NIHR Signal Home-based cardiac rehabilitation for heart failure has high rates of participation
Published on 8 January 2019
Home-based cardiac rehabilitation for people with heart failure improves quality of life at 12 months compared with usual care. Among those allocated to rehabilitation, 90% remained in the programme – more than double average attendance rate for hospital-based rehabilitation. The average cost was estimated at £418 per participant which is within the National Health Service tariff for cardiac rehabilitation in England of £477 per patient.
This NIHR-funded trial included 216 participants from four primary and secondary care centres across the UK. The home-based programme was facilitated by a trained cardiac nurse or physiotherapist via face-to-face and telephone sessions and included a choice of two home-based exercise programmes, a patient progress tracker and a caregiver resource.
Despite the proven effectiveness of cardiac rehabilitation programmes in reducing readmissions and risk of death from heart disease, attendance varies widely across the UK and is generally poor. This home-based programme appears acceptable, affordable and safe, with higher levels of participation than have been seen previously in hospital-based programmes.
- Cardiovascular system disorders, Primary care, Physical therapy, Acute and general medicine
Why was this study needed?
Heart failure affects around 900,000 people in the UK. Despite the effectiveness of cardiac rehabilitation in reducing re-admission and risk of death from heart disease, and in improving quality of life, availability and attendance in the UK are poor. On average, only 43% of people eligible actually attend, and this varies from 13 to 88% around the country.
Efforts to improve access by exploring newer more accessible alternative strategies to hospital-based rehabilitation are required. Home-based rehabilitation programmes for people following a heart attack have been shown to widen access and be effective, but less is known about the effectiveness for people with heart failure.
Cardiac rehabilitation programmes typically include individual exercise goals, education, behaviour change, counselling, support and strategies that are aimed at targeting traditional risk factors for cardiovascular disease such as smoking and diet.
This trial assessed whether home-based cardiac rehabilitation programmes could improve outcomes compared with usual care. In this trial, both groups received medical management according to guidelines. Usual care included access to a specialist heart failure nurse, but there was no centre-based or hospital cardiac rehabilitation.
What did this study do?
The REACH-HF trial recruited 216 people with heart failure from primary and secondary care in the UK. Participants were mostly men (78%), with an average age of 70.
All participants had usual medical management, and half were randomly allocated to also receive a 12-week home-based rehabilitation programme.
The primary outcome was quality of life focused on heart failure. The validated scale includes particular things which affect people with heart failure, like swelling in legs, difficulty walking up stairs, and shortness of breath.
The rehabilitation included a choice of two structured exercise programmes, an interactive patient progress tracker and a caregiver resource. Face-to-face and telephone contact with a trained cardiac nurse or physiotherapist provided person-centred counselling and tailoring of the intervention. The intervention had been designed based on theories of behaviour change and with input from patients and staff.
This was a relatively small study, and due to the nature of the trial, participants knew which group they were in which may have biased the self-reported outcomes in favour of the interventions.
What did it find?
- Of the participants in the home-exercise programme, 90% attended the first face-to-face contact with the facilitator and at least two facilitator contacts after that (of which one had to be face-to-face).
- At 12 months, there was a significant and clinically meaningful improvement in quality of life for people in the rehabilitation group compared to usual care (between-group difference of -5.7 points in the 21-point Minnesota Living with Heart Failure Questionnaire (MLHFQ) score, 95% confidence interval [CI] -10.6 to -0.7). The trial considered a reduction of 5 or more points in MLHFQ score (range 0 to 105) to be clinically meaningful.
- Apart from an improvement in maintenance of self-care of heart failure for participants in the rehabilitation group at 12 months, there were no significant differences in other outcomes including death, hospitalisations, measures of anxiety and depression, management and confidence aspects of self-care, exercise and physical activity capacity, or other measures of quality of life, either disease-specific (HeartQol) or non-disease specific (EQ-5D).
- At 12 months follow up, eight participants had died - four in the home-based exercise programme and four in the usual care group. Four deaths in total were considered to be related to heart failure – one in the home-based exercise group and three in the usual care group.
- The average cost of the intervention was estimated at £418 per participant based on 6.5 hours of facilitator contact, 8.25 hours of overall contact and non-contact time and facilitator training, travel and consumables. This cost is within the National Health Service tariff for cardiac rehabilitation in England of £477 per patient.
What does current guidance say on this issue?
NICE 2018 guidance recommends offering personalised exercise-based cardiac rehabilitation programmes to heart failure patients. The programme should be provided in a setting that is easily accessible for the person such as at home, in the community or hospital. This is providing that the person is stable and does not have a condition or device that would preclude an exercise-based rehabilitation programme.
NICE advises that the programme should include a psychological and educational component and that it may be incorporated within an existing cardiac rehabilitation programme.
What are the implications?
This study gives support to a 12-week home-based cardiac rehabilitation for people with heart failure.
Because the attendance at centre-based cardiac rehabilitation for people with heart failure is low, the 90% adherence rate achieved in this study is important. The evidence for an affordable home-based programme as an alternative to other settings is growing and may have future workforce implications.
Citation and Funding
Dalal H, Taylor R, Jolly K et al. The effects and costs of home-based rehabilitation for heart failure with reduced ejection fraction: The REACH-HF multicentre randomized controlled trial. Eur J Prev Cardiol. 2018; Oct 10. DOI: 10.1177/2047487318806358. [Epub ahead of print].
This study was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research (Grant Reference Number RP-PG-121012004). Two authors are part-funded by the NIHR Collaboration for Peninsula Leadership in Applied Health Research and Care. One author is part-funded by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West Midlands and one author is supported by the NIHR CLAHRC East Midlands.
BHF. Cardiac rehabilitation. London: British Heart Foundation; 2016.
BHF. National Audit of Cardiac Rehabilitation (NACR) Quality and Outcomes report 2018. London: British Heart Foundation; 2018.
NICE. Chronic heart failure in adults: diagnosis and management. NG106. London: National Institute for Health and Care Excellence; 2018.
NICE. Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease. CG172. London: National Institute for Health and Care Excellence; 2013.
Taylor RS, Sagar VA, Davies EJ et al. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev 2014;(4):CD003331.
Zwisler AD, Norton RJ, Dean SG et al. Home-based cardiac rehabilitation for people with heart failure: a meta-analysis. International Journal of Cardiology. 2016;221:963-9.
The recent release of the National Audit of Cardiac Rehabilitation report shows that we are still failing to recruit people who need cardiac rehabilitation most. The authors of the report suggest that recruiting patients with heart failure is in the top five priorities for cardiac rehab in the UK.
This study demonstrates that it is possible to deliver effective cardiac rehab at home for people living with heart failure at low cost. This further adds to the evidence that all cardiac rehabilitation services should offer flexible programmes with a range of options for participation.
The investigators involved patients, caregivers, and clinicians in the development of their programme. This is important to maximise engagement and ensure local tailoring of programmes. However, the majority (78%) of participants were men, and this shows there is still work to do to engage women in cardiac rehab, who remain underserved in cardiac rehab in the UK and globally.
Professor Lis Neubeck, School of Health and Social Care, Edinburgh Napier University; President-Elect, ESC Association of Cardiovascular Nursing and Allied Professions
The commentator declares no conflicting interests
The REACH-HF trial included participants with heart failure with reduced ejection fraction (the proportion of blood pumped out of the heart) below 45%, with an average of 34%.
Quality of life was measured using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) - a self-administered disease-specific questionnaire for people with heart failure that comprises 21 items rated on a five-point Likert scale ranging from 0 (no impact) to 5 (very much affected). It provides a total score (range from 0 to 105) with lower scores indicating better quality of life.