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Exclusive Cochrane summary

Rehabilitation: at home or at a centre?

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Cardiac rehabilitation programmes are intended to tackle unhealthy lifestyles that put patients at risk. This Cochrane review compared home-based and supervised centre-based cardiac rehabilitation

Wuxian C, Chuanyi N, (2011). Rehabilitation: at home or at a centre? Nursing Times; 107: 14, early online publication.

  • This article has been double-blind peer reviewed.

Review question

How effective are home-based and supervised centre-based cardiac rehabilitation programmes on patients with coronary heart disease?

Nursing implications

Cardiovascular disease causes a greater global public health burden than any other long-term condition. According to the World Health Organisation (2011), lifestyles are responsible for about 80% of cardiac and cerebral vascular diseases. The most important risk factors are an unhealthy diet, physical inactivity and tobacco use.

Rehabilitation can assist in managing and preventing these. The aim is to restore health through a combination of exercise, education and psychological support.

In addition to those offered in other settings, cardiac rehabilitation programmes are being offered in patients’ homes to make them more accessible. A systematic review was undertaken to determine the differences between home-based and supervised centre-based cardiac rehabilitation programmes.

Study characteristics

The review included 12 randomised studies with a total of 1,938 participants that compared home-based with centre-based cardiac rehabilitation programmes.

Home-based cardiac rehabilitation was 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”.

Centre-based cardiac rehabilitation took place in a variety of settings including hospital physiotherapy departments, university gymnasiums and community sports centres.

The majority of studies recruited lower-risk patients who had experienced an acute myocardial infarction and revascularisation; there were no restrictions on participants’ age. Those with significant arrhythmias, ischaemia or heart failure were excluded.

Eleven studies looked at short-term follow-up at between three and 12 months. Only three reported long-term results after a year or more, at between 12 and 24 months.

Outcomes considered by the studies included: mortality, morbidity (reinfarction, revascularisation, cardiac-related hospitalisation) and exercise capacity. Also included were changes in modifiable risk factors such as smoking behaviour, blood lipid levels and blood pressure, as well as health-related quality of life and cost effectiveness.

Only six studies reported blind outcome assessment; blinding of patients and implementers was impossible. This may have weakened the conclusions of the review.

Losses to follow-up or drop-outs were not reported. Reporting was poor and risk of bias was difficult to assess.

All trials chose intention-to-treat analysis. Pooled analysis was performed where studies were homogeneous.

Summary of key evidence

There was no evidence of a significant difference in mortality at short-term follow-up between home-based and centre-based cardiac rehabilitation. One study reported that, at 24 months’ follow-up, there was a non-significant difference in mortality between the types of rehabilitation.

No significant differences were found in cardiac clinical events including myocardial infarction and revascularisation, regardless of the duration of follow-up.

The pooled analysis across all studies for exercise capacity at short term follow-up indicated a non-significant difference between home-based and centre-based cardiac rehabilitation.

A pooled analysis of three studies showed some evidence of superiority in the home-based programme over the centre-based one in the short term, although there was no evidence of a statistically significant difference at long-term follow-up.

Diastolic blood pressure at follow-up was a slightly higher for home-based than centre-based cardiac rehabilitation in the short term. There was a non-significant difference in systolic blood pressure at short-term follow-up; at long-term follow-up, one study showed no significant difference in both systolic and diastolic blood pressure.

There was no evidence of a significant difference in total cholesterol between the groups at short-term and long-term follow-up. Similarly, there was no difference in HDL-cholesterol, LDL-cholesterol and triglyceride levels.

There was no evidence of a statistically significant difference in overall health-related quality of life or domain scores or with adherence and overall cost at follow-up across groups.

Recommendations

Little evidence was found of a difference in outcomes between patients who received home-based rehabilitation and those who received centre-based rehabilitation.

Where available, the evidence supported home-based rehabilitation. The results of the review should be viewed cautiously due to the lack of effective evaluation of the interventions. NT

For the full review report, including references, click here

Authors Chen Wuxian is medical master, vice-chief professor in cardiology, Institute of Cardiovascular Diseases; Ning Chuanyi is medical master, research student, both at The First Affiliated Hospital, Guangxi Medical University, Guangxi, People’s Republic of China. Both are members of the Cochrane Nursing Care Field (CNCF)

 

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