend -The Vale of Glamorgan -Cardiff -Rhondda Cynon Taff 6Merthyr Tydfil -Caerphilly -Blaenau Gwent -Torfaen -Monmouthshire -Newport -*a count of five patients or less is denoted by '-'

Trust Data

Counts of individual patients resident in Wales with any mention of cardiac defibrillator implant (OPCS code K59 during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06

2006

Cardiff and Vale 14

All English Providers 68




Implantable Defibrillators

LHB Data

Counts of individual patients with any mention of coronary stent placement (OPCS code K75) during a spell of hospital care, by Local Authority of residence, 2002-06Local Authority 2006Isle of Anglesey 57Gwynedd 65Conwy 100Denbighshire 59Flintshire 123Wrexham 82Powys 61Ceredigion -Pembrokeshire -Carmarthenshire 6Swansea -Neath Port Talbot -Bridgend -The Vale of Glamorgan 20Cardiff 66Rhondda Cynon Taff 26Merthyr Tydfil 10Caerphilly 29Blaenau Gwent 8Torfaen 15Monmouthshire 15Newport 28*a count of five patients or less is denoted by '-'

Trust Data

Counts of individual patients resident in Wales with any mention of coronary stent placement (OPCS code K75) during a spell of hospital care, by NHS Trust (current and previous constituents), 2002-06

2006

Cardiff and Vale 199

All English Providers 582



Cardiac Rehabilitation Capacity Tools

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