Are alternative home- and technology supported modes of rehabilitation delivery as effective as traditional centre-based programmes for people with heart disease? Findings from a Cochrane review.

Problem

Cardiovascular disease is the most common cause of death worldwide. Traditionally, centre-based cardiac rehabilitation (CBCR) programmes are offered to patients after cardiac events to support recovery and prevent further illness. Home-based programmes (HBCR) are sometimes offered as an alternative and may support increased access to, and participation in, rehabilitation. In 2017, our Cochrane review reported HBCR to be equally as effective as CBCR. With HBCR (± digital/telehealth platforms) becoming increasingly common, due to the SARS-CoV-2 pandemic, an update of the literature was required.The aim of this study was to compare the effect of CBCR and HBCR (± digital/telehealth platforms) on health-related outcomes in patients with heart disease.

Approach

We updated searches from the previous Cochrane review by searching CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, trial registries, as well as previous systematic reviews and reference lists of included studies to 16th September 2022. We included randomised controlled trials comparing CBCR with HBCR (± digital/telehealth platforms) in adults with myocardial infarction, angina, heart failure or who had undergone revascularisation.Two authors independently screened references, extracted outcome data and study characteristics, and assessed risk of bias (Cochrane ROB1). Quality of evidence was assessed using GRADE principles.

Findings

Three new trials were included in this update; 9 studies and 14 trial registrations await classification. Overall, 24 trials (3,046 participants) were included in analysis. No evidence of a difference was seen between CBCR and HBCR in primary outcomes up to 12-months of follow-up: total mortality (relative risk (RR)=1.15, 95% CI 0.65 to 2.16; participants=1647; studies=12/comparisons=14; low quality evidence), exercise capacity (standardised mean difference (SMD)=-0.10, 95% CI -0.24 to 0.04; participants=2343; studies=24/comparisons=28; low quality evidence), or health-related quality of life up to 24-months. Trials were of short duration, with only a few studies reporting outcomes after one year (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants=1074; studies=3; moderate quality evidence). Trial completion was similar between HBCR and CBCR participants (RR 1.03, 95% CI 0.99 to 1.08; participants=2638; studies =22/comparisons=26; low quality evidence) and the cost per patient of HBCR and CBCR were similar. Insufficient detail was provided to enable a comprehensive risk of bias assessment.

Consequences

HBCR (± digital/telehealth) and CBCR, formally supported by healthcare staff, are similarly effective in improving clinical and health-related quality of life outcomes in patients with heart disease; this finding therefore supports the wider implementation of HBCR programmes to improve access to, and uptake of, rehabilitation. Further data are needed to confirm if these short-term effects of HBCR and CBCR can be sustained, and if such programmes can be beneficial to other cardiac populations.