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Review
. 2019 Feb 5;8(2):189.
doi: 10.3390/jcm8020189.

Interventions to Promote Patient Utilization of Cardiac Rehabilitation: Cochrane Systematic Review and Meta-Analysis

Carolina Santiago de Araújo Pio  1 , Gabriela Chaves  2 , Philippa Davies  3 , Rod Taylor  4 , Sherry Grace  5   6
Affiliations
Review

Interventions to Promote Patient Utilization of Cardiac Rehabilitation: Cochrane Systematic Review and Meta-Analysis

Carolina Santiago de Araújo Pio et al. J Clin Med. .

Abstract

Too few patients utilize cardiac rehabilitation (CR), despite its benefits. The Cochrane review assessing the effectiveness of interventions to increase CR utilization (enrolment, adherence, and completion) was updated. A search was performed through July 2018 of the Cochrane and MEDLINE (Medical Literature Analysis and Retrieval System Online) databases, among other sources. Randomized controlled trials in adults with myocardial infarction, angina, revascularization, or heart failure were included. Interventions had to aim to increase utilization of comprehensive phase II CR. Two authors independently performed all stages of citation processing. Following the random-effects meta-analysis, meta-regression was undertaken to explore the impact of pre-specified factors. Twenty-six trials with 5299 participants were included (35.8% women). Low-quality evidence showed an effect of interventions in increasing enrolment (risk ratio (RR) = 1.27, 95% confidence interval (CI) = 1.13⁻1.42). Meta-regression analyses suggested that the intervention deliverer (nurse or allied healthcare provider, p = 0.02) and delivery format (face-to-face, p = 0.01) were influential in increasing enrolment. There was low-quality evidence that interventions to increase adherence were effective (standardized mean difference (SMD) = 0.38, 95% CI = 0.20⁻0.55), particularly where remotely-offered (SMD = 0.56, 95% CI = 0.36⁻0.76). There was moderate-quality evidence that interventions to increase program completion were effective (RR = 1.13, 95% CI = 1.02⁻1.25). There are effective interventions to increase CR utilization, but more research is needed to establish specific, implementable materials and protocols, particularly for completion.

Keywords: cardiac rehabilitation; coronary artery disease; healthcare access; secondary prevention.

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Conflict of interest statement

CSAP: none known. G.C.: none known. P.D.: none known. R.T.: currently a co-author of several other Cochrane Reviews on cardiac rehabilitation. He is Chief Investigator in receipt of ongoing National Institute of Health Research Programme Grants for Applied Research (RP-PG-1210-12004): Rehabilitation Enablement in Chronic Heart Failure (REACH-HF). He was involved in some of the included trials but, was not involved in the RoB or GRADE assessment related to these studies. S.G.: Was principal investigator of an included trial, but did not do the RoB or GRADE assessment relating to the trial.

Figures

Figure 1
Figure 1
Summary of the study selection process. CR—cardiac rehabilitation; RCTs—randomized or quasi-randomized controlled trials.
Figure 2
Figure 2
The risk of bias in included trials. Note: Review authors’ judgments about each risk of bias element are presented as percentages across all included trials.
Figure 3
Figure 3
Forest plot summarizing the effect of cardiac rehabilitation utilization interventions on enrollment. Note: Boxes represent the risk ratio (RR) for individual trials. The boxes are proportional to the weight of each study in the analysis and the lines represent their 95% confidence interval (CI). The diamond represents the pooled RR, and its width represents its 95% CI. M-H: Mantel Haenszel method. Tau2 represents the variance of the effect size across studies. Chi2 (Cochran Q test) represents the weighted sum of squared differences between individual studies and the pooled effect across studies. I2 statistic represents the percentage of variation across studies that is due to heterogeneity. Z represents the test for overall effect across all studies. df: degrees of freedom.
Figure 4
Figure 4
Forest plot for the enrollment—intervention deliverer. Note: Boxes represent the risk ratio (RR) for individual trials. The boxes are proportional to the weight of each study in the analysis and the lines represent their 95% confidence interval (CI). The diamond represents the pooled RR, and its width represents its 95% CI.
Figure 5
Figure 5
Forest plot for the enrollment—delivery format. Note: Boxes represent the risk ratio (RR) for individual trials. The boxes are proportional to the weight of each study in the analysis and the lines represent their 95% confidence interval (CI). The diamond represents the pooled RR, and its width represents its 95% CI.
Figure 6
Figure 6
Forest plot summarizing the effect of cardiac rehabilitation utilization interventions on adherence. Note: Boxes represent the standardized mean difference (SMD) for individual trials. The boxes are proportional to the weight of each study in the analysis and the lines represent their 95% confidence interval (CI). The diamond represents the pooled SMD, and its width represents its 95% CI.
Figure 7
Figure 7
Forest plot for adherence—cardiac rehabilitation setting. Note: Boxes represent the standardized mean difference (SMD) for individual trials. The boxes are proportional to the weight of each study in the analysis and the lines represent their 95% confidence interval (CI). The diamond represents the pooled SMD, and its width represents its 95%.
Figure 8
Figure 8
The effect of cardiac rehabilitation utilization interventions on program completion. Note: Boxes represent the risk ratio (RR) for individual trials. The boxes are proportional to the weight of each study in the analysis and the lines represent their 95% confidence interval (CI). The diamond represents the pooled RR, and its width represents its 95% CI.
Figure 9
Figure 9
Forest plot for completion—number of sites. Note: Boxes represent the risk ratio (RR) for individual trials. The boxes are proportional to the weight of each study in the analysis and the lines represent their 95% confidence interval (CI). The diamond represents the pooled RR, and its width represents its 95% CI.
Figure 10
Figure 10
Funnel plot for enrolment. RR - risk ratio; SE - standard error of the estimate.
See this image and copyright information in PMC

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