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Respuestas clínicas Cochrane

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PRISMA flow diagram

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Figure 1

PRISMA flow diagram

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Funnel plot of comparison: 4 Education versus no education, outcome: 4.1 Total mortality at the end of the follow up period.

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Figure 4

Funnel plot of comparison: 4 Education versus no education, outcome: 4.1 Total mortality at the end of the follow up period.

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Funnel plot of comparison: 1 Education versus no education, outcome: 1.6 Withdrawals.

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Figure 5

Funnel plot of comparison: 1 Education versus no education, outcome: 1.6 Withdrawals.

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Comparison 1: Education versus no education, Outcome 1: Total mortality at the end of the follow up period

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Analysis 1.1

Comparison 1: Education versus no education, Outcome 1: Total mortality at the end of the follow up period

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Comparison 1: Education versus no education, Outcome 2: Fatal and/or non‐fatal MI

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Analysis 1.2

Comparison 1: Education versus no education, Outcome 2: Fatal and/or non‐fatal MI

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Comparison 1: Education versus no education, Outcome 3: Other fatal and/or non‐fatal cardiovascular events

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Analysis 1.3

Comparison 1: Education versus no education, Outcome 3: Other fatal and/or non‐fatal cardiovascular events

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Comparison 1: Education versus no education, Outcome 4: Total revascularisations (including CABG and PCI)

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Analysis 1.4

Comparison 1: Education versus no education, Outcome 4: Total revascularisations (including CABG and PCI)

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Comparison 1: Education versus no education, Outcome 5: Hospitalisations

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Analysis 1.5

Comparison 1: Education versus no education, Outcome 5: Hospitalisations

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Comparison 1: Education versus no education, Outcome 6: Withdrawals

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Analysis 1.6

Comparison 1: Education versus no education, Outcome 6: Withdrawals

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Summary of findings 1. Patient education for the management of coronary heart disease

Patient education for the management of coronary heart disease

Patient or population: patients with coronary heart disease
Settings: Centre or home‐based
Intervention: Patient education

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Patient education

Total mortality at the end of the follow‐up period
No of deaths
Follow‐up: median 18 months

Study population

RR 0.80
(0.60 to 1.05)

10075
(13 studies)

⊕⊕⊕⊝
Moderate¹

46 per 1000

37 per 1000
(28 to 48)

Moderate population

43 per 1000

34 per 1000
(26 to 45)

Fatal and/or non‐fatal MI at the end of the follow up period
Follow‐up: median 33 months

Study population

RR 0.63
(0.26 to 1.48)

209
(2 studies)

⊕⊝⊝⊝
very low² ³ ⁴

118 per 1000

74 per 1000
(31 to 174)

Moderate population

106 per 1000

67 per 1000
(28 to 157)

Other fatal and/or non‐fatal cardiovascular events
Follow‐up: median 21 months

Study population

RR 0.36
(0.23 to 0.56)

310
(2 studies)

⊕⊕⊝⊝
low² ⁴

386 per 1000

139 per 1000

(89 to 216)

Moderate population

324 per 1000

117 per 1000
(75 to 181)

Total revascularisations (including CABG and PCI)
Follow‐up: median 36 months

Study population

RR 0.58
(0.19 to 1.71)

456
(3 studies)

⊕⊝⊝⊝
verylow² ³ ⁴

35 per 1000

20 per 1000
(7 to 60)

Moderate population

33 per 1000

19 per 1000
(6 to 56)

Hospitalisations (cardiac‐related)at end of follow up period
Follow‐up: median 12 months

Study population

RR 0.93
(0.71 to 1.21)

14849
(5 studies)

⊕⊝⊝⊝
very low¹ ² ⁵

79 per 1000

74 per 1000
(56 to 96)

Moderate population

141 per 1000

131 per 1000
(100 to 171)

All cause withdrawal at follow‐up
Follow‐up: median 12 months

Study population

RR 1.04
(0.88 to 1.22)

10972
(17 studies)

⊕⊕⊝⊝
low² ⁶ ⁷

92 per 1000

96 per 1000
(81 to 113)

Moderate population

70 per 1000

73 per 1000
(62 to 85)

HRQoL
Various HRQoL measures
Follow‐up: median 12 months

Not measurable

Not measurable

Not measurable

4393
(13 studies)

⊕⊕⊕⊝
moderate²

HRQoL in intervention > HRQoL in comparator, in then 9/99 domains

¹ 95% CIs include both no effect and appreciable benefit (i.e. CI < 0.75)
² Blinding of outcome assessors was poorly described in over 50% of included studies; bias likely
³ 95% CIs include both no effect, appreciate benefit and appreciable harm (i.e. CI < 0.75 and > 1.25)
⁴ The point estimate is likely to be imprecise due to very low event rates
⁵ I² > 40%; heterogeneity may be important
⁶ 95% CIs include both no effect and appreciate harm (i.e. CI > 1.25)
⁷ Evidence of funnel plot asymmetry therefore publication bias likely

Figuras y tablas -
Summary of findings 1. Patient education for the management of coronary heart disease
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Table 1. Results of sensitivity analysis for fixed‐effect versus random‐effects models

Outcome or subgroup

Studies

Participants

Effect estimate (random‐effect) RR (M‐H, random, 95% CI)

Effect estimate (fixed‐effect) RR (M‐H, fixed, 95% CI)

1.1 Total mortality at the end of the follow up period

13

10,075

0.80 [0.60, 1.05]

0.80 [0.66, 0.97]

1.1.1 Studies with 12 months or less follow‐up

6

4063

0.78 [0.35, 1.78]

0.87 [0.56, 1.36]

1.1.2 Studies with more than 12 months follow‐up

7

6012

0.78 [0.60, 1.02]

0.79 [0.64, 0.97]

2.1 Myocardial Infarction at the end of the follow‐up period

2

209

0.63 [0.26, 1.48]

0.59 [0.25, 1.38]

2.2 Total revascularisations

3

456

0.58 [0.19, 1.71]

0.58 [0.20, 1.69]

2.3 Other fatal and/or non‐fatal cardiovascular events

2

310

0.36 [0.23, 0.56]

0.36 [0.23, 0.56]

3.1 Cardiac hospitalisations at end of follow‐up period

5

14,849

0.93 [0.71, 1.21]

1.02 [0.90, 1.15]

4.1 All cause withdrawal or drop‐out at follow‐up

17

10,972

1.04 [0.88, 1.22]

0.98 [0.88, 1.10]

4.1.1 Studies with 12 months or less follow‐up

10

4960

1.18 [0.93, 1.49]

1.18 [0.94, 1.49]

4.1.2 Studies with more than 12 months follow‐up

7

6012

0.98 [0.80, 1.20]

0.92 [0.81, 1.05]
Figuras y tablas -
Table 1. Results of sensitivity analysis for fixed‐effect versus random‐effects models
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Table 2. Educational content of programs in included studies

Study ID

Description of Intervention

Theoretical basis

Tailored

Duration

One‐to‐one

Group

Face‐ to‐face

Telephone

Internet

Notes

Chow 2015

Text message‐based prevention program delivering regular semi‐personalised messages providing advice, motivation, and information to improve diet, increase physical activity, and encourage smoking cessation

NR

Y

4 messages per week for 24 weeks

Y

N

N

Y (text messages)

N

Content for each participant was selected using a prespecified algorithm dependent on key baseline characteristics

Clark 1997

*PRIDE

Y

Y

Once weekly for 4 weeks

Y

Y

Taught by health educator. Videotape and workbook aids

Clark 2000

*PRIDE

Y

Y

Once weekly for 4 weeks

Y

Y

Taught by health educator. Videotape and workbook aids

Clark 2009

*PRIDE

Y

Y

Once weekly for 6 weeks

Y

Y

Y

3 groups (self‐directed and group intervention and a control)

Cohen 2014

"House of Education" with individualised consultations with e.g. smoking cessation nurse

NR

Y

At least 6 sessions in 12 months

Y

N

Y

N

N

Consultations content was individualised according to a patient’s risk factors

Cupples 1994

Practical tailored advice on cardiovascular risk factors and appropriate health education

NR

Y

3 times a year for 2 years

Y

Y

Delivered at home by health visitor

Dracup 2009

Patients received education on ACS, anticipated emotional issues and social factors that could affect delay

Y

Y

55 mins (40 min face‐to‐face plus 15 min follow‐up call)

Y

N

Y

N

N

Delivered by a nurse with expertise in cardiology

Esposito 2008

Predesigned scripts to provide education on various aspects of care, geared to personalised clinical goals

NR

Y

Average 1.1 contacts per month for 18 months

Y

Y

Y

Nurse case manager, primarily by telephone but also face‐to‐face

Furuya 2015

Three booklets and three telephone follow‐up calls aimed at helping patient understand his cardiac condition, PCI and how to cope with CAD

Y

N

2 face to face sessions and 3 telephone calls over 16 weeks

Y

N

Y

Y

N

The first booklet was discussed with participants before undergoing PCI procedure

Hanssen 2007

Individualised education from a menu of topics to be covered

Y

Y

6 months (8 sessions in total)

Y

Y

Structured element and an on‐call element

Jorstad 2013

Outpatient clinic visits to a cardiovascular nurse

NR

Y

6 months (4 sessions)

NR

NR

Y

N

N

Nurse‐coordinated:

provided general lifestyle advice, and individual counselling

Lie 2009

A psycho‐educative intervention. Structured information and psychological support

NR

N/S

2 visits (1 hour each)

Y

Y

Critical care nurse, home based

Lisspers 1999

Health education and achievement of behavioural change

NR

Y

4 week residential then 11 month one‐to‐one individual sessions

Y

Y

Y

Trained nurses (personal coaches). Seminars, lectures, discussion and skills sessions

Melamed 2014

Lesson materials consisted of a patient brochure, teaching cards and curriculum poster/wall chart set

NR

N

NR

Y

N

Y

N

N

Patients were given an exercise diary to enable them to document their daily physical activity

Mooney 2014

Education intervention aimed at reducing total prehospital delay time

Y

Y

6 months (1 face‐to‐face session, 1 telephone call and one reinforcement letter at 6 months)

Y

N

Y

Y

N

Research nurses used preprinted flip charts and prescriptive scripts as educational aids

Moreno‐Palanco 2011

Health education on the meaning of patients' disease and the importance of treatment

NR

NR

3 years (at least 5 sessions)

Y

N

Y

N

N

Each visit consisted of a nursing intervention and a medical assessment

P.RE.COR Group 1991

Education and counselling on management of cardiovascular risk factors and exercise

NR

Y

1 group session, 1 individual session with cardiologist

Y

Y

Y

Multidisciplinary input to group. Cardiologist tailors therapy

Park 2013

Psycho‐educational intervention comprising tailored face‐to‐face education and telephone‐delivered health coaching

NR

Y

12 weeks (6 sessions)

Y

N

Y

Y

N

Patients made choices about risk factors they wanted to lower and participated in goal setting

Peikes 2009

Variable ‐ nurse provision of patient education

NR

NR

1 to 2.5 times a month for an average of 30 months

Y

Y

15 different programs, majority telephone, one‐to‐one

Pogosova 2008

Structured program addressing different risk factors in each session

Y

NR

6 sessions (twice weekly, 90 min)

Y

Y

Southard 2003

Modular internet sessions, Interactive multiple choice and self tests followed by feedback

NR

NR

Once weekly for 6 months (at least 30 min)

Y

Y

Y

Communication with case manager and online discussion group

Tingström 2005

Problem based rehabilitation to teach a planned curriculum

Y

NR

13 sessions over 1 year

Y

Y

Trained facilitator

PRIDE = Problem Identification, Researching one's routine, Identifying a management goal, Developing a plan to reach it, Expressing one's reactions and Establishing rewards for making progress.

Y = Yes; N = No; NR = not reported
Figuras y tablas -
Table 2. Educational content of programs in included studies
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Table 3. All‐cause withdrawal or drop‐out at follow‐up

Study ID

Number randomised

Number lost at follow‐up*

Notes

Chow 2015

Intervention

352

33

20 excluded from analysis, 9 unable to contact, 4 died

Control

358

25

21 excluded from analysis, 3 unable to contact, 1 died

Clark 2000

Intervention

309

51

36 withdrew, 14 died, 1 data missing

Control

262

42

33 withdrew, 8 died, 1 data missing

Clark 2009

Intervention

201

37

Self‐directed program; 33 withdrew, 4 died

Intervention

190

24

Group format; 19 withdrew, 5 died

Control

184

23

15 withdrew, 8 died

Cohen 2014

Intervention

251

48

6 did not meet inclusion criteria, 7 died, 23 follow‐up refusal, 10 lost to follow‐up, 2 in another protocol

Control

251

36

4 did not meet inclusion criteria, 7 died, 13 follow‐up refusal, 12 lost to follow‐up

Cupples 1994

Intervention

342

92

45 defaulted, 47 died; 21 defaulted at 2 years

Control

346

109

44 defaulted, 65 died; 25 defaulted at 2 years

Dracup 2009

Intervention

1777

197

89 lost to follow‐up, 41 withdrawn, 67 died

Control

1745

238

94 lost to follow‐up, 69 withdrawn, 75 died

Furuya 2015

Intervention

34

4

4 unable to contact by telephone at follow‐up

(90 participants were originally randomised (45 in each group), but 24 participants were excluded immediately after randomisation as they were indicated for surgery or enrolled in another study)

Control

32

2

2 did not return for 6 month follow‐up

Hanssen 2007

Intervention

156

55

40 withdrew, 7 died, 8 missing data

Control

132

38

21 withdrew, 7 died, 10 missing data

Jorstad 2013

Intervention

375

23

9 did not receive intervention, 3 died, 2 had early discontinuation of intervention, 9 had incomplete data

Control

379

35

12 were excluded from the study, 10 died, 1 lost to follow‐up, 7 didn't attend 12 month follow‐up, 5 had incomplete data

Lie 2009

Intervention

101

8

6 withdrew, 2 medical exclusions

Control

102

10

5 withdrew, 5 medical exclusions

Melamed 2014

Intervention

202

21

"patients were exclude (for example, because of missed training appointments)"

Control

205

19

"patients were excluded (for example, because of missed training appointments)"

Mooney 2014

Intervention

972

35

14 withdrew, 21 died

Control

972

27

10 withdrew, 17 died

Moreno‐Palanco 2011

Intervention

121

3

3 lost to follow‐up, 0 died

Control

126

5

5 lost to follow‐up, 0 died

P.RE.COR Group 1991

Intervention

60

0

Counseling program without exercise

Intervention

61

0

Comprehensive cardiac rehabilitation

Control

61

0

Usual care

Park 2013

Intervention

31

3

3 withdrew, 0 died

Control

32

2

2 withdrew, 0 died

Southard 2003

Intervention

53

4

Reasons for drop‐out stated: relocation, dietary intervention instead, psychiatric diagnosis, loss of interest

Control

51

0

Tingström 2005

Intervention

104

3

7 lost to follow‐up: 2 died, 5 did not attend

Control

103

4

Combined results

Intervention

5692

641

11.3%

Control

5341

615

11.5%

* All causes of drop out from follow0up included (including mortality)
Figuras y tablas -
Table 3. All‐cause withdrawal or drop‐out at follow‐up
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Table 4. Summary of HRQoL scores at follow‐up: Clark 1997

Sickness Impact Profile+++ at 12 months

Absolute mean outcome values at follow‐up++

Comparison

Education

Comparator

Between group P value

Clark 1997(12 months)

Total score

7.26

8.09

NS

Education = comparator

Psychosocial dimension

5.52

7.05

≤ 0.05

Education > comparator

Physical dimension

5.89

6.00

NS

Education = comparator

Sickness Impact Profile+++ at 18 months

Absolute mean outcome values at follow‐up++

Comparison

Education

Comparator

Between group P value

Total score

7.93

7.41

NS

Education = comparator

Psychosocial dimension

6.05

6.23

NS

Education = comparator

Physical dimension

6.40

5.25

NS

Education = comparator

++ for mean scores at follow‐up (adjusted for baseline scores)
+++ lower score higher HRQoL

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 4. Summary of HRQoL scores at follow‐up: Clark 1997
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Table 5. Summary of HRQoL scores at follow‐up: Clark 2000

Sickness Impact Profile at 12 months

Clark 2000(12 months)

Absolute means at follow‐up++

Comparison

Education

Comparator

Between group P value

Psychosocial dimension

5.15

5.91

0.144

Education = comparator

Physical dimension

7.09

7.66

0.05

Education > comparator

Means were adjusted to take account of baseline values

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 5. Summary of HRQoL scores at follow‐up: Clark 2000
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Table 6. Summary of HRQoL scores at follow‐up: Clark 2009

Sickness Impact Profile at 12 months

Absolute means (SD) at follow‐up

Comparison

Education

Education self directed

Comparator

Between group P value

Total score

8.13 (8.63)

9.79 (10.17)

9.49 (9.46)

NS

Education = comparator

Psychosocial dimension

5.84 (8.02)

7.31 (10.74)

6.75 (9.39)

NS

Education = comparator

Physical dimension

8.07 (9.63)

9.46 (10.11)

9.85 (10.79)

NS

Education = comparator

Sickness Impact Profile at 18 months

Total score

8.44 (9.13)

8.98 (10.29)

9.64 (9.45)

NS

Education = comparator

Psychosocial dimension

5.74 (9.68)

6.16 (8.20)

7.17 (10.40)

NS

Education = comparator

Physical dimension

8.27 (10.02)

8.98 (9.33)

9.65 (10.19)

NS

Education = comparator

Note: analysis of these data was reported, but the individual results were not. These were obtained by contacting the author directly

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 6. Summary of HRQoL scores at follow‐up: Clark 2009
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Table 7. Summary of HRQoL scores at follow‐up: Cohen 2014

SF‐12 (Short Form 12 item survey) at 6 months

Mean (SD) outcome values at follow‐up

Between group P value

Comparison

Education

Comparator

Mental component summary

47.5 (11.2)

47.7 (11.2)

0.43

Education = comparator

Physical component summary

47.5 (9.3)

47.3 (9.4)

0.44

Education = comparator

Negative baseline‐follow‐up difference favours intervention and positive favours control

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 7. Summary of HRQoL scores at follow‐up: Cohen 2014
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Table 8. Summary of HRQoL scores at follow‐up: Cupples 1994

Nottingham Health Profile+ at 24 months

MD (95% CI) between groups in change from baseline at follow‐up

Between group P value

Comparison

Emotional reaction

0.0 (‐5.2 to 5.2)

NS

Education = comparator

Energy

0.5 (‐7.8 to 8.8)

NS

Education = comparator

Physical mobility

‐0.4 (‐5.2 to 4.5)

NS

Education = comparator

Pain

0.5 (‐4.7 to 5.6)

NS

Education = comparator

Sleep

3.0 (‐4.0 to 9.9)

NS

Education = comparator

Social isolation

‐2.2 (‐6.6 to 2.1)

P < 0.05

Education > comparator

Nottingham Health Profile+ at 60 months

MD (95% CI) between groups in change from baseline at follow‐up

Between group P value

Comparison

Emotional reaction

‐2.1 (‐7.5 to 3.3)

NS

Education = comparator

Energy

 ‐4.7 (‐13.2 to 3.7)

NS

Education = comparator

Physical mobility

 ‐1.3 (‐6.3 to 3.6)

< 0.05

Education > comparator

Pain

‐3.4 (‐9.2 to 2.3)

< 0.05

Education > comparator

Sleep

 ‐2.4 (‐9.3 to 4.5)

NS

Education = comparator

Social isolation

0.0 (‐4.3 to 4.3)

NS

Education = comparator

+ Higher scores reflect poorer quality of life
The value quoted is the mean difference (MD) (CI) between groups from baseline to follow‐up
P related to t‐tests (two tailed)

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 8. Summary of HRQoL scores at follow‐up: Cupples 1994
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Table 9. Summary of HRQoL scores at follow‐up: Cupples 1994

Participant' self assessment of quality of life on a five‐point scale at 24 months

Initial scores
(% participants)

Follow‐up scores
(% participants)

Between group P value

Comparison

Education

Comparator

Education

Comparator

P < 0.03

Education > comparator

Poor

6.3

5.3

6.9

8.3

Fair

27.8

23.3

18.9

21.7

Average

35

39

33.1

33.7

Good

22.7

22.7

29.3

25.3

Very good

8.2

9.7

11.7

11

Note: the between group P value represents the overall "comparison of change in individuals' assessment for intervention and control groups" the significant difference being in favour of the intervention group

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 9. Summary of HRQoL scores at follow‐up: Cupples 1994
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Table 10. Summary of HRQoL scores at follow‐up: Furuya 2014

SF‐12* (Short Form 12 item survey) at 6 months

Mean (SD) outcome values at follow‐up

Between group P value

Comparison

Education

Comparator

Mental component summary

51.7 (9.5)

48.4 (9.2)

0.73

Education = comparator

Physical component summary

43.3 (10.6)

41.0 (11.0)

0.28

Education = comparator

SF‐36* (Short Form 36 item survey)

Mean (SD) outcome values at follow‐up

Between group P value

Comparison

Education

Comparator

Social functioning

79.2 (25.1)

64.2 (28.4)

0.1

Education = comparator

Mental health

70.9 (22.7)

70.1 (19.1)

0.98

Education = comparator

Physical functioning

72.5 (23.9)

64.5 (27.8)

0.2

Education = comparator

General health

66.1 (19.8)

63.9 (20.0)

0.61

Education = comparator

Vitality

69.7 (20.6)

62.5 (20.7)

0.52

Education = comparator

Bodily pain

63.8 (28.5)

55.7 (24.2)

0.22

Education = comparator

Role–emotional

77.8 (36.4)

64.4 (36.0)

0.72

Education = comparator

Role–physical

52.5 (40.7)

50.0 (44.0)

0.96

Education = comparator

*Negative baseline ‐ follow‐up difference favours intervention; positive difference favours control

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 10. Summary of HRQoL scores at follow‐up: Furuya 2014
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Table 11. Summary of HRQoL scores at follow‐up: Hanssen 2007

SF‐36* (Short Form 36 item survey) at 6 months

Between group difference in mean change from baseline
(95% CI) at follow‐up

Between group P value

Comparison

Overall physical

‐2.33 (‐4.54 to ‐0.12)

0.039

Education = comparator

Physical functioning

‐1.16 (‐3.28 to 0.95)

0.28

Education = comparator

Role physical

‐1.84 (‐5.32 to 1.64)

0.299

Education = comparator

Bodily pain

‐1.74 (‐4.54 to 1.05)

0.22

Education = comparator

General health

‐0.36 (‐2.64 to 1.91)

0.752

Education = comparator

Overall mental

1.07 (‐1.71 to 3.86)

0.447

Education = comparator

Vitality

‐0.07 (‐2.23 to 2.10)

0.951

Education = comparator

Social functioning

0.36 (‐2.96 to 3.67)

0.832

Education = comparator

Role‐emotional

0.78 (‐3.29 to to 4.84)

0.706

Education = comparator

Mental health

0.4 (‐1.81 to 2.60)

0.723

Education = comparator

SF‐36* (Short Form 36 item survey) at 18 months

Between group difference in mean change from baseline
(95% CI) at follow‐up

Between group P value

Comparison

Overall physical

‐1.44 (‐3.89 to 1.02)

0.25

Education = comparator

Physical functioning

‐0.79 (‐3.06 to 1.48)

0.491

Education = comparator

Role physical

‐0.94 (‐4.76 to 2.88)

0.627

Education = comparator

Bodily pain

‐0.77 (‐4.00 to 2.47)

0.641

Education = comparator

General health

0.25 (‐2.15 to 2.64)

0.838

Education = comparator

Overall mental

1.65 (‐1.35 to 4.65)

0.28

Education = comparator

Vitality

0.58 (‐1.95 to 3.12)

0.65

Education = comparator

Social functioning

0.55 (‐3.95 to 2.85)

0.751

Education = comparator

Role‐emotional

2.59 (‐1.58 to 6.77)

0.221

Education = comparator

Mental health

0.31 (‐2.11 to 2.73)

0.8

Education = comparator

*Negative baseline ‐ follow‐up difference favours intervention; positive difference favours control

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 11. Summary of HRQoL scores at follow‐up: Hanssen 2007
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Table 12. Summary of HRQoL scores at follow‐up: Lie 2009

Seattle Angina Questionnaire at 6 months

Absolute mean (SD) outcome values at follow‐up

Comparison

Education

P value

Comparator

P value

Physical limitation

86.4 (15.6)

P < 0.001

83.2 (18.7)

P < 0.001

Education = comparator

Angina frequency

91.7 (16.6)

P < 0.001

90.8 (18.9)

P < 0.001

Education = comparator

Treatment satisfaction

89.2 (15.4)

NS

88.0 (16.1)

NS

Education = comparator

Disease perception

77.8 (20.2)

P < 0.001

73.9 (24.2)

P < 0.001

Education = comparator

SF‐36 (Short Form 36 item survey) at 6 months

Absolute mean (SD) outcome values at follow‐up

Comparison

Education

P value

Comparator

P value

Overall physical

47.4 (9.6)

P < 0.001

47 (10)

P < 0.001

Education = comparator

Physical functioning

82.2 (19.2)

P < 0.001

82.3 (19.8)

P < 0.001

Education = comparator

Role physical

64 (41.2)

P < 0.001

57.2 (43.3)

P < 0.001

Education = comparator

Bodily pain

77.2 (22.3)

P < 0.001

78.5 (25.2)

P < 0.001

Education = comparator

General health

69.9 (23.3)

NS

65.7 (27.2)

NS

Education = comparator

Overall mental

52.1 (10.7)

P < 0.05

50.5 (10.8)

NS

Favours education

Vitality

61.9 (23.9)

P < 0.001

60.5 (21.6)

P < 0.001

Education = comparator

Social functioning

86.3 (21.4)

P < 0.001

84.3 (21.9)

P < 0.001

Education = comparator

Role‐ emotional

73.3 (38.2)

P < 0.01

67.4 (41.6)

P < 0.01

Education = comparator

Mental health

81.9 (17.3)

P < 0.001

78.5 (21)

P < 0.01

Education = comparator

Higher scores indicate better HRQoL

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 12. Summary of HRQoL scores at follow‐up: Lie 2009
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Table 13. Summary of HRQoL scores at follow‐up: Lisspers 1999

Angina Pectoris ‐ Quality of Life Questionnaire (AP‐QLQ) at 24 months

Mean (SD) score at follow‐up

Between group P value

Comparison

Education

Comparator

QLQ (total)

4.7 (0.8)

4.3 (1.0)

NS

Education = comparator

Somatic symptoms

4.8 (1.0)

4.3 (1.1)

NS

Education = comparator

Physical activity

4.8 (1.0)

4.1 (1.2)

NS

Education = comparator

Emotional distress

4.8 (0.8)

4.6 (1.1)

NS

Education = comparator

Life satisfaction

4.2 (1.0)

3.9 (1.2)

NS

Education = comparator

Figures quoted represent absolute scores on a self‐rating scale

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 13. Summary of HRQoL scores at follow‐up: Lisspers 1999
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Table 14. Summary of HRQoL scores at follow‐up: Melamed 2014

MacNew Heart Disease Quality of Life Questionnaire (MacNew) at 220 days

Mean (SD) outcome values at follow‐up

Between group P value

Comparison

Education

Comparator

Rank sum

5.75 (0.87)

5.74 (0.83)

0.056

Education = comparator

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 14. Summary of HRQoL scores at follow‐up: Melamed 2014
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Table 15. Summary of HRQoL scores at follow‐up: Park 2013

Seattle Angina Questionnaire‐Korean (SAQ‐K) at 6 months

Mean (SD) outcome values at follow‐up

Between group P value

Comparison

Education

Comparator

Physical symptoms

Physical limitation

90.77 (9.97)

85.74 (15.37)

0.901

Education = comparator

Angina stability

78.57 (20.09)

64.17 (23.38)

0.037

Education > comparator

Angina frequency

94.29 (7.90)

89.33 (14.84)

0.543

Education = comparator

Treatment satisfaction

86.38 (12.15)

73.13 (16.09)

0.021

Education > comparator

Diseases perception

74.40 (16.03)

52.78 (15.98)

0.005

Education > comparator

Higher scores indicate better HRQoL

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 15. Summary of HRQoL scores at follow‐up: Park 2013
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Table 16. Summary of HRQoL scores at follow‐up: Pogosova 2008

SF‐36 (Short Form 36 item survey) at 12 months

Mean change from baseline P value

Comparison

Education

Comparator

Overall physical

P > 0.05

P ≤ 0.05

Favours education

Physical functioning

P > 0.05

P ≤ 0.05

Favours education

Bodily pain

P > 0.05

P ≤ 0.05

Favours education

Overall mental

P > 0.05

P ≤ 0.05

Favours education

Vitality

P > 0.05

P ≤ 0.05

Favours education

Social functioning

P > 0.05

P ≤ 0.05

Favours education

Mental health

P > 0.05

P ≤ 0.05

Favours education

There were no significant changes demonstrated in the control group but no statistical comparison of the mean change between groups was reported

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 16. Summary of HRQoL scores at follow‐up: Pogosova 2008
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Table 17. Summary of HRQoL scores at follow‐up: Tingström 2005

SF‐36* (Short Form 36 item survey) at 12 months

Mean change from baseline (SD)

Between group P value+

Comparison

Education

Comparator

Physical functioning

3.6 (17.6)

4.4 (15.1)

0.749

Education = comparator

Role physical

38.2 (46.9)

33.8 (42.4)

0.504

Education = comparator

Bodily pain

5.69 (31.1)

6.18 (29.1)

0.911

Education = comparator

General health

1.4 (15.9)

1.8 (16.3)

0.862

Education = comparator

Vitality

5.3 (22.7)

4.9 (21.8)

0.921

Education = comparator

Social functioning

9.7 (24)

9.1 (25.3)

0.869

Education = comparator

Role emotional

15.8 (48.1)

16.5 (41.1)

0.913

Education = comparator

Mental health

2.9 (16.6)

4.2 (17.8)

0.566

Education = comparator

*Positive values indicate improvement in HRQL from baseline
+ P values are calculated on the difference between groups at pre‐test and on the mean change (post test minus pre‐test). 

NS: No significant difference demonstrated
Education = Comparator: no significant difference (P > 0.05) in HRQoL between the education and the comparator groups at follow‐up.
Education > Control: significant difference (P ≤ 0.05) in HRQoL in favour of the education group at follow‐up.
Comparator > Education: significant difference (P ≤ 0.05) in HRQoL in favour of the comparator group at follow‐up.
Favours education: Available evidence favours the intervention group but direct statistical comparison between intervention and control groups was not reported.
Favours comparator: Available evidence favours the control group but direct statistical comparison between intervention and control groups was not reported.

Figuras y tablas -
Table 17. Summary of HRQoL scores at follow‐up: Tingström 2005
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Table 18. Cost summary of intervention and comparison of healthcare costs incurred by intervention and control groups during follow‐up period

Variable

Clark 2000

Cupples 1994

Esposito 2008

Southard 2003

Peikes 2009

Follow‐up

24 months

24 months

6 months

7 to 12 months

12 months

18 months

6 months

25 months

Year

2000

NR

2005 to 2006

NR

2002 to 2005

Currency

USD

GBP

USD

USD

USD

Mean cost of cardiac rehabilitation program per patient

Total costs

USD 187

GBP 49.72

USD 162

USD 453

USD 196

Costs considered

Personnel, instructional materials, telephone supplies, ongoing staff training

Direct costs by health visitors (staff time), Travel Costs

Average monthly fee paid to the program per member

Nurse salary

Overheads

Subscription costs

Average monthly fee paid to the program per member

Comments

Participating site overheads were not measured, a "conservatively high" estimate of these was taken to double the treatment cost to USD 374

Costs of the health visitor also included time spent recording data collection for the study

Cost varied among the 15 included studies. Negotiated locally with Medicare and Medicaid Services. (Range USD 50 to USD 444) 

Mean total healthcare costs per patient

Total cost (intervention)

USD ~3300 (calc)

GBP 1801

USD 1627

USD 2356

USD 2288

USD 1793

USD 635

USD 1283*

Total cost (control)

USD ~6500

GBP 1812

USD 1632

USD 2464

USD 2372

USD 1818

USD 2053

USD 1314*

Between group difference

USD ~1800*

GBP 9.60

USD 5

USD 107

USD 84

USD 25

USD 1418

USD 144

(80% CI 99 to 188)

P value

NR

NS

0.895

0.077

0.132

0.365

NR

< 0.001

Cost saving per pt (when cost of intervention taken into account§)

USD ~1610 or USD ~1420 if estimated overheads were included

GBP 40

USD ‐157

USD ‐55

USD ‐78

USD ‐137

USD 965

USD ‐52

Additional healthcare costs considered

Number of admissions (heart related), number of inpatient days, In patient cost' emergency department costs

Prescription of drugs, GP visits, visits to hospital as inpatients and outpatients, all tests investigations and treatments carried out

Medicare medical claims

Cardiovascular‐related emergency department visits and hospitalisations

Comments

Expenditure was calculated from differences in % utilisation of hospital services. i.e. hospital charges for participants were on average 49% lower and the average annual expenditure was USD 6500.

* There was a calculated saving of a hospital charge of USD 3200, the ratio of payments to charges was 0.56 therefore USD 1800 actual saving

There was a difference in the drug usage at baseline which is not accounted for in these figures although this would make minimal impact to the results. The intervention group were more costly for drugs, procedures and service use

Claims quoted are per member per month

*Expenditure/pt/month enrolled

Overall costs were increased by 11% when the care coordination fees were taken into account

Summary difference between groups

Favours Rx

Rx = Control

Rx = control (for all time periods studied)

Favours Rx

Favours control

§ = Negative mean difference indicates a net cost of the intervention group
NR = not recorded
NS = not significant

Figuras y tablas -
Table 18. Cost summary of intervention and comparison of healthcare costs incurred by intervention and control groups during follow‐up period
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Table 19. 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 (% myocardial infarction patients) (n = 11)

RR = 1.004

0.988 to 1.020
P = 0.631

‐190.36%

No evidence that RR is associated with case mix

Age of participants (n = 13)

RR = 1.005

0.940 to 1.074
P = 0.876

‐28.26%

No evidence that RR is associated with the age of participants

Percentage of male participants (n = 13)

RR = 0.991

0.986 to 1.012
P = 0.882

‐25.27%

No evidence that RR is associated with the percentage of male participants

Type of CR (education only vs. education plus e.g. exercise or psychological intervention) (n = 13)

RR = 0.181

0.014 to 2.321
P = 0.168

28.25%

No evidence that RR is associated with type of CR

Method of structured educational delivery (one‐to‐one vs. group versus combination) (n = 13)

RR = 1.010

0.728 to 1.401
P = 0.948

‐28.28%

No evidence that RR is associated with method of delivery

Duration of intervention (n = 12)

RR = 0.978

0.948 to 1.010 P = 0.152

3.69%

No evidence that RR is associated with duration of intervention

Theoretical vs. no theoretical basis to educational intervention (n = 13)

RR = 1.473

0.750 to 2.895
P = 0.233

‐0.31%

No evidence that RR is associated with theoretical basis

Involvement of significant others (e.g. spouse, family member) in the education programme (n = 13)

RR = 1.245

0.890 to 1.722 P = 0.166

7.06%

No evidence that RR is associated with family involvement

Study location (n = 13)

RR = 1.050

0.714 to 1.543
P = 0.787

‐59.78%

No evidence that risk ratio is associated with study location

Setting (centre vs. home) (n = 13)

RR = 1.171

0.773 to 1.774
P = 0.421

‐44.55%

No evidence that RR is associated with centre status

Length of follow‐up (n = 13)

RR = 0998

0.964 to 1.033
P = 0.924

‐22.64%

No evidence that RR is associated with length of follow‐up

CR ‐ cardiac rehabilitation; RR ‐ risk ratio
Figuras y tablas -
Table 19. Results of univariate meta‐regression analysis for total mortality
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Table 20. Results of univariate meta‐regression analysis for withdrawal

Explanatory variable (n trials)

Exp(slope)*

95% CI univariate P value

Proportion of variation explained

Interpretation

Case mix (% myocardial infarction patients) (n = 12)

RR = 1.002

0.992 to 1.013
P = 0.611

‐9.25%

No evidence that RR is associated with case mix

Age of participants (n = 17)

RR = 0.998

0.963 to 1.034
P = 0.903

‐15.62%

No evidence that RR is associated with the age of participants

Percentage of male participants (n = 17)

RR = 0.999

0.992 to 1.005
P = 0.621

‐28.64%

No evidence that RR is associated with the percentage of male participants

Type of CR (education only vs. education plus e.g. exercise or psychological intervention) (n = 17)

RR = 0.752

0.260 to 2.174
P = 0.575

‐16.99%

No evidence that RR is associated with type of CR

Method of structured educational delivery (one‐to‐one vs. group versus combination) (n = 17)

RR = 1.033

0.860 to 1.242
P = 0.714

‐29.18%

No evidence that mortality risk is associated with method of delivery

Duration of intervention (n = 16)

RR = 0.993

0.964 to 1.023
P = 0.625

‐25.06%

No evidence that mortality risk is associated with duration of intervention

Theoretical vs. no theoretical basis to educational intervention (n = 17)

RR = 1.031

0.690 to 1.541
P = 0.874

‐24.70%

No evidence that RR is associated with theoretical basis

Involvement of significant others (e.g. spouse, family member) in the education (n = 17)

RR = 1.016

0.829 to 1.245
P = 0.872

‐33.62%

No evidence that RR is associated with family involvement

Study location (n = 17)

RR = 0.942

0.801 to 1.109
P = 0.449

24.47%

No evidence that RR is associated with study location

Setting (centre vs. home) (n = 17)

RR = 1.096

0.873 to 1.374
P = 0.404

‐13.38%

No evidence that RR is associated with centre status

Length of follow‐up (n = 17)

RR = 0.976

0.955 to 0.998
P = 0.035

90.79%

Significant evidence that risk of withdrawal is increased in studies with a shorter follow‐up

CR ‐ cardiac rehabilitation; RR ‐ risk ratio
Figuras y tablas -
Table 20. Results of univariate meta‐regression analysis for withdrawal
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Table 21. Results of sensitivity analysis for total mortality

Explanatory variable (n trials)

Exp(slope)*

95% CI univariate P value

Proportion of variation explained

Interpretation

Year of publication (n = 13)

RR = 0.998

0.950 to 1.047
P = 0.913

‐61.7%

No evidence that RR is associated with year of publication

Risk of bias (low risk in ≥ 5 items vs. < 5 items) (n = 13)

RR = 1.105

0.421 to 3.831
P = 2.899

‐84.29%

No evidence that RR is associated with risk of bias

RR ‐ risk ratio
Figuras y tablas -
Table 21. Results of sensitivity analysis for total mortality
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Table 22. Results of sensitivity analysis for withdrawal

Explanatory variable (n trials)

Exp(slope)*

95% CI univariate P value

Proportion of variation explained

Interpretation

Year of publication (before 2000 vs. 2000 or later) (n = 17)

RR = 1.017

0.982 to 1.052
P = 0.327

‐7.02%

No evidence that RR is associated with year of publication

Risk of bias (low risk in ≥ 5 items vs. < 5 items) (n = 17)

RR = 1.437

1.069 to 1.931
P = 0.020

15.35%

Significant evidence that risk of withdrawal is increased in studies with higher risk of bias

Figuras y tablas -
Table 22. Results of sensitivity analysis for withdrawal
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Comparison 1. Education versus no education

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1.1 Total mortality at the end of the follow up period Show forest plot

13

10075

Risk Ratio (M‐H, Random, 95% CI)

0.80 [0.60, 1.05]

1.1.1 Studies with 12 months or less follow‐up

6

4063

Risk Ratio (M‐H, Random, 95% CI)

0.78 [0.35, 1.78]

1.1.2 Studies with more than 12 months follow‐up

7

6012

Risk Ratio (M‐H, Random, 95% CI)

0.78 [0.60, 1.02]

1.2 Fatal and/or non‐fatal MI Show forest plot

2

209

Risk Ratio (M‐H, Random, 95% CI)

0.63 [0.26, 1.48]

1.3 Other fatal and/or non‐fatal cardiovascular events Show forest plot

2

310

Risk Ratio (M‐H, Random, 95% CI)

0.36 [0.23, 0.56]

1.4 Total revascularisations (including CABG and PCI) Show forest plot

3

456

Risk Ratio (M‐H, Random, 95% CI)

0.58 [0.19, 1.71]

1.5 Hospitalisations Show forest plot

5

14849

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.71, 1.21]

1.6 Withdrawals Show forest plot

17

10972

Risk Ratio (M‐H, Random, 95% CI)

1.04 [0.88, 1.22]

1.6.1 Studies with 12 months or less follow‐up

10

4960

Risk Ratio (M‐H, Random, 95% CI)

1.18 [0.93, 1.49]

1.6.2 Studies with more than 12 months follow‐up

7

6012

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.80, 1.20]
Figuras y tablas -
Comparison 1. Education versus no education
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