Home‐based versus centre‐based cardiac rehabilitation

Lindsey Anderson; Georgina A Sharp; Rebecca J Norton; Hasnain Dalal; Sarah G Dean; Kate Jolly; Aynsley Cowie; Anna Zawada; Rod S Taylor

doi:10.1002/14651858.CD007130.pub4

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Figure 1

PRISMA Flow Diagram

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Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study

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Figure 3

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies

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Figure 4

Funnel plot of comparison: 1 home‐base vs centre‐based, outcome: 1.1 Total mortality.

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Figure 5

Funnel plot of comparison: 1 home‐base vs centre‐based, outcome: 1.2 Exercise capacity ≤ 12 months.

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Figure 6

Funnel plot of comparison: 1 home‐base vs centre‐based, outcome: 1.4 Completers.

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Figure 7

Funnel plot of comparison: 1 home‐base vs centre‐based, outcome: 1.5 Total cholesterol 3 to 12 months.

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Figure 8

Funnel plot of comparison: 1 home‐base vs centre‐based, outcome: 1.9 Systolic blood pressure 3 to 12 months.

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Analysis 1.1

Comparison 1 home‐base vs centre‐based, Outcome 1 Total mortality.

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Analysis 1.2

Comparison 1 home‐base vs centre‐based, Outcome 2 Exercise capacity ≤ 12 months.

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Analysis 1.3

Comparison 1 home‐base vs centre‐based, Outcome 3 Exercise capacity 12 to 24 months.

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Analysis 1.4

Comparison 1 home‐base vs centre‐based, Outcome 4 Completers.

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Analysis 1.5

Comparison 1 home‐base vs centre‐based, Outcome 5 Total cholesterol 3 to 12 months.

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Analysis 1.6

Comparison 1 home‐base vs centre‐based, Outcome 6 HDL cholesterol 3 to 12 months.

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Analysis 1.7

Comparison 1 home‐base vs centre‐based, Outcome 7 LDL cholesterol 3 to 12 months.

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Analysis 1.8

Comparison 1 home‐base vs centre‐based, Outcome 8 Triglycerides 3 to 12 months.

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Analysis 1.9

Comparison 1 home‐base vs centre‐based, Outcome 9 Systolic blood pressure 3 to 12 months.

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Analysis 1.10

Comparison 1 home‐base vs centre‐based, Outcome 10 Diastolic blood pressure 3 to 12 months.

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Analysis 1.11

Comparison 1 home‐base vs centre‐based, Outcome 11 Smoking 3 to 12 months.

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Summary of findings for the main comparison. Home‐based versus supervised centre‐based cardiac rehabilitation for heart disease

Home‐based versus supervised centre‐based cardiac rehabilitation for heart disease
Patient or population: Patients with heart disease Settings: Home and rehabilitation centres Intervention: Home‐based cardiac rehabilitation Comparison: Centre‐based cardiac rehabilitation
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with centre‐based	Risk with home‐base
Total mortality Number of deaths Follow‐up: up to 12 months	Study population		RR 1.19 (0.65 to 2.16)	1505 (11 studies/ 13 comparisons)	⊕⊝⊝⊝ VERY LOW ^{1 2}
	22 per 1,000	26 per 1,000 (14 to 47)
Exercise capacity ≤ 12 months Validated outcome measure (e.g. VO₂ peak, 6 minute walk test) Follow‐up: 2 to 12 months	The mean exercise capacity ≤ 12 months ranged from ‐2 to 3,509.33	SMD 0.13 lower (0.28 lower to 0.02 higher)	‐	2255 (22 studies /26 comparisons)	⊕⊕⊝⊝ LOW ^{1 3}	Higher score indicates improved activity. A rule of thumb for interpreting SMD is that 0.2 represents a small effect, 0.5 a moderate effect and 0.8 a large effect (Cohen 1988)
Withdrawal from the intervention group Number of completers (participants with data at follow‐up) Follow‐up: 2 to 72 months	Study population		RR 1.04 (1.00 to 1.08)	2615 (22 studies/ 26 comparisons)	⊕⊕⊝⊝ LOW ^{1 3}
	816 per 1,000	848 per 1,000 (816 to 881)
HRQoL Validated measures of HRQoL (e.g. Short Form Health Survey (SF‐36), Sickness Impact Profile, Nottingham Health Profile) Follow‐up: 2 to 24 months	HRQoL in home‐based cardiac rehabilitation = HRQoL in centre‐based cardiac rehabilitation, in 61/67 domains		Not estimable	2079 (14 studies/ 15 comparison)	⊕⊕⊕⊝ MODERATE¹
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; OR: Odds ratio;
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Random sequence generation, allocation concealment or blinding of outcome assessors were poorly described in over 50% of included studies; bias likely, therefore quality of evidence downgraded by one level. ² The 95% CIs includes both no effect, appreciate benefit and appreciable harm (i.e. CI < 0.75 and > 1.25), therefore quality of evidence downgraded by two levels. ³ I² > 50%; heterogeneity may be important and therefore quality of evidence downgraded by one level

Summary of findings for the main comparison. Home‐based versus supervised centre‐based cardiac rehabilitation for heart disease

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Table 1. Results of univariate meta‐regression analysis for total mortality

Explanatory variable (n trials)	Exp(slope)*	95% CI univariate P value	Proportion of variation explained	Interpretation
Case mix (% MI patients) (n = 6)	RR = 0.997	0.970 to 1.024 P = 0.743	Not calculable²	No evidence that RR is associated with case mix
Dose of exercise (number of weeks of exercise training x average number of sessions/week x average duration of session in min) (n = )	Not calculable¹	Not calculable¹	Not calculable¹	No evidence that RR is associated with increased dose of exercise
Type of cardiac rehabilitation (exercise only versus comprehensive cardiac rehabilitation) (n = 7)	RR = 2.464	0.038 to 160.487 P = 0.603	Not calculable²	No evidence that RR is associated with type of cardiac rehabilitation
Duration of follow‐up (months) (n = 7)	RR = 1.022	0.872 to 1.198 P = 0.737	Not calculable²	No evidence that RR is associated with duration of follow‐up
Year of publication (n = 7)	RR = 0.988	0.851 to 1.147 P = 0.842	Not calculable²	No evidence that RR is associated with year of publication
Risk of bias (low risk in ≥ 4 items versus < 4 items) (n = 7)	RR = 0.902	0.197 to 4.127 P = 0.868	Not calculable²	No evidence that RR is associated with risk of bias
Study location (n = 7)	RR = 0.846	0.398 to 1.822 P = 0.613	Not calculable²	No evidence that RR is associated with study location
Sample size (n = 7)	RR = 1.001	0.995 to 1.006 P = 0.726	Not calculable²	No evidence that RR is associated with sample size
¹ Not calculable due to insufficient observations ² Not calculable; Tau² of all studies = 0 Abbreviations: MI, myocardial infarction; RR, risk ratio

Table 1. Results of univariate meta‐regression analysis for total mortality

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Table 2. Results of univariate meta‐regression analysis for exercise capacity

Explanatory variable (n trials)	Exp(slope)*	95% CI Univariate P value	Proportion of variation explained	Interpretation
Case mix (% MI patients) (n = 23)	RR = 0.003	‐0.001 to 0.008 P = 0.119	11.69%	No evidence that RR is associated with case mix
Dose of exercise (number of weeks of exercise training x average number of sessions/week x average duration of session in min) (n = 10)	RR = ‐0.001	‐0.003 to 0.001 P = 0.245	Not calculable¹	No evidence that RR is associated with increased dose of exercise
Type of cardiac rehabilitation (exercise only versus comprehensive cardiac rehabilitation) (n = 26)	RR = 0.210	‐0.026 to 0.447 P = 0.079	18.73%	No evidence that RR is associated with type of cardiac rehabilitation
Duration of follow‐up (months) (n = 25)	RR = 0.003	‐0.007 to 0.013 P = 0.544	‐5.17%	No evidence that RR is associated with duration of follow‐up
Year of publication (n = 25)	RR = ‐0.002	‐0.024 to 0.020 P = 0.841	‐5.52%	No evidence that RR is associated with year of publication
Risk of bias (low risk in ≥ 4 items versus < 4 items) (n = 25)	RR = 0.097	‐0.118 to 0.311 P = 0.360	2.94%	No evidence that RR is associated with risk of bias
Study location (n = 26)	RR = 0.195	‐0.033 to 0.423 P = 0.090	15.80%	No evidence that risk ratio is associated with study location
Sample size (n = 25)	RR = 0.000	‐0.001 to 0.002 P = 0.837	‐7.78%	No evidence that RR is associated with sample size
¹ Not calculable; Tau² of all studies = 0 Abbreviations: MI, myocardial infarction; RR, risk ratio

Table 2. Results of univariate meta‐regression analysis for exercise capacity

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Table 3. Summary of health‐related quality of life (HRQoL) at follow up for home and centre‐based cardiac rehabilitation

Study ID

Follow up

HRQoL measure

Outcome values at follow up

Mean (SD or range)

Home‐ versus centre‐based, between group P value

Between‐group difference

Aamot 2014 Treadmill

Home versus treadmill group

12 weeks

MacNew

Emotional domain

Social domain

Physical domain

Global

6.1 (3.9–6.7) versus 6.0 (4.8–6.5) ns

6.8 (4.9–7.0) versus 6.7 (5.6–6.9) ns

6.4 (4.9–6.9) versus 6.6 (5.4–6.9) ns

6.4 (4.7–6.8) versus 6.3 (5.2–6.7) ns

Home = Centre

Aamot 2014 Treadmill

Home versus group exercise

12 weeks

MacNew

Emotional domain

Social domain

Physical domain

Global

6.1 (3.9–6.7) versus 6.2 (3.6–6.9) ns

6.8 (4.9–7.0) versus 6.5 (5.0–7.0) ns

6.4 (4.9–6.9) versus 6.4 (5.2–7.0) ns

6.4 (4.7–6.8) versus 6.3 (4.5–6.7) ns

Home = Centre

Arthur 2002

/Smith 2004

6 months

18 months

SF‐36 PCS

MCS

SF‐36 PCS

MCS

51.2 (6.4) versus 48.6 (7.1) P = 0.003*

53.5 (6.4 ) versus 52.0 (8.1) P = 0.13*

48.3 (11.7) versus 47.6 (11.7) P = 0.67*

53.0 (10.9) versus 50.2 (10.9) P = 0.07*

Home > Centre

Home = Centre

Bell 1998

10.5 months

Nottingham Health Profile

Energy

Pain

Emotional reactions

Sleep

Social isolation

Physical mobility

18.6 (28.4) versus 17.3 (30.7) P = 0.78*

6.6 (15.3) versus 7.4 (15.5) P = 0.74*

6.6 (15.3) versus 16.9 (22.8) P = 0.0007*

3.7 (13.6) versus 6.7 (15.0) P = 0.18*

6.9 (13.5) versus 9.1 (15.9) P =0.33*

Home = Centre

Home < Centre

Home = Centre

Cowie 2012

3 months

SF‐36 PCS

MCS

MLWHF total

Physical

Emotional

34.01 (11.04) versus 31.33 (7.97) P = 0.82

44.44 (12.23) versus 48.25 (11.21) P = 0.04

37 (NR) vs 32 (NR) P = 0.18

21 (NR) vs 19 (NR) P = 0.31

7 (NR) vs 7 (NR) P = 0.13

Home = Centre

Home < Centre

Home = Centre

Home = Centre
Home = Centre

Marchionni 2003

2 months

8 months

14 months

Sickness Impact Profile

2.83 (14.5) versus 4.71 (11.1) P = 0.09*

2.83 (14.5) versus 3.40 (11.1) P = 0.61*

2.00 (8.3) versus 3.70 (11.8) P = 0.06*

Home = Centre

Dalal 2007/Taylor 2007

9 months

MacNew Global score

EQ‐5D

5.61 (1.14) versus 5.54 (1.10) P = 0.71

0.74 (0.04) versus 0.78 (0.04) P = 0.57

Home = Centre

Hadadzadeh 2015

12 week

SF 36

Physical Composite Score

Mental Composite Score

51.6 (4.7) versus 52.2 (4.7) P = 0.94

46.4 (4.9) versus 47.6 (6.4) P = 0.10

Home = Centre

Jolly 2007

6 months

12 months

24 months

EQ‐5D

SF‐12

PCS

MCS

EQ‐5D

0.74 (0.26) versus 0.76 (0.23) P = 0.37

42.28 (10.9) 42.56 (10.8) P = 0.8

49.19 (10.1) 50.33 (9.6) P = 0.3

0.74 (0.27) versus 0.76 (0.23) P = 0.52*

0.73 (0.29) versus 0.75 (0.26) P = 0.39*

Home = Centre

Karapolat 2009

8 weeks

SF‐36

Physical function

Physical role

Bodily pain

General health
Vitality

Social function

Emotional role

Mental health

59.39 (25.35) versus 69.57 (20.94),P = 0.08*

39.81 (41.75) versus 48.21 (45.10) P = 0.43*

62.42 (30.45) versus 74.23 (19.66) P = 0.07*

47.25 (23.42) versus 53.98 (25.00) P =0.33*

66.67 (19.82) versus 69.81 (17.41) P = 0.49*

65.33 (25.60) versus 69.33 (25.14) P = 0.52*

44.74 (39.77) versus 37.16 (39.24) P =0.44*

64.67 (19.04) versus 70.52 (20.37) P = 0.22*

Home = Centre

Home = Centre
Home = Centre

Home = Centre

Kraal 2014

12 weeks

MacNew (Dutch translation)

Physical scale

Emotional scale

Social scale

Total score

6.1 (0.6) versus 5.7 (0.8) P = 0.16

5.9 (0.8) versus 5.6 (0.9) P = 0.88

6.4 (0.6) versus 6.1 (0.7) P = 0.26

6.1 (0.5) versus 5.8 (0.7) P = 0.50

Home = Centre

Moholdt 2012

6 months

MacNew

Emotional domain

Physical domain

Social domain

1.2 (0.2) versus 1.4 (0.2) P > 0.05

1.4 (0.7) versus 1.6 (1.1) P > 0.05

4.3 (0.7) versus 4.3 (1.0) P > 0.05

Home = Centre

Oerkild 2011

3 months

6 months

SF‐36 PCS

SF‐36 MCS

SF‐36 PCS

SF‐36 MCS

1.4 (‐1.5 to 4.3) versus 0.5 (‐2.4 to 3.4) P > 0.05

0.8 (‐2.6 to 4.3) versus ‐0.2 (‐3.6 to 3.4) P > 0.05

1.0 (‐1.6 to 3.6) versus 1.2 (‐1.4 to 3.8) P > 0.05

2.3 (‐1.1 to 5.7) versus 2.6 (‐0.9 to ‐6.0) P > 0.05

Home = Centre

Piotrowicz 2010/

Piotrowicz 2014

8 weeks

SF‐36

Physical function

Role limitation caused by physical problems

Bodily pain

General health

Physical component summary

Social function

Mental health

Role limitation caused by physical problems

Vitality

Mental component summary

Total quality of life index

21.60 (9.65) versus 23.20 (10.71) ns

12.74 (7.17) versus 11.39 (8.43) ns

2.66 (2.22) versus 2.00 (2.07) ns

13.14 (3.80) versus 14.59 (4.03) P < 0.05

50.27 (17.06) versus 51.37 (19.60) ns

2.64 (2.84) versus 1.63 (1.54) P < 0.05

7.15 (4.00) versus 5.89 (3.58) ns

4.93 (6.15) versus 4.35 (6.07) ns

7.25 (3.78) versus 6.76 (3.17) ns

21.68 (12.46) versus 18.56 (9.18) ns

70.50 (25.40) versus 69.20 (26.40) ns

Home = Centre

Home < Centre

Home = Centre

Home > Centre

Home = Centre

Varnfield 2014

6 weeks

6 months

EQ5D‐Index

0.92 (0.9–1.0) versus 0.82 (0.7–0.9)

"The HRQoL (EQ5D‐Index) improved significantly in
CAP‐CR participants compared with TCR."

0.85 (0.1) versus 0.86 (0.2)

"Between‐group difference for changes in EQ5D‐Index was
not significant at 6 months"

Home > Centre

Home = Centre

*P value calculated by authors of this report based on independent 2‐group t‐test
Home = Centre: no statistically significant difference (P > 0.05) in HRQoL between home and centre‐based groups at follow up
Home > Centre: statistically significant (P ≤ 0.05) higher HRQoL in home versus centre‐based groups at follow up
Home < Centre: statistically significant (P ≤ 0.05) lower HRQoL in home versus centre‐based groups at follow up
Abbreviations: HRQoL = health related quality of life; MCS: mental component score; MLWHF: Minnesota Living With Heart Failure; PCS: physical component score; SF‐12: 12‐Item Short Form Health Survey; SF‐36: Short Form (36) Health Survey

Table 3. Summary of health‐related quality of life (HRQoL) at follow up for home and centre‐based cardiac rehabilitation

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Table 4. Results of univariate meta‐regression analysis for withdrawal (no of completers)

Explanatory variable (n trials)	Exp(slope)*	95% CI univariate P value	Proportion of variation explained	Interpretation
Case mix (% MI patients) (n = 21)	RR = 1.000	0.999 to 1.002 P = 0.949	‐15.22%	No evidence that RR is associated with case mix
Dose of exercise (number of weeks of exercise training x average number of sessions/week x average duration of session in min) (n = 10)	RR = 0.999	0.998 to 1.000 P = 0.217	16.94%	No evidence that RR is associated with increased dose of exercise
Type of cardiac rehabilitation (exercise only versus comprehensive cardiac rehabilitation) (n = 24)	RR = 1.041	0.975 to 1.111 P = 0.219	‐1.56%	No evidence that RR is associated with type of cardiac rehabilitation
Duration of follow‐up (months) (n = 23)	RR = 1.000	0.997 to 1.003 P = 0.940	‐21.09%	No evidence that RR is associated with duration of follow‐up
Year of publication (n = 23)	RR = 1.000	0.992 to 1.007 P = 0.930	‐12.08%	No evidence that RR is associated with year of publication
Risk of bias (low risk in ≥ 4 items versus < 4 items) (n = 23)	RR = 0.949	0.880 to 1.023 P =0.160	32.50%	No evidence that RR is associated with risk of bias
Study location (n = 24)	RR = 0.988	0.912 to 1.069 P = 0.747	‐21.54%	No evidence that RR is associated with study location
Sample size (n = 23)	RR = 1.000	1.000 to 1.000 P = 0.880	‐20.04%	No evidence that RR is associated with sample size
Abbreviations: MI: myocardial infarction; RR: risk ratio

Table 4. Results of univariate meta‐regression analysis for withdrawal (no of completers)

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Table 5. Results of univariate meta‐regression analysis for total cholesterol

Explanatory variable (n trials)	Exp(slope)*	95% CI univariate P value	Proportion of variation explained	Interpretation
Case mix (% MI patients) (n = 10)	RR = ‐0.007	‐0.011 to ‐0.002 P = 0.014	88.71%	Evidence that RR is associated with case mix
Dose of exercise (number of weeks of exercise training x average number of sessions/week x average duration of session in min) (n = )	Not calculable¹	Not calculable¹	Not calculable¹	No evidence that RR is associated with increased dose of exercise
Type of cardiac rehabilitation (exercise only vs comprehensive cardiac rehabilitation) (n = 10)	RR = ‐0.127	‐0.822 to 0.567 P = 0.684	‐17.11%	No evidence that RR is associated with type of cardiac rehabilitation
Duration of follow‐up (months) (n = 10)	RR = ‐0.007	‐0.038 to 0.024 P = 0.594	‐21.27%	No evidence that RR is associated with duration of follow‐up
Year of publication (n = 10)	RR = 0.027	‐0.012 to 0.066 P = 0.154	31.00%	No evidence that RR is associated with year of publication
Risk of bias (low risk in ≥ 4 items versus < 4 items) (n = 10)	RR = ‐0.077	‐0.404 to 0.249 P = 0.600	‐14.59%	No evidence that RR is associated with risk of bias
Study location (n = 10)	RR =0.015	‐0.304 to 0.333 P = 0.919	‐18.83%	No evidence that RR is associated with study location
Sample size (n = 10)	RR = ‐0.001	‐0.002 to 0.001 P = 0.347	‐7.77%	No evidence that RR is associated with sample size
¹Not calculable due to insufficient observations Abbreviations: MI: myocardial infarction; RR: risk ratio

Table 5. Results of univariate meta‐regression analysis for total cholesterol

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Table 6. Results of univariate meta‐regression analysis for systolic BP

Explanatory variable (n trials)	Exp(slope)*	95% CI univariate P value	Proportion of variation explained	Interpretation
Case mix (% MI patients) (n = 11)	RR = 0.026	‐0.095 to 0.146 P = 0.642	‐8.81%	No evidence that RR is associated with case mix
Dose of exercise (number of weeks of exercise training x average number of sessions/week x average duration of session in min) (n = 4)	RR = 0.001	‐0.110 to 0.112 P = 0.971	Not calculable¹	No evidence that RR is associated with increased dose of exercise
Type of cardiac rehabilitation (exercise only versus comprehensive cardiac rehabilitation) (n = 12)	RR = 5.021	‐0.929 to 10.971 P =0.089	51.60%	No evidence that RR is associated with type of cardiac rehabilitation
Duration of follow‐up (months) (n = 12)	RR = ‐0.053	‐0.540 to 0.435 P = 0.815	‐22.77%	No evidence that RR is associated with duration of follow‐up
Year of publication (n = 12)	RR = ‐0.008	‐0.607 to 0.591 P =0.976	‐15.85%	No evidence that RR is associated with year of publication
Risk of bias (low risk in ≥ 4 items versus < 4 items) (n = 12)	RR = 2.325	‐1.376 to 6.026 P =0.192	37.06%	No evidence that RR is associated with risk of bias
Study location (n = 12)	RR = 4.053	0.696 to 7.410 P = 0.023	71.21%	Evidence that RR is associated with study location
Sample size (n = 12)	RR = ‐0.005	‐0.029 to 0.018 P = 0.623	‐18.75%	No evidence that RR is associated with sample size
¹Not calculable; Tau² of all studies = 0 Abbreviations: MI: myocardial infarction; RR: risk ratio

Table 6. Results of univariate meta‐regression analysis for systolic BP

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Table 7. Results of univariate meta‐regression analysis for diastolic blood pressure

Explanatory variable (n trials)	Exp(slope)*	95% CI univariate P value	Proportion of variation explained	Interpretation
Case mix (% MI patients) (n = 10)	RR = 0.025	‐0.069 to 0.119 P = 0.561	‐11.53%	No evidence that risk RR is associated with case mix
Dose of exercise (number of weeks of exercise training x average number of sessions/week x average duration of session in min) (n = 4)	RR = ‐0.017	‐0.085 to 0.051 P = 0.391	Not calculable¹	No evidence that RR is associated with increased dose of exercise
Type of cardiac rehabilitation (exercise only versus comprehensive cardiac rehabilitation) (n = 11)	RR = 0.125	‐4.719 to 4.970 P = 0.955	‐20.57%	No evidence that RR is associated with type of cardiac rehabilitation
Duration of follow‐up (months) (n = 11)	RR = ‐0.051	‐0.377 to 0.276 P = 0.734	‐32.23%	No evidence that RR is associated with duration of follow‐up
Year of publication (n = 11)	RR = 0.234	‐0.144 to 0.613 P = 0.195	40.22%	No evidence that RR is associated with year of publication
Risk of bias (low risk in ≥ 4 items versus < 4 items) (n = 11)	RR = 0.761	‐2.082 to 3.605 P = 0.560	0.88%	No evidence that RR is associated with risk of bias
Study location (n = 11)	RR = ‐0.034	‐3.196 to 3.128 P = 0.981	‐25.38%	No evidence that RR is associated with study location
Sample size (n = 11)	RR = ‐0.001	‐0.017 to 0.015 P = 0.907	‐30.17%	No evidence that risk ratio is associated with sample size
¹Not calculable; Tau² of all studies = 0 Abbreviations: MI: myocardial infarction; RR: risk ratio

Table 7. Results of univariate meta‐regression analysis for diastolic blood pressure

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Table 8. Summary of adherence at follow up in home and centre‐based cardiac rehabilitation

Trial	Follow‐up	Method/definition of adherence assessment	Findings	Between‐group difference
Aamot 2014 Treadmill Home versus treadmill group	12 weeks	Completion of 70% of the exercise sessions (considered to be training per protocol). Median (range) number of exercise sessions completed	Home: 24/28 (86%) versus centre: 34/34 (100%) P = 0.04 Home: 24 (10–24) versus centre: 24 (7–24)	Home < Centre
Aamot 2014 Treadmill Home versus group exercise	12 weeks	Completion of 70% of the exercise sessions (considered to be training per protocol). Median (range) number of exercise sessions completed	Home: 24/28 (86%) versus centre: 28/28 (100%) P = 0.04 Home: 24 (10–24) versus centre: 23 (17–24)	Home < Centre
Table 6 Arthur 2002 /Smith 2004	6 months 18 months	Number of exercise session reported/week Percentage of patients seeking dietician consultation Percentage of patients seeking psychologist consultation Level of physical activity – Physical Activity Scale for the Elderly	Home: mean 6.5 (SD 4.6) Centre: mean 3.7 (SD 2.6) P < 0.0001† Home 50% (mean 3.5, SD 2.5 visits) Centre: 53% (mean 3.6, SD 2.3 visits) Home: 42% (mean 2.6, SD 2.4 visits) Centre: 51% (mean 2.5, SD 2.2 visits) Home: mean 232.6 (SD 99.4) Centre: mean 170.0 (SD 89.2) P < 0.0001†	Home > Centre ? Home = Centre** Home > Centre
Carlson 2000	6 months	Attendance at all 3 nutrition/risk factor classes Total exercise over follow up – number of sessions ≥ 30 min	Home: 27/38 (71%) Centre: 33/42 (79%) P = 0.438* Home: mean 111.8 (SD 29.1) Centre: mean 98.1 (SD 33.4) P = 0.06†	Home = Centre Home = Centre
Cowie 2012	3 months	Percentage completion of 16 exercise sessions	Home: 77% Centre: 86% P = 0.32	Home = Centre
Dalal 2007	9 months	Number who participated in intervention	Home: 40/60 (67%) Centre: 32/44 (72%) P = 0.51*	Home = Centre
Daskapan 2005	3 months	Percentage of sessions attended	Home: 97% Centre: 81% P value not calculable	?
Gordon 2002 Community	3 months	Percentage of completed scheduled appointments (exercise sessions, office/on site visits, “telephone visits” in accordance with intervention protocol)	Home (MD supervised): 83% Home (community‐based): 86% Centre: 81%	Home = Centre**
Grace 2016 Mixed Home versus mixed sex training	6 months	Percentage of cardiac rehabilitation sessions attended	Home: 58.12% (SD 34.68) Centre: 51.33% (SD 35.75) P = 0.63	Home = Centre
Grace 2016 Mixed Home versus women only training	6 months	Percentage of cardiac rehabilitation sessions attended	Home: 58.12% (SD 34.68) Centre: 54.4% (SD 34.72) P = 0.63	Home = Centre
Jolly 2007	3 months 6 months 12 months 24 months	Hours of self‐reported activity weighted for intensity	Home: mean 23.2 (SD 22.1) Centre: mean 18.7 (SD 19.3) P = 0.06† Home: mean 16.4 (SD 17.0) Centre: mean 18.1 (SD 25.4) P = 0.4† Home: mean 19.2 (SD 20.8) Centre: mean 15.9 (SD 16.7) P = 0.06† Home: mean 18.9 (SD 18.4) Centre: mean 16.6 (SD 16.4) P = 0.16†	Home = Centre Home = Centre Home = Centre Home = Centre
Karapolat 2009	8 weeks	Attendance at exercise sessions	Home: (32/37) 87.5% Centre: (33/37) 90% P = 0.72*	Home = Centre
Kraal 2014	12 weeks	Number of sessions attended	Home: Mean = 24 (100 %; SD 7.2; range: 13 to 41) Centre: Mean = 20.5 (86%; SD 4.5 range: 6 to 25) P = 0.049	Home > Centre
Marchionni 2003	4 months	Number of exercise sessions completed	Home: 37.3 (SD 3.4) Centre: 34.3 (SD 4.4) P < 0.0001†	Home > Centre
Miller 1984 Brief/ DeBusk 1985/ Taylor 1986	6 months	Ratio of exercise sessions completed versus prescribed	Home: 50/70 (72%) Centre: 28/40 (71%) P value not calculable	Home = Centre**
Moholdt 2012	6 months	Training diaries (only reported for home group)	Home: 7/10 patients (with complete diary data) reported ≥2 weekly interval sessions over 6 months follow up	?
Piotrowicz 2010	8 weeks	Percentage of patients who carried out the prescribed exercise training (home group: daily telephone contacts with monitoring centre; centre group: attendance at supervised sessions)	Home: 77/77 (100%) Centre: 59/75 (79%) P < 0.0001†	Home > Centre
Sparks 1993	3 months	Percentage of cardiac rehabilitation sessions attended	Home: 93% Centre: 88% P value not calculable	?
Varnfield 2014	6 weeks	"Attended baseline assessment and at least 4 weeks (8 of 12 sessions) of centre‐based gym sessions/uploaded exercise data to web portal for a minimum of 4 weeks"	Home: 45/48 (94%) Centre: 25/37 (68%) P < 0.005	Home > Centre
calculated by authors of this report based on Chi² test †calculated by authors of this report based on independent t‐test Home = Centre: no statistically significant difference (P > 0.05) in health‐related quality of life (HRQoL) between home‐ and centre‐based groups at follow up Home > Centre: statistically significant (P ≤ 0.05) higher HRQoL in home‐ versus centre‐based groups at follow up Home < Centre: statistically significant (P ≤ 0.05) lower HRQoL in home‐ versus centre‐based groups at follow up *Home‐ and centre‐based groups at follow up appear to be similar but P value not reported or calculable ? Home‐ and centre‐based groups at follow up appear different but P value not reported or calculable

Table 8. Summary of adherence at follow up in home and centre‐based cardiac rehabilitation

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Table 9. Summary of costs in home‐ and centre‐based settings

Study	CurrencyYear of costsFollow up	Cardiac rehabilitation programme cost(per patient)	Programme costs considered	Total healthcare cost(per patient)	Additional healthcare costs considered	Comments
Carlson 2000	USD Not reported 6 months	Home: mean USD 1519 Centre: mean USD 2349	Staff, ECG monitoring	Not reported
Cowie 2012	GBP 2013 to 2014 60 months	Home: GBP mean 197 Centre: GBP mean 221	Staff, HR monitors, DVD	Home: mean: GBP 7932 Centre: mean: GBP 7452	Hospitalisations, emergency admissions
Marchionni 2003	USD 2000 14 months	Home: mean USD 1650 Centre: mean USD 8841	Not reported	Home: USD 13,246 Centre: USD 21,298	Not reported
Dalal 2007	GBP 2002 to 2003 9 months	Home: mean GBP 170 (SD 8) Centre: mean GBP 200 (SD 3) Difference: mean GBP 30 (95% CI ‐45 to ‐12) P < 0.0001	Staff, exercise, equipment, staff travel	Home: mean GBP 3279 (SD 374) Centre: mean GBP 3201 (SD 443) Difference: mean GBP 78(95% CI ‐1103 to 1191) P = 0.894	Rehospitalisations, revascularisations, secondary preventive medication, investigations, primary care consultations
Jolly 2007	GBP 2003 24 months	Home: mean GBP 198 (95% CI 189 to 209) Centre: mean GBP 157 (95% CI 139 to 175) P < 0.05	Staff, telephone, consultations, staff travel	Not reported		With inclusion of patient costs (travel and time), the societal costs of home‐ and centre‐bas cardiac rehabilitation were not significantly different
Varnfield 2014/ Whittaker 2014	AUD Not reported Based on a 6 week programme	Home: AUD 1633 Centre: AUD 1845	Education, assessment, coaching and mentoring, gymnasium, communication, facility, technology, administration	Patient travel: Home: AUD 80 Centre: AUD 400	Re‐admissions ‐ Estimated AUD 39,670 per re‐admission (Collins 2001)	Based on evidence suggesting that completing a formal rehabilitation programme significantly reduces the risk of a secondary event and readmission, the net‐present value was calculated at AUD 4008 per patient, equating to a saving in health care costs of AUD 2375 per patient
Abbreviation: ECG = electrocardiogram

Table 9. Summary of costs in home‐ and centre‐based settings

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Table 10. Summary of healthcare utilisation in home‐ and centre‐based settings

Study	Dalal 2007	Gordon 2002 Community	Bell 1998		Carlson 2000	Marchionni 2003	Jolly 2007
Follow up	9 months	3 months	0 to 6 months	6 to 12 months	6 months	14 months	12 month	24 month
Rehospitalisations N patient (%) Mean (SD)	Home 9/60 (15%) Centre 6/44 (14%) P = 0.845 Home 2.2 (0.9)† Centre 1.2 (0.6) P = 0.383		Home 21/90 (23%) Centre 19/88 (22%) P = 0.78#	13/89 (15%) 12/84 (14%) P = 0.95#		Home 0.46 (SE 0.1) Centre 0.33 (SE 0.1) P = 0.49	Home 0.08 (0.34) Centre 0.12 (0.41) P = 0.3	Home 0.20 (0.45) Centre 0.26 (0.57) P = 0.3
Primary care consultations Mean (SD)	Home 6.3 (0.6) Centre 7.0 (0.9) P = 0.514		Home 6.6 (3.6)* Centre 6.6 (4.1) P = 1.00#	5.4 (4.1) 4.6 (3.7) P = 0.19#			Home 0.65 (1.14) Centre 0.72 (1.54) P = 0.8	Home 0.53 (1.14) Centre 0.66 (1.42) P = 0.7
Secondary prevention medication N patients (%) beta‐blockers ACE inhibitors Statins Antiplatelets	Home 31/49 (63%) Centre 24/34 (71%) P = 0.49 Home 30/49 (61%) Centre 24/33 (73%) P = 0.28 Home 48/49 (98%)* Centre 30/35 (88%)* P = 0.18 Home 46/49 (94%) Centre 30/35 (86%) P = 0.21	Home 36/97 (37%) Centre 17/45 (38%) NS Home 25/97 (26%) Centre 8/45 (18%) NS Home 73/97 (75%) Centre 33/45 (73%) NS Home 94/97 (97%)* Centre 45/45 (100%)* NS			Home 19/38 Centre 18/42 P = 0.52# Home 4/38 Centre 4/42 P = 0.88# Home 5/38 Centre 8/42 P = 0.47# Home 15/38 Centre 20/42 P = 0.54#		Home 169 (72.2%) Centre 171 (73.4%) P = 0.8 Home 176 (75.2%)* Centre 161 (69.1%)* P = 0.1 Home 216 (92.3%) Centre 221 (94.8%) P = 0.3 Home 227 (97.0%)† Centre 226 (97.0%)† P = 1.0	Home 161 (71.6%) Centre 164 (72.2%) P = 0.9 Home 177 (78.7%)* Centre 156 (68.7%)* P = 0.02 Home 195 (86.7%) Centre 206 (90.7%) P = 0.2 Home 214 (95.1%)+ Centre 220 (96.9%)+ P = 0.3
Comments	†number of nights *lipid lowering drugs	*antiplatelets & anticoagulants	*GP consultations				ACEi or Angiotensin II receptor antagonist *cholesterol‐lowering drugs †Aspirin or antiplatelet drugs
#P value calculated by authors of the present report NS: not statistically significant SE: standard error

Table 10. Summary of healthcare utilisation in home‐ and centre‐based settings

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Table 11. Summary of healthcare in hospital‐ and centre‐based settings, continued

Study	Moholdt 2012	Oerkild 2011
Follow up	6 months	12 months
Rehospitalisations N patient (%) Number Mean (SD)	Not reported	Number and length of admissions same between groups
Primary care Consultations Mean (SD)	Not reported	Not reported
Secondary prevention medication N patients (%) beta‐blockers ACE inhibitors Antihypertensives Statins Antiplatelets	Home: 8/14 (57%) Centre: 15/16 (94%) P = 0.02* Home: 1/14 (7%) Centre: 0/16 (0%) P = 0.28* Home: 6/14 (43%) Centre: 2/16 (13%) P = 0.07* Home: 14/14 (100%) Centre: 14/16 (100%) P = 0.18*	Not reported
Comments
*P value calculated by review authors ACE: angiotensin‐converting‐enzyme

Table 11. Summary of healthcare in hospital‐ and centre‐based settings, continued

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Comparison 1. home‐base vs centre‐based

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Total mortality Show forest plot	13	1505	Risk Ratio (M‐H, Fixed, 95% CI)	1.19 [0.65, 2.16]

2 Exercise capacity ≤ 12 months Show forest plot	26	2255	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.28, 0.02]

3 Exercise capacity 12 to 24 months Show forest plot	3	1074	Std. Mean Difference (IV, Fixed, 95% CI)	0.11 [‐0.01, 0.23]

4 Completers Show forest plot	26	2615	Risk Ratio (M‐H, Random, 95% CI)	1.04 [1.00, 1.08]

5 Total cholesterol 3 to 12 months Show forest plot	10	1151	Mean Difference (IV, Random, 95% CI)	0.06 [‐0.10, 0.23]

6 HDL cholesterol 3 to 12 months Show forest plot	8	925	Mean Difference (IV, Fixed, 95% CI)	‐0.07 [‐0.11, ‐0.03]

7 LDL cholesterol 3 to 12 months Show forest plot	6	430	Mean Difference (IV, Random, 95% CI)	0.04 [‐0.14, 0.22]

8 Triglycerides 3 to 12 months Show forest plot	6	396	Mean Difference (IV, Fixed, 95% CI)	0.15 [0.00, 0.29]

9 Systolic blood pressure 3 to 12 months Show forest plot	12	1292	Mean Difference (IV, Random, 95% CI)	‐0.27 [‐3.13, 2.60]

10 Diastolic blood pressure 3 to 12 months Show forest plot	11	1146	Mean Difference (IV, Random, 95% CI)	0.74 [‐1.04, 2.53]

11 Smoking 3 to 12 months Show forest plot	6	986	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.83, 1.27]

Comparison 1. home‐base vs centre‐based

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