Interventions to promote patient utilisation of cardiac rehabilitation

Abstract

Rationale: Clinical practice guidelines routinely recommend that cardiac patients participate in rehabilitation programmes as part of comprehensive secondary prevention of heart disease. However, only a small proportion of these patients utilise rehabilitation across global health systems. This is an update of a Cochrane review last published in 2019.

Objectives: Primary objective To assess the effects of interventions provided to increase patient enrolment in, adherence to, and completion of cardiac rehabilitation (CR) for people with myocardial infarction (MI), with angina, following coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI), or with heart failure (HF) who were eligible for CR in an inpatient or outpatient setting. Secondary objectives To assess intervention costs and associated harms with interventions intended to promote CR utilisation.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (Wiley), MEDLINE (Ovid), Embase (OVID), CINAHL Cumulative Index to Nursing and Allied Health Literature (EBSCO), and Conference Proceedings Citation Index - Science (CPCI-S) via Web of Science (Clarivate Analytics). We checked the reference lists of relevant systematic reviews for additional studies and searched two clinical trial registers. We did not apply any language restrictions. The date of search was 02 March 2025.

Eligibility criteria: We included randomised controlled trials (RCTs) and quasi-RCTs in adults with MI, with angina, undergoing CABG surgery or PCI, or with HF who were eligible for CR in an inpatient or outpatient setting. Interventions had to aim to increase patient utilisation of CR, and we included any study that aimed to increase patient enrolment in, adherence to, or completion of CR.

Outcomes: Critical outcome measures were CR programme enrolment, CR programme adherence, and CR programme completion. Important outcome measures included serious adverse events (SAEs) and costs.

Risk of bias: We used the Cochrane RoB 1 tool to assess the risk of bias in eligible trials.

Synthesis methods: One review author extracted trial data into piloted data extraction forms, which were checked by a second review author. We pooled outcome data across included studies using random-effects meta-analysis, and used meta-regression to explore the potential impact of prespecified intervention characteristics on intervention effects.

Included studies: We included 47 studies (58 comparisons) with 10,803 participants. Trials were conducted over a range of geographical settings, principally North America and Europe or other high-income economies. No studies from low- and middle-income country settings were included. Participants in most of the included studies were primarily male. The median percentage of females across studies was 40% (range 0% to 100%). Sixteen studies included patients with HF. We assessed most studies as having low or unclear risk of bias. Studies tested a variety of strategies to increase utilisation of CR. The most common intervention strategies tested were: education/self-management training/motivational interviewing (nine trials); switch from traditional centre-based CR to alternative models of delivery - home/digital/hybrid (eight trials); letters/messaging invites (seven trials); peer support strategies (five trials); women-only programmes (two studies); and use of financial incentives (two studies).

Synthesis of results: Interventions to promote patient utilisation of CR may increase programme enrolment (risk ratio (RR) 1.19, 95% confidence interval (CI) 1.11 to 1.29; 27 trials (31 comparisons), 7216 participants; low-certainty evidence). Meta-regression showed no evidence of significant differences in prespecific trial-level covariates, except for the intervention target where there was weak evidence of somewhat higher impact of interventions in trials where the intervention target was the patient. Interventions to promote patient utilisation of CR likely increase programme adherence (standardised mean difference (SMD) 0.32, 95% CI 0.15 to 0.49; 18 trials (21 comparisons), 3024 participants; moderate-certainty evidence). Meta-regression showed no evidence of significant differences in prespecific trial-level covariates and the impact of interventions. Interventions to promote patient utilisation of CR likely increase programme completion (RR 1.22, 95% CI 1.10 to 1.35; 19 trials (23 comparisons), 5432 participants; moderate-certainty evidence). Meta-regression showed no evidence of significant differences in prespecific trial-level covariates and the impact of interventions. There was strong evidence of small study bias for enrolment, and weak evidence of small study bias for completion. There was no evidence of small study bias for adherence. There was likely no increase in the incidence of SAEs with interventions to promote utilisation of CR (RR 0.82, 95% CI 0.44 to 1.51; 6 trials (6 comparisons), 716 participants; moderate-certainty evidence). Little information (four trials) was available on the costs or cost-effectiveness of interventions to promote utilisation of CR.

Authors' conclusions: This updated Cochrane review shows that a range of interventions may increase utilisation of CR in terms of CR enrolment, and likely increase CR adherence and completion. The certainty of the evidence was low to moderate due to high statistical heterogeneity across trials, which was likely due to the range of included interventions and the differences in outcome collection and reporting.

Funding: This Cochrane review was funded by the National Institute for Health Research (NIHR) under its Research and Innovation for Global Health Transformation (RIGHT) Programme (Grant reference: NIHR205540). LL, RST, and VW undertook this research as University of Glasgow-funded staff.

Registration: Protocol (2008): DOI 10.1002/14651858.CD007131/full Original review (2010): DOI 10.1002/14651858.CD007131.pub2 Review updates (2014): DOI 10.1002/14651858.CD007131.pub3; (2019): DOI 10.1002/14651858.CD007131.pub4.