Home-based cardiac rehabilitation for people with heart failure: A systematic review and meta-analysis

doi:10.1016/j.ijcard.2016.06.207

International Journal of Cardiology

Volume 221, 15 October 2016, Pages 963-969

https://doi.org/10.1016/j.ijcard.2016.06.207 Get rights and content

Abstract

Aims

To assess the effectiveness of home-based cardiac rehabilitation (CR) for heart failure compared to either usual medical care (i.e. no CR) or centre-based CR on mortality, morbidity, exercise capacity, health-related quality of life, drop out, adherence rates, and costs.

Methods

Randomised controlled trials were initially identified from previous systematic reviews of CR. We undertook updated literature searches of MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane Library to December 2015. A total of 19 trials with median follow up of 3 months were included — 17 comparisons of home-based CR to usual care (995 patients) and four comparing home and centre-based CR (295 patients).

Results

Compared to usual care, home-based CR improved VO_2max (mean difference: 1.6 ml/kg/min, 0.8 to 2.4) and total Minnesota Living with Quality of Life score (− 3.3, − 7.5 to 1.0), with no difference in mortality, hospitalisation or study drop out. Outcomes and costs were similar between home-based and centre-based CR with the exception of higher levels of trial completion in the home-based group (relative risk: 1.2, 1.0 to 1.3).

Conclusions

Home-based CR results in short-term improvements in exercise capacity and health-related quality of life of heart failure patients compared to usual care. The magnitude of outcome improvement is similar to centre-based CR. Home-based CR appears to be safe with no evidence of increased risk of hospitalisation or death. These findings support the provision of home-based CR for heart failure as an evidence-based alternative to the traditional centre-based model of provision.

Introduction

Systematic reviews and meta-analyses of randomised controlled trials (RCTs) have shown that the addition of cardiac rehabilitation (CR) to usual care is a safe and effective intervention for individuals with heart failure (HF) [1], [2], [3], [4]. Benefits include improvements in exercise capacity, cardiac function, and health-related quality of life and a reduction in the risk of HF-specific hospitalisation. However, the majority of RCT evidence has been collected in HF patients receiving CR in a supervised centre-based setting, such as a hospital outpatient department or a community leisure centre [1]. This is reflected in the current guideline recommendation by the National Institute for Health and Care Excellence (NICE) in the United Kingdom (UK) that a “supervised group exercise-based rehabilitation programme” should be offered to HF patients [5].

In spite of evidence for the benefits and safety of CR, the uptake and participation of CR by patients with HF is currently poor [6], [7], [8]. A variety of factors have been proposed for this poor access and uptake, including a lack of capacity of centre-based supervised programmes [6]. A national survey indicated that only 16% of UK centres in 2011/12 provide a specific rehabilitation programme for those with HF [7]. More recently, a European wide study found 39% of cardiac centres surveyed did not implement exercise programmes for HF resulting in 51% of eligible patients not receiving exercise-based rehabilitation [8]. Home-based CR programmes therefore offer an important opportunity to widen patient access and participation [7], [9].

Whilst, two previous systematic reviews have shown that home-based CR can safely improve the exercise capacity of individuals with HF, both have important limitations [10], [11]. First, they include non-randomised evidence and therefore their reported treatment effects may be subject to selection bias and confounding. Second, as they have included patients who have received either a period of centre-based provision prior to home-based CR or received concurrent home and centre-based provision, it is not possible to separate the effect of home-based CR per se. Furthermore, we are aware of a number of randomised head-to-head comparisons of home-based and centre-based CR for HF that have recently been published [12], [13], [14].

The aim of this study was to undertake an updated systematic review and meta-analysis of the RCT evidence for home-based CR programmes in individuals with HF. We sought to compare home-based CR to either centre-based CR or usual medical care (i.e. no CR) and consider the outcomes of mortality, morbidity, exercise capacity, health-related quality of life, drop out, CR programme adherence, and costs.

Section snippets

Methods

We conducted and report this systematic review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement [15].

Study selection

The two previous Cochrane reviews [1], [16] provided a total of eight RCTs (11 publications) meeting the inclusion criteria of this study. Our updated database searches yielded 12,949 titles. Following the review of titles and abstracts, we included 35 full publications. Nineteen publications were excluded (Appendix B), leaving 16 publications reporting the results of 11 RCTs. Thus, a total of 19 RCTs (26 publications) were included (see Appendix C for citations).^e1–e19 A summary of the study

Discussion

In this systematic review and meta-analysis we considered the RCT evidence for the efficacy and safety of home-based CR for HF compared to usual care (no CR) or supervised centre-based CR. We found that home-based CR improves the short-term exercise capacity and health-related quality of life compared to usual care. Head-to-head trials showed these improvements in patient-related outcomes to be similar to centre-based CR, although there was some evidence supporting superior trial completion

Conclusion

In conclusion, we found that home-based CR improves the short-term exercise capacity and health-related quality of life of HF patients compared to usual care. Head-to-head trials show that the magnitude of outcome improvements were similar to centre-based CR. Home-based CR appears safe with no evidence of increased risk of hospitalisation or death. These findings support the provision of home-based CR as an evidence-based alternative to the traditional model of centre-based programmes for HF.

Funding

RST and HMD are supported by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-1210-12004). RST and SGD are supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the

Conflicts of interest

RST is an author on a number of other Cochrane reviews of CR. HMD and RST are currently co-chief investigators on the REACH-HF programme of research, which is developing and evaluating a home-based CR intervention for people with HF and their carers (NIHR PGfAR RP-PG-0611-12004). The other authors declare no conflicts of interest.

Acknowledgements

We thank to Nicole Martin of the Cochrane Heart Group editorial team for updating the search strategies and running the updated searches.

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^☆: All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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Home-based cardiac rehabilitation for people with heart failure: A systematic review and meta-analysis☆

Abstract

Aims

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Study selection

Discussion

Conclusion

Funding

Conflicts of interest

Acknowledgements

Int. J. Cardiol.

Am. J. Med.

J. Physiother.

J. Clin. Epidemiol.

J. Am. Coll. Cardiol.

Int. J. Cardiol.

Exercise-based rehabilitation for heart failure

Cochrane Database Syst. Rev.

Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH)

BMJ

Chronic heart failure. Management of chronic heart failure in adults in primary and secondary care. NICE clinical guideline CG108 2010

Participation rates, process monitoring, and quality improvement among cardiac rehabilitation programs in the United States

J. Cardiopulm. Rehabil. Prev.

Why do so few patients with heart failure participate in cardiac rehabilitation? A cross-sectional survey from England, Wales and Northern Ireland

BMJ Open

Committee on Exercise Physiology & Training of the Heart Failure Association of the ESC. ExtraHF survey: the first European survey on implementation of exercise training in heart failure patients

Eur. J. Heart Fail.

Factors associated with referral to outpatient cardiac rehabilitation services

J. Cardiopulm. Rehabil. Prev.

Efficacy of home-based exercise programmes for people with chronic heart failure: a meta-analysis

Eur. J. Cardiovasc. Prev. Rehabil.