Home‐based versus centre‐based cardiac rehabilitation
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 originally published in 2009.
Objectives
To compare the effect of home‐based and supervised centre‐based cardiac rehabilitation on mortality and morbidity, health‐related quality of life, and modifiable cardiac risk factors in patients with heart disease.
Search methods
To update searches from the previous Cochrane review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9, 2014), MEDLINE (Ovid, 1946 to October week 1 2014), EMBASE (Ovid, 1980 to 2014 week 41), PsycINFO (Ovid, 1806 to October week 2 2014), and CINAHL (EBSCO, to October 2014). We checked reference lists of included trials and recent systematic reviews. No language restrictions were applied.
Selection criteria
Randomised controlled trials (RCTs) that compared centre‐based cardiac rehabilitation (e.g. hospital, gymnasium, sports centre) with home‐based programmes in adults with myocardial infarction (MI), angina, heart failure or who had undergone revascularisation.
Data collection and analysis
Two authors independently assessed the eligibility of the identified trials and data were extracted by a single author and checked by a second. Authors were contacted where possible to obtain missing information.
Main results
Seventeen trials included a total of 2172 participants undergoing cardiac rehabilitation following an acute MI or revascularisation, or with heart failure. This update included an additional five trials on 345 patients with heart failure. Authors of a number of included trials failed to give sufficient detail to assess their potential risk of bias, and details of generation and concealment of random allocation sequence were particularly poorly reported. In the main, no difference was seen between home‐ and centre‐based cardiac rehabilitation in outcomes up to 12 months of follow up: mortality (relative risk (RR) = 0.79, 95% confidence interval (CI) 0.43 to 1.47, P = 0.46, fixed‐effect), cardiac events (data not poolable), exercise capacity (standardised mean difference (SMD) = ‐0.10, 95% CI ‐0.29 to 0.08, P = 0.29, random‐effects), modifiable risk factors (total cholesterol: mean difference (MD) = 0.07 mmol/L, 95% CI ‐0.24 to 0.11, P = 0.47, random‐effects; low density lipoprotein cholesterol: MD = ‐0.06 mmol/L, 95% CI ‐0.27 to 0.15, P = 0.55, random‐effects; systolic blood pressure: mean difference (MD) = 0.19 mmHg, 95% CI ‐3.37 to 3.75, P = 0.92, random‐effects; proportion of smokers at follow up (RR = 0.98, 95% CI 0.79 to 1.21, P = 0.83, fixed‐effect), or health‐related quality of life (not poolable). Small outcome differences in favour of centre‐based participants were seen in high density lipoprotein cholesterol (MD = ‐0.07 mmol/L, 95% CI ‐0.11 to ‐0.03, P = 0.001, fixed‐effect), and triglycerides (MD = ‐0.18 mmol/L, 95% CI ‐0.34 to ‐0.02, P = 0.03, fixed‐effect, diastolic blood pressure (MD = ‐1.86 mmHg; 95% CI ‐0.76 to ‐2.95, P = 0.0009, fixed‐effect). In contrast, in home‐based participants, there was evidence of a marginally higher levels of programme completion (RR = 1.04, 95% CI 1.01 to 1.07, P = 0.009, fixed‐effect) and adherence to the programme (not poolable). No consistent difference was seen in healthcare costs between the two forms of cardiac rehabilitation.
Authors' conclusions
This updated review supports the conclusions of the previous version of this review that home‐ and centre‐based forms of cardiac rehabilitation seem to be equally effective for improving the clinical and health‐related quality of life outcomes in low risk patients after MI or revascularisation, or with heart failure. This finding, together with the absence of evidence of important differences in healthcare costs between the two approaches, 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 should reflect the preference of the individual patient. Further data are needed to determine whether the effects of home‐ and centre‐based cardiac rehabilitation reported in these short‐term trials can be confirmed in the longer term. A number of studies failed to give sufficient detail to assess their risk of bias.
PICOs
Plain language summary
Comparison of different modes of cardiac rehabilitation
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 within a hospital, gymnasium or a sport centre setting) are offered to individuals after cardiac events, while home‐based cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation. The aim of this review was to compare the effects of home‐based cardiac rehabilitation programmes with supervised centre‐based cardiac rehabilitation. The findings of this review show that home‐ and hospital‐based interventions are similar in their benefits on coronary heart disease risk factors (e.g. smoking, lipids, and blood pressure), health‐related quality of life, death, clinical events, and costs. There was some evidence to suggest that home‐based interventions were associated with a higher level of adherence. The general lack of reporting of methods in the included trial reports made it difficult to assess their methodological quality and thereby judge their risk of bias. Further data are needed to confirm whether these short‐term effects of home‐ and centre‐based cardiac rehabilitation can be confirmed in the longer term.
Authors' conclusions
Summary of findings
| Trial First author (year) | Follow up | HRQoL measure | Outcome values at follow up Mean (SD) Home vs. centre, between group P‐value | Between‐group difference |
| Bell (1998) | 10.5 months | Nottingham Health Profile Energy Pain Emotional reactions Sleep Social isolation Physical mobility | 18.6 (28.4) vs. 17.3 (30.7) P = 0.78* 6.6 (15.3) vs. 7.4 (15.5) P = 0.74* 6.6 (15.3) vs. 7.4 (15.5) P = 0.74* 6.6 (15.3) vs. 16.9 (22.8) P = 0.0007* 3.7 (13.6) vs. 6.7 (15.0) P = 0.18* 6.9 (13.5) vs. 9.1 (15.9) P =0.33* | Home = Centre Home = Centre Home = Centre Home < Centre Home = Centre Home = Centre |
| Arthur (2002) /Smith (2004) | 6 months 18 months | SF‐36 PCS MCS SF‐36 PCS MCS | 51.2 (6.4) vs. 48.6 (7.1) P = 0.003* 53.5 (6.4 ) vs. 52.0 (8.1) P = 0.13* 48.3 (11.7) vs.47.6 (11.7) P = 0.67* 53.0 (10.9) vs. 50.2 (10.9) P = 0.07* | Home > Centre Home = Centre Home = Centre Home = Centre |
| Cowie (2012) | 3 months | SF‐36 PCS MCS MLWHF Total Physical Emotional | 34.01 (11.04) vs 31.33 (7.97) P = 0.82 44.44 (12.23) vs. 48.25 (11.21) P = 0.04 37 (NR) vs 32 (NR) P = 0.18 21 (NR) vs 19 (NR) P = 0.31 7 (NR) vs 7 (NR) P = 0.13 | Home = Centre Home < Centre Home = Centre Home = Centre Home = Centre |
| Marchionni (2003) | 2 months 8 months 14 months | Sickness Impact Profile | 2.83 (14.5) vs. 4.71 (11.1) P = 0.09* 2.83 (14.5) vs. 3.40 (11.1) P = 0.61* 2.00 (8.3) vs. 3.70 (11.8) P = 0.06* | Home = Centre Home = Centre Home = Centre |
| Dalal (2007)/Taylor (2007) | 9 months | MacNew Global score EQ‐5D | 5.61 (1.14) vs. 5.54 (1.10) P = 0.71 0.74 (0.04) vs. 0.78 (0.04) P = 0.57 | Home = Centre Home = Centre |
| Jolly (2007) | 6 months 12 months 24 months | EQ‐5D SF‐12 PCS MCS EQ‐5D EQ‐5D | 0.74 (0.26) vs. 0.76 (0.23) P = 0.37 42.28 (10.9) 42.56 (10.8) P = 0.8 49.19 (10.1) 50.33 (9.6) P = 0.3 0.74 (0.27) vs. 0.76 (0.23) P = 0.52* 0.73 (0.29) vs. 0.75 (0.26) P = 0.39* | Home = Centre Home = Centre Home = Centre Home = Centre Home = Centre |
| Karapolat (2009) | 8 weeks | SF‐36 Physical function Physical role Bodily pain General health Vitality Social function Emotional role Mental health | 59.39 (SD 25.35) vs. 69.57 (SD 20.94), P = 0.08* 39.81 (SD 41.75) vs. 48.21 (SD 45.10) P =0.43* 62.42 (SD 30.45) vs. 74.23 (SD 19.66) P = 0.07* 47.25 (SD 23.42) vs. 53.98 SD 25.00) P =0.33* 66.67 (SD 19.82) vs. 69.81 (SD 17.41) P = 0.49* 65.33 (SD 25.60) vs. 69.33 (SD 25.14) P = 0.52* 44.74 (SD 39.77) vs. 37.16 (SD 39.24) P =0.44* 64.67 (SD 19.04) vs. 70.52 (SD 20.37) P = 0.22* | Home = Centre Home = Centre Home = Centre Home = Centre Home = Centre Home = Centre Home = Centre Home = Centre |
| Moholdt (2012) | 6 months | MacNew Emotional domain Physical domain Social domain | 1.2 (0.2) vs. 1.4 (0.2) P>0.05 1.4 (0.7) vs. 1.6 (1.1) P>0.05 4.3 (0.7) vs. 4.3 (1.0) P>0.05 | Home = Centre Home = Centre Home = Centre |
| Oerkild (2011) | 3 months 6 months | SF‐36 PCS SF‐36 MCS SF‐36 PCS SF‐36 MCS | 1.4 (‐1.5 to 4.3) vs, 0.5 (‐2.4 to 3.4), P>0.05 0.8 (‐2.6 to 4.3) vs. ‐0.2 (‐3.6 to 3.4), P>0.05 1.0 (‐1.6 to 3.6) vs. 1.2 (‐1.4 to 3.8), P>0.05 2.3 (‐1.1 to 5.7) vs. 2.6 (‐0.9 to ‐6.0), P>0.05 | Home = Centre Home = Centre Home = Centre Home = Centre |
| Piotrowicz (2010) | 8 weeks | SF‐36 Total | 70.5 (SD 25.4) vs. 69.2 (SD 26.4) | Home = Centre |
| *P‐value calculated by authors of this report based on independent 2‐group t‐test | ||||
| Trial First author (year) | Follow up | Method/definition of adherence assessment | Findings | Between‐group difference |
| Miller (1984)/ DeBusk (1985)/ Taylor (1986) | 6 months | Ratio of exercise sessions completed vs. prescribed | Home: 50/70 (72%) Centre: 28/40 (71%) P‐value not calculable | Home = Centre** |
| Sparks (1993) | 3 months | Percentage of sessions attended | Home: 93% Centre: 88% P‐value not calculable | ? |
| Cowie (2012) | 3 months | Percentage completion of 16 exercise sessions | Home: 77% Centre: 86% P = 0.32 | Home = Centre |
| Karapolat (2009) | 8 weeks | Attendance at exercise sessions | Home: (32/37) 87.5% Centre: (33/37) 90% P = 0.72* | Home = Centre |
| Carlson (2000) | 6 months | Attendance at all 3 nutrition/risk factor classes Total exercise over follow up – number of sessions ≥ 30 min | Home: 27/38 (71%) Centre: 33/42 (79%) P = 0.438* Home: mean 111.8 (SD 29.1) Centre: mean 98.1 (SD 33.4) P = 0.06† | Home = Centre Home = Centre |
| Gordon (2002) | 3 months | Percentage of completed scheduled appointments (exercise sessions, office/on site visits, “telephone visits” in accordance with intervention protocol) | Home (MD supervised): 83% Home (community‐based): 86% Centre: 81% | Home = Centre** |
| Arthur (2002) /Smith (2004) | 6 months 18 months | Number of exercise session reported/week Percentage of patients seeking dietician consultation Percentage of patients seeking psychologist consultation Level of physical activity – Physical Activity Scale for the Elderly | Home: mean 6.5 (SD 4.6) Centre: mean 3.7 (SD 2.6) P < 0.0001† Home 50% (mean 3.5, SD 2.5 visits) Centre: 53% (mean 3.6, SD 2.3 visits) Home: 42% (mean 2.6, SD 2.4 visits) Centre: 51% (mean 2.5, SD 2.2 visits) Home: mean 232.6 (SD 99.4) Centre: mean 170.0 (SD 89.2) P < 0.0001† | Home > Centre ? Home = Centre** Home > Centre |
| Marchionni (2003) | 4 months | Number of exercise sessions completed | Home: 37.3 (SD 3.4) Centre: 34.3 (SD 4.4) P < 0.0001† | Home > Centre |
| Daskapan (2005) | 3 months | Percentage of sessions attended | Home: 97% Centre: 81% P‐value not calculable | ? |
| Dalal (2007) | 9 months | Number who participated in intervention | Home: 40/60 (67%) Centre: 32/44 (72%) P = 0.51* | Home = Centre |
| Jolly (2007) | 3 months 6 months 12 months 24 months | Hours of self‐reported activity weighted for intensity | Home: mean 23.2 (SD 22.1) Centre: mean 18.7 (SD 19.3) P = 0.06† Home: mean 16.4 (SD 17.0) Centre: mean 18.1 (SD 25.4) P = 0.4† Home: mean 19.2 (SD 20.8) Centre: mean 15.9 (SD 16.7) P = 0.06† Home: mean 18.9 (SD 18.4) Centre: mean 16.6 (SD 16.4) P = 0.16† | Home = Centre Home = Centre Home = Centre Home = Centre |
| Moholdt (2012) | 6 months | Training diaries (only reported for home group) | Home: 7/10 patients (with complete diary data) reported ≥2 weekly interval sessions over 6 months follow up | ? |
| Piotrowicz (2010) | 8 weeks | Percentage of patients who carried out the prescribed exercise training (home group: daily telephone contacts with monitoring centre; centre group: attendance at supervised sessions). | Home: 77/77 (100%) Centre: 59/75 (79%) P < 0.0001† | Home > Centre |
| *calculated by authors of this report based on Chi2 test †calculated by authors of this report based on independent t‐test | ||||
| Trial First author (year) | Currency Year of costs Follow up | Cardiac rehabilitation programme cost (per patient) | Programme costs considered | Total healthcare cost (per patient)
| Additional healthcare costs considered | Comments |
| US$ Not reported 6 months | Home: mean 1,519 Centre: mean 2,349
| Staff, ECG monitoring | Not reported |
|
| |
| US$ 2000 14 months | Home: mean 1,650 Centre: mean 8,841 | Not reported | Home: 21,298 Centre: 13,246 | Not reported |
| |
| UK£ 2002‐3 9 months | Home: mean 170 (SD 8) Centre: mean 200 (SD 3) Difference: mean 30 95% CI ‐45 to ‐12 P < 0.0001 | Staff, exercise equipment, staff travel | Home: mean 3,279 (SD 374) Centre: mean 3,201 (SD 443) Difference: mean 78 95% CI ‐1,103 to 1,191 P = 0.894 | Rehospitalisations, revascularisations, secondary preventive medication, investigations, primary care consultations |
| |
| UK£ 2003 24 months | Home: mean 198 95% CI 189 to 209 Centre: Mean 157 95% CI 139 to 175 P < 0.05 | Staff, telephone consultations, staff travel | Not reported | With inclusion of patient costs (travel and time), the societal costs of home‐ and centre‐based cardiac rehabilitation were not significantly different | ||
| ECG = electrocardiogram | ||||||
| Trial First author (year) | Dalal (2007) | Gordon (2002) | Bell (1998) | Carlson (2000) | Marchonni (2003) | Jolly (2007) | ||
| Follow up | 9 months | 3 months | 0‐6 months | 6‐12 months | 6 months | 14 months | 12 month | 24 month |
| Rehospitalisations N patient (%)
Mean (SD) | Home 9/60 (15%) Centre 6/44 (14%) P = 0.845 Home 2.2 (0.9)† Centre 1.2 (0.6) P = 0.383 |
| Home 21/90 (23%) Centre 19/88 (22%) P = 0.78#
| 13/89 (15%) 12/84 (14%) P = 0.95# |
|
Home 0.46 (SE 0.1) Centre 0.33 (SE 0.1) P = 0.49 |
Home 0.08 (0.34) Centre 0.12 (0.41) P = 0.3 |
Home 0.20 (0.45) Centre 0.26 (0.57) P = 0.3 |
| Primary care consultations Mean (SD) |
Home 6.3 (0.6) Centre 7.0 (0.9) P = 0.514 |
|
Home 6.6 (3.6)* Centre 6.6 (4.1) P = 1.00# |
5.4 (4.1) 4.6 (3.7) P = 0.19# |
|
| Home 0.65 (1.14) Centre 0.72 (1.54) P = 0.8 | Home 0.53 (1.14) Centre 0.66 (1.42) P = 0.7 |
| Secondary prevention medication N patients (%) beta‐blockers
ACE inhibitors
Statins
Antiplatelets |
Home 31/49 (63%) Centre 24/34 (71%) P = 0.49 Home 30/49 (61%) Centre 24/33 (73%) P = 0.28 Home 48/49 (98%)* Centre 30/35 (88%)* P = 0.18 Home 46/49 (94%) Centre 30/35 (86%) P = 0.21 |
Home 36/97 (37%) Centre 17/45 (38%) NS Home 25/97 (26%) Centre 8/45 (18%) NS Home 73/97 (75%) Centre 33/45 (73%) NS Home 94/97 (97%)* Centre 45/45 (100%)* NS |
|
|
Home 19/38 Centre 18/42 P = 0.52# Home 4/38 Centre 4/42 P = 0.88# Home 5/38 Centre 8/42 P = 0.47# Home 15/38 Centre 20/42 P = 0.54# |
|
Home 169 (72.2%) Centre 171 (73.4%) P = 0.8 Home 176 (75.2%)* Centre 161 (69.1%)* P = 0.1 Home 216 (92.3%)** Centre 221 (94.8%)** P = 0.3 Home 227 (97.0%)† Centre 226 (97.0%)† P = 1.0 |
Home 161 (71.6%) Centre 164 (72.2%) P = 0.9 Home 177 (78.7%)* Centre 156 (68.7%)* P = 0.02 Home 195 (86.7%)** Centre 206 (90.7%)** P = 0.2 Home 214 (95.1%)+ Centre 220 (96.9%)+ P = 0.3 |
| Comments
| †number of nights *lipid lowering drugs | *antiplatelets & anticoagulants | *GP consultations |
|
|
| *ACEi or Angiotensin II receptor antagonist **cholesterol‐lowering drugs †Aspirin or antiplatelet drugs | |
| #P‐value calculated by authors of the present report | ||||||||
| Trial First author (year) | Moholdt (2012) | Oerkild (2011) |
| Follow up | 6 months | 12 months |
| Rehospitalisations N patient (%) Number Mean (SD) | Not reported | Number and length of admissions same between groups |
| Primary care Consultations Mean (SD) | Not reported | Not reported |
| Secondary prevention medication N patients (%) beta‐blockers ACE inhibitors Antihypertensives Statins Antiplatelets | Home: 8/14 (57%) Centre: 15/16 (94%) P = 0.02* Home: 1/14 (7%) Centre: 0/16 (0%) P = 0.28* Home: 6/14 (43%) Centre: 2/16 (13%) P = 0.07* Home: 14/14 (100%) Centre: 14/16 (100%) P = 0.18* | Not reported |
| Comments | ||
| *P‐value calculated by authors of the present report | ||
Background
Description of the condition
Cardiovascular disease is the leading cause of death globally: in 2004 there were an estimated 7.2 million deaths attributable to coronary heart disease (CHD; WHO 2010). CHD causes significant morbidity and mortality, and as a chronic disease it contributes greatly to disability in developed countries; it accounts for 11.1% of total disability adjusted life years in European countries (WHO 2008). CHD can result in difficulties in functionality and performing everyday activities, and impairs sexual function (Racca 2010), all contributing to a reduction in health‐related quality of life (Gravely‐Witte 2007).
Mortality from CHD has decreased in many developed countries in recent decades. However, morbidity is increasing; as a result of improved diagnosis and more successful treatment of acute illness, a larger number of people survive myocardial infarction (MI; WHO 2008), as well as live with heart failure (Kostis 1997).
Description of the intervention
Whilst there are many definitions of cardiac rehabilitation (CR), the following describes their combined key elements: “The coordinated sum of activities required to influence favourably the underlying cause of cardiovascular disease, as well as to provide the best possible physical, mental, and social conditions, so that the patients may, by their own efforts, preserve or resume optimal functioning in their community and through improved health behaviour, slow or reverse progression of disease” (BACPR 2012; Buckley 2013). A central component of CR is exercise training (Piepoli 1998; Piepoli 2010). However, in addition to exercise, it is recommended that programmes provide lifestyle education on CHD risk factor management plus counselling and psychological support ‐ so‐called ‘comprehensive CR’ (Corra 2005).
CR has been shown to improve health‐related quality of life and reduce future morbidity (Heran 2009; Davies 2014a; Taylor 2004). Based on current evidence, national and international guidelines on the management of CHD and heart failure, including those from the American College of Cardiology/American Heart Association, European Society of Cardiology, the National Institute for Health and Care Excellence (NICE) in the United Kingdom and the Canadian Association of Cardiovascular Prevention and Rehabilitation recommend CR as an effective and safe intervention (NICE 2010; NICE 2013; McMurray 2012; Stone 2005; Yancy 2013).
How the intervention might work
There are a number of mechanisms by which exercise training benefits patients dependent on the cause of their heart disease. For people with CHD, approximately half of the 28% reduction in cardiac mortality achieved with exercise‐based CR has been attributed to reductions in major risk factors, particularly smoking (Taylor 2006). For patients with ischaemic causes of heart failure, exercise training appears to improve myocardial perfusion by alleviating endothelial dysfunction thereby dilating coronary vessels, and by stimulating new vessel formation by way of intermittent ischaemia (ExTraMatch 2004). Indeed, Haykowsky and colleagues have demonstrated that aerobic training in heart failure patients improves myocardial contractility and diastolic filling (Haykowsky 2007). A meta‐analysis by Haykowsky et al demonstrated the benefits of exercise training in heart failure patients in terms of cardiac remodelling as measured by ejection fraction, end‐diastolic volume, and end‐systolic volume (Haykowsky 2007). Skeletal muscle dysfunction and wasting may also respond to exercise training (Haykowsky 2007). In addition, regular physical activity in heart failure patients stimulates vasodilation in the skeletal muscle vasculature and improves oxidative capacity (Hambrecht 1998).
Why it is important to do this review
Although the beneficial effects of CR have been shown, participation remains sub‐optimal (Dalal 2012). Two of the main reasons people give for not accepting the invitation to attend CR are difficulty with regularly attending sessions at their local hospital and reluctance to take part in group‐based classes (Beswick 2004). Home‐based CR programmes have therefore been introduced in an attempt to improve rates of participation. In the UK, home‐based CR with a self‐help manual ‐ the Heart Manual ‐ supported by a nurse facilitator is a popular method of rehabilitation (Lewin 1992). Home‐based CR programmes can include supervised and unsupervised elements. Figures from the National Audit for Cardiac Rehabilitation (NACR) indicate that of the 199 sites in the UK and Republic of Ireland that provide CR, 39 (20%) of these sites are currently providing the Heart Manual (NACR 2013), with some 13,000 copies given to patients in UK each year (Heart Manual 2008). The Heart Manual has also been used in Italy, Canada, Australia, and New Zealand (Heart Manual 2008).
In the previous version of this Cochrane review, the authors identified 12 head‐to‐head randomised controlled trials (˜1900 participants) of home‐ versus centre‐based CR and found them to be equally effective in improving exercise capacity, risk factors, mortality, health‐related quality of life outcomes, and costs (Taylor 2009; Dalal 2010). On the basis of this evidence, the authors concluded that the provision of home‐based programmes should continue in addition to the more traditional centre‐based model of CR. However, the majority of studies recruited low risk patients following MI or revascularisation. Only two studies included a total of ˜150 patients with New York Heart Association class II‐III heart failure (Daskapan 2005; Kassaian 2000). This review update includes additional new trials comparing home‐ and centre‐based CR in the heart failure population.
Objectives
To compare the effect of home‐based and supervised centre‐based CR on mortality and morbidity, health‐related quality of life, and modifiable cardiac risk factors in patients with CHD.
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials (RCTs; individual or cluster level), including parallel group, cross‐over or quasi‐randomised designs, were eligible for inclusion. Systematic reviews and meta‐analyses were identified as a means to identify additional RCTs.
Types of participants
The study population includes adults who are post MI, have angina, or have undergone revascularisation (coronary artery bypass grafting, percutaneous transluminal coronary angioplasty or coronary artery stent) or who have heart failure, who have taken part, or been invited to take part, in CR.
Studies will be excluded if they include participants with heart transplants, those implanted with either cardiac resynchronisation therapy or implantable defibrillators, or those who have previously received CR.
Types of interventions
Home‐based CR is defined as a structured programme with clear objectives for the participants, including monitoring, follow up visits, letters or telephone calls from staff or at least self‐monitoring diaries (Jolly 2006). The comparison group is centre‐based CR based in a variety of settings (e.g. hospital physiotherapy department, university gymnasium, community sports centre). We included CR programmes whether they were based solely on exercise or included other intervention elements (comprehensive CR).
Types of outcome measures
To be included the study must include one or more of the following outcomes:
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Mortality (cardiac and overall).
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Morbidity (reinfarction, revascularisation, cardiac‐associated hospitalisation).
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Exercise capacity, modifiable coronary risk factors (smoking behaviour, blood lipid levels, blood pressure).
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Health‐related quality of life.
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Adverse events (withdrawal from the exercise programme).
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Adherence to CR.
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Health service use.
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Cost.
Search methods for identification of studies
Electronic searches
For the previous version of the review, studies were identified from a previously published systematic review (Jolly 2006), and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2007), MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science (2001 to January 2008) were searched (Taylor 2009).
We updated this search on 14 October 2014 by searching CENTRAL (The Cochrane Library, Issue 9, 2014), MEDLINE (Ovid, 1946 to October week 1 2014), EMBASE (Ovid, 1980 to 2014 week 41), PsycINFO (OVID, 1806 to October week 2 2014), and CINAHL plus (EBSCO, to October 2014). We did not search Web of Science for this update due to limited resources. We also checked trial registers (Controlled‐trials.com and Clinicaltrials.gov).
We limited searches to RCTs in humans, without language or other restrictions. Search strategies were designed with reference to those of the previous systematic review (Taylor 2009), and in accordance with the Cochrane Handbook of Reviews of Interventions (Higgins 2011; see Appendix 1). The search strategy for the 2009 version of the review is detailed in Appendix 2.
Searching other resources
Reference lists of all eligible trials and systematic reviews were searched for additional studies.
Data collection and analysis
Selection of studies
We screened the titles and abstracts of identified studies, and discarded clearly irrelevant ones. Two authors then obtained and independently assesses the full‐text reports of all potentially relevant randomised and quasi‐randomised trials for eligibility, based on the defined inclusion criteria. Any disagreement was resolved by discussion and in those few occasions where uncertainty remained, the opinion of two further authors was taken.
Data extraction and management
We extracted relevant data regarding inclusion criteria (study design, participants, interventions, and outcomes), risk of bias (see below), and results. Data extraction was carried out by a single author and checked by a second author. Excluded studies and reasons for exclusion are detailed in Characteristics of excluded studies. Where necessary, authors of included studies were contacted for missing information.
Assessment of risk of bias in included studies
Factors considered included the quality of random sequence generation and allocation concealment, the description of drop‐outs and withdrawals (including analysis by intention‐to‐treat), consideration of blinding (participants, personnel and outcome assessors), and degree of selective outcome reporting. In addition evidence was sought that the groups were balanced at baseline and that intention‐to‐treat analysis was undertaken. The risk of bias in eligible trials was assessed by a single author and checked by a second author.
Data synthesis
We processed data in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We sought outcome results at follow up and the focus of this review was the between‐group difference in home‐ versus centre‐based groups. For dichotomous variables, relative risks (RR) and 95% confidence intervals (CI) were derived for each outcome. For continuous variables, mean differences (MD) and 95% CI were calculated for each outcome. When the results at follow up and differences between groups of the individual trials were not reported in the original publication, we calculated P‐values for the differences using the reported mean and standard deviation with the ittest command in STATA.
Heterogeneity amongst included studies was explored qualitatively (by comparing the characteristics of included studies) and quantitatively (using the Chi2 test of homogeneity and I2 statistic). Where appropriate, the results from included studies were combined for each outcome to give an overall estimate of treatment effect. A fixed‐effect meta‐analysis was used except where statistical heterogeneity was indicated by a I2 of > 50%, in which case a random‐effects model was used.”
Given the variety of exercise capacity measures reported, results for this outcome were expressed as a standardised mean difference (SMD). Where a trial reported more than one exercise capacity endpoint we used the first one reported in the publication. Other continuous outcomes were pooled as weighted mean differences (WMD).
We had intended to use stratified meta‐analysis and meta‐regression to further explore heterogeneity and examine potential treatment effect modifiers. Given the small number of included trials, however, such analyses were deemed inappropriately underpowered (Higgins 2011).
Marchionni 2003 reported outcomes for home‐ versus centre‐based care according to three patient age subgroups (i.e. 45 to 65, 66 to 75, > 75 years). We have pooled these data to obtain single overall outcome results for home‐ and centre‐based groups.
Gordon et al compared two home‐based exercise groups: a physician‐supervised nurse‐case‐managed programme and a community‐based programme (Gordon 2002 Supervised; Gordon 2002 Community, respectively), versus a centre‐based CR programme. The study by Miller et al compared home‐ versus centre‐based CR programmes that were either 11 weeks long or 26 weeks long (Miller 1984 Brief; Miller 1984 Expanded, respectively). For each of these two studies, we report outcome results separately for each comparison.
Given the small number of studies, it was not possible to assess potential small study effects and publication bias using funnels plots and Egger tests (Egger 1997) with the exception of the outcome of exercise capacity.
Results
Description of studies
Results of the search
The 2009 version of the Cochrane review contributed 12 trials to this latest analysis (Arthur 2002; Bell 1998; Carlson 2000; Dalal 2007; Daskapan 2005; Gordon 2002 Community; Gordon 2002 Supervised; Jolly 2007; Kassaian 2000; Marchionni 2003; Miller 1984 Brief; Miller 1984 Expanded; Sparks 1993; Wu 2006). For this update, we identified one previously included trial with longer follow up (Arthur 2002) and five new trials (Cowie 2012; Karapolat 2009; Moholdt 2012; Oerkild 2011; Piotrowicz 2010). Therefore we included a total of 17 trials (28 papers) in the review. The study selection process is summarised in the PRISMA flow diagram (Figure 1).
Included studies
The 17 trials (19 home‐ vs centre‐based comparisons) included a total of 2172 participants.
Four studies were UK‐based (Bell 1998; Cowie 2012; Dalal 2007; Jolly 2007); four were based in the US (Carlson 2000; Gordon 2002 Community; Gordon 2002 Supervised); Miller 1984 Brief; Miller 1984 Expanded; Sparks 1993; two were from Turkey (Karapolat 2009; Daskapan 2005); and one each was from Canada (Arthur 2002), Denmark (Oerkild 2011), Norway (Moholdt 2012), Italy (Marchionni 2003), Iran (Kassaian 2000), Poland (Piotrowicz 2010), and China (Wu 2006). Most studies reported outcomes up to 12‐month post‐randomisation. Only three studies reported longer‐term follow up at 14 months (Marchionni 2003), 18 months (Arthur 2002), and 24 months (Jolly 2007). Eleven studies compared comprehensive programmes (i.e. exercise plus education and/or psychological management) while the remainder reported only an exercise intervention (Cowie 2012; Daskapan 2005; Karapolat 2009; Kassaian 2000; Miller 1984 Brief; Miller 1984 Expanded; Wu 2006). The CR programmes differed considerably in duration (range: one and a half to six months), frequency (one to five sessions per week) and session length (20‐60 minutes per session). Most programmes used individually tailored exercise prescription which makes it difficult to precisely quantify the amount of exercise undertaken. Centre‐based programmes typically provided supervised cycle and treadmill exercise while virtually all home programmes were based on walking, with some level of intermittent nurse or exercise specialist telephone support. The majority of studies recruited a lower risk patient following an acute MI and revascularisation, excluding those with significant arrhythmias, ischaemia, or heart failure. Five studies included individuals (345 participants) with New York Heart Association (NYHA) class II or III heart failure (Cowie 2012; Daskapan 2005; Karapolat 2009; Kassaian 2000; Piotrowicz 2010).
Details of included studies are listed in Characteristics of included studies.
Excluded studies
Twenty three papers were excluded: 20 were comparisons of home‐ or centre‐based CR versus usual care and three were non‐RCTs. Details of excluded studies are listed in Characteristics of excluded studies.
Risk of bias in included studies
A number of study reports did not contain sufficient detail to assess their potential risk of bias (Figure 2; Figure 3). Details of generation and concealment of random allocation sequence were particularly poorly reported. In two cases there was objective evidence of imbalances in baseline characteristics (Arthur 2002; Cowie 2012). Given the nature of these trials, it is not possible to blind the patients or carers to group allocation; in such situations, blinding outcome assessors to knowledge of allocation is probably of greater importance. However, only seven studies stated that they took measures to blind outcome assessment (Arthur 2002; Bell 1998; Cowie 2012; Dalal 2007; Jolly 2007; Marchionni 2003; Wu 2006).
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Loss to follow up varied considerably across studies and was often asymmetric across home‐ and centre‐based CR groups. Although the type of analysis was often not stated, all studies appeared to undertake an intention‐to‐treat analysis, in that groups were analysed according to initial random allocation, and there was generally good evidence of balance in baseline characteristics between groups. Only a few trials examined the impact of losses to follow up or drop out. As discussed above, the rehabilitation intervention was usually tailored to the individual patient, so it is difficult to quantify the precise level of intervention; however, the intensity of the rehabilitation programme seemed to differ substantively between home‐ and centre‐based arms. For example, the studies by Bell 1998, Dalal 2007, and Jolly 2007 included hospital CR programmes which were fixed in terms frequency and content over the period of the study. In contrast the home‐based intervention in these studies consisted of use of the Heart Manual where the patients could self‐regulate the frequency and nature of rehabilitation sessions they undertook. The majority of trials were judged to be of low risk of bias in terms of selective reporting and whether groups received the same co‐interventions.
Effects of interventions
See: Summary of findings for the main comparison Summary of health‐related quality of life (HRQoL) at follow up for home and centre‐based CR; Summary of findings 2 Summary of adherence at follow up in home and centre‐based CR; Summary of findings 3 Summary of costs in home‐ and centre‐based settings; Summary of findings 4 Summary of healthcare utilisation in home‐ and centre‐based settings; Summary of findings 5 Summary of healthcare in hospital‐ and centre‐based settings, continued
Clinical events
Mortality
Eight trials reported all‐cause mortality up to 1 year following the intervention (Bell 1998; Dalal 2007; Daskapan 2005; Jolly 2007; Miller 1984 Brief; Miller 1984 Expanded; Moholdt 2012; Oerkild 2011; Piotrowicz 2010). Miller and colleagues reported no deaths in either the home‐ or centre‐based CR groups over the period of the study, therefore these results have not been included in the pooled analysis (Miller 1984 Brief; Miller 1984 Expanded). A pooled analysis of the remaining studies (1166 participants) found no evidence of a significant difference in mortality at three to 12 months of follow up between home‐ and centre‐based CR (fixed‐effect RR = 0.79, 95% CI 0.43 to 1.47; I2 = 0%; 1166 participants; Analysis 5.1). Jolly 2007 reported there to be no between‐group difference in mortality at 24‐month follow up (home group: 6/263; centre group: 3/262 , P = 0.32).
Cardiac events
Only four studies reported cardiac events. Given the differing nature of the events reported it was not possible to pool the data. Dalal 2007 and Jolly 2007 reported no difference in revascularisation or recurrent MI events between home‐ and centre‐basd CR. Piotrowicz 2010 reported no heart failure related admissions in either group. Oerkild 2011 stated that “the number and length of acute and non‐acute admissions and adverse events (admission for MI, progressive angina, decompensated congestive heart failure, severe bleeding, new malignant disease and performance of [percutaneous coronary intervention]) to be equally distributed [across groups at 12 months follow up]” but did not report numbers of events. The recent six‐year follow up report of the Arthur 2002 study by described that a total of 46/79 (62%) centre‐based CR patients experienced a hospitalisation compared to 35/70 (50%) in the home‐based group (P = 0.31). However, the total number of hospitalisations in centre‐based patients was greater than that in home‐based ones (79 vs 42, P < 0.0001).
Exercise capacity
All 17 included studies (19 comparisons) reported on exercise capacity in the short‐term (eight weeks to 12 months follow up), while three (Arthur 2002; Jolly 2007; Marchionni 2003) presented longer‐term data (> 12 months follow up) and one reported outcomes at 6‐year follow up (Arthur 2002). All studies reported absolute exercise capacity at follow up, except two trials (Gordon 2002 Supervised; Gordon 2002 Community; Oerkild 2011) which instead reported change in exercise capacity at follow up compared to baseline. Studies reported exercise capacity using a variety of metrics that included direct measures of oxygen uptake, walking distance, and workload on a static cycle.
The pooled analysis across all 17 studies (1876 participants) showed no evidence of a statistically significant difference in short‐term exercise capacity between home‐based and centre‐based CR (random‐effects SMD = ‐0.10, 95% CI ‐0.29 to 0.08, P = 0.29, Analysis 1.1). There was evidence of substantial heterogeneity (I2 = 72%).
In a pooled analysis of three studies reporting longer‐term data (>12 months; 1,074 participants; Arthur 2002; Jolly 2007; Marchionni 2003), there was no evidence of a difference in exercise capacity following home‐based CR compared with centre‐based CR (fixed‐effect SMD = 0.11, 95% CI ‐0.01 to 0.23; P = 0.06, I2 = 0%; Analysis 1.2). Arthur 2002 reported that mean peak oxygen consumption (VO2) at six‐year follow up was higher in the 96 patients who had undergone home‐based CR (1543 mL/min (SD 444)) compared to the 74 patients who had received centre‐based CR (1412 mL/min (SD 356); P = 0.01).
Modifiable risk factors
Blood pressure
Eight of the included trials (9 comparisons) reported on systolic and diastolic blood pressure (Carlson 2000; Dalal 2007; Daskapan 2005; Gordon 2002 Community; Gordon 2002 Supervised; Jolly 2007; Kassaian 2000; Oerkild 2011), or systolic blood pressure alone (Bell 1998). Absolute values at follow up were reported in all but two studies (Gordon 2002 Supervised; Gordon 2002 Community; Oerkild 2011) where the change from baseline was reported. We obtained unpublished data for the study by Dalal et al (Dalal 2007).
Although no difference in pooled systolic blood pressure was found between groups (random‐effects MD = 0.19 mmHg, 95% CI ‐3.37 to 3.75; P = , 0.82, I2 = 65%); Analysis 3.1; 1117 participants), diastolic blood pressure at follow up was slightly lower following centre‐ compared to home‐based CR (fixed‐effect WMD = ‐1.86 mmHg; 95% CI ‐0.76 to ‐2.95; P = 0.009, I2 = 37%; 991 participants; Analysis 3.2). At 24‐month follow up, Jolly 2007 reported no significant difference between home‐ and centre‐based CR groups in systolic blood pressure (MD = 0.85 mmHg; 95% CI ‐2.48 to 4.18) or diastolic blood pressure (MD = 0.76 mmHg, 95% CI ‐1.12 to 2.64)
Blood lipids
Eight of the included trials (9 comparisons) reported data on blood lipids (Bell 1998; Carlson 2000; Dalal 2007; Gordon 2002 Community; Gordon 2002 Supervised; Jolly 2007; Kassaian 2000; Moholdt 2012; Oerkild 2011). All reported total cholesterol values, six reported high density lipoprotein concentrations (Carlson 2000; Gordon 2002 Community; Gordon 2002 Supervised; Jolly 2007; Kassaian 2000; Moholdt 2012; Oerkild 2011), and four reported low density lipoprotein and triglyceride concentrations (Carlson 2000; Gordon 2002 Community; Gordon 2002 Supervised; Kassaian 2000; Oerkild 2011). All reported absolute follow up data except two where data were reported as the change at follow up from baseline (Gordon 2002 Community; Gordon 2002 Supervised; Oerkild 2011). Study results were expressed as millimols per litre (mmol/L; Bell 1998; Dalal 2007; Jolly 2007) or milligrams per decilitre (mg/dL; Carlson 2000; Gordon 2002 Community; Gordon 2002 Supervised; Kassaian 2000); in the latter case we converted values into mmol/L before pooling in the meta‐analysis.
Total cholesterol
The pooled analysis of data at 3 to 12 months of follow up revealed no evidence of a significant difference in the total cholesterol between home‐ and centre‐based groups (random‐effects MD = ‐0.07 mmol/L, 95% CI ‐0.24 to 0.11; I2 = 62%; P = 0.47; 1,109 participants; Analysis 2.1).
Jolly 2007 reported no significant difference between home‐ and centre‐based CR groups in total cholesterol concentration at 24‐month follow up (MD = 0.11 mmol/L, 95% CI ‐0.06 to 0.28).
High density lipoprotein cholesterol
The pooled analysis of data at 3 to 12 months of follow up revealed some evidence of a lower high density lipoprotein concentration after centre‐ compared to home‐based CR (random‐effects WMD = ‐0.07 mmol/L, 95% CI ‐0.03 to ‐0.11; P = 0.011, I2 = 43%; 883 participants; Analysis 2.2).
Jolly 2007 reported no significant difference between home‐ and centre‐based CR groups in high density lipoprotein level at 24‐month follow up (MD = 0.03 mmol/L, 95% CI ‐0.10 to 0.04).
Low density lipoprotein cholesterol
In the pooled analysis of data at 3 to 12 months of follow up there was no evidence of a difference in low density lipoprotein concentration between centre‐ and home‐based CR (random‐effects MD = ‐0.06 mmol/L, 95% CI ‐0.27 to 0.15; P = 0.05, I2 = 62%; 388 participants; Analysis 2.3).
Triglycerides
In the pooled analysis of data at 3 to 12 months of follow up there was evidence of slightly lower triglyceride levels in centre‐based CR participants (fixed‐effect MD = ‐0.18 mmol/L, 95% CI ‐0.02 to ‐0.34; P = 0.03, 354 participants; Analysis 2.4).
Smoking behaviour
Five studies reported on patient self‐reported smoking behaviour at 3 to 12 months of follow up (Bell 1998; Dalal 2007; Gordon 2002 Community; Gordon 2002 Supervised; Jolly 2007; Oerkild 2011). There was no evidence indicating a difference in the proportion of smokers at follow up between centre‐ and home‐based CR (fixed‐effect RR = 0.98, 95% CI 0.79 to 1.21; P = 0.83; 986 participants; Analysis 4.1). Jolly 2007 reported no difference in smoking between home‐ and centre‐based arms at 24 months (RR = 1.16, 95% CI 0.58 to 33.3).
There was evidence of a consistent reduction in self‐reported smoking behaviour following both home‐ and centre‐based CR. This finding was confirmed in the one study that used cotinine‐validated assessments of smoking (Jolly 2007).
Health‐related quality of life
Ten of the trials reported validated measures of health‐related quality of life (HRQoL; summary of findings Table for the main comparison). These included four generic HRQoL instruments: EQ‐5D (EuroQoL 1990), Nottingham Health Profile (Hunt 1980), Short‐Form 36 (SF‐36; McHorney 1993), Sickness Impact Profile (Bergner 1976), and one disease‐specific instrument (MacNew; Höfer 2004). This wide variation in health‐related quality of life outcomes meant that pooling across studies was inappropriate.
Taking individual findings of all studies into account, there was no strong evidence of a difference in overall HRQoL outcomes or domain scores at follow up between home‐ and centre‐based CR.
Individual studies reported consistent improvements in HRQoL at follow up with both home‐ and centre‐based CR compared to baseline. The notable exception was in studies that used the EQ‐5D, which failed to identify significant improvements with home‐ or centre‐based CR (Dalal 2007; Jolly 2007).
Withdrawals & adherence
Withdrawal from intervention
Drop‐out rates from the intervention were inconsistently reported, and the reasons were often unclear. Using the number of completers, i.e. the number of patients with outcome data at follow up, we found some limited evidence of small increase in the level of completion with home‐based compared with centre‐based programmes (fixed‐effect RR 1.04, 95% CI 1.01 to 1.07; Chi2 = 30.26, I2 = 44%, P = 0.02; 1984 participants; Analysis 6.1).
Adherence
Except for four (Bell 1998; Daskapan 2005; Kassaian 2000; Wu 2006), all studies reported adherence to CR over the duration of the study (summary of findings Table 2). There was substantial variation in the way in which adherence was defined and measured, and some studies reported more than one measure of adherence. Pooling across studies was therefore deemed inappropriate. Seven studies (Carlson 2000; Cowie 2012; Dalal 2007; Gordon 2002 Community; Gordon 2002 Supervised; Jolly 2007; Karapolat 2009; Miller 1984 Brief; Miller 1984 Expanded) found no evidence of a significant difference in the level of adherence between groups, while there was evidence of superior adherence in home‐based CR in three studies (Arthur 2002; Marchionni 2003; Piotrowicz 2010). Although three studies (Daskapan 2005; Moholdt 2012; Sparks 1993) reported adherence, it was not possible to assess if there was a statistically significant difference between home and centre.
Costs and healthcare use
Four studies reported costs (summary of findings Table 3). Difference in currencies and timing of studies means that is not possible compare the costs directly across studies. In three of the four studies the healthcare costs associated with CR were lower for the home‐based than centre‐based programmes (Carlson 2000; Dalal 2007; Marchionni 2003), although in only one study was cost significantly lower (Dalal 2007). Jolly 2007 found that home‐based CR was more expensive than centre‐based CR, although the costs of the two would have been the same if patient costs were included. Eight studies reported different aspects of consumption of healthcare resources, including readmissions to hospital, primary care consultations, and use of secondary care medication (summary of findings Table 4; summary of findings Table 5). No significant between‐group differences were seen.
Small study bias
There was no evidence of funnel plot asymmetry for exercise capacity (Egger test P = 0.706; Figure 4).
Funnel plot of comparison: 1 Exercise capacity, outcome: 1.1 Exercise capacity ≤ 12 month.
Discussion
Summary of main findings
The mainstay approach to CR delivery in many countries is an inpatient and outpatient hospital‐based provision, which often takes place in a supervised University, hospital or community setting. The availability of home‐based programmes may provide an opportunity to widen access to, and participation in, CR and thereby may improve uptake and adherence. UK figures suggest that only some 20% of CR programmes currently offer home‐based CR provision (NACR 2013).
This updated review found no evidence supporting important differences in outcomes for patients receiving home‐based or centre‐based CR either in the short‐term (three to 12 months) or longer‐term (up to 24 months). Outcomes considered in this review included exercise capacity, modifiable risk factors (blood pressure, concentrations of lipids in blood, and smoking), health‐related quality of life, cardiac events (including mortality, revascularisation, and readmission to hospital), and adherence to CR. There was some evidence to support superior adherence and completion of rehabilitation in the home‐based setting.
The model of home‐based provision in the largest three included trials was the Heart Manual (Bell 1998; Dalal 2007; Jolly 2007), a home‐based CR programme that consists of a self‐help manual supported by a nurse facilitator (Lewin 1992).
Overall completeness and applicability of evidence
This updated review extends the evidence base of the 2009 review (Taylor 2009), that was primarily limited to trials in individuals with stable CHD either following an acute MI or revascularisation, by including five trials in 345 patients with heart failure.
Quality of the evidence
The general lack of reporting of methods in the included RCT reports made it difficult to assess their methodological quality and thereby judge their risk of bias. There was some evidence of an improvement in the quality of reporting in more recent trials. It was also not possible to consistently judge whether the rehabilitation programmes included in the studies fulfilled recommended quality criteria for delivery of CR programmes, such as the BACPR guidelines (BACPR 2012).
Potential biases in the review process
Our review has limitations. Although the majority of patients in this review receiving home‐based CR were exposed to the Heart Manual model, there was evidence of considerable statistical heterogeneity across a number of outcomes across trials. This heterogeneity may well reflect the variety of centre‐based CR interventions. Data were pooled using a random‐effects meta‐analysis in the presence of statistical heterogeneity. The majority of studies were of relatively short duration; only three trials reported outcomes beyond 12 months of follow up (Arthur 2002; Jolly 2007; Marchionni 2003). Details of interventions were often poorly reported and it was therefore to difficult to assess whether the CR programmes used would meet current recommendations of good practice (BACPR 2012; Piepoli 2010).
It has been hypothesised that patient preference may have an impact on uptake and adherence to home‐based CR, and there is evidence that white patients who work full‐ or part‐time and who perceive time constraints as a barrier to adherence are more likely to have a preference for home‐based provision (Grace 2005). However, such a hypothesis is difficult to test in a traditional RCT and therefore our finding of similar adherence between home‐ and centre‐based CR needs to be interpreted with caution. Dalal 2007 employed a comprehensive cohort design in addition to the randomised element of home‐ and centre‐based allocation in which there was also a patient preference element (patients could choose between home‐ and hospital‐based CR). The authors reported that outcome differences between the home and hospital arms in the preference (non‐randomised) sample were very similar to those in the randomised comparison. Adherence to home‐based CR was also comparable between the randomised (75%) and preference arms (73%). This finding does not support the hypothesis that patients who can choose a programme to suit their lifestyle and preferences will have a higher adherence rate and improved outcomes. However, as with the randomised comparison, the number of patients in the preference arms were small (n = 126).
Agreement and disagreements with other studies or reviews
The findings of this update are consistent with the previous version of this Cochrane review (Taylor 2009). Although not the primary focus of this review, in accord with the two Cochrane reviews of exercise‐based CR (Heran 2009; Davies 2014a), we found there to be an improvement in within‐trial outcomes as the result of receiving either home‐ or centre‐based CR. Healthcare costs seem to depend on the healthcare economy in which CR provision is made. However, this review found no consistent evidence to support an important difference in the cost of providing home‐ versus centre‐based programmes.
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Funnel plot of comparison: 1 Exercise capacity, outcome: 1.1 Exercise capacity ≤ 12 month.
Comparison 1 Exercise capacity, Outcome 1 Exercise capacity ≤ 12 month.
Comparison 1 Exercise capacity, Outcome 2 Exercise capacity 12‐24 month.
Comparison 2 Blood lipids (mmol/L), Outcome 1 Total cholesterol 3‐12 month.
Comparison 2 Blood lipids (mmol/L), Outcome 2 HDL cholesterol 3‐12 month.
Comparison 2 Blood lipids (mmol/L), Outcome 3 LDL cholesterol 3‐12 month.
Comparison 2 Blood lipids (mmol/L), Outcome 4 Triglycerides 3‐12 month.
Comparison 3 Blood Pressure (mmHg), Outcome 1 Systolic BP 3‐12 month.
Comparison 3 Blood Pressure (mmHg), Outcome 2 Diastolic BP 3‐12 month.
Comparison 4 Smoking, Outcome 1 Smoking 3‐12 month.
Comparison 5 Mortality, Outcome 1 Mortality.
Comparison 6 Completers, Outcome 1 Completers.
| Trial First author (year) | Follow up | HRQoL measure | Outcome values at follow up Mean (SD) Home vs. centre, between group P‐value | Between‐group difference |
| Bell (1998) | 10.5 months | Nottingham Health Profile Energy Pain Emotional reactions Sleep Social isolation Physical mobility | 18.6 (28.4) vs. 17.3 (30.7) P = 0.78* 6.6 (15.3) vs. 7.4 (15.5) P = 0.74* 6.6 (15.3) vs. 7.4 (15.5) P = 0.74* 6.6 (15.3) vs. 16.9 (22.8) P = 0.0007* 3.7 (13.6) vs. 6.7 (15.0) P = 0.18* 6.9 (13.5) vs. 9.1 (15.9) P =0.33* | Home = Centre Home = Centre Home = Centre Home < Centre Home = Centre Home = Centre |
| Arthur (2002) /Smith (2004) | 6 months 18 months | SF‐36 PCS MCS SF‐36 PCS MCS | 51.2 (6.4) vs. 48.6 (7.1) P = 0.003* 53.5 (6.4 ) vs. 52.0 (8.1) P = 0.13* 48.3 (11.7) vs.47.6 (11.7) P = 0.67* 53.0 (10.9) vs. 50.2 (10.9) P = 0.07* | Home > Centre Home = Centre Home = Centre Home = Centre |
| Cowie (2012) | 3 months | SF‐36 PCS MCS MLWHF Total Physical Emotional | 34.01 (11.04) vs 31.33 (7.97) P = 0.82 44.44 (12.23) vs. 48.25 (11.21) P = 0.04 37 (NR) vs 32 (NR) P = 0.18 21 (NR) vs 19 (NR) P = 0.31 7 (NR) vs 7 (NR) P = 0.13 | Home = Centre Home < Centre Home = Centre Home = Centre Home = Centre |
| Marchionni (2003) | 2 months 8 months 14 months | Sickness Impact Profile | 2.83 (14.5) vs. 4.71 (11.1) P = 0.09* 2.83 (14.5) vs. 3.40 (11.1) P = 0.61* 2.00 (8.3) vs. 3.70 (11.8) P = 0.06* | Home = Centre Home = Centre Home = Centre |
| Dalal (2007)/Taylor (2007) | 9 months | MacNew Global score EQ‐5D | 5.61 (1.14) vs. 5.54 (1.10) P = 0.71 0.74 (0.04) vs. 0.78 (0.04) P = 0.57 | Home = Centre Home = Centre |
| Jolly (2007) | 6 months 12 months 24 months | EQ‐5D SF‐12 PCS MCS EQ‐5D EQ‐5D | 0.74 (0.26) vs. 0.76 (0.23) P = 0.37 42.28 (10.9) 42.56 (10.8) P = 0.8 49.19 (10.1) 50.33 (9.6) P = 0.3 0.74 (0.27) vs. 0.76 (0.23) P = 0.52* 0.73 (0.29) vs. 0.75 (0.26) P = 0.39* | Home = Centre Home = Centre Home = Centre Home = Centre Home = Centre |
| Karapolat (2009) | 8 weeks | SF‐36 Physical function Physical role Bodily pain General health Vitality Social function Emotional role Mental health | 59.39 (SD 25.35) vs. 69.57 (SD 20.94), P = 0.08* 39.81 (SD 41.75) vs. 48.21 (SD 45.10) P =0.43* 62.42 (SD 30.45) vs. 74.23 (SD 19.66) P = 0.07* 47.25 (SD 23.42) vs. 53.98 SD 25.00) P =0.33* 66.67 (SD 19.82) vs. 69.81 (SD 17.41) P = 0.49* 65.33 (SD 25.60) vs. 69.33 (SD 25.14) P = 0.52* 44.74 (SD 39.77) vs. 37.16 (SD 39.24) P =0.44* 64.67 (SD 19.04) vs. 70.52 (SD 20.37) P = 0.22* | Home = Centre Home = Centre Home = Centre Home = Centre Home = Centre Home = Centre Home = Centre Home = Centre |
| Moholdt (2012) | 6 months | MacNew Emotional domain Physical domain Social domain | 1.2 (0.2) vs. 1.4 (0.2) P>0.05 1.4 (0.7) vs. 1.6 (1.1) P>0.05 4.3 (0.7) vs. 4.3 (1.0) P>0.05 | Home = Centre Home = Centre Home = Centre |
| Oerkild (2011) | 3 months 6 months | SF‐36 PCS SF‐36 MCS SF‐36 PCS SF‐36 MCS | 1.4 (‐1.5 to 4.3) vs, 0.5 (‐2.4 to 3.4), P>0.05 0.8 (‐2.6 to 4.3) vs. ‐0.2 (‐3.6 to 3.4), P>0.05 1.0 (‐1.6 to 3.6) vs. 1.2 (‐1.4 to 3.8), P>0.05 2.3 (‐1.1 to 5.7) vs. 2.6 (‐0.9 to ‐6.0), P>0.05 | Home = Centre Home = Centre Home = Centre Home = Centre |
| Piotrowicz (2010) | 8 weeks | SF‐36 Total | 70.5 (SD 25.4) vs. 69.2 (SD 26.4) | Home = Centre |
| *P‐value calculated by authors of this report based on independent 2‐group t‐test | ||||
| Trial First author (year) | Follow up | Method/definition of adherence assessment | Findings | Between‐group difference |
| Miller (1984)/ DeBusk (1985)/ Taylor (1986) | 6 months | Ratio of exercise sessions completed vs. prescribed | Home: 50/70 (72%) Centre: 28/40 (71%) P‐value not calculable | Home = Centre** |
| Sparks (1993) | 3 months | Percentage of sessions attended | Home: 93% Centre: 88% P‐value not calculable | ? |
| Cowie (2012) | 3 months | Percentage completion of 16 exercise sessions | Home: 77% Centre: 86% P = 0.32 | Home = Centre |
| Karapolat (2009) | 8 weeks | Attendance at exercise sessions | Home: (32/37) 87.5% Centre: (33/37) 90% P = 0.72* | Home = Centre |
| Carlson (2000) | 6 months | Attendance at all 3 nutrition/risk factor classes Total exercise over follow up – number of sessions ≥ 30 min | Home: 27/38 (71%) Centre: 33/42 (79%) P = 0.438* Home: mean 111.8 (SD 29.1) Centre: mean 98.1 (SD 33.4) P = 0.06† | Home = Centre Home = Centre |
| Gordon (2002) | 3 months | Percentage of completed scheduled appointments (exercise sessions, office/on site visits, “telephone visits” in accordance with intervention protocol) | Home (MD supervised): 83% Home (community‐based): 86% Centre: 81% | Home = Centre** |
| Arthur (2002) /Smith (2004) | 6 months 18 months | Number of exercise session reported/week Percentage of patients seeking dietician consultation Percentage of patients seeking psychologist consultation Level of physical activity – Physical Activity Scale for the Elderly | Home: mean 6.5 (SD 4.6) Centre: mean 3.7 (SD 2.6) P < 0.0001† Home 50% (mean 3.5, SD 2.5 visits) Centre: 53% (mean 3.6, SD 2.3 visits) Home: 42% (mean 2.6, SD 2.4 visits) Centre: 51% (mean 2.5, SD 2.2 visits) Home: mean 232.6 (SD 99.4) Centre: mean 170.0 (SD 89.2) P < 0.0001† | Home > Centre ? Home = Centre** Home > Centre |
| Marchionni (2003) | 4 months | Number of exercise sessions completed | Home: 37.3 (SD 3.4) Centre: 34.3 (SD 4.4) P < 0.0001† | Home > Centre |
| Daskapan (2005) | 3 months | Percentage of sessions attended | Home: 97% Centre: 81% P‐value not calculable | ? |
| Dalal (2007) | 9 months | Number who participated in intervention | Home: 40/60 (67%) Centre: 32/44 (72%) P = 0.51* | Home = Centre |
| Jolly (2007) | 3 months 6 months 12 months 24 months | Hours of self‐reported activity weighted for intensity | Home: mean 23.2 (SD 22.1) Centre: mean 18.7 (SD 19.3) P = 0.06† Home: mean 16.4 (SD 17.0) Centre: mean 18.1 (SD 25.4) P = 0.4† Home: mean 19.2 (SD 20.8) Centre: mean 15.9 (SD 16.7) P = 0.06† Home: mean 18.9 (SD 18.4) Centre: mean 16.6 (SD 16.4) P = 0.16† | Home = Centre Home = Centre Home = Centre Home = Centre |
| Moholdt (2012) | 6 months | Training diaries (only reported for home group) | Home: 7/10 patients (with complete diary data) reported ≥2 weekly interval sessions over 6 months follow up | ? |
| Piotrowicz (2010) | 8 weeks | Percentage of patients who carried out the prescribed exercise training (home group: daily telephone contacts with monitoring centre; centre group: attendance at supervised sessions). | Home: 77/77 (100%) Centre: 59/75 (79%) P < 0.0001† | Home > Centre |
| *calculated by authors of this report based on Chi2 test †calculated by authors of this report based on independent t‐test | ||||
| Trial First author (year) | Currency Year of costs Follow up | Cardiac rehabilitation programme cost (per patient) | Programme costs considered | Total healthcare cost (per patient)
| Additional healthcare costs considered | Comments |
| US$ Not reported 6 months | Home: mean 1,519 Centre: mean 2,349
| Staff, ECG monitoring | Not reported |
|
| |
| US$ 2000 14 months | Home: mean 1,650 Centre: mean 8,841 | Not reported | Home: 21,298 Centre: 13,246 | Not reported |
| |
| UK£ 2002‐3 9 months | Home: mean 170 (SD 8) Centre: mean 200 (SD 3) Difference: mean 30 95% CI ‐45 to ‐12 P < 0.0001 | Staff, exercise equipment, staff travel | Home: mean 3,279 (SD 374) Centre: mean 3,201 (SD 443) Difference: mean 78 95% CI ‐1,103 to 1,191 P = 0.894 | Rehospitalisations, revascularisations, secondary preventive medication, investigations, primary care consultations |
| |
| UK£ 2003 24 months | Home: mean 198 95% CI 189 to 209 Centre: Mean 157 95% CI 139 to 175 P < 0.05 | Staff, telephone consultations, staff travel | Not reported | With inclusion of patient costs (travel and time), the societal costs of home‐ and centre‐based cardiac rehabilitation were not significantly different | ||
| ECG = electrocardiogram | ||||||
| Trial First author (year) | Dalal (2007) | Gordon (2002) | Bell (1998) | Carlson (2000) | Marchonni (2003) | Jolly (2007) | ||
| Follow up | 9 months | 3 months | 0‐6 months | 6‐12 months | 6 months | 14 months | 12 month | 24 month |
| Rehospitalisations N patient (%)
Mean (SD) | Home 9/60 (15%) Centre 6/44 (14%) P = 0.845 Home 2.2 (0.9)† Centre 1.2 (0.6) P = 0.383 |
| Home 21/90 (23%) Centre 19/88 (22%) P = 0.78#
| 13/89 (15%) 12/84 (14%) P = 0.95# |
|
Home 0.46 (SE 0.1) Centre 0.33 (SE 0.1) P = 0.49 |
Home 0.08 (0.34) Centre 0.12 (0.41) P = 0.3 |
Home 0.20 (0.45) Centre 0.26 (0.57) P = 0.3 |
| Primary care consultations Mean (SD) |
Home 6.3 (0.6) Centre 7.0 (0.9) P = 0.514 |
|
Home 6.6 (3.6)* Centre 6.6 (4.1) P = 1.00# |
5.4 (4.1) 4.6 (3.7) P = 0.19# |
|
| Home 0.65 (1.14) Centre 0.72 (1.54) P = 0.8 | Home 0.53 (1.14) Centre 0.66 (1.42) P = 0.7 |
| Secondary prevention medication N patients (%) beta‐blockers
ACE inhibitors
Statins
Antiplatelets |
Home 31/49 (63%) Centre 24/34 (71%) P = 0.49 Home 30/49 (61%) Centre 24/33 (73%) P = 0.28 Home 48/49 (98%)* Centre 30/35 (88%)* P = 0.18 Home 46/49 (94%) Centre 30/35 (86%) P = 0.21 |
Home 36/97 (37%) Centre 17/45 (38%) NS Home 25/97 (26%) Centre 8/45 (18%) NS Home 73/97 (75%) Centre 33/45 (73%) NS Home 94/97 (97%)* Centre 45/45 (100%)* NS |
|
|
Home 19/38 Centre 18/42 P = 0.52# Home 4/38 Centre 4/42 P = 0.88# Home 5/38 Centre 8/42 P = 0.47# Home 15/38 Centre 20/42 P = 0.54# |
|
Home 169 (72.2%) Centre 171 (73.4%) P = 0.8 Home 176 (75.2%)* Centre 161 (69.1%)* P = 0.1 Home 216 (92.3%)** Centre 221 (94.8%)** P = 0.3 Home 227 (97.0%)† Centre 226 (97.0%)† P = 1.0 |
Home 161 (71.6%) Centre 164 (72.2%) P = 0.9 Home 177 (78.7%)* Centre 156 (68.7%)* P = 0.02 Home 195 (86.7%)** Centre 206 (90.7%)** P = 0.2 Home 214 (95.1%)+ Centre 220 (96.9%)+ P = 0.3 |
| Comments
| †number of nights *lipid lowering drugs | *antiplatelets & anticoagulants | *GP consultations |
|
|
| *ACEi or Angiotensin II receptor antagonist **cholesterol‐lowering drugs †Aspirin or antiplatelet drugs | |
| #P‐value calculated by authors of the present report | ||||||||
| Trial First author (year) | Moholdt (2012) | Oerkild (2011) |
| Follow up | 6 months | 12 months |
| Rehospitalisations N patient (%) Number Mean (SD) | Not reported | Number and length of admissions same between groups |
| Primary care Consultations Mean (SD) | Not reported | Not reported |
| Secondary prevention medication N patients (%) beta‐blockers ACE inhibitors Antihypertensives Statins Antiplatelets | Home: 8/14 (57%) Centre: 15/16 (94%) P = 0.02* Home: 1/14 (7%) Centre: 0/16 (0%) P = 0.28* Home: 6/14 (43%) Centre: 2/16 (13%) P = 0.07* Home: 14/14 (100%) Centre: 14/16 (100%) P = 0.18* | Not reported |
| Comments | ||
| *P‐value calculated by authors of the present report | ||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Exercise capacity ≤ 12 month Show forest plot | 19 | 1876 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.10 [‐0.29, 0.08] |
| 2 Exercise capacity 12‐24 month Show forest plot | 3 | 1074 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.11 [‐0.01, 0.23] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Total cholesterol 3‐12 month Show forest plot | 9 | 1109 | Mean Difference (IV, Random, 95% CI) | ‐0.07 [‐0.24, 0.11] |
| 2 HDL cholesterol 3‐12 month Show forest plot | 7 | 883 | Mean Difference (IV, Fixed, 95% CI) | ‐0.07 [‐0.11, ‐0.03] |
| 3 LDL cholesterol 3‐12 month Show forest plot | 5 | 388 | Mean Difference (IV, Random, 95% CI) | ‐0.06 [‐0.27, 0.15] |
| 4 Triglycerides 3‐12 month Show forest plot | 5 | 354 | Mean Difference (IV, Fixed, 95% CI) | ‐0.18 [‐0.34, ‐0.02] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Systolic BP 3‐12 month Show forest plot | 9 | 1117 | Mean Difference (IV, Random, 95% CI) | 0.19 [‐3.37, 3.75] |
| 2 Diastolic BP 3‐12 month Show forest plot | 8 | 991 | Mean Difference (IV, Fixed, 95% CI) | ‐1.86 [‐2.95, ‐0.76] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Smoking 3‐12 month Show forest plot | 6 | 986 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.98 [0.79, 1.21] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Mortality Show forest plot | 7 | 1166 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.79 [0.43, 1.47] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Completers Show forest plot | 18 | 1984 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.04 [1.01, 1.07] |
