Home-based versus supervised centre-based cardiac rehabilitation

Review question

We compared home-based cardiac rehabilitation programmes with supervised centre-based cardiac rehabilitation for adults with myocardial infarction (blood flow to the heart has stopped), angina (chest pain), heart failure or who had undergone revascularisation.

Background

Cardiac rehabilitation aims to restore people with heart disease to health, through a combination of exercise, education and psychological support. Traditionally, centre-based cardiac rehabilitation programmes (e.g. based at a hospital, gymnasium or in sport centre) are offered to people after cardiac events. Home-based cardiac rehabilitation programmes have been introduced to increase access and participation.

Search date

We searched up to September 2016.

Study characteristics

We searched for randomised controlled trials (trials that randomly allocate participants to one of two or more treatment groups) looking at the effectiveness of home-based versus supervised centre-based cardiac rehabilitation programmes, in adults with heart disease.

We included 23 trials (2890 participants). Most trials were relatively small (median 104 participants, range: 20 to 525). The average age of trial participants ranged from 51.6 to 69 years. Women accounted for only 19% of recruited participants; four trials did not include women.

The mix of people recruited to the trials varied; 10 studies included a mixed population of people with coronary heart disease, five studies included people who had had a heart attack, and four studies each recruited people following revascularisation or who had heart failure.

Study funding sources

Sixteen studies reported sources of funding; seven did not. No study reported funding from an agency with commercial interest in the results.

Key results

We found that home- and centre-based cardiac rehabilitation programmes are similar in benefits measured in terms of numbers of deaths, exercise capacity and health-related quality of life. Further data are needed to confirm if these short-term effects of home- and centre-based cardiac rehabilitation can be sustained over time.

Quality of the evidence

Poor reporting made it difficult to assess methodological quality of the included studies and their risk of bias. Evidence quality ranged from very low (total mortality), to moderate (exercise capacity over 12 months and health-related quality of life). The main reasons for the low assessment of quality was poor reporting in the included studies.

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.

Read the full 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 strategy: 

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.

Share/Save