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The Birmingham Rehabilitation Uptake Maximisation Study (BRUM)
The Birmingham Rehabilitation Uptake Maximisation Study (BRUM). Home-based compared with hospital-based cardiac rehabilitation in a multi-ethnic population: cost-effectiveness and patient adherenceK. Jolly, R. Taylor, G.Y.H. Lip, S. Greenfield, J. Raftery, J. Mant, D. Lane, M. Jones, K.W. Lee and A. Stevens
The study aimed to evaluate the relative effectiveness and cost-effectiveness of a home-based programme of cardiac rehabilitation using the Heart Manual, with centre-based programmes in patients who have experienced a myocardial infarction (MI) or coronary revascularisation within the previous 12 weeks. In addition, it sought to explore the reasons for non-adherence to cardiac rehabilitation programmes.
This was an individually randomised trial, with minimisation for age, gender, ethnicity, initial diagnosis and hospital of recruitment. Participants were followed up after 6, 12 and 24 months by questionnaire and clinical assessment. Individual semistructured interviews were undertaken in the homes of a purposive sample of patients who did not adhere to their allocated programme, and focus groups were undertaken with groups of patients who adhered to the programmes.
Setting and patients
Recruitment took place of patients referred to cardiac rehabilitation teams at four hospitals in predominantly inner-city, multi-ethnic, socio-economically deprived areas of the West Midlands, for two years from 1 February 2002. Patients were excluded if they were deemed as too high risk for a home-exercise programme, which included patients with unstable angina, clinically significant heart failure, important cardiac arrhythmias or significant lesions remaining post-angioplasty or bypass. Of the 1997 patients presenting with the index events, 1,207 (60 per cent) were eligible for the study and 525 (43 per cent of eligible patients) were recruited, with 263 randomised to the home-based arm and 262 to the centre-based arm. Interviews were undertaken with 49 participants who were “non-adherers” and five focus groups were run for adhering participants.
All the rehabilitation programmes included exercise, relaxation, education and lifestyle counselling. All patients were seen by a cardiac rehabilitation nurse prior to hospital discharge and provided with information about their condition and counselling about risk factor modification.
The four centre-based programmes varied in length from nine sessions at weekly intervals of education, relaxation and circuit training to 24 individualised sessions over 12 weeks of mainly walking, fixed cycling and rowing with group-based education.
The home-based programme consisted of a manual, home visits and telephone contact. Patients who had had an MI were discharged home with The Heart Manual (second edition). Those who had had a revascularisation received an adapted version of the Heart Manual for this patient group. The Heart Manual was introduced to patients on an individual basis, either in hospital or on a home visit. Home visits by a nurse took place at approximately 1, 6 and 12 weeks after recruitment, with a telephone call at three weeks. At the final visit, patients were encouraged to maintain their lifestyle changes and to continue with their exercise programme. Patients who had an insufficient command of English were followed up by a rehabilitation nurse who spoke Punjabi. An audiotape of an abridged version of the Heart Manual in Punjabi accompanied the manual for patients with a limited command of English.
Main outcome measures
Primary outcomes were smoking cessation, blood pressure, total and high-density lipoprotein cholesterol, exercise capacity measured by the incremental shuttle walking test and psychological status measured by the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes included self-reported diet, physical activity, cardiac symptoms and quality of life. Health service resource use and costs of rehabilitation programmes from health service and societal perspectives were also measured. Adherence to the physical activity element of the rehabilitation programmes was measured by questionnaire at 6, 9 and 12 weeks.
At all three follow-up points no clinically or statistically significant differences were found in any of the primary outcome measures between the home- and centre-based groups or in any of the secondary outcomes.
Significant improvements in total cholesterol, smoking prevalence, the HADS anxiety score, self-reported physical activity and diet were seen in both the home- and centre-based arms between baseline and the six-month follow-up.
Five or more contacts with a cardiac rehabilitation nurse were received by 96 per cent of participants in the home-based arm, whereas only 56 per cent of participants in the centre-based arm attended this many rehabilitation classes (p<0.001).
The direct rehabilitation costs to the health service were significantly higher for the home-based programme; the mean cost was £198 (95 per cent confidence interval (CI) £189 to £208) versus £157 (95 per cent CI £139 to £175), p<0.05, for the centre-based programme. When patient costs were included, the mean cost of the centre-based arm rose to £182 (difference not significant). The programme at Hospital 1 had a significantly higher mean cost than that for Hospital 2 or Hospitals 3 and 4 combined.
Patients’ reasons for not taking up or adhering to cardiac rehabilitation were multifactorial and very individual. Other health problems, such as arthritis, and continuing cardiac problems limited some patients’ ability to exercise. The majority of non-adherers found some aspects of their cardiac rehabilitation programme helpful. Many had adapted advice on rehabilitation and were continuing to exercise in other ways and had made lifestyle changes, particularly to their diet. On the home-based programme, patients’ lack of motivation to exercise on their own at home was a major factor in non-adherence.
The focus groups revealed little diversity of views among patients from each programme. In particular, patients in the hospital programme enjoyed the camaraderie of group exercise and the home-based patients valued the wealth of information and advice in the Heart Manual.
For low- to moderate-risk patients following MI, percutaneous transluminal coronary angioplasty or coronary artery bypass graft, a home-based cardiac rehabilitation programme does not produce inferior outcomes compared with the traditional centre-based programmes. With the level of home visiting in this trial, the home-based programme was more costly to the health service, but with the difference in costs borne by patients attending centre-based programmes.
Reasons for non-participation/non-adherence were multifactorial and individualistic, with in most cases one critical factor that determined eventual cardiac rehabilitation behaviour. There were differences in the reasons given by home and hospital cardiac rehabilitation patients, with home-based patients often citing a lack of motivation to exercise at home. Social characteristics, individual patient needs and the location of cardiac rehabilitation programmes need to be taken into account in programme design to maximise participation.
Recommendations for further research
Research is recommended in the following areas:
cardiac rehabilitation in patients from ethnic minority groups;
development of measurement tools to assess physical activity and dietary change and translated and validated tools in minority languages for these and to measure psychological status;
evaluation of the Heart Manual in patients who decline centre-based cardiac rehabilitation;
evaluation of the implementation of home-based programmes in the UK; and
evaluation of strategies that sustain physical activity in the long term.
© 2007 Crown Copyright
K. Jolly and A. Stevens are based at the Department of Public Health and Epidemiology, University of Birmingham, UK. R. Taylor is based at the Peninsula College of Medicine and Dentistry, Universities of Exeter and Plymouth, UK. G.Y.H. Lip and D. Lane are based at the University Department of Medicine at City Hospital, Birmingham, UK. S. Greenfield, J. Mant and M. Jones are based at the Department of Primary Care and General Practice, University of Birmingham, UK. J. Raftery is based at the Wessex Institute of Health Research and Development, University of Southampton, UK. K.W. Lee is based at the University Hospitals of Coventry and Warwickshire, Coventry, UK. K. Jolly is the corresponding author.
Jolly, K., Taylor, R., Lip, G.Y.H., Greenfield, S., Raftery, J., Mant, J., Lane, D., Jones, M., Lee, K.W. and Stevens, A. (2007), “The Birmingham Rehabilitation Uptake Maximisation Study (BRUM). Home-based compared with hospital-based cardiac rehabilitation in a multi-ethnic population: cost-effectiveness and patient adherence”, Health Technol Assess, Vol. 11 No. 35