Heart failure: referral for cardiac rehabilitation

Indicator

The percentage of patients with heart failure diagnosed within the preceding 15 months with a record of an offer of referral for an exercise-based rehabilitation programme.

Introduction

This report covers one new indicator relating to heart failure (cardiac rehabilitation). This indicator is part of the NICE menu of potential Quality and Outcomes Framework (QOF) indicators for 2013/14, following the recommendations of the independent QOF advisory committee in June 2012. The indicator has been piloted as part of the NICE QOF indicator development process.

This report considers the likely cost impact of incentivising the clinical interventions associated with the proposed indicator in terms of the number of additional interventions provided and the cost of each intervention. Costs to NHS commissioners are outlined where relevant, along with the cost of additional activity at general practices.

Cardiac rehabilitation has been shown to increase physical health and decrease subsequent morbidity and mortality in people with coronary heart disease – specifically in people with chronic heart failure and those who have had a myocardial infarction.

This potential new QOF indicator aims to improve the management of heart failure by incentivising referral for an exercise-based cardiac rehabilitation programme.

NICE's guideline on heart failure, recommendation 1.3.1.1, states: 

• Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure.
  • Ensure the patient is stable and does not have a condition or device that would preclude an exercise-based rehabilitation programme. The conditions and devices that may preclude an exercise-based rehabilitation programme include: uncontrolled ventricular response to atrial fibrillation, uncontrolled hypertension, and high-energy pacing devices set to be activated at rates likely to be achieved during exercise.
  • Include a psychological and educational component in the programme. The programme may be incorporated within an existing cardiac rehabilitation programme.

Cost implication

Number of people affected

The eligible population is people with newly diagnosed heart failure.
The NICE commissioning guide on heart failure gives a benchmark of 0.07% per year of the population diagnosed with heart failure. This equates around 36,000 people. This indicator refers to people with heart failure diagnosed in the preceding 15 months, not to the total heart failure register.

Current care

People for whom rehabilitation is suitable may be referred to cardiac rehabilitation programmes by secondary care after acute and unplanned admissions. Primary care plays a significant role in the management of coronary heart disease, including heart failure. GPs are involved in secondary prevention, which includes giving advice on lifestyle and optimising long-term secondary prevention drug therapy. GPs may refer people to cardiac rehabilitation programmes if appropriate.

Information from the QOF indicator pilot shows that baseline achievement was very low, with access to heart failure exercise-based rehabilitation programmes being extremely limited among pilot practices.

Therefore we have assumed currently there is limited cost incurred from offering a referral to an exercise-based rehabilitation programme.

Proposed care

Given the evidence from the pilot we have assumed a 60% offer of referral for an exercise-based rehabilitation programme, with sensitivity analysis of 40% and 80%.

Resource impact

We have assumed that the cost of an exercise-based rehabilitation programmes is £495 per person. This is consistent with NICE clinical guideline 108. We have also assumed that the offer of the exercise-based rehabilitation is done opportunistically as part of GP consultation rather than through an additional consultation.

The estimated cost of indicator IND102 is £10.7 million as set out in table 1.

Table 1 Estimated cost offer of referral for an exercise-based rehabilitation programme 

-	Total
Population	51,220,200
Incidence of heart failure	0.07%
Number of people with heart failure	35,854
% of people offered exercised-based rehabilitation programme	60.0%
Number of people offered exercised-based rehabilitation programme	21,512
Average cost of exercised-based rehabilitation programme	£495
Estimated cost indicator	£10,648,680

Sensitivity analysis

Using sensitivity analysis of 40% and 80% of people offered a referral for an exercise-based rehabilitation programme, the costs range from £7.1 million to £14.2 million.

Potential savings

We have not assumed any effectiveness for this indicator in either improved mortality or reduced resource use (notably in not reducing hospitalisations). However, the Cochrane review and NICE's guideline on heart failure both concluded that the evidence was supportive of improvements in quality of life.

Conclusions

The estimated cost impact of this indicator is £10.7 million per year, with sensitivity analysis showing a range of cost from £7.1million to £14.2 million.

Related QOF indicators

Current QOF indicator	Numerator	Denominator	Underlying achievement
HF01: The practice can produce a register of patients with heart failure	N/A	N/A	N/A

References

Health and Social Care Information Centre (2011) QOF 2010/11 data [online].

University of Birmingham and University of York Health Economics Consortium Health (NICE External Contractor), Development feedback report on piloted indicator, 2012

University of Birmingham and University of York Health Economics Consortium Health (NICE External Contractor), Health economic report on piloted indicator [NM48], 2012