economic and humanistic outcomes of post acs in cardiac rehabilitation program at sarawak general...

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


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


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/


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.


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


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.


METHODOLOGY


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


CCRPCONTROL MCRP

Inpatient

Outpatient


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.


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)


RESULTS


Screening and Recruitment process from Jan-Dec 2008


At baseline there were no difference in demographic, socioeconomic

background, or physical characteristic data


Clinical & Physical Characteristic


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


Several dimensions of HRQOL measures were found improved in MCRP. BP, GH. VT and MH

Baseline 12-months assessment


Baseline compare with Malaysian Population Norms


Six Months Assessment


12 Months Assessment

MHBP, GH & VT


NnotMCRP


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.


Mean Differences after 12 months follow up


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


Utility Score from EQ5D Questionnaire

Baseline 12 months


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


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.


CONCLUSION


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


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.


THANK YOU Sarawak General HospitalSarawak General Hospital

It is not the number that count, but the heart….

economic and humanistic outcomes of post acs in cardiac rehabilitation program at sarawak general...

Health & Medicine

cardiac rehabilitation

health examples

patient outcomes

patient education

generic health questionnaire

short course phase

general phases

outpatient hospital