Review
Home-based cardiac rehabilitation compared with centre-based rehabilitation and usual care: A systematic review and meta-analysis

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Abstract

Background

To determine the effectiveness of home-based cardiac rehabilitation programmes compared with (i) usual care and (ii) supervised centre-based cardiac rehabilitation on mortality, health related quality of life and modifiable cardiac risk factors of patients with coronary heart disease.

Methods

Systematic review and meta-analysis of randomised controlled trials. Main outcome measures: mortality, smoking cessation, exercise capacity, systolic blood pressure, total cholesterol, psychological status, and health related quality of life.

Results

Eighteen included trials for home versus usual rehabilitation and six trials of home versus supervised centre-based rehabilitation were identified. The home-based interventions were clinically heterogeneous, trials often small, with quality poorly reported. Compared with usual care, home-based cardiac rehabilitation had a 4 mm Hg (95% CI 6.5, 1.5) greater reduction in systolic blood pressure, and a reduced relative risk of being a smoker at follow-up (RR 0.71, 95% CI 0.51, 1.00). Differences in exercise capacity, total cholesterol, anxiety and depression were all in favour of the home-based group. In patients post-myocardial infarction exercise capacity was significantly improved in the home rehabilitation group by 1.1 METS (95% CI 0.2, 2.1) compared to usual care. The comparison of home-based with supervised centre-based cardiac rehabilitation revealed no significant differences in exercise capacity, systolic blood pressure and total cholesterol.

Conclusions

Current evidence does not show home-based cardiac rehabilitation to be significantly inferior to centre-based rehabilitation for low-risk cardiac patients. However, the numbers of patients included are less than 750 and ongoing trials will contribute to the debate on the acceptability, effectiveness and cost-effectiveness of home-based cardiac rehabilitation.

Introduction

Cardiac rehabilitation is a multidisciplinary activity that aims to facilitate physical, psychological and emotional recovery and to enable patients to achieve and maintain better health [1]. This is generally achieved through exercise, relaxation and health education, usually provided to groups of patients within a hospital or community setting. There is good evidence that both exercise-only and comprehensive cardiac rehabilitation programmes are effective, reducing all-cause mortality by 27% following a myocardial infarction [2], [3]. The National Service Framework for Coronary Heart Disease in England and Wales seeks to expand the uptake and coverage of cardiac rehabilitation to patients following a heart attack, coronary artery bypass graft or coronary angioplasty, and also patients with heart failure and angina [4]. However, using current models of cardiac rehabilitation, this would need considerable protracted investment.

Uptake of hospital-based cardiac rehabilitation programmes is poor, particularly among women, the elderly and people from minority ethnic groups [1]. Home-based cardiac rehabilitation programmes were first reported in the early 1980s and might be more acceptable and convenient for some patients, thus increasing uptake. This review explores whether there is any evidence that home-based cardiac rehabilitation programmes are superior to usual care in improving cardiac risk factors and mortality and whether benefits occur to patients' post-myocardial infarction (MI) and after a revascularisation procedure. In addition we have explored whether the outcomes from home-based cardiac rehabilitation are similar to centre (or hospital) -based programmes.

The objective of this systematic review was to critically appraise the available data and determine the effectiveness of home-based cardiac rehabilitation programmes compared with (i) usual care and (ii) supervised centre (or hospital) -based cardiac rehabilitation on mortality, health related quality of life and modifiable cardiac risk factors of patients with coronary heart disease.

Section snippets

Methods

We conducted computer searches with standardised search strategies. We searched Medline (1966 to June 2003), EMBASE (1980 to June 2003), CINAHL (1982 to June 2003), and the Cochrane Controlled Trials Register (issue 3, 2003). The search strategy was used to identify randomised controlled trials (RCTs) of home-based cardiac rehabilitation. In addition we manually searched reference lists of retrieved articles and review articles. Unpublished trials were sought by contacting experts in the field

Results

Fig. 1 shows details of exclusion and inclusion of studies. Table 1, Table 2 show details of the 21 included trials.

Discussion

We believe that this is the first systematic review of home-based cardiac rehabilitation interventions compared to usual care and centre-based supervised rehabilitation. The current standard practice for cardiac rehabilitation is hospital provision in the UK and many other countries, but home-based programmes are an alternative for low to moderate risk patients. Increasingly, risk stratification is carried out at the time of referral to determine short and long term risk with allocation to a

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