Promoting Patient Utilization of Outpatient Cardiac Rehabilitation: a joint International Council and Canadian Association of Cardiovascular prevention and rehabilitation position statement

Cardiac rehabilitation (CR) is a recommendation in international clinical practice guidelines given its benefits; however, use is suboptimal. The purpose of this position statement was to translate evidence on interventions that increase CR enrollment and adherence into implementable recommendations. The writing panel was constituted by representatives of societies internationally concerned with preventive cardiology and included disciplines that would be implementing the recommendations. Patient partners served, as well as policy makers. The statement was developed in accordance with AGREE II, among other guideline checklists. Recommendations were based on our update of the Cochrane review on interventions to promote patients' utilization of CR. These were circulated to panel members, who were asked to rate each on a 7-point Likert scale in terms of scientific acceptability, actionability, and feasibility of assessment. A Web call was convened to achieve consensus and confirm strength of the recommendations (based on Grading of Recommendations Assessment, Development, and Evaluation [GRADE]). The draft underwent external review and public comment. The 3 drafted recommendations were that to increase enrollment, health care providers, particularly nurses (strong), should promote CR to patients face-to-face (strong), and that to increase adherence, part of CR could be delivered remotely (weak). Ratings (mean ± SD) for the 3 recommendations were 5.95 ± 0.69, 5.33 ± 1.12, and 5.64 ± 1.08, respectively. Interventions can significantly increase utilization of CR and hence should be widely applied. We call upon cardiac care institutions to implement these strategies to augment CR utilization and to ensure that CR programs are adequately resourced to serve enrolling patients and support them to complete programs.

Interventions to Promote Patient Utilization of Cardiac Rehabilitation: Cochrane Systematic Review and Meta-Analysis.

Too few patients utilize cardiac rehabilitation (CR), despite its benefits. The Cochrane review assessing the effectiveness of interventions to increase CR utilization (enrolment, adherence, and completion) was updated. A search was performed through July 2018 of the Cochrane and MEDLINE (Medical Literature Analysis and Retrieval System Online) databases, among other sources. Randomized controlled trials in adults with myocardial infarction, angina, revascularization, or heart failure were included. Interventions had to aim to increase utilization of comprehensive phase II CR. Two authors independently performed all stages of citation processing. Following the random-effects meta-analysis, meta-regression was undertaken to explore the impact of pre-specified factors. Twenty-six trials with 5299 participants were included (35.8% women). Low-quality evidence showed an effect of interventions in increasing enrolment (risk ratio (RR) = 1.27, 95% confidence interval (CI) = 1.13⁻1.42). Meta-regression analyses suggested that the intervention deliverer (nurse or allied healthcare provider, p = 0.02) and delivery format (face-to-face, p = 0.01) were influential in increasing enrolment. There was low-quality evidence that interventions to increase adherence were effective (standardized mean difference (SMD) = 0.38, 95% CI = 0.20⁻0.55), particularly where remotely-offered (SMD = 0.56, 95% CI = 0.36⁻0.76). There was moderate-quality evidence that interventions to increase program completion were effective (RR = 1.13, 95% CI = 1.02⁻1.25). There are effective interventions to increase CR utilization, but more research is needed to establish specific, implementable materials and protocols, particularly for completion.