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Improve outcomes for the socially disadvantaged by spending more on rehabilitation and less on palliative revascularisation
- Michael R Chester, John Bridson, Clinical Ethicist (4 April 2009)
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Michael R Chester, Professor of Rehabilitation and Preventive Health Education National Refractory Angina Centre & Hope University, John Bridson, Clinical Ethicist
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The observation that survival following cardiac surgery is worse in socially deprived areas would correspond with most people’s intuitions and it is reasonable to speculate that there is probably a parallel disadvantage in terms of symptom control. Given their findings, it makes sense for Pagano and colleagues to recommend comprehensive rehabilitation to, “maximise the benefits of expensive and complex healthcare interventions, such as cardiac surgery.” However, against the backdrop of the current recession, there can be little reason to expect that any worthwhile extension of rehabilitation services could be funded with new money. If that growth is to take place one has to assume it must come from reallocation of existing resources. With this in mind, Pagano et al are to be applauded for their call for renewed attention to rehabilitation. It is especially encouraging to see a research group with such a strong surgical representation implicitly advocating a reallocation of resources towards rehabilitation, because that is what their call surely entails in the current economic climate. The question is, in which area of existing expenditure might there be potential to make such savings? One place to start looking could be cardiac surgical interventions themselves. Pagano et al point out that, “Cardiac surgical procedures are generally performed for symptomatic relief or prognostic benefit, and usually both,” and, certainly, when surgical procedures are associated with prognostic benefit then there are often no alternative strategies which can compete with surgery on prognostic grounds. If the overall objective is to improve prognosis for the socially disadvantaged, one would not want to reallocate resources from evidence-based prognostic interventions. However, one can reasonably look to palliative revascularisation as a candidate for possible savings. The merits of such an approach would be far-reaching and the idea is not new. It is interesting to note that in 1997, at the beginning of the study period, the ESC stable angina guidelines recommended comprehensive rehabilitation as a way of avoiding expensive cardiac interventions, and these recommendations were endorsed by the 1999 American stable angina guidelines (1,2). Based on our own clinical observations and following the ESC and AHA/ACC’s lead, the National Refractory Angina Centre has consistently argued that a coherent approach to education through a comprehensive rehabilitation programme would render many expensive cardiac interventions unnecessary (3,4,5). At the moment it is not controversial to suggest that current provision of comprehensive rehabilitation before palliative revascularisation is practically non- existent and this is at least partly the result of over-concentration of resources on revascularisation. Moreover, it is possible to be quite specific about which cardiac interventions look like good candidates for avoidance and hence offer potential for reallocation of resources. Lewin showed that a comprehensive rehabilitation programme delivered while patients were awaiting planned cardiac surgery enabled over half the patients to avoid the procedure (6). Ornish found that, of 194 patients in whom revascularisation was deemed appropriate, only 29% went on to have a procedure within three years after they received comprehensive rehabilitation (7). This fits with a recent report on the appropriateness of revascularisation produced by the American Heart Association and American College of Cardiology which concluded, “Appropriateness also does not equate to medical necessity. Shared physician/patient decision making for many scenarios would be expected and may result in the patient deferring coronary revascularization while maintaining medical therapy” (8). However, we would suggest that it is not cardiac surgery that has the greatest potential for yielding resources to fund appropriate provision of rehabilitation. Rather the real potential for generating savings by avoiding costly cardiac interventions lies with palliative PCI. It is reasonable to suggest that the reason why rehabilitation and education have been so badly neglected is because commissioners have concentrated on out of date revascularisation targets without considering the weakness of the evidence base. The results of the largest UK study of PCI versus continued medical therapy was published in 1997 (RITA-2) and demonstrated that angioplasty was associated with a 78% increase in cardiovascular risk and with only a small and transient improvement in angina achieved at considerable additional cost (9, 10). The largest study to date, called “COURAGE” tested the hypothesis that angioplasty is superior to optimal medical treatment in preventing heart attacks. The result mirrored the earlier RITA-2 trial and showed that at best angioplasty temporarily improved quality of life (11). The cost effectiveness analysis was completed recently and showed that the small overall benefit was so costly ($150,000 to $300,000 per QALY) that it exceeded the NICE cost effectiveness barrier ($50,000 per QALY) by between three and six fold (12). This is consistent with an earlier UK study that showed PCI cost per QALY was over £50,000 and raised questions over the health economic justification for continuing to fund angioplasty for stable angina (13). Cardiac surgeons are right to point out when surgery offers clear prognostic advantage over PCI and have debated similar issues with interventional cardiologists in the paper and electronic versions of this journal (14). Such extravagances as palliative angioplasty for stable angina sneaked under the radar in more prosperous times. The case for palliative PCI is not helped by either the evidence base or present economic conditions. Surely it is time to review unaffordable palliative revascularisation targets? References 1. ESC stable angina management guidelines Eur Heart J 1997;18:394- 413 2. Gibbons et al ACC/AHA/ACP–ASIM Stable Angina Guidelines Circ 1999; 99: 2829-2848 3. Bridson J, Hammond C, Leach A, Chester MR ‘Making consent patient centred’ BMJ 2003;327;1159-1161 4. Chester MR ‘Saving lives means spending NHS resources effectively’ Featured Correspondence. Heart http://heart.bmj.com/cgi/eletters/hrt.2007.118323v1 5. Chester MR ‘Racing with lemmings’. Letter BMJ. http://www.bmj.com/cgi/eletters/334/7601/970-a 6. Lewin B, Cay E, Todd I, Soryal I, Goodfield N, Bloomfield P, Elton R ‘The angina management programme: a rehabilitation treatment’ British Journal of Cardiology 1995; 2(8): 221-226 7. Ornish D. ‘Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle Demonstration Project’ Am J Cardiol. 1998 Nov 26;82(10B):72T-76T. 8. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization http://content.onlinejacc.org/cgi/content/full/j.jacc.2008.10.005v1 9. RITA-2 Trial Participants. ‘Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial’ Lancet 10. Sculpher MJ, Smith DH, Clayton T, Henderson R, Buxton MJ, Pocock SJ, et al. ‘Coronary angioplasty versus medical therapy for angina’ Eur Heart J 2002;23:1291-300. 11. Boden et al. ‘Optimal Medical Therapy with or without PCI for Stable Coronary Disease’ N Engl J Med 2007; 356:1503-1516 12. Weintraub et al. ‘Cost-Effectiveness of Percutaneous Coronary Intervention in Optimally Treated Stable Coronary Patients’ http://circoutcomes.ahajournals.org/cgi/content/full/1/1/12 13. Griffin et al. ‘Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study’ BMJ 2007;334:624 (24 March) 14. Taggart DP, ‘Surgery is the best intervention for severe coronary artery disease’ BMJ 2005; 330:785-786 Competing interests: None declared |
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