BACKGROUND: Coronary heart disease (CHD) is the most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people living with CHD may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane Review previously published in 2016.
OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of exercise-based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with 'no exercise' control, on mortality, morbidity and health-related quality of life (HRQoL) in people with CHD.
SEARCH METHODS: We updated searches from the previous Cochrane Review, by searching CENTRAL, MEDLINE, Embase, and two other databases in September 2020. We also searched two clinical trials registers in June 2021.
SELECTION CRITERIA: We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months' follow-up, compared with 'no exercise' control. The study population comprised adult men and women who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or have angina pectoris, or coronary artery disease.
DATA COLLECTION AND ANALYSIS: We screened all identified references, extracted data and assessed risk of bias according to Cochrane methods. We stratified meta-analysis by duration of follow-up: short-term (6 to 12 months); medium-term (> 12 to 36 months); and long-term ( > 3 years), and used meta-regression to explore potential treatment effect modifiers. We used GRADE for primary outcomes at 6 to 12 months (the most common follow-up time point). MAIN RESULTS: This review included 85 trials which randomised 23,430 people with CHD. This latest update identified 22 new trials (7795 participants). The population included predominantly post-MI and post-revascularisation patients, with a mean age ranging from 47 to 77 years. In the last decade, the median percentage of women with CHD has increased from 11% to 17%, but females still account for a similarly small percentage of participants recruited overall ( < 15%). Twenty-one of the included trials were performed in low- and middle-income countries (LMICs). Overall trial reporting was poor, although there was evidence of an improvement in quality over the last decade. The median longest follow-up time was 12 months (range 6 months to 19 years). At short-term follow-up (6 to 12 months), exercise-based CR likely results in a slight reduction in all-cause mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.73 to 1.04; 25 trials; moderate certainty evidence), a large reduction in MI (RR 0.72, 95% CI 0.55 to 0.93; 22 trials; number needed to treat for an additional beneficial outcome (NNTB) 75, 95% CI 47 to 298; high certainty evidence), and a large reduction in all-cause hospitalisation (RR 0.58, 95% CI 0.43 to 0.77; 14 trials; NNTB 12, 95% CI 9 to 21; moderate certainty evidence). Exercise-based CR likely results in little to no difference in risk of cardiovascular mortality (RR 0.88, 95% CI 0.68 to 1.14; 15 trials; moderate certainty evidence), CABG (RR 0.99, 95% CI 0.78 to 1.27; 20 trials; high certainty evidence), and PCI (RR 0.86, 95% CI 0.63 to 1.19; 13 trials; moderate certainty evidence) up to 12 months' follow-up. We are uncertain about the effects of exercise-based CR on cardiovascular hospitalisation, with a wide confidence interval including considerable benefit as well as harm (RR 0.80, 95% CI 0.41 to 1.59; low certainty evidence). There was evidence of substantial heterogeneity across trials for cardiovascular hospitalisations (I2 = 53%), and of small study bias for all-cause hospitalisation, but not for all other outcomes. At medium-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.90, 95% CI 0.80 to 1.02; 15 trials), MI (RR 1.07, 95% CI 0.91 to 1.27; 12 trials), PCI (RR 0.96, 95% CI 0.69 to 1.35; 6 trials), CABG (RR 0.97, 95% CI 0.77 to 1.23; 9 trials), and all-cause hospitalisation (RR 0.92, 95% CI 0.82 to 1.03; 9 trials), a large reduction in cardiovascular mortality was found (RR 0.77, 95% CI 0.63 to 0.93; 5 trials). Evidence is uncertain for difference in risk of cardiovascular hospitalisation (RR 0.92, 95% CI 0.76 to 1.12; 3 trials). At long-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.91, 95% CI 0.75 to 1.10), exercise-based CR may result in a large reduction in cardiovascular mortality (RR 0.58, 95% CI 0.43 to 0.78; 8 trials) and MI (RR 0.67, 95% CI 0.50 to 0.90; 10 trials). Evidence is uncertain for CABG (RR 0.66, 95% CI 0.34 to 1.27; 4 trials), and PCI (RR 0.76, 95% CI 0.48 to 1.20; 3 trials). Meta-regression showed benefits in outcomes were independent of CHD case mix, type of CR, exercise dose, follow-up length, publication year, CR setting, study location, sample size or risk of bias. There was evidence that exercise-based CR may slightly increase HRQoL across several subscales (SF-36 mental component, physical functioning, physical performance, general health, vitality, social functioning and mental health scores) up to 12 months' follow-up; however, these may not be clinically important differences. The eight trial-based economic evaluation studies showed exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years (QALYs).
AUTHORS' CONCLUSIONS: This updated Cochrane Review supports the conclusions of the previous version, that exercise-based CR provides important benefits to people with CHD, including reduced risk of MI, a likely small reduction in all-cause mortality, and a large reduction in all-cause hospitalisation, along with associated healthcare costs, and improved HRQoL up to 12 months' follow-up. Over longer-term follow-up, benefits may include reductions in cardiovascular mortality and MI. In the last decade, trials were more likely to include females, and be undertaken in LMICs, increasing the generalisability of findings. Well-designed, adequately-reported RCTs of CR in people with CHD more representative of usual clinical practice are still needed. Trials should explicitly report clinical outcomes, including mortality and hospital admissions, and include validated HRQoL outcome measures, especially over longer-term follow-up, and assess costs and cost-effectiveness.
OBJECTIVE: To summarise the available scientific evidence on the health effects of exposure to working beyond the limit number of hours established by the European Working Time Directive (EWTD) on physicians.
DESIGN: A systematic literature search was conducted in PubMed and EMBASE. Study selection, quality appraisal and data extraction were carried out by independent pairs of researchers using pre-established criteria.
SETTING: Physicians of any medical, surgical or community specialty, working in any possible setting (hospitals, primary healthcare, etc), as well as trainees, residents, junior house officers or postgraduate interns, were included.
PARTICIPANTS: The total number of participants was 14 338.
PRIMARY AND SECONDARY OUTCOME MEASURES: Health effects classified under the International Classification of Diseases (ICD-10).
RESULTS: Over 3000 citations and 110 full articles were reviewed. From these, 11 studies of high or intermediate quality carried out in North America, Europe and Japan met the inclusion criteria. Six studies included medical residents, junior doctors or house officers and the five others included medical specialists or consultants, medical, dental, and general practitioners and hospital physicians. Evidence of an association was found between percutaneous injuries and road traffic accidents with extended long working hours (LWH)/days or very LWH/weeks. The evidence was insufficient for mood disorders and general health. No studies on other health outcomes were identified.
CONCLUSIONS: LWH could increase the risk of percutaneous injuries and road traffic accidents, and possibly other incidents at work through the same pathway. While associations are clear, the existing evidence does not allow for an established causal or 'dose-response' relationship between LWH and incidents at work, or for a threshold number of extended hours above which there is a significantly higher risk and the hours physicians could work and remain safe and healthy. Policymakers should consider safety issues when working on relaxing EWTD for doctors.
OBJECTIEVEN VAN DE STUDIE: Het Institute of Medicine (IOM) heeft opgeroepen tot de opheffing van de aldaar gevestigde werk verschuivingen van meer dan 16 uur zonder slaap. We zochten uitgebreid kunnen de effecten van de voorkoming of vermindering van verschuivingen in de 16 uur.
ONTWERP EN UITKOMSTMATEN: We voerden een systematische review van gepubliceerde en ongepubliceerde studies (1950-2008) aan gegevens over alle interventiestudies die zijn verminderd of weggenomen inwoners van de VS 'extended verschuivingen te synthetiseren. Een totaal van 2.984 citaten werden aanvankelijk geïdentificeerd, die onafhankelijk werden beoordeeld door twee auteurs aan in aanmerking komen, vast te stellen voor opname. Alle resultaten die relevant zijn voor de kwaliteit van leven, onderwijs en veiligheid werden verzameld. Onderzoek kwaliteit werd beoordeeld met behulp van de US Preventive Services Task Force methode.
MATEN EN RESULTATEN: Twenty-drie studies ontmoette inclusie-criteria (kappa = 0,88 [95% CI, 0.77-0.94] voor opname beslissingen). Na vermindering of afschaffing van lange diensten, 8 van de 8 studies meten inwoner kwaliteit van het leven gevonden verbeteringen. Vier van de 14 studies dat de onderzochte onderwijsresultaten gevonden verbeteringen, 9 vonden geen significante veranderingen, en een gevonden onderwijs verslechterd. Zeven van de 11 geïdentificeerde statistisch significante verbeteringen in de veiligheid van patiënten of de kwaliteit van de zorg, geen studies blijkt dat de veiligheid of de kwaliteit van de zorg verslechterd.
CONCLUSIES: In een systematische review, vonden we dat vermindering of afschaffing van de aldaar gevestigde werk verschuift van meer dan 16 uur geen negatieve gevolgen hadden geen invloed op intern onderwijs, en werd in verband gebracht met verbeteringen in de veiligheid van de patiënt en de bewoner de kwaliteit van het leven in de meeste studies. Verder multi-center studies zijn nodig om deze bevindingen te staven, en definitief het meten van de effecten van het elimineren van lange diensten op de resultaten bij patiënten.
DOELSTELLINGEN: Deze studie had als doel de huidige kennis bekijken op burn-out in de medische inwoners, met inbegrip van meldingen prevalentie, en vastgesteld aan welke risico's en de weerstand factoren dragen bij aan of voorkomen van burn-out in de medische bewoners.
Methode: Wij hebben een uitgebreide zoektocht van de literatuur gepubliceerd tussen 1975 en 2005 met behulp van de Medline, EMBASE (vanaf 1989) en PsychINFO databases.
RESULTATEN: Een totaal van 19 studies voldeden aan onze inclusiecriteria. Slechts 5 studies verschenen aan meer dan 2 van de Cochrane kwaliteitscriteria voldoen. De verschillende studies rapporteren de meest uiteenlopende burn-out percentage bij medische bewoners, variërend van 18% naar 82%. Voorspellers van burn-out kan worden gekarakteriseerd als een beroeps-of individu. Inconsistente resultaten werden gemeld ten aanzien van de effecten van een aantal van deze factoren op de burn-out. Vier van de 16 arbeidsrisico's bleek sterk gerelateerd te zijn aan burn-out. De 11 individuele risicofactoren onderzocht waren slechts zwak of matig in verband met burn-out.
CONCLUSIES: Onderzoek naar burnout bij medische bewoners is schaars. De zwakke kwaliteit van de studies, de grote verscheidenheid en een beperkte voorspellende kracht van de voorspellende variabelen opgenomen en de inconsistente bevindingen illustreren de noodzaak van een meer systematische ontwerp met betrekking tot toekomstig onderzoek onder medische bewoners. Een toekomstig onderzoek het model moet rekening houden met het individu, beroeps-en opleiding eisen ervaren door medische bewoners.
DOEL: De klinische prestaties van artsen zijn gekomen onder de loep genomen als het publiek meer aandacht wordt besteed aan de kwaliteit van de gezondheidszorg. Echter, de determinanten van de arts, de prestaties niet goed opgehelderd. De auteurs getracht een theoretisch model van de arts, de prestaties te ontwikkelen, en verkende de literatuur over factoren die van invloed inwoner prestaties.
METHODE: Het gebruik van expert consensus panel, in 2002-03 de auteurs ontwikkelde een hypothese-genererende model van de ingezeten prestaties. Het ontwikkelde model had drie inputfactoren (individuele inwoner factoren, gezondheidszorg infrastructuur en medisch onderwijs infrastructuur), tussen-proces maatregelen (kennis, vaardigheden, attitudes, gewoonten), en de uiteindelijke gevolgen voor de gezondheid (bij de patiënt, de gemeenschap en de bevolking). De auteurs gebruikten factoren uit het model naar een PubMed search (1967-2002) voor alle originele artikelen met betrekking tot de factoren van de individuele inwoner prestaties te focussen.
RESULTATEN: De auteurs vonden 52 originele studies die factoren van de prestaties van een individuele bewoner onderzocht. Ze beschrijven elk onderzoek van meetinstrument, onderzoeksopzet, de belangrijkste bevindingen en beperkingen. Studies werden ingedeeld in vijf domeinen: leerstijlen / persoonlijkheid, sociale / financiële factoren, de praktijk voorkeuren, persoonlijke gezondheid, en de reactie op job-omgeving. Er zijn maar weinig studies onderzocht tussen-of eindproduct prestaties resultaten. De meesten waren single-instelling, cross-sectionele, en controle op basis van studies.
CONCLUSIES: Een poging om inwoner prestaties te begrijpen zonder inzicht in factoren die van invloed zijn prestaties is analoog aan de behandeling van de patiënt vasthouden aan medicatie regimes zonder begrip van de individuele patiënt en zijn omgeving. Op basis van een systematische review van de literatuur, vonden de auteurs enkele discrete relaties tussen de factoren van de individuele bewoner en de bewoner de werkelijke prestaties op het werk. Daarnaast maken zij identificeren en te bespreken grote hiaten in het opleidingsniveau literatuur.
Intense werk eisen, beperkte controle, en een hoge mate van werk-thuis interferentie in overvloed in residentie opleidingsprogramma's en moeten sterk inwoner artsen om burn-out zoals zij dat doen andere beroepsbeoefenaren in de gezondheidszorg vatbaar. Dit artikel studies in de medische literatuur dat het adres van het niveau van burn-out en de bijbehorende persoonlijke en zakelijke factoren, gezondheid en problemen met de prestaties en middelen en interventies op bij bewoners. MEDLINE en PubMed databanken werden doorzocht voor peer-reviewed, Engels-talige studies rapporteren primaire gegevens over burn-out of de afmetingen van burn-out onder bewoners, gepubliceerd tussen 1983 en 2004, met behulp van combinaties van de Medical Subject rubriek termen burn-out, professioneel, emotionele uitputting, cynisme, depersonalisatie en stage en verblijf, housestaff, intern, verblijfplaats heeft, of artsen in opleiding en door het onderzoeken van referentielijsten van gevonden artikelen naar relevante studies. In totaal zijn 15 heterogene artikels op inwoner burn-out werden aldus geïdentificeerd. De studies wijzen erop dat burn-out hoog zijn onder de bewoners en kan gepaard gaan met depressie en problematisch patiëntenzorg. Echter, op dit moment onvoldoende gegevens beschikbaar zijn om causale verbanden te identificeren en geen ondersteuning voor gebruik van demografische of persoonskenmerken aan risicogroepen bewoners te identificeren. Bovendien is de heterogene aard en beperkingen van de beschikbare studies, evenals het belang van betrouwbare gegevens te begrijpen en te voorkomen inwoner burn-out, grote gegeven, zijn prospectieve studies nodig zijn.
Coronary heart disease (CHD) is the most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people living with CHD may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane Review previously published in 2016.
OBJECTIVES:
To assess the clinical effectiveness and cost-effectiveness of exercise-based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with 'no exercise' control, on mortality, morbidity and health-related quality of life (HRQoL) in people with CHD.
SEARCH METHODS:
We updated searches from the previous Cochrane Review, by searching CENTRAL, MEDLINE, Embase, and two other databases in September 2020. We also searched two clinical trials registers in June 2021.
SELECTION CRITERIA:
We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months' follow-up, compared with 'no exercise' control. The study population comprised adult men and women who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or have angina pectoris, or coronary artery disease.
DATA COLLECTION AND ANALYSIS:
We screened all identified references, extracted data and assessed risk of bias according to Cochrane methods. We stratified meta-analysis by duration of follow-up: short-term (6 to 12 months); medium-term (> 12 to 36 months); and long-term ( > 3 years), and used meta-regression to explore potential treatment effect modifiers. We used GRADE for primary outcomes at 6 to 12 months (the most common follow-up time point).
MAIN RESULTS:
This review included 85 trials which randomised 23,430 people with CHD. This latest update identified 22 new trials (7795 participants). The population included predominantly post-MI and post-revascularisation patients, with a mean age ranging from 47 to 77 years. In the last decade, the median percentage of women with CHD has increased from 11% to 17%, but females still account for a similarly small percentage of participants recruited overall ( < 15%). Twenty-one of the included trials were performed in low- and middle-income countries (LMICs). Overall trial reporting was poor, although there was evidence of an improvement in quality over the last decade. The median longest follow-up time was 12 months (range 6 months to 19 years). At short-term follow-up (6 to 12 months), exercise-based CR likely results in a slight reduction in all-cause mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.73 to 1.04; 25 trials; moderate certainty evidence), a large reduction in MI (RR 0.72, 95% CI 0.55 to 0.93; 22 trials; number needed to treat for an additional beneficial outcome (NNTB) 75, 95% CI 47 to 298; high certainty evidence), and a large reduction in all-cause hospitalisation (RR 0.58, 95% CI 0.43 to 0.77; 14 trials; NNTB 12, 95% CI 9 to 21; moderate certainty evidence). Exercise-based CR likely results in little to no difference in risk of cardiovascular mortality (RR 0.88, 95% CI 0.68 to 1.14; 15 trials; moderate certainty evidence), CABG (RR 0.99, 95% CI 0.78 to 1.27; 20 trials; high certainty evidence), and PCI (RR 0.86, 95% CI 0.63 to 1.19; 13 trials; moderate certainty evidence) up to 12 months' follow-up. We are uncertain about the effects of exercise-based CR on cardiovascular hospitalisation, with a wide confidence interval including considerable benefit as well as harm (RR 0.80, 95% CI 0.41 to 1.59; low certainty evidence). There was evidence of substantial heterogeneity across trials for cardiovascular hospitalisations (I2 = 53%), and of small study bias for all-cause hospitalisation, but not for all other outcomes. At medium-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.90, 95% CI 0.80 to 1.02; 15 trials), MI (RR 1.07, 95% CI 0.91 to 1.27; 12 trials), PCI (RR 0.96, 95% CI 0.69 to 1.35; 6 trials), CABG (RR 0.97, 95% CI 0.77 to 1.23; 9 trials), and all-cause hospitalisation (RR 0.92, 95% CI 0.82 to 1.03; 9 trials), a large reduction in cardiovascular mortality was found (RR 0.77, 95% CI 0.63 to 0.93; 5 trials). Evidence is uncertain for difference in risk of cardiovascular hospitalisation (RR 0.92, 95% CI 0.76 to 1.12; 3 trials). At long-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.91, 95% CI 0.75 to 1.10), exercise-based CR may result in a large reduction in cardiovascular mortality (RR 0.58, 95% CI 0.43 to 0.78; 8 trials) and MI (RR 0.67, 95% CI 0.50 to 0.90; 10 trials). Evidence is uncertain for CABG (RR 0.66, 95% CI 0.34 to 1.27; 4 trials), and PCI (RR 0.76, 95% CI 0.48 to 1.20; 3 trials). Meta-regression showed benefits in outcomes were independent of CHD case mix, type of CR, exercise dose, follow-up length, publication year, CR setting, study location, sample size or risk of bias. There was evidence that exercise-based CR may slightly increase HRQoL across several subscales (SF-36 mental component, physical functioning, physical performance, general health, vitality, social functioning and mental health scores) up to 12 months' follow-up; however, these may not be clinically important differences. The eight trial-based economic evaluation studies showed exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years (QALYs).
AUTHORS' CONCLUSIONS:
This updated Cochrane Review supports the conclusions of the previous version, that exercise-based CR provides important benefits to people with CHD, including reduced risk of MI, a likely small reduction in all-cause mortality, and a large reduction in all-cause hospitalisation, along with associated healthcare costs, and improved HRQoL up to 12 months' follow-up. Over longer-term follow-up, benefits may include reductions in cardiovascular mortality and MI. In the last decade, trials were more likely to include females, and be undertaken in LMICs, increasing the generalisability of findings. Well-designed, adequately-reported RCTs of CR in people with CHD more representative of usual clinical practice are still needed. Trials should explicitly report clinical outcomes, including mortality and hospital admissions, and include validated HRQoL outcome measures, especially over longer-term follow-up, and assess costs and cost-effectiveness.
