What this means in practice
Can be used with evidence generation
The 7 technologies in recommendation 1.1 can be used as an option in the NHS during the evidence generation period (3 years) and paid for using core NHS funding. During this time, more evidence will be collected to address any uncertainties. Companies are responsible for organising funding for evidence generation activities.
After this, NICE will review this guidance, and the recommendations may change. Take this into account when negotiating the length of contracts and licence costs.
Potential benefits of use in the NHS with evidence generation
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Access: Access to and uptake of cardiac rehabilitation is limited across the NHS. Digital technologies to support cardiac rehabilitation may help improve access, uptake and adherence for people offered cardiac rehabilitation but who may not be able to or may be less inclined to attend in-person sessions. This could include, for example, people:
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with work or caring responsibilities
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living in rural communities with long travel times to clinics
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who think that the current in-person offering is not suited to their needs.
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System benefit: Increasing the number of people who use cardiac rehabilitation programmes could reduce secondary cardiovascular events and unplanned hospital admissions.
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Clinical benefit: Clinical evidence suggests that these digital technologies may improve the exercise capacity, cardiovascular risk profile, health-related quality of life and psychological wellbeing of people with CVD.
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Resources: Increasing the number of people who do cardiac rehabilitation is likely to use fewer resources if those people use digital tools compared with conventional cardiac rehabilitation.
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Equality: Offering digital technologies could increase flexibility so that patient preferences, needs and commitments can be accommodated better.
Managing the risk of use in the NHS with evidence generation
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Costs: Early economic modelling suggests that the technologies could be cost effective, but the results are uncertain. This guidance will be reviewed after 3 years and the recommendations may change. Trusts should take into account the costs of the digital technologies in this evaluation when implementing the technologies. When negotiating with companies, trusts should also consider the upfront costs for implementing a technology, delivering staff and patient training, integrating with NHS systems, and providing smart devices.
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Clinical risk: Evidence comparing digital technologies with conventional cardiac rehabilitation is limited and the results are uncertain. When deciding whether to do digital or conventional cardiac rehabilitation, healthcare professionals and people with CVD should consider how likely it is that digital technologies will have similar effectiveness to conventional cardiac rehabilitation for that person. People who choose to do digital cardiac rehabilitation should have continued access to support from the cardiac rehabilitation team.
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Clinical subgroups: There is no evidence to show whether digital technologies to support cardiac rehabilitation are clinically effective in particular subgroups. CVD risk is higher in older people, people living in more deprived areas and people in certain ethnic groups. The incidence of CVD is increasing in younger people. Uptake of cardiac rehabilitation is low among women, people living in more deprived areas and people in ethnic minority groups. It is uncertain whether the digital technologies are as effective in these subgroups as in the general CVD population.
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Clinical assessment: A trained NHS healthcare professional should do a full clinical assessment before offering these technologies to make sure they are suitable for the person with CVD. Referral to these services should be in line with national and local guidelines. Some people may choose not to use a digital service and may prefer another treatment option. People with CVD should always be given the option to do conventional cardiac rehabilitation. Everyone has the right to make informed decisions about their care (see the NICE guideline on shared decision making).
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Resources: Implementing digital technologies for cardiac rehabilitation could lead to an increase in the number of people doing cardiac rehabilitation and the number of appointments needed for assessments. Also, staff may have to spend time training people how to use digital tools.
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Equality: There is a risk that using digital technologies could widen the gap in access to cardiac rehabilitation. There are groups of people who may struggle to use digitally supported cardiac rehabilitation, such as people:
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less comfortable or skilled in using digital technology
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with limited access to equipment and the internet
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experiencing homelessness
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living in houses in multiple occupation or in residential care.
Additional support may be needed for people who:
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have visual, hearing or cognitive impairment
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have reduced manual dexterity
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have a learning disability
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do not have English as a first language
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do not understand health-related information.
People's cultural, ethnic or religious backgrounds may affect how cardiac rehabilitation should be delivered. These people should be supported through shared decision making to select the appropriate treatment option for them and may need additional support.
More research is needed
There is not enough evidence to support funding in the NHS for the 5 technologies listed in recommendation 1.4.
Access to technologies should be through company, research or non-core NHS funding, and clinical or financial risks should be managed appropriately.
NICE has produced tools and resources to support the implementation of this guidance.