Description of Intervention

Theoretical Basis

Tailored

Duration

One to One

Group

Face to Face

Telephone

Internet

Notes

Clark 1997

*PRIDE

Y

Y

Once a week for 4 weeks

Y

Y

Taught by health educator. Videotape and workbook aids.

Clark 2000

*PRIDE

Y

Y

Once a week for 4 weeks

Y

Y

Taught by health educator. Videotape and workbook aids.

Clark 2009

*PRIDE

Y

Y

Once a week for 6 weeks

Y

Y

Y

3 groups (self‐directed and group intervention and a control)

Cupples 1994

Practical tailored advice on cardiovascular risk factors and appropriate health education.

N/S

Y

3 times a year for 2 years

Y

Y

Delivered at home by health visitor

Esposito 2008

Predesigned scripts to provide education on various aspects of care, geared to personalised clinical goals.

N/S

Y

Average 1.1 contacts a month for 18 months

Y

Y

Y

Nurse case manager, primarily by telephone but also face to face.

Hanssen 2007

Individualised education from a menu of topics to be covered.

Y

Y

6 months (8 sessions in total)

Y

Y

Structured element and an on‐call element

Lie 2009

A psychoeducative intervention. Structured information and psychological support.

N/S

N/S

2 visits (1 hour each)

Y

Y

Critical care nurse, home based.

Lisspers 1999

Health education and achievement of behavioural change.

N/S

Y

4 week residential then 11 month one to one individual sessions

Y

Y

Y

Trained nurses (personal coaches). Seminars, lectures, discussion and skills sessions.

P.RE.Cor Group 1991

Education and counselling on management of cardiovascular risk factors and exercise.

N/s

Y

1 group session, 1 individual session with cardiologist

Y

Y

Y

Multi‐disciplinary input to group. Cardiologist tailors therapy.

Piekes 2009

Variable ‐ nurse provision of patient education.

N/s

N/S

1‐2.5 times a month for an average of 30 months

Y

Y

15 different programs, majority telephone, one‐to‐one

Pogosova 2008

Structured program addressing different risk factors in each session.

Y

N/S

6 Sessions (twice a week, 90 mins)

Y

Y

Southard 2003

Modular internet sessions, Interactive multiple choice and self tests followed by feedback.

N/S

N/S

Once a week for 6 months (at least 30 mins)

Y

Y

Y

Communication with case manager and on‐line discussion group.

Tingstrom 2005

Problem based rehabilitation to teach a planned curriculum

Y

N/S

13 sessions over 1 year

Y

Y

Trained Facilitator

Study

Number Randomised

Number Lost at Follow‐up*

Notes

Clark 2000

Intervention

309

51

36 withdrew, 14 died, 1 data missing

Control

262

42

33 withdrew, 8 died, 1 data missing

Clark 2009

Intervention

201

37

Self‐directed program

33 withdrew, 4 died

Intervention

190

24

Group format

19 withdrew, 5 died

Control

184

23

15 withdrew, 8 died

Cupples 1994

Intervention

250

92

45 defaulted, 47 died

21 defaulted at 2 yrs

Control

237

109

44 defaulted, 65 died

25 defaulted at 2 yrs

Hanssen 2007

Intervention

156

55

40 withdrew, 7 died, 8 missing data

Control

132

38

21 withdrew, 7 died, 10 missing data

Lie 2009

Intervention

101

8

6 withdrew, 2 medical exclusions

Control

102

10

5 withdrew, 5 medical exclusions

P.RE.COR 1991

Intervention

60

0

Comprehensive cardiac rehabilitation

Intervention

61

0

Counseling program without exercise

Control

61

0

Southard 2003

Intervention

53

4

Reasons for drop out stated; Relocation, dietary intervention instead, psychiatric diagnosis, loss of interest

Control

51

0

Tingstrom 2005

Intervention

104

3

Out of the 7 lost to follow‐up 2 died and 5 did not attend

Control

103

4

Combined Results

Intervention

1485

274

18.5%

Control

1132

226

20.0%

Seattle Angina Questionnaire 

Lie 2009 (6 months)

Absolute mean (SD) outcome values at follow‐up

Comparison

Rx

p‐value

Control

p‐value          

Physical Limitation

86.4(15.6)

p<0.001

83.2(18.7)

p<0.001

Rx=Control

Angina Frequency

91.7(16.6)

p<0.001

90.8(18.9)

p<0.001

Rx=Control

Treatment Satisfaction

89.2(15.4)

NS

88.0(16.1)

NS

Rx=Control

Disease Perception

77.8(20.2)

p<0.001

73.9(24.2)

p<0.001

Rx=Control

AP‐QLQ (Angina Pectoris ‐ Quality of Life Questionnaire)

Lisspers 1999 (24 Months)

Mean (SD) score at follow‐up

Between group p‐value

Comparison

Rx

Control

QLQ (Total)

4.7(0.8)

4.3(1.0)

NS

Rx=Control

Somatic symptoms

4.8(1.0)

4.3(1.1)

NS

Rx=Control

Physical Activity

4.8(1.0)

4.1(1.2)

NS

Rx=Control

Emotional Distress

4.8(0.8)

4.6(1.1)

NS

Rx=Control

Life Satisfaction

4.2(1.0)

3.9(1.2)

NS

Rx=Control

SF‐36* (Short Form 36 item survey)

Between group difference in mean change from baseline (95% CI) at follow‐up

Between group p‐value

Comparison

Hanssen 2007 (6 months)

Overall Physical

‐2.33 (‐4.54,‐0.12)

0.039

Rx=Control

Physical Functioning

‐1.16 (‐3.28,0.95)

0.28

Rx=Control

Role Physical

‐1.84 (‐5.32,1.64)

0.299

Rx=Control

Bodily Pain

‐1.74 (‐4.54,1.05)

0.22

Rx=Control

General Health

‐0.36 (‐2.64,1.91)

0.752

Rx=Control

Overall Mental

1.07 (‐1.71,3.86)

0.447

Rx=Control

Vitality

‐0.07 (‐2.23,2.10)

0.951

Rx=Control

Social Functioning

0.36 (‐2.96,3.67)

0.832

Rx=Control

Role Emotional

0.78 (‐3.29,4.84)

0.706

Rx=Control

Mental Health

0.4 (‐1.81,2.60)

0.723

Rx=Control

Hanssen 2007 (18 months)

Overall Physical

‐1.44 (‐3.89,1.02)

0.25

Rx=Control

Physical Functioning

‐0.79 (‐3.06,1.48)

0.491

Rx=Control

Role physical

‐0.94 (‐4.76,2.88)

0.627

Rx=Control

Bodily Pain

‐0.77 (‐4.00,2.47)

0.641

Rx=Control

General Health

0.25 (‐2.15,2.64)

0.838

Rx=Control

Overall Mental

1.65 (‐1.35,4.65)

0.28

Rx=Control

Vitality

0.58 (‐1.95,3.12)

0.65

Rx=Control

Social Functioning

0.55 (‐3.95,2.85)

0.751

Rx=Control

Role Emotional

2.59 (‐1.58,6.77)

0.221

Rx=Control

Mental Health

0.31 (‐2.11,2.73)

0.8

Rx=Control

SF‐36* (Short Form 36 item survey)

Tingstrom 2005 (12 months)

Mean change from baseline (SD)

Between group p‐value⁺

Comparison

Rx

Control

Physical Functioning

3.6 (17.6)

4.4 (15.1)

0.749

Rx=Control

Role Physical

38.2 (46.9)

33.8 (42.4)

0.504

Rx=Control

Bodily Pain

5.69 (31.1)

6.18 (29.1)

0.911

Rx=Control

General Health

1.4 (15.9)

1.8 (16.3)

0.862

Rx=Control

Vitality

5.3 (22.7)

4.9 (21.8)

0.921

Rx=Control

Social Functioning

9.7 (24)

9.1 (25.3)

0.869

Rx=Control

Role Emotional

15.8 (48.1)

16.5 (41.1)

0.913

Rx=Control

Mental Health

2.9 (16.6)

4.2 (17.8)

0.566

Rx=Control

SF‐36 (Short Form 36 item survey)

Pogosova 2008 (12 months)

Mean change from baseline p‐value

Comparison

Control

Rx

Overall Physical

p>0.05

p≤0.05

Favours Rx

Physical Functioning

p>0.05

p≤0.05

Favours Rx

Bodily Pain

p>0.05

p≤0.05

Favours Rx

Overall Mental

p>0.05

p≤0.05

Favours Rx

Vitality

p>0.05

p≤0.05

Favours Rx

Social Functioning

p>0.05

p≤0.05

Favours Rx

Mental Health

p>0.05

p≤0.05

Favours Rx

SF‐36 (Short Form 36 item survey)

Lie 2009 (6 months)

Absolute mean (SD) outcome values at follow‐up

Comparison

Rx

p‐value

Control

p‐value

Overall Physical

47.4 (9.6)

p<0.001

47 (10)

p<0.001

Rx=Control

Physical Functioning

82.2 (19.2)

p<0.001

82.3 (19.8)

p<0.001

Rx=Control

Role Physical

64 (41.2)

p<0.001

57.2 (43.3)

p<0.001

Rx=Control

Bodily Pain

77.2 (22.3)

p<0.001

78.5 (25.2)

p<0.001

Rx=Control

General Health

69.9 (23.3)

NS

65.7 (27.2)

NS

Rx=Control

Overall Mental

52.1 (10.7)

p<0.05

50.5 (10.8)

NS

Favours Rx

Vitality

61.9 (23.9)

p<0.001

60.5 (21.6)

p<0.001

Rx=Control

Social Functioning

86.3 (21.4)

p<0.001

84.3 (21.9)

p<0.001

Rx=Control

Role Emotional

73.3 (38.2)

p<0.01

67.4 (41.6)

p<0.01

Rx=Control

Mental Health

81.9 (17.3)

p<0.001

78.5 (21)

p<0.01

Rx=Control

Nottingham Health Profile+

Cupples 1994

(24 months)

Mean change from baseline (SD) at follow‐up

Comparison

Rx

Control

Between group p‐value

Emotional Reaction

‐0.79 (19.52)

‐1.91 (21.31)

0.52

Rx=Control

Energy

‐3.88 (33.97)

‐6.52 (35.87)

0.33

Rx=Control

Physical Mobility

‐1.49 (16.17)

‐6.19 (18.12)

0.003

Rx>Control

Pain

‐1.23 (20.5)

‐2.7 (23.46)

0.92

Rx=Control

Sleep

‐1.67 (26.22)

‐0.1 (24.95)

0.38

Rx=Control

Social Isolation

1.42 (16.96)

‐3.01 (21.27)

0.08

Rx=Control

Nottingham Health Profile+

Cupples 1994 (60 months)

Mean difference (95% CI) between groups in change from baseline at follow‐up

Between group p‐value

Comparison

Emotional Reaction

‐2.1 (‐7.5,3.3)

NS

Rx=Control

Energy

‐4.7 (‐13.2,3.7)

NS

Rx=Control

Physical Mobility

‐1.3 (‐6.3,3.6)

<0.05

Rx>Control

Pain

‐3.4 (‐9.2,2.3)

<0.05

Rx>Control

Sleep

‐2.4 (‐9.3,4.5)

NS

Rx=Control

Social Isolation

0.0 (‐4.3,4.3)

NS

Rx=Control

Sickness Impact Profile+++

Absolute mean outcome values at follow‐up++

Comparison

Rx

Control

Between group p‐value

Clark 1997 (12 months)

Total Score

7.26

8.09

NS

Rx=Control

Psychosocial Dimension

5.52

7.05

≤0.05

Rx>Control

Physical Dimension

5.89

6.00

NS

Rx=Control

Clark 1997 (18 months)

Total Score

7.93

7.41

NS

Rx=Control

Psychosocial Dimension

6.05

6.23

NS

Rx=Control

Physical Dimension

6.40

5.25

NS

Rx=Control

Sickness Impact Profile

Clark 2000 (12 months)

Absolute means at follow‐up++

Comparison

Rx

Control

Between group p‐value

Psychosocial Dimension

5.15

5.91

0.144

Rx=Control

Physical Dimension

7.09

7.66

0.05

Rx>Control

Sickness Impact Profile

Absolute means (SD) at follow‐up

Comparison

Rx group

Rx self directed

Control

Between group p‐value

Clark 2009 (12 months)

Total Score

8.13 (8.63)

9.79 (10.17)

9.49 (9.46)

NS

Rx=Control

Psychosocial Dimension

5.84 (8.02)

7.31 (10.74)

6.75 (9.39)

NS

Rx=Control

Physical Dimension

8.07 (9.63)

9.46 (10.11)

9.85 (10.79)

NS

Rx=Control

Clark 2009 (18 months)

Total Score

8.44 (9.13)

8.98 (10.29)

9.64 (9.45)

NS

Rx=Control

Psychosocial Dimension

5.74 (9.68)

6.16 (8.20)

7.17 (10.40)

NS

Rx=Control

Physical Dimension

8.27 (10.02)

8.98 (9.33)

9.65 (10.19)

NS

Rx=Control

Patients' Assessment of their Quality of Life on a five‐point scale

Cupples 1994

(24 months)

Initial scores

(% of patients)

Follow‐up Scores

(% of patients)

Between

group p‐value

Comparison

Rx

Control

Rx

Control

p<0.03

Rx>Control

Poor

6.3

5.3

6.9

8.3

Fair

27.8

23.3

18.9

21.7

Average

35

39

33.1

33.7

Good

22.7

22.7

29.3

25.3

Very Good

8.2

9.7

11.7

11

Variable

Clark 2000

Cupples 1994

Esposito 2008

Southard 2003

Peikes 2009

Follow‐up

24 months

24 months

6 months

7‐12 months

12 months

18 months

6 months

25 months

Year of Costs

2000

NR

2005‐6

NR

2002‐2005

Currency

US$

GBP£

US$

US$

US$

Mean cost of cardiac rehabilitation program per patient

Total Costs

$187

£49.72

$162

$453

$196

Costs Considered

Personnel, Instructional Materials, Telephone Supplies, Ongoing Staff Training

Direct Costs by Health Visitors (Staff Time), Travel Costs.

Average monthly fee paid to the program per member

Nurse Salary

Overheads

Subscription Costs

Average monthly fee paid to the program per member

Comments

Participating site overheads were not measured, a "conservatively high" estimate of these was taken to double the cost of the Rx to $374.

Costs of the health visitor also included time spent recording data collection for the study.

Cost varied between the included 15 studies. Negotiated locally with center of Medicare and Medicaid Services. (Range $50‐$444) 

Mean total healthcare costs per patient

Total Cost (Intervention)

˜$3300 (calc)

£1801

$1627

$2356

$2288

$1793

$635

$1283 ^*

Total Cost (Control)

˜$6500

£1812

$1632

$2464

$2372

$1818

$2053

$1314 ^*

Between Group Difference

˜$1800*

£9.60

$5

$107

$84

$25

$1418

$144

(80% CI 99 to 188)

p value

NR

NS

0.895

0.077

0.132

0.365

NR

<0.001

Cost Saving per pt (when cost of intervention taken into account§)

˜$1610 or ˜$1420 if estimated overheads are included.

£40

‐$157

‐$55

‐$78

‐$137

$965

‐$52

Additional Healthcare Costs Considered

Number of Admissions (Heart Related), Number of inpatient days, In patient cost. Emergency Dept costs

Prescription of drugs, visits to the GP, Visits to hospital as inpatients and outpatients, all tests investigations and treatments carried out

Medicare Medical Claims

Cardiovascular related emergency room visits and hospitalisations

Comments

Expenditure was calculated from differences in % utilisation of hospital services. i.e. Hospital charges for participants were on average 49% lower and the average annual expenditure was $6500.

* There was a calculated saving of a hospital charge of $3200, the ratio of payments to charges was 0.56 therefore $1800 actual saving. 

There was a difference in the drug usage at baseline which is not accounted for in these figures although this would make minimal impact to the results. The intervention group were more costly for drugs, procedures and service use.

Claims quoted are per member per month.

*Expenditure/pt/month enrolled

Overall costs were increased by 11% when the care coordination fees were taken into account.

Summary Difference Between Groups

Favours Rx

Rx=Control

Rx=Control (for all time periods studied)

Favours Rx

Favours Control