Home-based versus centre-based cardiac rehabilitation - PubMed (original) (raw)

Review

Home-based versus centre-based cardiac rehabilitation

Lindsey Anderson et al. Cochrane Database Syst Rev. 2017.

Update in

Abstract

Background: Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation. This is an update of a review previously published in 2009 and 2015.

Objectives: To compare the effect of home-based and supervised centre-based cardiac rehabilitation on mortality and morbidity, exercise-capacity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease.

Search methods: We updated searches from the previous Cochrane Review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) on 21 September 2016. We also searched two clinical trials registers as well as previous systematic reviews and reference lists of included studies. No language restrictions were applied.

Selection criteria: We included randomised controlled trials, including parallel group, cross-over or quasi-randomised designs) that compared centre-based cardiac rehabilitation (e.g. hospital, gymnasium, sports centre) with home-based programmes in adults with myocardial infarction, angina, heart failure or who had undergone revascularisation.

Data collection and analysis: Two review authors independently screened all identified references for inclusion based on pre-defined inclusion criteria. Disagreements were resolved through discussion or by involving a third review author. Two authors independently extracted outcome data and study characteristics and assessed risk of bias. Quality of evidence was assessed using GRADE principles and a Summary of findings table was created.

Main results: We included six new studies (624 participants) for this update, which now includes a total of 23 trials that randomised a total of 2890 participants undergoing cardiac rehabilitation. Participants had an acute myocardial infarction, revascularisation or heart failure. A number of studies provided insufficient detail to enable assessment of potential risk of bias, in particular, details of generation and concealment of random allocation sequencing and blinding of outcome assessment were poorly reported.No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in clinical primary outcomes up to 12 months of follow up: total mortality (relative risk (RR) = 1.19, 95% CI 0.65 to 2.16; participants = 1505; studies = 11/comparisons = 13; very low quality evidence), exercise capacity (standardised mean difference (SMD) = -0.13, 95% CI -0.28 to 0.02; participants = 2255; studies = 22/comparisons = 26; low quality evidence), or health-related quality of life up to 24 months (not estimable). Trials were generally of short duration, with only three studies reporting outcomes beyond 12 months (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants = 1074; studies = 3; moderate quality evidence). However, there was evidence of marginally higher levels of programme completion (RR 1.04, 95% CI 1.00 to 1.08; participants = 2615; studies = 22/comparisons = 26; low quality evidence) by home-based participants.

Authors' conclusions: This update supports previous conclusions that home- and centre-based forms of cardiac rehabilitation seem to be similarly effective in improving clinical and health-related quality of life outcomes in patients after myocardial infarction or revascularisation, or with heart failure. This finding supports the continued expansion of evidence-based, home-based cardiac rehabilitation programmes. The choice of participating in a more traditional and supervised centre-based programme or a home-based programme may reflect local availability and consider the preference of the individual patient. Further data are needed to determine whether the effects of home- and centre-based cardiac rehabilitation reported in the included short-term trials can be confirmed in the longer term and need to consider adequately powered non-inferiority or equivalence study designs.

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Conflict of interest statement

LA is an author on number of other Cochrane cardiac rehabilitation reviews.

RST, HD, KJ and AC are investigators on randomised controlled trials included in this review. RST, HD and KJ are chief investigators/co‐applicants on an ongoing National Institute for Health Research (NIHR) Programme Grants for Applied Research funded study ‐ Rehabilitation Enablement in Chronic Heart Failure (REACH‐HF) ‐ to develop and evaluate the costs and outcomes of a home‐based self help heart failure rehabilitation manual (RP‐PG‐1210‐12004) http://medicine.exeter.ac.uk/research/healthserv/primarycare/projects/reach‐hf/.

SJD's position at the University of Exeter Medical School is partially supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health in England. The textbook 'Interprofessional Rehabilitation: a person‐centred approach' has a section on adherence in rehabilitation, drawing upon earlier work than this Cochrane Review.

KJ is part funded by NIHR CLAHRC‐WM.

RJN, AZ and GAS declare that they have no conflicts of interest.

Figures

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PRISMA Flow Diagram

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Methodological quality summary: review authors' judgements about each methodological quality item for each included study

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Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies

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Funnel plot of comparison: 1 home‐base vs centre‐based, outcome: 1.1 Total mortality.

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Funnel plot of comparison: 1 home‐base vs centre‐based, outcome: 1.2 Exercise capacity ≤ 12 months.

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Funnel plot of comparison: 1 home‐base vs centre‐based, outcome: 1.4 Completers.

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Funnel plot of comparison: 1 home‐base vs centre‐based, outcome: 1.5 Total cholesterol 3 to 12 months.

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Funnel plot of comparison: 1 home‐base vs centre‐based, outcome: 1.9 Systolic blood pressure 3 to 12 months.

1.1

1.1. Analysis

Comparison 1 home‐base vs centre‐based, Outcome 1 Total mortality.

1.2

1.2. Analysis

Comparison 1 home‐base vs centre‐based, Outcome 2 Exercise capacity ≤ 12 months.

1.3

1.3. Analysis

Comparison 1 home‐base vs centre‐based, Outcome 3 Exercise capacity 12 to 24 months.

1.4

1.4. Analysis

Comparison 1 home‐base vs centre‐based, Outcome 4 Completers.

1.5

1.5. Analysis

Comparison 1 home‐base vs centre‐based, Outcome 5 Total cholesterol 3 to 12 months.

1.6

1.6. Analysis

Comparison 1 home‐base vs centre‐based, Outcome 6 HDL cholesterol 3 to 12 months.

1.7

1.7. Analysis

Comparison 1 home‐base vs centre‐based, Outcome 7 LDL cholesterol 3 to 12 months.

1.8

1.8. Analysis

Comparison 1 home‐base vs centre‐based, Outcome 8 Triglycerides 3 to 12 months.

1.9

1.9. Analysis

Comparison 1 home‐base vs centre‐based, Outcome 9 Systolic blood pressure 3 to 12 months.

1.10

1.10. Analysis

Comparison 1 home‐base vs centre‐based, Outcome 10 Diastolic blood pressure 3 to 12 months.

1.11

1.11. Analysis

Comparison 1 home‐base vs centre‐based, Outcome 11 Smoking 3 to 12 months.

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References

References to studies included in this review

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Moholdt 2012 {published data only}
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Sparks 1993 {published data only}
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References to studies excluded from this review

Ades 2000 {published data only}
    1. Ades PA, Pashkow FJ, Fletcher G, Pina IL, Zohman LR, Nestor JR. A controlled trial of cardiac rehabilitation in the home setting using electrocardiographic and voice transtelephonic monitoring. American Heart Journal 2000;139(3):543‐8. - PubMed
Austin 2005 {published data only}
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Chen 2016 {published data only}
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Chien 2011 {published data only}
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Corvera‐Tindel 2004 {published data only}
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Haddadzadeh 2011 {published data only}
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HF ACTION 2009 {published data only}
    1. Flynn KE, Piña IL, Whellan DJ, Lin L, Blumenthal JA, Ellis SJ, et al. Effects of exercise training on health status in patients with chronic heart failure: HF‐ACTION randomized controlled trial. JAMA 2009;301(14):1451‐9. - PMC - PubMed
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Higgins 2001 {published data only}
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Hovland‐Tanneryd 2016 {published data only}
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Jolly 2009 {published data only}
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Khalife‐Zadeh 2015 {published data only}
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Kim 2011 {published data only}
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Lear 2014 {published data only}
    1. Lear SA, Singer J, Banner‐Lukaris D, Horvat D, Park JE, Bates J, et al. Randomized trial of a virtual cardiac rehabilitation program delivered at a distance via the internet. Circulation. Cardiovascular Quality and Outcomes 2014; Vol. 7, issue 6:952‐9. - PubMed
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References to studies awaiting assessment

Doletsky 2013 {published data only}
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References to ongoing studies

ACTRN12616000426482 {unpublished data only}
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NCT02047942 {unpublished data only}
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NCT02711631 {unpublished data only}
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NCT02791685 {unpublished data only}
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NCT02796404 {unpublished data only}
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References to other published versions of this review

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