Chaves, Gabriela

Davies, Philippa

Grace, Sherry L.

Santiago de Araújo Pio, Carolina

Taylor, Rod

Enlighten

     Santiago de Araújo Pio, C., Chaves, G., Davies, P., Taylor, R. and Grace, S. L. (2020) Cochrane corner: increasing patient utilisation of cardiac rehabilitation. Heart, 106(4), pp. 248-250. (doi: 10.1136/heartjnl-2019-315348).  This is the author’s final accepted version.  There may be differences between this version and the published version. You are advised to consult the publisher’s version if you wish to cite from it.  http://eprints.gla.ac.uk/221027/                              Deposited on: 20 July 2020         Enlighten – Research publications by members of the University of Glasgow http://eprints.gla.ac.uk     Cochrane corner: increasing patient utilisation of cardiac rehabilitation  Authors: Carolina Santiago de Araújo Pio1, Gabriela SS Chaves2, Philippa Davies3, Rod S Taylor,4, Sherry L Grace1,5 1School of Kinesiology and Health Science, York University, Toronto, Canada 2Rehabilitation Science Program, Federal University of Minas Gerais, Belo Horizonte, Brazil 3School of Social and Community Medicine, University of Bristol, Bristol, UK 4Institute of Health Research, University of Exeter Medical School, Exeter, UK 5KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Canada  Correspondence to: Sherry L. Grace, PhD, CRFC, FCCS, FAACVPR, York University, Bethune 368, 4700 Keele St, Toronto, Ontario M3J 1P3, Canada; sgrace@yorku.ca     Background  Cardiac rehabilitation (CR) is a medically-sponsored program to aid recovery and prevent further cardiac events. Programs offer core components to optimize cardiovascular risk reduction, foster healthy behaviours (e.g. exercise, healthy eating, no smoking), increase patient's understanding of their disease, and improve psychosocial well-being CR has been shown to improve quality of life, as well as decrease subsequent morbidity and cardiovascular mortality by approximately 20%. [1] As a result, CR is an integral recommendation in many clinical guidelines for secondary prevention in cardiac patients. [2]  However, CR utilization remains sub-optimal. Such under-utilization can be attributed in part to low referral by healthcare providers. However, even among patients referred, few enroll in CR, and many of those who do, dropout. [3] Factors impacting utilization of CR include: distance, financial resources, work and other time constraints, gender, age, social support, illness perceptions, and depression. [4] Herein we highlight the updated systematic review and meta-analysis of interventions to increase patient utilisation of CR. [5] This was operationalized as enrolment (i.e., patient attendance at a first visit), adherence (i.e., percentage of prescribed sessions completed), and completion (i.e., patients attended at least some of program and had a formal re-assessment by staff at end of program) of CR. [6] The review also considered harms, costs, and equity (secondary outcomes). Review methods  A search was performed through July 2018, to identify trials published since the previous systematic review. The Cochrane Library, MEDLINE, Embase, CINAHL, EBSCOhost,  Conference Proceedings Citation Index, among other databases were searched. The reference   lists of relevant systematic reviews were hand-searched for additional trials, and two clinical trial registers were also searched.  Randomised controlled trials (RCTs) in adults with myocardial infarction, angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for CR were included. Interventions had to aim to increase utilisation of comprehensive (i.e., initial patient assessment, structured exercise, and at least one other strategy to control risk factors) phase II CR.  Methods outlined in the Cochrane Handbook were used to select eligible trials, assess risk of bias, extract and analyse data, as well as assess the certainty of evidence. Random-effects meta-regression was performed for each outcome, with pre-specified study and intervention characteristics explored. Main results  Ultimately, 26 trials with 5299 participants (29 comparisons) were included: sixteen trials (3164 participants) reported interventions to improve enrolment in CR, 11 trials (2319 participants) reported interventions to improve adherence, and seven trials (1567 participants) reported interventions to increase programme completion. Participants were primarily male (64.2%); Ten (38.5%) trials included participants with heart failure. Most trials were rated as having low or unclear risk of bias.  Researchers tested a variety of interventions to increase CR utilisation, consisting of a mean of 14.5±32.3 contacts. In many trials, patient contacts were made by a healthcare provider during or shortly after an acute care hospitalisation. Authors of effective interventions were contacted to request their materials for posting open source; received materials are collated at: http://sgrace.info.yorku.ca/tools-to-promote-cardiac-rehabilitation-utilization/.    Table 1 shows the summary of findings. Low-quality evidence showed 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 [e.g., physiotherapists]; p=0.02) and the delivery format (face-to-face; p=0.01) were influential in increasing enrolment. Note that no trials tested physician intervention delivery.  Low-quality evidence showed 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 showed 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 trials were less effective than those given in single-centre trials, leading to questions regarding generalisability.  A moderate level of statistical heterogeneity across trials reflected the heterogeneity in intervention approaches. There was no evidence of small-study bias for enrolment (insufficient trials to test for this in the other outcomes).  With regard to secondary outcomes, no trials reported on harms associated with the interventions. Only two trials examined costs, and these were trials testing the impact of delivering CR remotely versus supervised. A review on cost-effectiveness of home-based CR is available elsewhere. [7]  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 trials that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment. Limitations  Despite the many strengths of this review, including application of GRADEpro for the first time for this review, and that this is the first time utilization trials have been pooled quantitatively, it suffers from some limitations as well. Due to the nature of the interventions, blinding of participants and personnel to treatment allocation was not possible. Instead, blinding of outcome assessors was evaluated. Nevertheless, the lack of blinding of participants and personnel may introduce a potential source of bias in all these trials. Additionally, the evidence may not be applicable to the average cardiac patient (indirectness). Despite the fact that some included trials considered women and older patients specifically, most study participants included in this review were middle-aged male patients with acute coronary syndrome (± revascularisation).  Implications  There was significant heterogeneity, suggesting some strategies are more effective than others. For adherence, patients adhered to a greater degree to unsupervised programs. However, adherence ascertainment in supervised and unsupervised settings may not be comparable, therefore the latter finding should be interpreted with caution. Investigating differences in functional capacity in future research may overcome this incomparability. However, CR is shown to be of equivalent efficacy regardless of setting, [7]  thus if offering CR remotely improves utilisation, better outcomes could be achieved. Many programs offer alternative models, but a low proportion of patients are treated in these settings. [8]    To translate these findings into actionable recommendations, a joint Canadian Association of Cardiovascular Prevention and Rehabilitation and International Council of Cardiovascular Prevention and Rehabilitation position statement was developed using best practices.[9] It has been endorsed by 23 associations. Moreover, as a guideline implementation tool, an online course was developed to inform inpatient cardiac healthcare providers about communicating with patients about CR (see: http://learnonthego.ca/Courses/promoting_patient_participation_in_CR/story_html5.html). It has a corresponding tool summarizing key points for the point-of-care. No such educational activity exists globally to our knowledge. Results of the course evaluation are forthcoming.  More research is needed to understand how to increase CR completion. A recently-published trial suggests financial incentives may be effective, [10] including in patients of low socioeconomic status, who are under-represented in programs despite great need. Results of some other ongoing trials are also eagerly anticipated.[11][12]  What healthcare providers should communicate to patients when interacting with them face-to-face to optimise utilisation needs to be established. [13] This would likely most feasibly and cost-efficiently be achieved at the bedside. Feasibility of offering effective interventions at scale must also be considered.  In conclusion, in this first quantitative pooling of randomized trials of interventions to increase CR utilisation, it was established that such approaches are indeed successful, resulting in greater enrolment, adherence, and completion than is observed with usual care. Enrolment interventions were most successful if delivered by nurses or other allied healthcare professionals, face-to-face, which is likely most feasibly achieved at scale through bedside discussions before hospital discharge. Interventions to increase adherence and completion require expeditious study.     Acknowledgments: We would like to thank Mark Berendsen for undertaking the search update and Roland Buchter for translation assistance. We would also like to thank Andrew Beswick, Nicole Martin, Shah Ebrahim, Kunal Kamali, Karen Rees, Tiffany Moxham, Ingolf Griebsch, Madeline Burke, Robert R. West, J Victory, Juliet Brown and Frances Wise, authors of previous versions of this Cochrane review.   References  1. Anderson L, Oldridge N, Thompson DR, Zwisler A-D, Rees K, Martin N, et al. Exercise-based cardiac rehabilitation for coronary heart disease. J Am Coll Cardiol. 2016;67:1–12.  2. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol. Elsevier; 2013;62:e147–239.  3. Oosenbrug E, Marinho RP, Zhang J, Marzolini S, Colella TJF, Pakosh M, et al. Sex differences in cardiac rehabilitation adherence: A meta-analysis. Can J Cardiol. 2016;32:1316–24.  4. Clark AM, King-Shier KM, Thompson DR, Spaling MA, Duncan AS, Stone JA, et al. A qualitative systematic review of influences on attendance at cardiac rehabilitation programs after referral. Am Heart J. 2012;164:835-845.e2.  5. Santiago de Araújo Pio C, Chaves GS, Davies P, Taylor RS, Grace SL. Interventions to promote patient utilisation of cardiac rehabilitation. Cochrane Database Syst Rev [Internet]. 2019;Feb 1:CD007131. Available from: http://doi.wiley.com/10.1002/14651858.CD007131.pub4 6. Grace SL, Poirier P, Norris CM, Oakes GH, Somanader DS, Suskin N. Pan-Canadian development of cardiac rehabilitation and secondary prevention quality indicators. Can J Cardiol. Elsevier; 2014;30:945–8.  7. Anderson L, Sharp GA, Norton RJ, Dalal H, Dean SG, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst. Rev. 2017. p. CD007130.  8. Ghisi GLM, Pesah E, Turk-Adawi K, Supervia Pola M, Lopez Jimenez F, Grace SL. Alternative models of cardiac rehabilitation around the globe. J Clin Med. 2018;7:1–13.  9. Santiago de Araujo Pio C, Beckie T, Sarrafzadegan N, Babu A, Baidya S, Buckley J, et al. Promoting patient utilization of cardiac rehabilitation: A joint International Council and Canadian Association of Cardiovascular Prevention and Rehabilitation Position Statement. J Cardiovasc Rehabil Prev. 2019;In Press.  10. Gaalema DE, Elliott RJ, Savage PD, Rengo JL, Cutler AY, Pericot-Valverde I, et al.   Financial Incentives to Increase Cardiac Rehabilitation Participation Among Low-Socioeconomic Status Patients. JACC Hear Fail. 2019;Epub.  11. Ivers N, Schwalm JD, Witteman HO, Presseau J, Taljaard M, McCready T, et al. Interventions Supporting Long-term Adherence aNd Decreasing cardiovascular events (ISLAND): Pragmatic randomized trial protocol. Am Heart J. 2017;190:64–75.  12. La Valley G, Szalai H, Pack Q, Storer A. A telephone intervention to improve patient return rates in cardiac rehabilitation: a pilot study. AACVPR 32nd Annu Meet Sci Abstr Present. 2017. p. 5:S209.  13. Pourhabib S, Kentner AC, Grace SL. The impact of patient-healthcare provider discussions on enrollment in cardiovascular rehabilitation. J Rehabil Med. 2014;46:924–31.    Table 1. Summary of Findings Table  Outcomes № of participants (trials) Follow up Certainty of the evidence (GRADE) Relative effect (95% CI) Anticipated absolute effects* (95% CI) Risk with no interventions to promote utilization of CR Risk difference with interventions to promote utilization of CR Enrolment 3096 (19 RCTs) ⊕⊕⊝⊝ LOW 1 2 RR 1.27 (1.13 to 1.42) Study population 406 per 1,000 110 more per 1,000 (53 more to 171 more) Adherence 1654 (9 RCTs) ⊕⊕⊝⊝ LOW 1 2 -  SMD 0.38 SD higher (0.20 higher to 0.55 higher) Completion 1565 (8 RCTs) ⊕⊕⊕⊝ MODERATE 2 RR 1.13 (1.02 to 1.25) Study population 649 per 1,000 84 more per 1,000 (13 more to 162 more) *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; RCT: Randomised controlled trial; RR: Risk ratio; SD: Standard deviation SMD: Standardized mean difference       Footnotes Contributors: All authors conceived and made substantial contributions to this editorial Funding: The authors have not declared any funding for this research.  Competing interests: None declared.  Patient consent: Not required. Data sharing statement: Not applicable  

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Cochrane corner: increasing patient utilisation of cardiac rehabilitation

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                          Santiago de Araújo Pio, C., Chaves, G., Davies, P., Taylor, R., & Grace, S.L. (2019). Cochrane corner: increasing patient utilisation of cardiacrehabilitation. Heart. https://doi.org/10.1136/heartjnl-2019-315348Peer reviewed versionLink to published version (if available):10.1136/heartjnl-2019-315348Link to publication record in Explore Bristol ResearchPDF-documentThis is the author accepted manuscript (AAM). The final published version (version of record) is available onlinevia BMJ Publishing Group at https://heart.bmj.com/content/early/2019/08/18/heartjnl-2019-315348 . Please referto any applicable terms of use of the publisher.University of Bristol - Explore Bristol ResearchGeneral rightsThis document is made available in accordance with publisher policies. Please cite only the publishedversion using the reference above. Full terms of use are available:http://www.bristol.ac.uk/pure/about/ebr-terms  Cochrane corner: increasing patient utilisation of cardiac rehabilitation  Authors: Carolina Santiago de Araújo Pio1, Gabriela SS Chaves2, Philippa Davies3, Rod S Taylor,4, Sherry L Grace1,5 1School of Kinesiology and Health Science, York University, Toronto, Canada 2Rehabilitation Science Program, Federal University of Minas Gerais, Belo Horizonte, Brazil 3School of Social and Community Medicine, University of Bristol, Bristol, UK 4Institute of Health Research, University of Exeter Medical School, Exeter, UK 5KITE-Toronto Rehabilitation Institute, University Health Network, University of Toronto, Canada  Correspondence to: Sherry L. Grace, PhD, CRFC, FCCS, FAACVPR, York University, Bethune 368, 4700 Keele St, Toronto, Ontario M3J 1P3, Canada; sgrace@yorku.ca     Background  Cardiac rehabilitation (CR) is a medically-sponsored program to aid recovery and prevent further cardiac events. Programs offer core components to optimize cardiovascular risk reduction, foster healthy behaviours (e.g. exercise, healthy eating, no smoking), increase patient's understanding of their disease, and improve psychosocial well-being CR has been shown to improve quality of life, as well as decrease subsequent morbidity and cardiovascular mortality by approximately 20%. [1] As a result, CR is an integral recommendation in many clinical guidelines for secondary prevention in cardiac patients. [2]  However, CR utilization remains sub-optimal. Such under-utilization can be attributed in part to low referral by healthcare providers. However, even among patients referred, few enroll in CR, and many of those who do, dropout. [3] Factors impacting utilization of CR include: distance, financial resources, work and other time constraints, gender, age, social support, illness perceptions, and depression. [4] Herein we highlight the updated systematic review and meta-analysis of interventions to increase patient utilisation of CR. [5] This was operationalized as enrolment (i.e., patient attendance at a first visit), adherence (i.e., percentage of prescribed sessions completed), and completion (i.e., patients attended at least some of program and had a formal re-assessment by staff at end of program) of CR. [6] The review also considered harms, costs, and equity (secondary outcomes). Review methods  A search was performed through July 2018, to identify trials published since the previous systematic review. The Cochrane Library, MEDLINE, Embase, CINAHL, EBSCOhost,  Conference Proceedings Citation Index, among other databases were searched. The reference   lists of relevant systematic reviews were hand-searched for additional trials, and two clinical trial registers were also searched.  Randomised controlled trials (RCTs) in adults with myocardial infarction, angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for CR were included. Interventions had to aim to increase utilisation of comprehensive (i.e., initial patient assessment, structured exercise, and at least one other strategy to control risk factors) phase II CR.  Methods outlined in the Cochrane Handbook were used to select eligible trials, assess risk of bias, extract and analyse data, as well as assess the certainty of evidence. Random-effects meta-regression was performed for each outcome, with pre-specified study and intervention characteristics explored. Main results  Ultimately, 26 trials with 5299 participants (29 comparisons) were included: sixteen trials (3164 participants) reported interventions to improve enrolment in CR, 11 trials (2319 participants) reported interventions to improve adherence, and seven trials (1567 participants) reported interventions to increase programme completion. Participants were primarily male (64.2%); Ten (38.5%) trials included participants with heart failure. Most trials were rated as having low or unclear risk of bias.  Researchers tested a variety of interventions to increase CR utilisation, consisting of a mean of 14.5±32.3 contacts. In many trials, patient contacts were made by a healthcare provider during or shortly after an acute care hospitalisation. Authors of effective interventions were contacted to request their materials for posting open source; received materials are collated at: http://sgrace.info.yorku.ca/tools-to-promote-cardiac-rehabilitation-utilization/.    Table 1 shows the summary of findings. Low-quality evidence showed 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 [e.g., physiotherapists]; p=0.02) and the delivery format (face-to-face; p=0.01) were influential in increasing enrolment. Note that no trials tested physician intervention delivery.  Low-quality evidence showed 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 showed 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 trials were less effective than those given in single-centre trials, leading to questions regarding generalisability.  A moderate level of statistical heterogeneity across trials reflected the heterogeneity in intervention approaches. There was no evidence of small-study bias for enrolment (insufficient trials to test for this in the other outcomes).  With regard to secondary outcomes, no trials reported on harms associated with the interventions. Only two trials examined costs, and these were trials testing the impact of delivering CR remotely versus supervised. A review on cost-effectiveness of home-based CR is available elsewhere. [7]  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 trials that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment. Limitations  Despite the many strengths of this review, including application of GRADEpro for the first time for this review, and that this is the first time utilization trials have been pooled quantitatively, it suffers from some limitations as well. Due to the nature of the interventions, blinding of participants and personnel to treatment allocation was not possible. Instead, blinding of outcome assessors was evaluated. Nevertheless, the lack of blinding of participants and personnel may introduce a potential source of bias in all these trials. Additionally, the evidence may not be applicable to the average cardiac patient (indirectness). Despite the fact that some included trials considered women and older patients specifically, most study participants included in this review were middle-aged male patients with acute coronary syndrome (± revascularisation).  Implications  There was significant heterogeneity, suggesting some strategies are more effective than others. For adherence, patients adhered to a greater degree to unsupervised programs. However, adherence ascertainment in supervised and unsupervised settings may not be comparable, therefore the latter finding should be interpreted with caution. Investigating differences in functional capacity in future research may overcome this incomparability. However, CR is shown to be of equivalent efficacy regardless of setting, [7]  thus if offering CR remotely improves utilisation, better outcomes could be achieved. Many programs offer alternative models, but a low proportion of patients are treated in these settings. [8]    To translate these findings into actionable recommendations, a joint Canadian Association of Cardiovascular Prevention and Rehabilitation and International Council of Cardiovascular Prevention and Rehabilitation position statement was developed using best practices.[9] It has been endorsed by 23 associations. Moreover, as a guideline implementation tool, an online course was developed to inform inpatient cardiac healthcare providers about communicating with patients about CR (see: http://learnonthego.ca/Courses/promoting_patient_participation_in_CR/story_html5.html). It has a corresponding tool summarizing key points for the point-of-care. No such educational activity exists globally to our knowledge. Results of the course evaluation are forthcoming.  More research is needed to understand how to increase CR completion. A recently-published trial suggests financial incentives may be effective, [10] including in patients of low socioeconomic status, who are under-represented in programs despite great need. Results of some other ongoing trials are also eagerly anticipated.[11][12]  What healthcare providers should communicate to patients when interacting with them face-to-face to optimise utilisation needs to be established. [13] This would likely most feasibly and cost-efficiently be achieved at the bedside. Feasibility of offering effective interventions at scale must also be considered.  In conclusion, in this first quantitative pooling of randomized trials of interventions to increase CR utilisation, it was established that such approaches are indeed successful, resulting in greater enrolment, adherence, and completion than is observed with usual care. Enrolment interventions were most successful if delivered by nurses or other allied healthcare professionals, face-to-face, which is likely most feasibly achieved at scale through bedside discussions before hospital discharge. Interventions to increase adherence and completion require expeditious study.     Acknowledgments: We would like to thank Mark Berendsen for undertaking the search update and Roland Buchter for translation assistance. We would also like to thank Andrew Beswick, Nicole Martin, Shah Ebrahim, Kunal Kamali, Karen Rees, Tiffany Moxham, Ingolf Griebsch, Madeline Burke, Robert R. West, J Victory, Juliet Brown and Frances Wise, authors of previous versions of this Cochrane review.   References  1. Anderson L, Oldridge N, Thompson DR, Zwisler A-D, Rees K, Martin N, et al. Exercise-based cardiac rehabilitation for coronary heart disease. J Am Coll Cardiol. 2016;67:1–12.  2. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol. Elsevier; 2013;62:e147–239.  3. Oosenbrug E, Marinho RP, Zhang J, Marzolini S, Colella TJF, Pakosh M, et al. Sex differences in cardiac rehabilitation adherence: A meta-analysis. Can J Cardiol. 2016;32:1316–24.  4. Clark AM, King-Shier KM, Thompson DR, Spaling MA, Duncan AS, Stone JA, et al. A qualitative systematic review of influences on attendance at cardiac rehabilitation programs after referral. Am Heart J. 2012;164:835-845.e2.  5. Santiago de Araújo Pio C, Chaves GS, Davies P, Taylor RS, Grace SL. Interventions to promote patient utilisation of cardiac rehabilitation. Cochrane Database Syst Rev [Internet]. 2019;Feb 1:CD007131. Available from: http://doi.wiley.com/10.1002/14651858.CD007131.pub4 6. Grace SL, Poirier P, Norris CM, Oakes GH, Somanader DS, Suskin N. Pan-Canadian development of cardiac rehabilitation and secondary prevention quality indicators. Can J Cardiol. Elsevier; 2014;30:945–8.  7. Anderson L, Sharp GA, Norton RJ, Dalal H, Dean SG, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst. Rev. 2017. p. CD007130.  8. Ghisi GLM, Pesah E, Turk-Adawi K, Supervia Pola M, Lopez Jimenez F, Grace SL. Alternative models of cardiac rehabilitation around the globe. J Clin Med. 2018;7:1–13.  9. Santiago de Araujo Pio C, Beckie T, Sarrafzadegan N, Babu A, Baidya S, Buckley J, et al. Promoting patient utilization of cardiac rehabilitation: A joint International Council and Canadian Association of Cardiovascular Prevention and Rehabilitation Position Statement. J Cardiovasc Rehabil Prev. 2019;In Press.  10. Gaalema DE, Elliott RJ, Savage PD, Rengo JL, Cutler AY, Pericot-Valverde I, et al.   Financial Incentives to Increase Cardiac Rehabilitation Participation Among Low-Socioeconomic Status Patients. JACC Hear Fail. 2019;Epub.  11. Ivers N, Schwalm JD, Witteman HO, Presseau J, Taljaard M, McCready T, et al. Interventions Supporting Long-term Adherence aNd Decreasing cardiovascular events (ISLAND): Pragmatic randomized trial protocol. Am Heart J. 2017;190:64–75.  12. La Valley G, Szalai H, Pack Q, Storer A. A telephone intervention to improve patient return rates in cardiac rehabilitation: a pilot study. AACVPR 32nd Annu Meet Sci Abstr Present. 2017. p. 5:S209.  13. Pourhabib S, Kentner AC, Grace SL. The impact of patient-healthcare provider discussions on enrollment in cardiovascular rehabilitation. J Rehabil Med. 2014;46:924–31.    Table 1. Summary of Findings Table  Outcomes № of participants (trials) Follow up Certainty of the evidence (GRADE) Relative effect (95% CI) Anticipated absolute effects* (95% CI) Risk with no interventions to promote utilization of CR Risk difference with interventions to promote utilization of CR Enrolment 3096 (19 RCTs) ⊕⊕⊝⊝ LOW 1 2 RR 1.27 (1.13 to 1.42) Study population 406 per 1,000 110 more per 1,000 (53 more to 171 more) Adherence 1654 (9 RCTs) ⊕⊕⊝⊝ LOW 1 2 -  SMD 0.38 SD higher (0.20 higher to 0.55 higher) Completion 1565 (8 RCTs) ⊕⊕⊕⊝ MODERATE 2 RR 1.13 (1.02 to 1.25) Study population 649 per 1,000 84 more per 1,000 (13 more to 162 more) *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; RCT: Randomised controlled trial; RR: Risk ratio; SD: Standard deviation SMD: Standardized mean difference       Footnotes Contributors: All authors conceived and made substantial contributions to this editorial Funding: The authors have not declared any funding for this research.  Competing interests: None declared.  Patient consent: Not required. Data sharing statement: Not applicable  

Cochrane corner:increasing patient utilisation of cardiac rehabilitation

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Cochrane corner:increasing patient utilisation of cardiac rehabilitation

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