British Heart Foundation

   British Heart Foundation (BHF) National Audit of Cardiac Rehabilitation

NACR
NHS Digital

               

Quality Assurance and Guidelines


New commissioning guides for Cardiac Rehabilitation and the role of the NACR

DH Commissioning Pack;   NICE;   BACPR

The Government have made big changes to the organisation of the health service. The white paper makes it clear that clinical audit will inform commissioning and that the new National Commissioning Board and the local Clinical Commissioning Groups will require high quality audit data from providers and the ability to benchmark against other services in the region. The NACR is ahead of the curve with these needs.

Department of Health (DH) Commissioning Pack - Update

Monitor has released its new tariff advice which builds on the 2010 DH CR Pack cost model. The model only takes account of staff costs over 16 one hour sessions. This means local programmes will need to add other capital and services costs and adjust in respect of the number of sessions they run. Link below is for Monitor who are promoting this approach.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/
file/509697/2016-17_National_Tariff_Payment_System.pdf

In 2009-10 the cost of CR using the model was 477 (staff costs over 16 sessions). If programmes use the model they can calculate their own costs based on current staff costs. Please see DH costing tool excel sheet and guidelines attached below:

Download Cardiac Rehabilitation Costing Tool Guidance

Download DH Excel Costing Tool

NICE

The BACPR

The British Association for Cardiovascular Prevention and Rehabilitation (BACPR) is the association representing cardiac rehabilitation professionals, which sets the standards by which clinicians work to in the UK. The new standards and core components from the BACPR (2017) acknowledge the NACR as a minimum standard and core component, and recommend it for evaluating CR programmes.

DownloadBACPR Standards

Department of Health Commissioning Pack for Cardiac Rehabilitation: Final evaluation report June 2012

A key aim of the project was to identify how audit data collection could be adapted to more effectively explore the key outcomes and indicators specified in the DH CR Commissioning Pack, with the objective of producing a user-friendly report that could be generated by the NACR database. This report could then be used by commissioners and providers of services to clearly and simply present progress towards achieving the outcomes recommended in the pack.

The pilot project showed that it has been possible to amend the existing NACR database to capture the key outcome requirements (with one adaptation) as set out in the DH CR Commissioning Pack. It has also demonstrated that a report can be generated by the database which can be used to present these outcomes with the proviso that collection of the data is a shared commissioner-provider responsibility. However more work needs to be done by commissioners, providers and central audit teams to offer more effective guidance for users on developing robust mechanisms for obtaining key data on 'in-scope' patients and reductions in readmissions in addition to measures of patient satisfaction/experience.

Acknowledgements

This pilot project has been a collaborative endeavour between NHS Improvement, the NACR and the seven CR programmes. Generous thanks are extended to everyone who gave their time and effort to participate in or contribute to the pilot and the evaluation.

Download DH Commissioning Pack Final Report (pdf)

Information for Managers and Commissioners about the effect of the RAMIT trial on the evidence for Cardiac Rehabilitation

The recent publication of the RAMIT trial has led some to question the value of cardiac rehabilitation (CR).

The evidence base for cardiac rehabilitation, which includes 47 RCTs, remains secure. Even with the widely questioned RAMIT data added the Cochrane meta-analyses (1), the NICE reviews and all other guidance still show that CR reduces both relative mortality and morbidity very significantly. Results from the National Audit of Cardiac Rehabilitation NACR (2) demonstrate improved health behaviours and health related quality of life from UK CR programmes. There is also evidence that CR remains as effective as in previous eras despite recent changes in cardiology procedures (3). All of the current evidence shows that withdrawing CR from patients would put them at substantial added risk of early mortality. Commissioners should ensure that the programmes they are funding meet the NICE (4) recommendations and comply with the BACPR standards (5) for CR. This will ensure that they are implementing evidence-based treatment. In some cases this may require the restructuring of inadequately funded programmes (6).

References

  1. Heran BS, Chen JM, Ebrahim S, et al. Exercise based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011;(7):CD001800.
  2. National Audit of Cardiac Rehabilitation (NACR). Annual Statistical Report. Vol. 5. British Heart Foundation, 2011:6e11. http://www.cardiacrehabilitation.org.uk/nacr/index.htm
  3. Taylor R. The RAMIT trial: its results in the context of the 2012 Cochrane Review. Heart April 2012 BMJ Heart 2012;98:8:672-673 doi:10.1136/heartjnl-2012-301728
  4. National Institute for Health and Clinical Excellence (NICE). Secondary Prevention in Primary and Secondary Care for Patients Following a Myocardial Infarction. NICE, 2007:1e34. CG48. http://guidance.nice.org.uk/CG48/NICEGuidance/pdf/
  5. British Association for Cardiovascular Rehabilitation (2012) BACPR Standards and Core Components (2nd Edition). http://www.bacpr.com/pages/page_box_contents.asp?pageid=791
  6. Doherty P & Lewin B. The RAMIT trial, a pragmatic RCT of cardiac rehabilitation versus usual care: what does it tell us? Heart 2012;98:8:605-606 doi:10.1136/heartjnl-2012-301728

Acknowledgements:

The British Heart Foundation, the Care Quality Commission, NHS Digital, British Association for Cardiovascular Prevention and Rehabilitation, the Royal College of Physicians, the DOH Heart Team, NHS Improvement, clinicians and patients continue to work together in support of the National Audit of Cardiac Rehabilitation.


 The University of York