International clinical practice guidelines routinely recommend that cardiac patients
participate in rehabilitation programmes for comprehensive secondary prevention. However,
data show that only a small proportion of these patients utilise rehabilitation. First,
to assess interventions provided to increase patient enrolment in, adherence to, and
completion of cardiac rehabilitation. Second, to assess intervention costs and associated
harms, as well as interventions intended to promote equitable CR utilisation in vulnerable
patient subpopulations. Review authors performed a search on 10 July 2018, to identify
studies published since publication of the previous systematic review. We searched
the Cochrane Central Register of Controlled Trials (CENTRAL); the National Health
Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology
Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)), in the Cochrane
Library (Wiley); MEDLINE (Ovid); Embase (Elsevier); the Cumulative Index to Nursing
and Allied Health Literature (CINAHL) (EBSCOhost); and Conference Proceedings Citation
Index ‐ Science (CPCI‐S) on Web of Science (Clarivate Analytics). We checked the reference
lists of relevant systematic reviews for additional studies and also searched two
clinical trial registers. We applied no language restrictions. We included randomised
controlled trials (RCTs) in adults with myocardial infarction, with angina, undergoing
coronary artery bypass graft surgery or percutaneous coronary intervention, or with
heart failure who were eligible for cardiac rehabilitation. Interventions had to aim
to increase utilisation of comprehensive phase II cardiac rehabilitation. We included
only studies that measured one or more of our primary outcomes. Secondary outcomes
were harms and costs, and we focused on equity. Two review authors independently screened
the titles and abstracts of all identified references for eligibility, and we obtained
full papers of potentially relevant trials. Two review authors independently considered
these trials for inclusion, assessed included studies for risk of bias, and extracted
trial data independently. We resolved disagreements through consultation with a third
review author. We performed random‐effects meta‐regression for each outcome and explored
prespecified study characteristics. Overall, we included 26 studies with 5299 participants
(29 comparisons). Participants were primarily male (64.2%). Ten (38.5%) studies included
patients with heart failure. We assessed most studies as having low or unclear risk
of bias. Sixteen studies (3164 participants) reported interventions to improve enrolment
in cardiac rehabilitation, 11 studies (2319 participants) reported interventions to
improve adherence to cardiac rehabilitation, and seven studies (1567 participants)
reported interventions to increase programme completion. Researchers tested a variety
of interventions to increase utilisation of cardiac rehabilitation. In many studies,
this consisted of contacts made by a healthcare provider during or shortly after an
acute care hospitalisation. Low‐quality evidence shows an effect of interventions
on increasing programme enrolment (19 comparisons; risk ratio (RR) 1.27, 95% confidence
interval (CI) 1.13 to 1.42). Meta‐regression revealed that the intervention deliverer
(nurse or allied healthcare provider; P = 0.02) and the delivery format (face‐to‐face;
P = 0.01) were influential in increasing enrolment. Low‐quality evidence shows interventions
to increase adherence were effective (nine comparisons; standardised mean difference
(SMD) 0.38, 95% CI 0.20 to 0.55), particularly when they were delivered remotely,
such as in home‐based programs (SMD 0.56, 95% CI 0.37 to 0.76). Moderate‐quality evidence
shows interventions to increase programme completion were also effective (eight comparisons;
RR 1.13, 95% CI 1.02 to 1.25), but those applied in multi‐centre studies were less
effective than those given in single‐centre studies, leading to questions regarding
generalisability. A moderate level of statistical heterogeneity across intervention
studies reflects heterogeneity in intervention approaches. There was no evidence of
small‐study bias for enrolment (insufficient studies to test for this in the other
outcomes). With regard to secondary outcomes, no studies reported on harms associated
with the interventions. Only two studies reported costs. In terms of equity, trialists
tested interventions designed to improve utilisation among women and older patients.
Evidence is insufficient for quantitative assessment of whether women‐tailored programmes
were associated with increased utilisation, and studies that assess motivating women
are needed. For older participants, again while quantitative assessment could not
be undertaken, peer navigation may improve enrolment. Interventions may increase cardiac
rehabilitation enrolment, adherence and completion; however the quality of evidence
was low to moderate due to heterogeneity of the interventions used, among other factors.
Effects on enrolment were larger in studies targeting healthcare providers, training
nurses, or allied healthcare providers to intervene face‐to‐face; effects on adherence
were larger in studies that tested remote interventions. More research is needed,
particularly to discover the best ways to increase programme completion. Background
Cardiac rehabilitation programmes aid recovery from cardiac events such as heart attack,
coronary stent placement, and bypass surgery, and reduce the likelihood of further
illness. Cardiac rehabilitation programmes offer the following core components: exercise,
education, risk factor management, and psychological counselling/support. Despite
the benefits of cardiac rehabilitation, not everyone enrolls, and, of those who do,
many people do not adhere to and complete the programme. This review evaluated trials
of strategies to promote the utilisation of cardiac rehabilitation (enrolment, adherence,
and completion). Search The search was current to July 2018. Study characteristics
We searched a wide variety of scientific databases for randomised controlled trials
(studies that allocate participants to one of two or more treatment groups in a random
manner) in adults (over 18 years of age) who had a heart attack, had angina (chest
pain), underwent coronary artery bypass grafting (a surgical procedure that diverts
blood around narrowed or clogged sections of the major arteries to improve blood flow
and oxygen supply to the heart muscle) or percutaneous coronary intervention (a procedure
that opens up blocked coronary arteries), or with heart failure who were eligible
for cardiac rehabilitation. Reviewers found 26 trials (5299 participants) that were
suitable for inclusion (16 trials of interventions to improve enrolment, eight trials
of interventions to improve adherence, and seven trials of interventions to improve
programme completion). These studies evaluated a variety of techniques to improve
utilisation such as providing peer support, starting cardiac rehabilitation early
after hospitalisation, providing patient education, offering cardiac rehabilitation
outside a hospital setting, and offering shorter programmes or women‐only programmes.
Key results Strategies to increase enrolment were effective, particularly those that
targeted healthcare providers, training nurses, or allied healthcare providers to
intervene face‐to‐face. Interventions to increase adherence to programmes and to increase
completion were effective, but it remains unclear which specific strategies were implemented.
We found no studies providing information about potential harms and two studies reporting
costs of these strategies to increase use of cardiac rehabilitation. Some studies
provided interventions to increase rehabilitation utilisation in women and older patients.
Evidence was insufficient for quantitative assessment of whether women‐tailored programmes
were associated with increased utilisation, but motivating women appears key. For
older participants, qualitative analysis suggested that peer support or postdischarge
visits may improve enrolment, and group sessions promoting self‐regulation skills
may increase completion. Quality of the evidence Most of the included studies were
of good quality (i.e. low risk of arriving at wrong conclusions because of favouritism
by researchers). The quality of the evidence was low for enrolment and adherence and
was moderate for completion. Publication bias for enrolment was not evident.