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NIHR Signal Home-based cardiac rehabilitation may be a convenient alternative to centre-based rehabilitation

Published on 18 October 2016

doi: 10.3310/signal-000316

Home-based cardiac rehabilitation for people with heart failure is safe and effective. It improved exercise capacity slightly compared to care without cardiac rehabilitation, and may also be more convenient than centre-based rehabilitation as more people completed treatment.

This updated review included 19 trials, with seven from the UK. The home-based rehabilitation mostly took the form of aerobic exercise, though some included resistance training and there was wide variation in the nature and length of the programmes and the support offered at home. People involved in the studies were classed as having mild to moderate heart failure.

Nevertheless, this review provides stronger evidence to support NICE's recommendation that cardiac rehabilitation should be made more available and accessible to people with heart failure. It gives another safe option to centre-based care, which may increase participation.

Share your views on the research.

Why was this study needed?

Heart failure affects around 900,000 people in the UK. Despite the effectiveness of cardiac rehabilitation in reducing readmission and risk of death from heart disease, availability and attendance in the UK is poor. On average, only 43% of people eligible actually attend, though this varies from 13 to 88% around the country. Efforts to improve access by using alternative settings and through telehealth have shown some promise, but strong evidence of their effectiveness is lacking.

Cardiac rehabilitation programmes typically include exercise, education, behaviour change, counselling, support and strategies that are aimed at targeting traditional risk factors for cardiovascular disease.

This review assessed whether home-based cardiac rehabilitation programmes could be a suitable alternative to centre-based programmes.

What did this study do?

This systematic review and meta-analysis pooled the results of 19 randomised controlled trials. It compared studies of home-based cardiac rehabilitation, centre-based cardiac rehabilitation or usual medical care that measured deaths, exercise capacity, health-related quality of life, adherence rates and cost.

Overall there were 1,290 adults aged between 44 and 70. Most were male, with mild to moderate heart failure causing breathlessness on mild to moderate exercise.

The home-based interventions were largely based around aerobic exercise, with only a handful including education or psychological elements. They ranged from two to five sessions of 10 to 60 minutes per week for eight weeks to 12 months. Professional support was offered  as part of most home based interventions (home visits, phone calls or tele-monitoring).The results should be viewed with some caution as most studies were small, on average 55 participants and the intensity, frequency and duration of the programs varied widely.

What did it find?

  • There was a 16% higher rate of completion of the home-based cardiac rehabilitation than the centre-based cardiac rehabilitation (relative risk [RR] 1.16, 95% confidence interval [CI] 1.02 to 1.32).
  • Improvements in exercise capacity (cardiorespiratory fitness) measured by peak oxygen consumption were slightly more with home-based cardiac rehabilitation compared with usual care (VO2max mean difference 1.6ml/kg/min, 95% CI 0.8 to 2.4). There was no difference in the exercise capacity between home-based and centre-based rehabilitation.
  • There was no difference in quality of life, hospitalisation or death with home-based cardiac rehabilitation compared with usual care.
  • One UK trial reported on costs and found that both home-based and centre-based cardiac rehabilitation were cost effective compared to routine care due to the decrease in hospital admissions for heart failure.

What does current guidance say on this issue?

NICE 2010 guidelines recommend that a “supervised group exercise-based rehabilitation programme” should be offered to heart failure patients, but does not specify where this should take place. This is providing that the patient is stable and does not have a condition or device that would preclude an exercise-based rehabilitation programme.

They advise that the programme should include a psychological and educational component.

Cardiac rehabilitation is also recommended in NICE 2013 guidelines for people following a heart attack. In order to increase uptake, they recommend a variety of settings including the person’s home.

What are the implications?

This study supports home based cardiac rehabilitation for people with heart failure. It improved exercise capacity compared to usual care and was as effective as centre-based rehabilitation with a better adherence rate.

The wide range of programs included in the study makes it difficult to draw firm conclusions about what constitutes the best form of home-based rehabilitation, what components are required and what level of support (home visits or phone calls) is required.

Citation and Funding

Zwisler AD, Norton RJ, Dean SG, et al. Home-based cardiac rehabilitation for people with heart failure: A systematic review and meta-analysis. International Journal of Cardiology. 2016;221:963-9.

Two authors 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). Two authors are supported by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsular at the Royal Devon and Exeter NHS Foundation Trust.

Bibliography

American Heart Association. Classes of heart failure. Dallas (TX): American Heart Association; 2016.

BHF. Cardiac rehabilitation. London: British Heart Foundation; 2016.

NICE. Guidance on chronic heart failure in adults: management. CG108. London: National Institute for Health and Care Excellence; 2010.

NICE. Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease. CG172. London: National Institute for Health and Care Excellence; 2013.

Why was this study needed?

Heart failure affects around 900,000 people in the UK. Despite the effectiveness of cardiac rehabilitation in reducing readmission and risk of death from heart disease, availability and attendance in the UK is poor. On average, only 43% of people eligible actually attend, though this varies from 13 to 88% around the country. Efforts to improve access by using alternative settings and through telehealth have shown some promise, but strong evidence of their effectiveness is lacking.

Cardiac rehabilitation programmes typically include exercise, education, behaviour change, counselling, support and strategies that are aimed at targeting traditional risk factors for cardiovascular disease.

This review assessed whether home-based cardiac rehabilitation programmes could be a suitable alternative to centre-based programmes.

What did this study do?

This systematic review and meta-analysis pooled the results of 19 randomised controlled trials. It compared studies of home-based cardiac rehabilitation, centre-based cardiac rehabilitation or usual medical care that measured deaths, exercise capacity, health-related quality of life, adherence rates and cost.

Overall there were 1,290 adults aged between 44 and 70. Most were male, with mild to moderate heart failure causing breathlessness on mild to moderate exercise.

The home-based interventions were largely based around aerobic exercise, with only a handful including education or psychological elements. They ranged from two to five sessions of 10 to 60 minutes per week for eight weeks to 12 months. Professional support was offered  as part of most home based interventions (home visits, phone calls or tele-monitoring).The results should be viewed with some caution as most studies were small, on average 55 participants and the intensity, frequency and duration of the programs varied widely.

What did it find?

  • There was a 16% higher rate of completion of the home-based cardiac rehabilitation than the centre-based cardiac rehabilitation (relative risk [RR] 1.16, 95% confidence interval [CI] 1.02 to 1.32).
  • Improvements in exercise capacity (cardiorespiratory fitness) measured by peak oxygen consumption were slightly more with home-based cardiac rehabilitation compared with usual care (VO2max mean difference 1.6ml/kg/min, 95% CI 0.8 to 2.4). There was no difference in the exercise capacity between home-based and centre-based rehabilitation.
  • There was no difference in quality of life, hospitalisation or death with home-based cardiac rehabilitation compared with usual care.
  • One UK trial reported on costs and found that both home-based and centre-based cardiac rehabilitation were cost effective compared to routine care due to the decrease in hospital admissions for heart failure.

What does current guidance say on this issue?

NICE 2010 guidelines recommend that a “supervised group exercise-based rehabilitation programme” should be offered to heart failure patients, but does not specify where this should take place. This is providing that the patient is stable and does not have a condition or device that would preclude an exercise-based rehabilitation programme.

They advise that the programme should include a psychological and educational component.

Cardiac rehabilitation is also recommended in NICE 2013 guidelines for people following a heart attack. In order to increase uptake, they recommend a variety of settings including the person’s home.

What are the implications?

This study supports home based cardiac rehabilitation for people with heart failure. It improved exercise capacity compared to usual care and was as effective as centre-based rehabilitation with a better adherence rate.

The wide range of programs included in the study makes it difficult to draw firm conclusions about what constitutes the best form of home-based rehabilitation, what components are required and what level of support (home visits or phone calls) is required.

Citation and Funding

Zwisler AD, Norton RJ, Dean SG, et al. Home-based cardiac rehabilitation for people with heart failure: A systematic review and meta-analysis. International Journal of Cardiology. 2016;221:963-9.

Two authors 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). Two authors are supported by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsular at the Royal Devon and Exeter NHS Foundation Trust.

Bibliography

American Heart Association. Classes of heart failure. Dallas (TX): American Heart Association; 2016.

BHF. Cardiac rehabilitation. London: British Heart Foundation; 2016.

NICE. Guidance on chronic heart failure in adults: management. CG108. London: National Institute for Health and Care Excellence; 2010.

NICE. Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease. CG172. London: National Institute for Health and Care Excellence; 2013.

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

Published on 22 July 2016

Zwisler, A. D.,Norton, R. J.,Dean, S. G.,Dalal, H.,Tang, L. H.,Wingham, J.,Taylor, R. S.

Int J Cardiol Volume 221 , 2016

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 3months 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 VO2max (mean difference: 1.6ml/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.

Cardiac rehabilitation is recommended within two weeks of diagnosis or discharge from hospital for conditions such as stable angina, stable heart failure and following a heart attack and heart operations. It involves help to modify lifestyle risk factors such as smoking and diet, and support to achieve individualised physical activity goals. Other elements include addressing any psychosocial problems and measures to reduce medical risk factors including high blood pressure and cholesterol.

Expert commentary

Cardiac rehabilitation (CR) has been shown to be effective in improving outcomes in patients with heart failure. However, provision of suitable CR programmes and attendance at these programmes is poor. Therefore, it is interesting to consider whether the benefits of CR can be realised by delivering it 'closer to home'. The cost of providing a home based programme is a key issue. Unfortunately, there are no robust data on cost-effectiveness, but there is a suggestion from one study that home based CR is no more expensive than CR delivered in a health care setting. If compliance can be increased by offering home based CR this may be a useful step for commissioners to consider - but it needs to be evaluated as it is rolled out.

Professor Sarah Purdy, Associate Dean, University of Bristol