Promoting patient uptake and adherence in cardiac rehabilitation
Abstract
Background
Cardiac rehabilitation is an important component of recovery from coronary events but uptake and adherence to such programmes are below the recommended levels. This aim is to update a previous non‐Cochrane systematic review which examined interventions that may potentially improve cardiac patient uptake and adherence in rehabilitation or its components and concluded that there is insufficient evidence to make specific recommendations.
Objectives
To determine the effects of interventions to increase patient uptake of, and adherence to, cardiac rehabilitation.
Search methods
A previous systematic review identified studies published prior to June 2001. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 4 2007), MEDLINE (2001 to January 2008), EMBASE (2001 to January 2008), CINAHL (2001 to January 2008), PsycINFO (2001 to January 2008), Web of Science: ISI Proceedings (2001 to April 2008), and NHS Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)) from 2001 to January 2008. Reference lists of identified systematic reviews and randomised control trials (RCTs) were also checked for additional studies.
Selection criteria
Adults with myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, heart failure, angina, or coronary heart disease eligible for cardiac rehabilitation and randomised or quasi‐randomised trials of interventions to increase uptake or adherence to cardiac rehabilitation or any of its component parts. Only studies reporting a measure of adherence were included.
Data collection and analysis
Titles and abstracts of all identified references were screened for eligibility by two reviewers independently and full papers of potentially relevant trials were obtained and checked. Included studies were assessed for risk of bias by two reviewers.
Main results
Ten studies were identified, three of interventions to improve uptake of cardiac rehabilitation and seven of interventions to increase adherence. Meta‐analysis was not possible due to multiple sources of heterogeneity. All three interventions targeting uptake of cardiac rehabilitation were effective. Two of seven studies intended to increase adherence had a significant effect. Only one study reported the non‐significant effects of the intervention on cardiovascular risk factors and no studies reported data on mortality, morbidities, costs or health care resource utilisation.
Authors' conclusions
There is some evidence to suggest that interventions to increase the uptake of cardiac rehabilitation can be effective. Few practice recommendations for increasing adherence to cardiac rehabilitation can be made at this time. Interventions targeting patient identified barriers may increase the likelihood of success. Further high quality research is needed.
PICOs
Plain language summary
Promoting patient uptake and adherence in cardiac rehabilitation
People with coronary heart disease are at an increased risk of experiencing adverse cardiac events such as heart attack. Cardiac rehabilitation programmes aid recovery from a cardiac event or surgery and reduce the likelihood of further illness. Cardiac rehabilitation programmes vary, but usually include one or more of the following: exercise, education, and psychological counselling/support. Despite the benefits of cardiac rehabilitation, not everyone agrees to participate and, of those who do, many people do not adhere to the programme recommended. This Cochrane review evaluated trials of ways to increase the uptake of cardiac rehabilitation and to improve adherence amongst those who choose to participate.
We searched a wide variety of databases and found ten randomised control trials that were suitable for inclusion (three trials of interventions to improve uptake, and seven of interventions to improve adherence). The studies evaluated a variety of techniques to improve uptake or adherence and in many studies a combination of strategies was employed. The quality of studies was generally low. All three interventions targeting uptake of cardiac rehabilitation were effective. Two of seven studies intended to increase adherence to exercise as part of cardiac rehabilitation had a significant effect (one of which was of poor quality). Very few studies reported the effects of the interventions on clinical outcomes or health related quality of life and none provided information about costs or resource implications.
The differences between the strategies used in the studies we identified mean that it is difficult to make recommendations at this stage. Interventions targeting patient identified barriers may increase the likelihood of success. Further high quality research is needed, particularly in under‐represented groups such as women, ethnic minorities, older patients, heart failure patients, and those with co‐morbidities.
