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Cardiac Rehabilitation Program in Cardiac Center, Sarawak General Hospital.
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Sarawak General Hospital
3 Lawrence Anchah, 1, 2 Prof. Dr. Sim Kui Hian, 4 Prof. Dr. Mohd. Izham Mohd Ibrahim,
1, 2 Dr. Alan Fong Yean Yip , 3 Yanti Nasyuhana Sani, 3 Tiong Lee Len, 3 Bibi Faridha Mohd
Salleh,
4 Dr Mohd. Azmi Ahmad Hassali, 4 Prof. Dr. Yahaya Hassan, 5 Karen Tang Siew Lang,
1 Hii Ai Ching,1 Sii Lik Ngoh 1 Dept of Cardiology, Sarawak General Hospital
2 Clinical Research Centre, Sarawak General Hospital3 Dept of Pharmacy, Sarawak General Hospital
4 School Pharmaceutical Sciences, Universiti Sains Malaysia 5 Dept of Physiotherapy, Sarawak General Hospital
The Economic and Humanistic Outcomes of Post Acute
Coronary Syndrome in Cardiac Rehabilitation Program: A Quasi-experimental Design of 12-months Follow-up
Sarawak General Hospital
Background
The World Health Organization (WHO) defines cardiac rehabilitation as1 :
“the sum of activities* required to ensure patients the best possible physical,
mental and social conditions so that they may resume and maintain as normal a
place as possible in the community.”
Cardiac rehabilitation uses a multidisciplinary team approach toward lifestyle
modification with the thought that optimal outcomes are achieved when
rehabilitative strategies are combined
* Activities includes: medical evaluation, prescribed exercise, patient education and counseling
World Health Organization. Needs and action priorities in cardiac rehabilitation and secondary prevention in patients with CHD. Geneva: WHO regional Office for Europe, 1993
National Heart Foundation of Australia & Australian Cardiac Rehabilitation Association. Recommended Framework for Cardiac Rehabilitation ’04
Sarawak General Hospital
General Phases in Cardiac RehabilitationPhase I - Inpatient Program
begins soon after a cardiac events – CCU/CTW/Gen Med end when the patient is ready to go home low-level exercise and education for the patient and family.
Phase II - Outpatient Hospital-based > 2 weeks after discharge ( 1 day, 1 week to 8 weeks) dietitians, social workers, pharmacists, clinicians & others emphasizes monitored exercise education and lifestyle management.
Phase III - Community-based Or Clinic Or Polyclinic
ongoing exercise & education – health facilities maintenance program
Phase IV - Community-based without supervision – community centre patients continue to apply what they have learned
American Association of Cardiovascular & Pulmonary Rehabilitation. AACVPR Cardiac Rehabilitation Resource Manual (2006). USA, Human Kinetics, Library of Congress. Web site: http://www.humakinetics.com/
Sarawak General Hospital
The Innovative Model – Modified CRP
Door-to-balloon time improvement & combine with many other components of care process or measures that can affect outcomes *
The interdisciplinary teamwork coincide with the existing Conventional model CRP (CCRP) differ from the conventional model different levels of intervention structures
We developed a service models, Phase I CRP is intensified and improved in-patient based education intervention counselling for patients and family
The cost effectiveness and humanistic outcomes studies in phase I and short course phase II of CRP are lacking in our local setting.
* Wang TY, et al. The dissociation between door-to-balloon time improvement and improvements in other acute myocardial infarction care processes and patient outcomes. Arch Intern Med 2009; 169:1411-1419.
Sarawak General Hospital
Measurement for Interventional Outcomes
A patient perspective: quantitative surveys such as health status, work performance, symptom burden, and satisfaction.
Health status can be measured using disease specific or general instruments
General instrument measuring health-related quality of life (HRQoL)
patients’ perceptions of health status
the preference-based weights
calculate QALYs (Tradeoff in incremental costs and gains in health)
Examples: SF-36, EQ-5D
Brazier, J. E., Dixon, S., & Ratcliffe, J. (2009). The role of patient preferences in cost-effectiveness analysis: a conflict of values? PharmacoEconomics, 27(9), 705-712.
Van Stel, H., & Buskens, E. (2006). Comparison of the SF-6D and the EQ-5D in patients with coronary heart disease. Health and Quality of Life Outcomes, 4(1), 20
Sarawak General Hospital
Objectives
1. To evaluate the modified phase I and short course of phase II cardiac
rehabilitation.
2. To measure the quality of life outcomes in patients who undergo variety
of interventions after the post acute coronary syndrome (ACS).
3. To evaluate the cost-effectiveness of cardiac rehabilitation program.
Sarawak General Hospital
METHODOLOGY
Sarawak General Hospital
Methodology: Data collection
Approved by MREC, MOH. Written informed consent was obtained
Design & Setting: ACS cases on January 2008 to Dec 2009 An interview (one to one) session while patients on admission. In-patient intensive cardiac care unit (CCU) and the cardiothoracic ward
(CTW) at Sarawak General Hospital, east Malaysia.
Inclusion Criteria: Consented for the trial No other chronic comorbidities Below 75 years old Able to talk in Bahasa and English and local dialect STEMI, NSTEMI and UA
"nonequivalent" because in this design we do not explicitly control the assignment and the groups were nonequivalent
Sarawak General Hospital
CCRPCONTROL MCRP
Inpatient
Outpatient
Sarawak General Hospital
SF-36 The SF-36 is a generic health questionnaire that measure eight
dimensions (scales) of health status. Scores range from 0–100
Physical Component Summary (PCS)
1. Physical functioning (PF)
2. Role limitation-physical (RP)
3. Bodily pain (BP), and
4. General health perception (GH)
Mental Component Summary (MCS)
5. Energy and vitality (VT)
6. Social functioning (SF)
7. Role limitation-emotional (RE)
8. Mental health (MH)
Ware, EJ. SF-36 Health Survey: Manual and Interpretation Guide. The Health Institute, New England Medical Center; 1993. p. 4:3.
Sarawak General Hospital
Statistical Analysis
Minimal Clinically Important Difference (MCID) to indentify clinical significant of HRQoL outcomes. Population Norms Comparison as Anchor-Based Methods to Determine
Changes Analysing Paired Data as Distribution-based Approach to Determine
Changes
Manual by using SF-36, range of MID is 2 -20 points and depending to sample size. Walters and Brazier, 2003
SPSS 16 Paired t-test for continuous dependent One-way ANOVA and post-hoc test for 3 groups over time
QALY = Preference based ( EQ5D utility ) X time (year)
Sarawak General Hospital
RESULTS
Sarawak General Hospital
Screening and Recruitment process from Jan-Dec 2008
Sarawak General Hospital
At baseline there were no difference in demographic, socioeconomic
background, or physical characteristic data
Sarawak General Hospital
Clinical & Physical Characteristic
Sarawak General Hospital
Overall improvement compare to baseline Poor in physical components & emotional components
Baseline vs. Malaysian Norms by Azman et al., (2003) * Six months assessment
* Azman A.B., Sararaks S., Rugayah B., Low L.L., Azian A.A., Geeta S., Tiew C.T. (2003). Quality of life of the Malaysian general population: Results from a postal survey using the SF-36. Med J Malaysia, 58(5):694-711
Sarawak General Hospital
Several dimensions of HRQOL measures were found improved in MCRP. BP, GH. VT and MH
Baseline 12-months assessment
Sarawak General Hospital
Baseline compare with Malaysian Population Norms
Sarawak General Hospital
Six Months Assessment
Sarawak General Hospital
12 Months Assessment
MHBP, GH & VT
Sarawak General Hospital
NnotMCRP
Sarawak General Hospital
Minimal Clinically Important Difference (MCID)
MCID is used to report the success rate (proportion of patients improved or in an acceptable state) in trial arms.
"the smallest difference in score in the domain of interest which patients perceive as beneficial and which would cause clinicians to consider a change in patient's management". (Jaeschke et al., 1989; Fayers & Machin, 2007).
The minimal clinically important difference (MCID) : the patient acceptable symptom state (PASS) cut-offs dichotomizing continuous values improved or not improved
0.5 SD = mean change of the small change (rated by patients on global rating scale) Norman et al., 2003
0.5 SD vs. standardized response mean (Example 0.3 for SF-6D) Walters and Brazier., 2003
Manual by using SF-36, range of MID is 2 -20 points and depending to sample size.
Tubach, F., Giraudeau, B., & Ravaud, P. (2009). The variability in minimal clinically important difference and patient acceptable symptomatic state values did not have an impact on treatment effect estimates. Journal of Clinical Epidemiology, 62(7), 725-728.
Sarawak General Hospital
Mean Differences after 12 months follow up
Sarawak General Hospital
Estimation of the cost of treatment based expenditure (top-down), services, salary, hospital days, medication, procedure cost etc.
Admission Cost
Stage I, II, III
OPD Phase 2
Follow-up Medication
Cost
COROS TOTAL Cost (Annually)
QALY Gain
Rx MCRP 1,788.21 43.05 17.21 2,302.72 1,901.24 6,052.43 $7,213.86
CCRP 1,788.21 17.21 2,302.72 1,901.24 6,009.38 $7,162.55
Control 1,788.21 2,302.72 1,901.24 5,992.17 $8,000.23
DES BMS
PCI MCRP 16,893.92 43.05 17.21 2,302.72 13,393.92 15,756.90 $18,780.57
CCRP 16,893.92 17.21 2,302.72 13,393.92 15,713.85 $18,729.26
Control 16,893.92 2,302.72 13,393.92 15,696.64 $20,956.79
COROS
CABG MCRP 49,341.08 43.05 17.21 2,302.72 1,901.24 53,605.30 $63,891.89
CCRP 49,341.08 17.21 2,302.72 1,901.24 53,562.25 $63,840.58
Control 49,341.08 2,302.72 1,901.24 53,545.04 $71,488.70
Sarawak General Hospital
Utility Score from EQ5D Questionnaire
Baseline 12 months
Sarawak General Hospital
Incremental Cost Ratio
Optimised Medical Therapy
TOTAL Cost Annually QALY
Incremental Cost Ratio(ICR)
MCRP 6,052.43 7,213.86 $51.31
CCRP * 6,009.38 7,162.55 -
Control 5,992.17 8,000.23 $837.68
PCI (Angiogram)
MCRP 15,756.90 18,780.57 $51.31
CCRP 15,713.85 18,729.26 -
Control 15,696.64 20,956.79 $2,227.53
CABG (Bypass)
MCRP 53,605.30 63,891.89 $51.31CCRP 53,562.25 63,840.58 -
Control 53,545.04 71,488.70 $7,648.12
* CCRP as a reference point
Sarawak General Hospital
Cost per QALY
Without Cardiac Rehabilitation Program:
1. Very poor of patients’ perceptions of health status (utility score)
2. After one-year post ACS the incremental cost (IC) for each patient was;
IC = RM 837.68 (cost per QALY RM 8,032.40) in usual care without intervention;
IC = RM 2,227.53 (cost per QALY RM 20,956.79) for PCI; and
IC = RM 7,648.12 (cost per QALY RM 71,488.70) for CABG.
Sarawak General Hospital
CONCLUSION
Sarawak General Hospital
Conclusions
This study demonstrates post ACS population with SF-36 may aid in the further development and health economic evaluation of CRP.
The domains in HRQoL of post ACS patients differ significantly in physical (PCS) and mental (MCS) scores compare with the Malaysian norms.
1.Modified Cardiac rehabilitation have improved quality of life of patients after long period of time in Physical Functioning (PF), Role of Physical (RP), Social Functioning (SF), and Role of Emotion (RE), that clinically difficult to assess with conventional metrics or surrogate makers
2.Cardiac rehabilitation program have improved both PCS in Body Pain and MCS of Social Functioning
3.Without any cardiac rehabilitation for post ACS patients will cause a high impact in annual cost of treatment and poor improvement in quality of life.
LIMITATION
Sarawak General Hospital
Suggestion:
Multicentre research (Cardiology Centre: PGH, QEH, SAGH, IJN)
More investigators, unlimited funding.
Recommendation of Improvement in Cardiac Rehabilitation:
More time spent in phase I cardiac rehabilitation, in term of;
1. Patient Education on drug –disease counseling
2. Medication adherence & understanding
3. More emphasize the intensive counseling and motivation of phase I CRP by
clinical pharmacists.
Incremental Cost Ratio (ICR) of modified cardiac rehabilitation program is very
minimum in term of operational cost for clinical pharmacy services.
MCRP can easily implemented in all hospitals and it is highly cost-effective program.
Sarawak General Hospital
THANK YOU Sarawak General HospitalSarawak General Hospital
It is not the number that count, but the heart….
Sarawak General Hospital