Patient and family satisfaction levels in the intensive care unit after elective cardiac surgery: study protocol for a randomised controlled trial of a preoperative patient education intervention

Learning Needs and Educational Strategies for Adult Patients in the Preoperative Period of Myocardial Revascularization: Scoping Review

Objective: To identify and map learning needs and educational strategies for adult patients in the preoperative period of myocardial revascularization. Materials and method: Scoping review conducted between March and April 2021 in national and international databases to identify records published in scientific journals and gray literature, without period. Results: The selected sample consisted of 35 records, composed mostly of articles (32; 91.42 %) published from 1990 to 2021. The learning needs of patients before surgery were categorized into cardiovascular system and coronary artery disease; procedures and routines before, during, and after surgery. In addition, several educational strategies implemented in the studies were identified. Conclusions: The learning needs identified can contribute to planning and implementing patient-centered educational strategies before surgery.

Educational approaches for patients with heart surgery: a systematic review of main features and effects

Introduction

Patients who undergo heart surgery are exposed to mental and physical difficulties after discharge from hospital. They often need support and follow-up after discharge. The use of educational approaches or solutions before or after heart surgery can increase patients' knowledge on the post-operative complications and self-care. The main purpose of this systematic review is to determine the applications of educational approaches and investigate the effects of these approaches on patients with heart surgery.

Method and materiel

A thorough search was conducted in Medline (through PubMed), Scopus, ISI web of science to select related articles published between 2011 and May 2022. All of the retrieved papers were screened according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.

Results

A total of 29 articles were obtained from the search, which included in this systematic review after being assessed based on inclusion and exclusion criteria. Most of the articles (n = 10, 34.48%) had been conducted in Canada and Iran, with the most significant number published in 2016. Out of 29 studies, 23 were experimental studies, and six were observational-analytical studies. The number of participants in the studies ranged from 11 to 600 (IQR1: 57.5, median: 88, IQR3: 190). In 28 (96.55%) studies, the educational approaches had a significant effect on clinical, economic or patient-reported outcomes. The greatest effect reported by the studies was related to clinical outcomes such as patient care improvement or change in clinical practice. The most effects in the patient-reported outcomes were related to improving patient satisfaction and patient knowledge. In terms of global rating scores, 17.24% of the included studies were considered as weak, 20.68% as moderate, and 62.06% as strong.

Conclusion

The results of systematic review showed that the use of educational approaches by patients before and after heart surgery can have significant effects on reducing stress and financial burden, and increasing the quality of care and level of knowledge in patients.

Satisfaction with preoperative education and surgical services among adults elective surgical patients at selected public hospitals in Addis Ababa, Ethiopia

Objectives:

The purpose of this study was to determine the level of satisfaction with preoperative education and surgical services among adult elective surgical patients at governmental hospitals in Addis Ababa, Ethiopia.

Methods:

Four hundred and twenty-two elective surgical patients at Addis Ababa’s governmental hospitals took part in a facility-based cross-sectional study from 8 October to 8 November 2021. Based on past experiments, an instrument for structured data collection was modified and employed. The data were cleaned and sent to Epidata version 4.2 before being exported and analysed in SPSS version 25. Descriptive statistics were used to describe the participant characteristics, and logistic regression, which also included bivariate and multivariate analysis, was used to evaluate the association between the independent and outcome variables. The level of statistical significance was indicated by a p value of 0.05.

Results:

84.6% of the participants reported feeling very satisfied with their preoperative education. Preoperative education about surgery (adjusted odds ratios (AOR) = 0.005; 95% confidence interval (CI): (0.000, 0.061)), previous surgery (AOR = 2.7; 95% CI: (2.51, 6.85)), and preoperative anxiety (AOR = 0.013; 95% CI: (0.003, 0.06)) were all significantly associated.

Conclusions:

About 84% of survey participants reported being satisfied with preoperative education and services. Preoperative patient satisfaction was negatively predicted by preoperative anxiety, prior surgery, and preoperative information about surgery. The decrease of anxiety and enhancement of surgical patient satisfaction may be significantly impacted by proper preoperative education.

The Impact of Nonpharmacological Interventions on Patient Experience, Opioid Use, and Health Care Utilization in Adult Cardiac Surgery Patients: Protocol for a Mixed Methods Study

BACKGROUND

Despite pharmacological treatments, patients undergoing cardiac surgery experience severe anxiety and pain, which adversely affect outcomes. Previous work examining pediatric and nonsurgical adult patients has documented the effectiveness of inexpensive, nonpharmacological techniques to reduce anxiety and pain as well as health care costs and length of hospitalization. However, the impact of nonpharmacological interventions administered by a dedicated comfort coach has not been evaluated in an adult surgical setting.

OBJECTIVE

This trial aims to assess whether nonpharmacological interventions administered by a trained comfort coach affect patient experience, opioid use, and health care utilization compared with usual care in adult cardiac surgery patients. This study has 3 specific aims: assess the effect of a comfort coach on patient experience, measure differences in inpatient and outpatient opioid use and postoperative health care utilization, and qualitatively evaluate the comfort coach intervention.

METHODS

To address these aims, we will perform a prospective, randomized controlled trial of 154 adult cardiac surgery patients at Michigan Medicine. Opioid-naive patients undergoing first-time, elective cardiac surgery via sternotomy will be randomized to undergo targeted interventions from a comfort coach (intervention) versus usual care (control). The individualized comfort coach interventions will be administered at 6 points: preoperative outpatient clinic, preoperative care unit on the day of surgery, extubation, chest tube removal, hospital discharge, and 30-day clinic follow-up. To address aim 1, we will examine the effect of a comfort coach on perioperative anxiety, self-reported pain, functional status, and patient satisfaction through validated surveys administered at preoperative outpatient clinic, discharge, 30-day follow-up, and 90-day follow-up. For aim 2, we will record inpatient opioid use and collect postdischarge opioid use and pain-related outcomes through an 11-item questionnaire administered at the 30-day follow-up. Hospital length of stay, readmission, number of days in an extended care facility, emergency room, urgent care, and an unplanned doctor's office visit will be recorded as the primary composite endpoint defined as total days spent at home within the first 30 days after surgery. For aim 3, we will perform semistructured interviews with patients in the intervention arm to understand the comfort coach intervention through a thematic analysis.

RESULTS

This trial, funded by Blue Cross Blue Shield of Michigan Foundation in 2019, is presently enrolling patients with anticipated manuscript submissions from our primary aims targeted for the end of 2020.

CONCLUSIONS

Data generated from this mixed methods study will highlight effective nonpharmacological techniques and support a multidisciplinary approach to perioperative care during the adult cardiac surgery patient experience. This study's findings may serve as the foundation for a subsequent multicenter trial and broader dissemination of these techniques to other types of surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04051021; https://clinicaltrials.gov/ct2/show/NCT04051021.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21350.

Patient Satisfaction With Heart Health Clinics in Fraser Health, Canada

The Fraser Health heart function clinics explored patient satisfaction using a survey with the goal of understanding and improving care and service delivery. Data were collected from 124 respondents at 3 ambulatory care sites in the region. Patient satisfaction scores were high, with an average score of 8.85 out of 10 and 95% of respondents rating the service higher than 6 out of 10. The results highlighted the importance of multidisciplinary teams, good communication, adequate information, and emphasis on how a patient is treated. The patient's understanding of the information provided and of their heart health treatment plan were identified as two areas that require greater awareness.

Enhancing Family-Centered Care in Cardiothoracic Surgery

The psychological impact of critical illness is far reaching, affecting patients and their loved ones. Family members face a multitude of stressors, ranging from concerns about death or permanent disability to stress over health care costs and lost wages. Patients are at risk for developing post-intensive care syndrome. Professional groups and patient safety organizations have crafted family-centered care (FCC) models that support hospitalized patients and their families. There is a paucity of data on use of FCC in cardiothoracic intensive care units. This article discusses FCC models and why they are beneficial to the needs of families of postoperative cardiothoracic surgery patients.

A quasi-experimental study examining QR code-based video education program on anxiety, adherence, and satisfaction in coronary angiography patients

Background: QR (quick response) codes are a promising tool for health education, however effects of QR code application in providing peri-procedure education to patients with coronary angiography is unclear.Aim/Objective: This study investigated the effect of a QR code-based video education program on anxiety, adherence, and satisfaction in Chinese coronary angiography patients.Material and Methods: This prospective controlled clinical trial included 335 patients undergoing coronary angiography, including 166 patients in the experimental group and 169 patients in the control group. On the day before coronary angiography, patients in the experimental group had access to and could watch an educational video on their smartphones by scanning a QR code for multiple times, while patients in the control group watched the same video on a tablet once only. The primary outcome was anxiety assessed using the Chinese State Anxiety Inventory (C-SAI). Adherence to instructions and patient satisfaction with the information delivery method were also evaluated.Results: The C-SAI scores improved in the experimental group compared to the control group (F = 9.8, P < 0.001) over time. There is a significant difference in the changes of anxiety scores from baseline to pre-procedure (P < 0.001) and post-procedure (P < 0.01) between the two groups. Individuals in the experimental group showed better adherence to instructions on removing dentures and jewelry, and taking medicines before the procedure (P < 0.05), and limb activity, water consumption, and diet after the procedure (P < 0.001).Conclusion: Patient education programs on smartphone that can be accessed multiple times by scanning a QR code can be an effective and convenient approach to reducing anxiety and enhancing adherence to instructions among Chinese coronary angiography patients. Hospitals and clinicians should consider more investments in developing such patient education programs and also help improve ehealth literacy.

Effect of preoperative education and ICU tour on patient and family satisfaction and anxiety in the intensive care unit after elective cardiac surgery: a randomised controlled trial

BACKGROUND

Preoperative education may help participants to psychologically prepare themselves for surgery, but the outcomes of such preparation have rarely been assessed in patients requiring postoperative care in the intensive care unit (ICU) as well as in family members.

OBJECTIVE

To assess the effect of a preoperative multifaceted education intervention on patient and family satisfaction levels in the ICU and measures of perioperative patients' anxiety and depression.

TRIAL DESIGN

Single-centre, two-armed, parallel, superiority, randomised controlled trial. Healthcare professionals in ICU and outcome assessor were blinded to treatment allocation.

PARTICIPANTS

100 elective coronary artery bypass grafting±valve surgery patients and their family members.

INTERVENTIONS

Preoperative education comprising of a video and ICU tour in addition to standard care (treatment), versus standard care (control).

OUTCOMES

Patient and family satisfaction levels with ICU using validated PS-ICU23 and FS-ICU24 questionnaires (0-100), respectively; change in perioperative anxiety and depression scores between 1 day presurgery and 3 days postsurgery.

RESULTS

Among 100 (50 treatment, 50 control) patients and 98 (49 treatment, 49 control) family members, 94 (48 treatment, 46 control) patients and 94 (47 treatment, 47 control) family members completed the trial. Preoperative education was associated with higher overall patient (mean difference (MD) 6.7, 95% CI 0.2 to 13.2) and family (MD 10.0, 95% CI 3.8 to 16.3) satisfaction scores. There was a weak association between preoperative education and a reduction in patient's anxiety scores over time (MD -1.7, 95% CI -3.5 to 0.0). However, there was no evidence of a treatment effect on patient's depression scores over time (MD -0.6, 95% CI -2.3 to 1.2).

CONCLUSION

Providing comprehensive preoperative information about ICU to elective cardiac surgical patients improved patient and family satisfaction levels and may decrease patients' anxiety levels.

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-15006971.

Effect of peer support on patient anxiety during the coronary angiography or percutaneous coronary intervention perioperative period: a protocol for a systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

The purpose of this study is to investigate the effect of peer support on patient anxiety during the perioperative period of coronary angiography or percutaneous coronary intervention (PCI).

METHODS AND ANALYSIS

We will search the following databases (PubMed, Web of Science, EMBASE, Cochrane Library, CINAHL, Clinicaltrials.gov, WHO International Clinical Trials Registry Platform, Google Scholar, Chinese National Knowledge Infrastructure, Chinese Science and Technology Periodicals Database, Chinese BioMedical Database and Wanfang Data) from the date of database inception to January 2019. Only randomised controlled trials will be included. For the data analysis, we will use RevMan V.5.3.5 software to evaluate the risk of bias, and the heterogeneity will be investigated using the Q statistic and P index. Additionally, the Grading of Recommendations Assessment, Development and Evaluation system will be used to assess the quality of evidence.

ETHICS AND DISSEMINATION

No ethics approval will be required since this is a systematic review of published studies. We aim to report information regarding the effects of peer support on patient anxiety during the perioperative period of coronary angiography or PCI. This systematic review and meta-analysis will be submitted to a peer-reviewed journal for publication.

PROSPERO REGISTRATION NUMBER

CRD42019123290.

Examining satisfaction of older adult patients and their caregivers following traumatic injury: a cross-sectional study of three level I trauma centres

OBJECTIVE

To explore satisfaction of care received by older adult patients and their primary caregivers following traumatic injury.

DESIGN

Prospective, cross-sectional study using the FAMCARE (Family Satisfaction with Advanced Cancer Care Scale) satisfaction surveys prior to discharge.

SETTING

Three level I trauma centres in Colorado from November 2016 to December 2017.

PARTICIPANTS

Trauma patients ≥55 years old and their primary caregivers.

OUTCOME MEASURES

Overall mean (SD) satisfaction, satisfaction <80% vs ≥80%, and mean satisfaction by survey conceptual structures.

RESULTS

Of the 319 patients and 336 caregivers included, the overall mean (SD) patient satisfaction was 81.7% (15.0%) and for caregivers was 83.6% (13.4%). The area with the highest mean for patient and caregiver satisfaction was psychosocial care (85.4% and 86.9%, respectively). Information giving was the lowest for patients (80.4%) and caregivers (80.9%). When individual items were examined, patients were significantly more satisfied with 'availability of nurses to answer questions' (84.5 (15.3) vs 87.4 (14.8), p=0.02) and significantly less satisfied with 'speed with which symptoms were treated' (80.6 (17.9) vs 84.0 (17.0), p=0.03) compared with caregivers. Patients with a history of smoking (least squares mean difference: -0.096 (-0.18 to -0.07), p<0.001) and hospital discharge destination to an outside facility of care (adjusted OR: 1.6 (1.0 to 2.4), p=0.048) were identified as independent predictors of lower overall satisfaction in generalised linear and logistic models, respectively.

CONCLUSIONS

Our data suggest that patients' medical history was driving both patient and caregiver satisfaction. Patient characteristics and expectations need to be considered when tailoring healthcare interventions.

Effects of a visit prior to hospital admission on anxiety, depression and satisfaction of patients in an intensive care unit

OBJECTIVES

To assess the effects of a vists prior to hospital admission on anxiety, depression and satisfaction of patients admitted electively to an intensive care unit (ICU).

DESIGN

A randomised clinical trial [NCT03605407].

SETTING

A sample of 38 patients was recruited who were to be electively admiited to ICU divided into experimental (n = 19 patients receiving one visit prior to hospital ICU admission for surgery) and control (n = 19 patients not receiving a visit prior to hospital ICU admission for surgery) groups.

MAIN OUTCOME MEASUREMENTS

Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale-Revised (IES-R) were self-reported by patients before ICU admission, at 3-days and 90-days after ICU discharge. Critical Care Family Needs Inventory (CCFNI) and Family Satisfaction with Care in the Intensive Care Unit (FS-ICU) were used to measure the users' satisfaction before ICU admission and 3-days after ICU discharge.

RESULTS

There were statistically significant differences between experimental and control groups for FS-ICU, but not for HADS, IES-R and CCFNI. Indeed, control group patients were more satisfied with regard to emotional support, ease of getting information, control feeling, concerns and questions expression ability and overall score for decision-making satisfaction.

CONCLUSIONS

The visit prior to hospital admission did not seem to modify anxiety or depression, but may impair satisfaction of ICU patients.

Psychometric validation of the Chinese patient- and family satisfaction in the intensive care unit questionnaires

PURPOSE

To assess the psychometric properties of the Chinese version of the 23-item Patient Satisfaction in the Intensive Care Unit (PS-ICU-23) and 24-item Family Satisfaction in the Intensive Care Unit (FS-ICU-24) questionnaires.

MATERIALS AND METHODS

Patients (n = 243) discharged from an intensive care unit (ICU) in Hong Kong and family members (n = 237) completed the translated questionnaires. We used confirmatory factor analysis to assess the construct validity and measurement equivalence across groups (gender, mechanical ventilation, casemix, length of stay in ICU), coefficient alpha for internal consistency (reliability) and concordance correlation coefficient (ρ_c) for agreement between patients' and family members' perspective on satisfaction.

RESULTS

A three-factor model provided a better fit than the two-factor model for both PS-ICU-23 and FS-ICU-24 questionnaires. Factorial equivalence was present across groups in both questionnaires. Internal consistency was adequate for PS-ICU-23 (coefficient alpha overall domain 0.85; care subscale, 0.83; information subscale, 0.90; decision-making process subscale, 0.67) and for FS-ICU-24 (coefficient alpha overall scale 0.86; care subscale, 0.84; information subscale, 0.89; decision-making process subscale, 0.65). Overall ICU satisfaction agreement was moderate (0.40).

CONCLUSIONS

Both Chinese PS-ICU-23 and FS-ICU-24 questionnaires have sound psychometric properties but family satisfaction may not be a good proxy for patient satisfaction in ICU.

Information or education interventions for adult intensive care unit (ICU) patients and their carers

BACKGROUND

During intensive care unit (ICU) admission, patients and their carers experience physical and psychological stressors that may result in psychological conditions including anxiety, depression, and post-traumatic stress disorder (PTSD). Improving communication between healthcare professionals, patients, and their carers may alleviate these disorders. Communication may include information or educational interventions, in different formats, aiming to improve knowledge of the prognosis, treatment, or anticipated challenges after ICU discharge.

OBJECTIVES

To assess the effects of information or education interventions for improving outcomes in adult ICU patients and their carers.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO from database inception to 10 April 2017. We searched clinical trials registries and grey literature, and handsearched reference lists of included studies and related reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), and planned to include quasi-RCTs, comparing information or education interventions presented to participants versus no information or education interventions, or comparing information or education interventions as part of a complex intervention versus a complex intervention without information or education. We included participants who were adult ICU patients, or their carers; these included relatives and non-relatives, including significant representatives of patients.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias, and applied GRADE criteria to assess certainty of the evidence.

MAIN RESULTS

We included eight RCTs with 1157 patient participants and 943 carer participants. We found no quasi-RCTs. We identified seven studies that await classification, and three ongoing studies.Three studies designed an intervention targeted at patients, four at carers, and one at both patients and carers. Studies included varied information: standardised or tailored, presented once or several times, and that included verbal or written information, audio recordings, multimedia information, and interactive information packs. Five studies reported robust methods of randomisation and allocation concealment. We noted high attrition rates in five studies. It was not feasible to blind participants, and we rated all studies as at high risk of performance bias, and at unclear risk of detection bias because most outcomes required self reporting.We attempted to pool data statistically, however this was not always possible due to high levels of heterogeneity. We calculated mean differences (MDs) using data reported from individual study authors where possible, and narratively synthesised the results. We reported the following two comparisons.Information or education intervention versus no information or education intervention (4 studies)For patient anxiety, we did not pool data from three studies (332 participants) owing to unexplained substantial statistical heterogeneity and possible clinical or methodological differences between studies. One study reported less anxiety when an intervention was used (MD -3.20, 95% confidence interval (CI) -3.38 to -3.02), and two studies reported little or no difference between groups (MD -0.40, 95% CI -4.75 to 3.95; MD -1.00, 95% CI -2.94 to 0.94). Similarly, for patient depression, we did not pool data from two studies (160 patient participants). These studies reported less depression when an information or education intervention was used (MD -2.90, 95% CI -4.00 to -1.80; MD -1.27, 95% CI -1.47 to -1.07). However, it is uncertain whether information or education interventions reduce patient anxiety or depression due to very low-certainty evidence.It is uncertain whether information or education interventions improve health-related quality of life due to very low-certainty evidence from one study reporting little or no difference between intervention groups (MD -1.30, 95% CI -4.99 to 2.39; 143 patient participants). No study reported adverse effects, knowledge acquisition, PTSD severity, or patient or carer satisfaction.We used the GRADE approach and downgraded certainty of the evidence owing to study limitations, inconsistencies between results, and limited data from few small studies.Information or education intervention as part of a complex intervention versus a complex intervention without information or education (4 studies)One study (three comparison groups; 38 participants) reported little or no difference between groups in patient anxiety (tailored information pack versus control: MD 0.09, 95% CI -3.29 to 3.47; standardised general ICU information versus control: MD -0.25, 95% CI -4.34 to 3.84), and little or no difference in patient depression (tailored information pack versus control: MD -1.26, 95% CI -4.48 to 1.96; standardised general ICU information versus control: MD -1.47, 95% CI -6.37 to 3.43). It is uncertain whether information or education interventions as part of a complex intervention reduce patient anxiety and depression due to very low-certainty evidence.One study (175 carer participants) reported fewer carer participants with poor comprehension among those given information (risk ratio 0.28, 95% CI 0.15 to 0.53), but again this finding is uncertain due to very low-certainty evidence.Two studies (487 carer participants) reported little or no difference in carer satisfaction; it is uncertain whether information or education interventions as part of a complex intervention increase carer satisfaction due to very low-certainty evidence. Adverse effects were reported in only one study: one participant withdrew because of deterioration in mental health on completion of anxiety and depression questionnaires, but the study authors did not report whether this participant was from the intervention or comparison group.We downgraded certainty of the evidence owing to study limitations, and limited data from few small studies.No studies reported severity of PTSD, or health-related quality of life.

AUTHORS' CONCLUSIONS

We are uncertain of the effects of information or education interventions given to adult ICU patients and their carers, as the evidence in all cases was of very low certainty, and our confidence in the evidence was limited. Ongoing studies may contribute more data and introduce more certainty when incorporated into future updates of the review.

Patient education in the management of coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the single most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people live with CHD and may need support to manage their symptoms and improve prognosis. Cardiac rehabilitation is a complex multifaceted intervention which aims to improve the health outcomes of people with CHD. Cardiac rehabilitation consists of three core modalities: education, exercise training and psychological support. This is an update of a Cochrane systematic review previously published in 2011, which aims to investigate the specific impact of the educational component of cardiac rehabilitation.

OBJECTIVES

1. To assess the effects of patient education delivered as part of cardiac rehabilitation, compared with usual care on mortality, morbidity, health-related quality of life (HRQoL) and healthcare costs in patients with CHD.2. To explore the potential study level predictors of the effects of patient education in patients with CHD (e.g. individual versus group intervention, timing with respect to index cardiac event).

SEARCH METHODS

We updated searches from the previous Cochrane review, by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 6, 2016), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) in June 2016. Three trials registries, previous systematic reviews and reference lists of included studies were also searched. No language restrictions were applied.

SELECTION CRITERIA

1. Randomised controlled trials (RCTs) where the primary interventional intent was education delivered as part of cardiac rehabilitation.2. Studies with a minimum of six-months follow-up and published in 1990 or later.3. Adults with a diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on the above inclusion criteria. One author extracted study characteristics from the included trials and assessed their risk of bias; a second review author checked data. Two independent reviewers extracted outcome data onto a standardised collection form. For dichotomous variables, risk ratios and 95% confidence intervals (CI) were derived for each outcome. Heterogeneity amongst included studies was explored qualitatively and quantitatively. Where appropriate and possible, results from included studies were combined for each outcome to give an overall estimate of treatment effect. Given the degree of clinical heterogeneity seen in participant selection, interventions and comparators across studies, we decided it was appropriate to pool studies using random-effects modelling. We planned to undertake subgroup analysis and stratified meta-analysis, sensitivity analysis and meta-regression to examine potential treatment effect modifiers. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the quality of the evidence and the GRADE profiler (GRADEpro GDT) to create summary of findings tables.

MAIN RESULTS

This updated review included a total of 22 trials which randomised 76,864 people with CHD to an education intervention or a 'no education' comparator. Nine new trials (8215 people) were included for this update. We judged most included studies as low risk of bias across most domains. Educational 'dose' ranged from one 40 minute face-to-face session plus a 15 minute follow-up call, to a four-week residential stay with 11 months of follow-up sessions. Control groups received usual medical care, typically consisting of referral to an outpatient cardiologist, primary care physician, or both.We found evidence of no difference in effect of education-based interventions on total mortality (13 studies, 10,075 participants; 189/5187 (3.6%) versus 222/4888 (4.6%); random effects risk ratio (RR) 0.80, 95% CI 0.60 to 1.05; moderate quality evidence). Individual causes of mortality were reported rarely, and we were unable to report separate results for cardiovascular mortality or non-cardiovascular mortality. There was evidence of no difference in effect of education-based interventions on fatal and/or non fatal myocardial infarction (MI) (2 studies, 209 participants; 7/107 (6.5%) versus 12/102 (11.8%); random effects RR 0.63, 95% CI 0.26 to 1.48; very low quality of evidence). However, there was some evidence of a reduction with education in fatal and/or non-fatal cardiovascular events (2 studies, 310 studies; 21/152 (13.8%) versus 61/158 (38.6%); random effects RR 0.36, 95% CI 0.23 to 0.56; low quality evidence). There was evidence of no difference in effect of education on the rate of total revascularisations (3 studies, 456 participants; 5/228 (2.2%) versus 8/228 (3.5%); random effects RR 0.58, 95% CI 0.19 to 1.71; very low quality evidence) or hospitalisations (5 studies, 14,849 participants; 656/10048 (6.5%) versus 381/4801 (7.9%); random effects RR 0.93, 95% CI 0.71 to 1.21; very low quality evidence). There was evidence of no difference between groups for all cause withdrawal (17 studies, 10,972 participants; 525/5632 (9.3%) versus 493/5340 (9.2%); random effects RR 1.04, 95% CI 0.88 to 1.22; low quality evidence). Although some health-related quality of life (HRQoL) domain scores were higher with education, there was no consistent evidence of superiority across all domains.

AUTHORS' CONCLUSIONS

We found no reduction in total mortality, in people who received education delivered as part of cardiac rehabilitation, compared to people in control groups (moderate quality evidence). There were no improvements in fatal or non fatal MI, total revascularisations or hospitalisations, with education. There was some evidence of a reduction in fatal and/or non-fatal cardiovascular events with education, but this was based on only two studies. There was also some evidence to suggest that education-based interventions may improve HRQoL. Our findings are supportive of current national and international clinical guidelines that cardiac rehabilitation for people with CHD should be comprehensive and include educational interventions together with exercise and psychological therapy. Further definitive research into education interventions for people with CHD is needed.