We are grateful for the editorial comments by Ski and Thompson (2011). Generally, their comments reinforce the importance of cardiac rehabilitation (CR) and that our findings have ‘clinical relevance’ to improve quality of life, depression and anxiety for patients with coronary heart disease (CHD) (Yohannes et al. 2010). However, we are perturbed with their comments that our findings offer little new information or are a ‘rehearsal’ of the existing literature. The veracity for this statement is questionable. Therefore, we vigorously attest this assertion with the following points:
First, the comment about ‘rehearsal’ questions the peer review process of the journal, which the editors will defend. Reviewers are encouraged to qualify the originality of findings, and it strikes us as odd that Ski and Thompson feel the need to take this line.
Second, the comment that the study required a control group to draw conclusions about efficacy is simply lack of insight, as the design was a cohort study. There is a wealth of evidence for efficacy of CR and as we stated in our aims, we planned to study the ability of CR, over six weeks, to deliver beneficial changes.
Third, as acknowledged by Ski and Thompson, the British Heart Foundation (2009) stated that there is little evidence available to show the long-term benefits of CR. Our study was based on the current evidence available that CR should be provided twice a week at least for six weeks. The assertion that 105 patients at 12 months are inadequate for analysis reflects a lack of understanding from Ski and Thompson (2011). Our findings showed that CR was beneficial in improving quality of life, exceeding a change of 0·5, which has been identified as the minimal important difference to show the smallest score clinically meaningful for patients with cardiac problems after CR (Oldridge et al. 2002) both at six and 12 months follow-up. The population in our study came from the National Health Service and included patients from varying social and ethnic groups. This is the strength of the study, as many other research projects have tended to be less inclusive. We believe this is an important finding to increase the level of evidence-based pool and may aid the healthcare providers to justify the provision of CR for this patient group.
Fourth, it is gratifying to observe the level of improvement from the baseline to 12 months in depression score is corresponding well with the level of improvement in quality of life. The possible explanation might be that psychological well-being is an important determinant of quality of life in patients with chronic diseases (Yohannes et al. 1998) including patients with CHD or quality of life in part includes the psychological well-being of an individual.
Fifth, the correlation between total energy expenditure (TEE, a measure of physical activity) and Hospital Anxiety Depression Scale from the baseline (R2 < 1%) improved at 12 months (R2 = 5%), albeit minor, but it was statistically significant (p < 0·02). The possible explanation might be that the physical status (TEE) from the questionnaire may be not sensitive enough to capture subtle changes when compared to more direct measures such as accelerometers (Yohannes et al. 2010). We have acknowledged this point in the limitation section of our paper. Therefore, further work is required to provide additional evidence in this area.
Finally, we suggest that Ski and Thompson (2011) have confused ‘apples with oranges’. Hofer et al. (2010) showed a four-week inpatient CR programme with two years follow-up, whereas in our study (outpatient phase III study), we examined a six-week CR programme with one year follow-up. We are unsurprised with the differences in the outcome of these studies regarding the long-term follow-up. In this economic climate, inpatient CR might be an (unjustified) beacon for sacrifice as the evidence for the long term is not available. This further affirms the importance of our findings that 6 weeks is the minimum outpatient CR programme that should be offered for all patients with CHD.