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Meta-Analysis
. 2017 Jun 28;6(6):CD008895.
doi: 10.1002/14651858.CD008895.pub3.

Patient education in the management of coronary heart disease

Lindsey Anderson  1 , James Pr Brown, Alexander M Clark, Hasnain Dalal, Henriette K Rossau, Charlene Bridges, Rod S Taylor
Affiliations
Meta-Analysis

Patient education in the management of coronary heart disease

Lindsey Anderson et al. Cochrane Database Syst Rev. .

Abstract

Background: Coronary heart disease (CHD) is the single most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people live with CHD and may need support to manage their symptoms and improve prognosis. Cardiac rehabilitation is a complex multifaceted intervention which aims to improve the health outcomes of people with CHD. Cardiac rehabilitation consists of three core modalities: education, exercise training and psychological support. This is an update of a Cochrane systematic review previously published in 2011, which aims to investigate the specific impact of the educational component of cardiac rehabilitation.

Objectives: 1. To assess the effects of patient education delivered as part of cardiac rehabilitation, compared with usual care on mortality, morbidity, health-related quality of life (HRQoL) and healthcare costs in patients with CHD.2. To explore the potential study level predictors of the effects of patient education in patients with CHD (e.g. individual versus group intervention, timing with respect to index cardiac event).

Search methods: We updated searches from the previous Cochrane review, by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 6, 2016), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) in June 2016. Three trials registries, previous systematic reviews and reference lists of included studies were also searched. No language restrictions were applied.

Selection criteria: 1. Randomised controlled trials (RCTs) where the primary interventional intent was education delivered as part of cardiac rehabilitation.2. Studies with a minimum of six-months follow-up and published in 1990 or later.3. Adults with a diagnosis of CHD.

Data collection and analysis: Two review authors independently screened all identified references for inclusion based on the above inclusion criteria. One author extracted study characteristics from the included trials and assessed their risk of bias; a second review author checked data. Two independent reviewers extracted outcome data onto a standardised collection form. For dichotomous variables, risk ratios and 95% confidence intervals (CI) were derived for each outcome. Heterogeneity amongst included studies was explored qualitatively and quantitatively. Where appropriate and possible, results from included studies were combined for each outcome to give an overall estimate of treatment effect. Given the degree of clinical heterogeneity seen in participant selection, interventions and comparators across studies, we decided it was appropriate to pool studies using random-effects modelling. We planned to undertake subgroup analysis and stratified meta-analysis, sensitivity analysis and meta-regression to examine potential treatment effect modifiers. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the quality of the evidence and the GRADE profiler (GRADEpro GDT) to create summary of findings tables.

Main results: This updated review included a total of 22 trials which randomised 76,864 people with CHD to an education intervention or a 'no education' comparator. Nine new trials (8215 people) were included for this update. We judged most included studies as low risk of bias across most domains. Educational 'dose' ranged from one 40 minute face-to-face session plus a 15 minute follow-up call, to a four-week residential stay with 11 months of follow-up sessions. Control groups received usual medical care, typically consisting of referral to an outpatient cardiologist, primary care physician, or both.We found evidence of no difference in effect of education-based interventions on total mortality (13 studies, 10,075 participants; 189/5187 (3.6%) versus 222/4888 (4.6%); random effects risk ratio (RR) 0.80, 95% CI 0.60 to 1.05; moderate quality evidence). Individual causes of mortality were reported rarely, and we were unable to report separate results for cardiovascular mortality or non-cardiovascular mortality. There was evidence of no difference in effect of education-based interventions on fatal and/or non fatal myocardial infarction (MI) (2 studies, 209 participants; 7/107 (6.5%) versus 12/102 (11.8%); random effects RR 0.63, 95% CI 0.26 to 1.48; very low quality of evidence). However, there was some evidence of a reduction with education in fatal and/or non-fatal cardiovascular events (2 studies, 310 studies; 21/152 (13.8%) versus 61/158 (38.6%); random effects RR 0.36, 95% CI 0.23 to 0.56; low quality evidence). There was evidence of no difference in effect of education on the rate of total revascularisations (3 studies, 456 participants; 5/228 (2.2%) versus 8/228 (3.5%); random effects RR 0.58, 95% CI 0.19 to 1.71; very low quality evidence) or hospitalisations (5 studies, 14,849 participants; 656/10048 (6.5%) versus 381/4801 (7.9%); random effects RR 0.93, 95% CI 0.71 to 1.21; very low quality evidence). There was evidence of no difference between groups for all cause withdrawal (17 studies, 10,972 participants; 525/5632 (9.3%) versus 493/5340 (9.2%); random effects RR 1.04, 95% CI 0.88 to 1.22; low quality evidence). Although some health-related quality of life (HRQoL) domain scores were higher with education, there was no consistent evidence of superiority across all domains.

Authors' conclusions: We found no reduction in total mortality, in people who received education delivered as part of cardiac rehabilitation, compared to people in control groups (moderate quality evidence). There were no improvements in fatal or non fatal MI, total revascularisations or hospitalisations, with education. There was some evidence of a reduction in fatal and/or non-fatal cardiovascular events with education, but this was based on only two studies. There was also some evidence to suggest that education-based interventions may improve HRQoL. Our findings are supportive of current national and international clinical guidelines that cardiac rehabilitation for people with CHD should be comprehensive and include educational interventions together with exercise and psychological therapy. Further definitive research into education interventions for people with CHD is needed.

PubMed Disclaimer

Conflict of interest statement

LA is an author on number of other Cochrane cardiac rehabilitation reviews.

RST is co‐author on a number of Cochrane rehabilitation reviews and in receipt of two ongoing NIHR research grants in cardiac rehabilitation (PGfAR RP‐PG‐0611‐12004; HTA 15/80/30 and one past (HTA 12/189/06).

JPRB, DH, AC, HKR and CB declare no conflicts of interest.

Figures

1
1
PRISMA flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
4
4
Funnel plot of comparison: 4 Education versus no education, outcome: 4.1 Total mortality at the end of the follow up period.
5
5
Funnel plot of comparison: 1 Education versus no education, outcome: 1.6 Withdrawals.
1.1
1.1. Analysis
Comparison 1: Education versus no education, Outcome 1: Total mortality at the end of the follow up period
1.2
1.2. Analysis
Comparison 1: Education versus no education, Outcome 2: Fatal and/or non‐fatal MI
1.3
1.3. Analysis
Comparison 1: Education versus no education, Outcome 3: Other fatal and/or non‐fatal cardiovascular events
1.4
1.4. Analysis
Comparison 1: Education versus no education, Outcome 4: Total revascularisations (including CABG and PCI)
1.5
1.5. Analysis
Comparison 1: Education versus no education, Outcome 5: Hospitalisations
1.6
1.6. Analysis
Comparison 1: Education versus no education, Outcome 6: Withdrawals
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Delaney 2008 {published data only}
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Divison 2014 {published data only}
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Dusseldorp 1999 {published data only}
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Dusseldorp 2000 {published data only}
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    1. Engblom E, Korpilahti K, Hämäläinen H, Puukka P, Rönnemaa T. Effects of five years of cardiac rehabilitation after coronary artery bypass grafting on coronary risk factors. American Journal of Cardiology 1996;78(12):1428-31. - PubMed
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    1. Engblom E, Korpilahti K, Hämäläinen H, Rönnemaa T, Puukka P. Quality of life and return to work 5 years after coronary artery bypass surgery. Long-term results of cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation 1997;17(1):29-36. - PubMed
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Eshah 2010 {published data only}
    1. Eshah NF, Bond AE, Froelicher ES. The effects of a cardiovascular disease prevention program on knowledge and adoption of a heart healthy lifestyle in Jordanian working adults. European Journal of Cardiovascular Nursing 2010;9(4):244-53. - PubMed
Eshah 2013 {published data only}
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Eshah 2014 {published data only}
    1. Eshah NF. Predischarge education improves adherence to a healthy lifestyle among Jordanian patients with acute coronary syndrome. European Journal of Cardiovascular Nursing 2014;13:S6-7. - PubMed
Espinosa Caliani 2004 {published data only}
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Fang 2015 {published data only}
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Fernandez 2009 {published data only}
    1. Fernandez RS, Davidson P, Griffiths R, Juergens C, Stafford B, Salamonson Y. A pilot randomised controlled trial comparing a health-related lifestyle self-management intervention with standard cardiac rehabilitation following an acute cardiac event: implications for a larger clinical trial. Australian Critical Care 2009;22(1):17-27. - PubMed
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Fredericks 2009 {published data only}
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Fredericks 2009a {published data only}
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Fredericks 2013 {published data only}
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Frederix 2015 {published data only}
    1. Frederix I, Hansen D, Van Driessche N, Coninx K, Vandervoort P, Vrints C, et al. Do we keep cardiac patients out of hospital by adding telerehabilitation to standard rehabilitation? Cardiology 2015;131:183.
Froelicher 1994 {published data only}
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Goodman 2008 {published data only}
    1. Goodman H, Parsons A, Davison J, Preedy M, Peters E, Shuldham C. A randomised controlled trial to evaluate a nurse led programme of support and lifestyle management for patients awaiting cardiac surgery: ' Fit for surgery: Fit for life' Study. European Journal of Cardiovascular Nursing 2008;7(3):189-95. - PubMed
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Heilmann 2014 {published data only}
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Jamshidi 2013 {published data only}
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Shahamfar 2010 {published data only}
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Sherrard 2000 {published data only}
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Shuldham 2001 {published data only}
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Shuldham 2002 {published data only}
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Stewart 2013 {published data only}
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Vale 2003 {published data only}
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Vida 2011 {published data only}
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Volpe 2012 {published data only}
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References to studies awaiting assessment

Gao 2011 {published data only}
    1. Gao Y, Li Y, Zheng J, Wang R, Meng H, Zhang L. The effects of a comprehensive health education program in Chinese patients after percutaneous coronary intervention. IIOAB Journal 2011;2(7):23-30.
Licina 2010 {published data only}
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Soliman 2013 {published data only}
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Vona 2009 {published data only}
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Xiaolin 2012 {published data only}
    1. Xiaolin Hu, Guiying You, Jiping Li. Analysis on health education demand of patients with coronary heart disease accepting interventual procedures. Chinese Nursing Research 2012;26:1751.

References to ongoing studies

ACTRN12613000395730 {unpublished data only}
    1. ACTRN12613000395730. Evaluation of an educational resource for cardiac secondary prevention: a randomised controlled trial. https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364009 First received 8 April 2013.
ACTRN12613000793718 {unpublished data only}
    1. ACTRN12613000793718. TEXT messages to improve MEDication adherence & Secondary prevention - TEXTMEDS. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364448 First received 18 June 2013.
ACTRN12616000426482 {unpublished data only}
    1. ACTRN12616000426482. SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes: A Randomized Controlled Trial Protocol [SMART-REHAB Trial]. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370434 First received 30 March 2016.
Brewer 2015 {published data only}
    1. Brewer LC, Kaihoi B, Zarling KK, Squires RW, Thomas R, Kopecky S. The use of virtual world-based cardiac rehabilitation to encourage healthy lifestyle choices among cardiac patients: intervention development and pilot study protocol. JMIR Research Protocols 2015;4(2):e39. - PMC - PubMed
Dwinger 2013 {published data only}
    1. Dwinger S, Dirmaier J, Herbarth L, Konig HH, Eckardt M, Kriston L, et al. Telephone-based health coaching for chronically ill patients: study protocol for a randomized controlled trial. Trials [Electronic Resource] 2013;14:337. - PMC - PubMed
IRCT201307162621N13 {unpublished data only}
    1. IRCT201307162621N13. The effects of application of Prochaska's stages of change model in education of coronary artery bypass grafting patients on quality of life, lipid profile & some psychological complications of CABG, Shiraz 2012. http://en.search.irct.ir/view/14373 First receive 17 January 2014.
ISRCTN15839687 {unpublished data only}
    1. ISRCTN15839687. Examining the effectiveness of a self-help psychoeducation programme on outcomes of outpatients with coronary heart disease (CHD). http://www.isrctn.com/ISRCTN15839687?q=ISRCTN15839687&filters=&s... First receive 21 January 2014.
Kärner 2012 {published data only}
    1. Kärner A, Nilsson S, Jaarsma T, Andersson A, Wiréhn AB, Wodlin P, et al. The effect of problem-based learning in patient education after an event of CORONARY heart disease--a randomised study in PRIMARY health care: design and methodology of the COR-PRIM study. BMC Family Practice 2012;Volume:110. - PMC - PubMed
    1. Karner A, Nilsson S, Jaarsma T, Tingstrom P, Abrandt Dahlgren M, Dahl L, et al. COR-PRIM: Patient education after coronary disease - Long-term evaluation in primary care. Scandinavian Cardiovascular Journal 2010;44:39-40.
    1. Karner A, Tingstrom P, Nilsson S, Jaarsma T. COR-PRIM: Longitudinal study on PBL in self-care after CVD - Preliminary results from a pilot study. European Journal of Cardiovascular Nursing 2011;10:S23-4.
Lai 2016 {published data only}
    1. Lai, VKW, Lee A, Leung P, et al. Patient and family satisfaction levels in the intensive care unit after elective cardiac surgery: study protocol for a randomised controlled trial of a preoperative patient education intervention. BMJ Open 2016;6:e011341. - PMC - PubMed
Lynggaard 2014 {published data only}
    1. Lynggaard V, May O, Beauchamp A, Nielsen C V, Wittrup I. LC-REHAB: randomised trial assessing the effect of a new patient education method--learning and coping strategies--in cardiac rehabilitation. BMC Cardiovasc Disord 2014;14:186. - PMC - PubMed
NCT01028066 {unpublished data only}
    1. NCT01028066. Feeding Education in Patients Submitted to Coronary Angioplasty (PTCA-Nutri). https://clinicaltrials.gov/ct2/show/NCT01028066 First received December 8 2009.
NCT01275716 {unpublished data only}
    1. NCT01275716. Impact of Coronary Images Used During Patient Education on Coronary Artery Disease and Subsequent Lifestyle Modifications. Is a Picture Really Worth a Thousand Words? https://clinicaltrials.gov/ct2/show/NCT01275716 First received January 10 2011.
NCT01925079 {unpublished data only}
    1. NCT01925079. Intensive Education on Lipid Management. https://clinicaltrials.gov/ct2/show/NCT01925079 First received August 15 2013.
NCT02185391 {unpublished data only}
    1. NCT02185391. Interactive Education of Patients With Coronary Heart Disease (INSERT). https://clinicaltrials.gov/ct2/show/NCT02185391 First received June 23 2014.
NTR2388 {unpublished data only}
    1. NTR2388. Evaluation Program “Coaching patients On Achieving Cardiovascular Health” (COACH). http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2388 First received 21June 2010.
Shah 2011 {published data only}
    1. Shah B R, Adams M, Peterson E D, Powers B, Oddone E Z, Royal K, et al. Secondary Prevention Risk Interventions Via Telemedicine and Tailored Patient Education (SPRITE): A Randomized Trial to Improve Postmyocardial Infarction Management. Circulation: Cardiovascular Quality & Outcomes 2011;4:235-42. - PubMed

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References to other published versions of this review

Brown 2010
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