Abstract:
Objective: 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 coronary heart disease.
Design: Systematic review. Data sources Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, Medline, Embase, CINAHL, and PsycINFO, without language restriction, searched from 2001 to January 2008.
Review methods: Reference lists checked and advice sought from authors. Included randomised controlled trials that compared centre based cardiac rehabilitation with home based programmes in adults with acute myocardial infarction, angina, or heart failure or who had undergone coronary revascularisation. Two reviewers independently assessed the eligibility of the identified trials and extracted data independently. Authors were contacted when possible to obtain missing information.
Results: 12 studies (1938 participants) were included. Most studies recruited patients with a low risk of further events after myocardial infarction or revascularisation. No difference was seen between home based and centre based cardiac rehabilitation in terms of mortality (relative risk 1.31, 95% confidence interval 0.65 to 2.66), cardiac events, exercise capacity (standardised mean difference –0.11, –0.35 to 0.13), modifiable risk factors (weighted mean difference systolic blood pressure (0.58 mm Hg, –3.29 mm Hg to 4.44 mm Hg), total cholesterol (–0.13 mmol/l, –0.31 mmol/l to 0.05 mmol/l), low density lipoprotein cholesterol (–0.15 mmol/l, –0.31 mmol/l to 0.01 mmol/l), or relative risk for proportion of smokers at follow-up (0.98, 0.73 to 1.31)), or health related quality of life, with the exception of high density lipoprotein cholesterol (–0.06, –0.11 to –0.02) mmol/l). In the home based participants, there was evidence of superior adherence. No consistent difference was seen in the healthcare costs of the two forms of cardiac rehabilitation.
Conclusions: Home and centre based forms of cardiac rehabilitation seem to be equally effective in improving clinical and health related quality of life outcomes in patients with a low risk of further events after myocardial infarction or revascularisation. This finding, together with the absence of evidence of differences in patients’ adherence and healthcare costs between the two approaches, supports the further provision of evidence based, home based cardiac rehabilitation programmes such as the "Heart Manual." The choice of participating in a more traditional supervised centre based or evidence based home based programme should reflect the preference of the individual patient.
Comment:
The article below, and accompanying editorial, just published in January in the British Medical Journal, is likely to generate much debate in cardiovascular prevention and rehabilitation circles.
Can home-based rehabilitation be as effective as centre-based services – as the review concludes? If so what does it mean for service development? What it MUST not mean is sending patients home with a glossy booklet or DVD and advising them to ‘get on with it’ and assuming this is cardiac rehabilitation. Invariably clinical trials evaluating new methods of delivery of care go to great lengths to ensure that the service is delivered optimally, including staff as well as patient education and supervision.
In doing this they provide services that are not usually less costly than mainstream services. The danger in extrapolating from these well-run studies is that home-based rehabilitation will be seen as a panacea for under-budgeted services rather than a choice for well selected and suitable candidates.