Original Title: Efectividad y coste-efectividad de la rehabilitación cardiaca en pacientes con cardiopatía isquémica en el ámbito extra-hospitalario (actualización)

Authors' objectives: To determine the effectiveness and cost-effectiveness of nonhospital based cardiac rehabilitation in coronary heart disease patients, particularly, in patients who have suffered myocardial infarction. • To determine the content of effective non-hospital based cardiac rehabilitation in its different modalities.

Authors' results and conclusions: RESULTS: We found 2333 article references. Once duplicates were discarded, that figure shrank to 2067 references. We retrieved 121 articles for full review, of which we finally included 11. From the review of bibliographies and manual search one additional reference was found. These results together with the studies included in the previous literature review total to 32 articles included, which correspond to 26 different clinical trials and 2 economic evaluations. Almost all the studies that compared a non-hospital CR programme with control concluded that taking part in home or community based CR was more beneficial than not taking part in CR for some measures such as the ones related to the functional capacity or to the cardiovascular risk factors. In general, studies that compared home-based CR with hospital-based CR found no differences in results between both. Thus the authors concluded that home-based CR may be as effective as hospital-based CR. Concerning the type of intervention, 12 studies assessed interventions based primarily on exercises and 14 studies evaluated comprehensive interventions. Most studies evaluating interventions based on exercises reported significant improvements in health related quality of life assessed through validated questionnaires and differences between groups after intervention in favour of non-hospital CR groups. As for cholesterol levels, only one study found significant differences between home-based CR group and the group which performed CR in a primary care centre. Finally, in general, the number or percentage of smokers decreased after intervention although no study found statistically significant differences between groups. In studies evaluating comprehensive interventions, health related quality of life was assessed by means of both specific questionnaires (MacNew, MIDAS, Velasco-del Barrio) and generic questionnaires (SF36, EQ-5D). Most authors found improvements in quality of life that benefited patients taking part in a non-hospital programme. Regarding the level of blood lipids, most studies found no differences between groups in the level of cholesterol or triglycerides. Finally, tobacco consumption was taking into account as an outcome measure in 7 studies, but only 2 found differences between groups in favour of nonhospital CR group. It is important to point out that high risk patients were excluded in the majority of studies analysed, hence we can only state the interventions were safe and effective for low and moderate risk patients. The methodological quality of some trials is low due to the lack of randomization or allocation concealment or due to the small sample size. Two of the best studies recently published in UK, BRUMS and CHARMS studies, compared the Heart Manual (comprehensive CR consisting mainly of a manual containing education and further instructions to continue at home) with hospital-based CR. These 2 estudies included economic evaluations also. Both studies concluded that there were no significant differences in healthcare costs or in quality adjusted life years between the two types of CR analysed. We can concluded that, in general, performing exercises at home is good to improve the functional capacity and that comprehensive interventions could have a positive effect on other measures such as quality of life, tobacco consumption and resumption of work activity. The Heart Manual, a home-based CR programme, could be as effective and cost-effective as the hospital-based CR. CONCLUSIONS: • Home or community-based CR is more effective than no CR in terms of improvement of the functional capacity or modification of cardiovascular risk factors. • Home-based CR could be at least as effective as hospital-based CR in low and moderate risk patients. This is based on clinical trials conducted in low and moderate risk patients. • Home-based CR could be a cost-effective alternative to hospitalbased CR. This is based on only two economic evaluations conducted in UK in which The Heart Manual was assessed from the social perspective.

Authors' recommendations: Given the results and conclusions of this systematic review, the following recommendations for the CR for patients who had suffered a myocardial infarction are stated: • To design non-hospital based CR programmes (Primary Care, home, community) of a proved effectiveness and cost-effectiveness such as some of the described in this review (e.g. Heart-Manual) and give priority of access to these programmes to low and moderate risk patients. • To prioritize hospital-based CR programmes for high risk patients and derive low and moderate risk patients to non-hospital based CR programmes in a Primary Care setting. • To assess the effectiveness and cost-effectiveness of non-hospital based CR programmes that already exist in Spain.

Authors' methods: We conducted an update of a systematic review of the effectiveness and cost-effectiveness of non-hospital based CR previously published. We systematically searched electronic databases such as MEDLINE and MEDLINE in process, The Cochrane Library Plus (CENTRAL, Cochrane Systematic Reviews Database), CRD (DARE, HTA, NHS-EED), CINAHL, IME, IBECS and LILACS in September 2012. In addition, we reviewed the literature of the selected articles.. The literature search strategy was limited to clinical trials. In order to search the economic literature, a complementary strategy was used. Both strategies were limited only to studies published since 2006. We selected articles published in English or Spanish about randomized and non-randomized controlled clinical trials which assessed the effectiveness of the CR in any follow-up period. We also selected full economic evaluations. The participants were patients who suffered a myocardial infarction with or without subsequent interventional procedure. We included studies in which at least a complex CR programme or an exercise based CR programme, which would be carried out outside the hospital (home, community or Primary Care), was compared to hospital-based CR or control group. We excluded the studies where patients had previously attended a hospitalbased CR programme. We included several effectiveness measures such as the reduction of morbidity and mortality rates, health-related quality of life, functional capacity, modifiable cardiovascular risk factors, psychological state and return to work. The studies were selected independently by two reviewers. The data extraction from the included studies was carried out by a reviewer and checked by a second reviewer. The data were gathered in spreadsheets designed ad hoc. The methodological quality was independently reviewed by two reviewers. Where the reviewers disagreed, they would negotiate. When consensus was not reached, a third reviewer was consulted. The quality of the selected articles was assessed according to several tools and criteria from different organizations and authors: Jadad Scale, allocation concealment, losses to follow-up and blinding of outcome assessment for the clinical trials; Drummond, Stoddart and Torrance’s criteria for the economic evaluation. The collected information was synthesised by means of narrative procedures with detailed tabulation of the results of each of the included studies.

Project Status: Completed

Year Published: 2012

URL for published report: https://sescs.es/efectividad-rehabilitacion-cardiaca-pacientes-con-cardiopatia-isquemica-ambito-extra-hospitalarioact/

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Spain

Organisation Name: Canary Health Service

Contact Address: Dirección del Servicio. Servicio Canario de la Salud, Camino Candelaria 44, 1ª planta, 38109 El Rosario, Santa Cruz de Tenerife

Contact Name: sescs@sescs.es

Contact Email: sescs@sescs.es