Participating in home cardiac rehabilitation after a heart attack or heart surgery was associated with a 36 percent lower chance of dying from heart-related complications among U.S. military veterans within four years compared to those who dropped out, according to new research. rehabilitation programs. is published today at Journal of the American Heart Associationan open-access, peer-reviewed journal of the American Heart Association.
Although cardiac rehabilitation has been shown to reduce the risks of hospital readmissions and death, it is significantly underused, according to the American Heart Association. Cardiac rehabilitation emphasizes eliminating tobacco use, improving diet, exercising, managing stress, and taking medications that treat high blood pressure or high cholesterol.
“Whether in the hospital or at home, cardiac rehabilitation is all about healthy behavior changes,” said senior study author Mary A. Whooley, MD, a primary care physician at the San Francisco Veterans Affairs Medical Center and professor of medicine at the University of California, San Francisco. “However, behavior change is difficult, and while care facilities may offer on-site cardiac rehabilitation, many patients do not choose to benefit from follow-up therapy. The biggest surprise of our analysis was how few patients chose to participate in cardiac Rehabilitation.”
Although cost may be a barrier to participation in cardiac rehabilitation, along with geography and logistics, cost should not be a factor as health care services were covered by the VA in this study.
“We don’t know why so many patients chose to drop out of rehabilitation,” Whooley said. “Even when home cardiac rehabilitation was offered at a time and place of their choosing, only 44% of eligible patients chose to participate. Many patients simply weren’t interested in changing their behavior.”
The data showed that among patients hospitalized for a heart attack from 2007-2011, only 16% of Medicare patients and 10% of veterans participated in cardiac rehabilitation. Among eligible Medicare beneficiaries in 2016, only 24% chose to participate in on-site/facility-based cardiac rehabilitation. According to the Million Hearts® Cardiac Rehabilitation Collaborative, a national initiative co-sponsored by the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services, it is estimated that increasing participation in cardiac rehabilitation to 70% of cardiac patients after hospitalization will could save 25,000 lives and prevent 180,000 additional hospitalizations each year.
“Several randomized trials have shown similar mortality benefits from home and facility-based cardiac rehabilitation,” Whooley said.
According to the study authors, this is the first study in the US to provide evidence of a survival benefit with home cardiac rehabilitation in people with heart disease. The ongoing COVID-19 pandemic, which has temporarily shut down countless in-facility rehabilitation programs, suggests a growing need to explore opportunities in telehealth care for people with heart disease, they said.
This study analyzed data on 1,120 veterans who were eligible for cardiac rehabilitation at the San Francisco VA Medical Center between August 2013 and December 2018. Among this study group, 98% were male, 2% were female, 76% were white , 88% were non-Hispanic and 68% lived in an urban area. About half had been hospitalized for percutaneous coronary intervention — also known as angioplasty, 20% for a coronary artery bypass graft, 14% for a heart attack and 18% for other reasons. Enrollment in San Francisco’s Healthy Heart home cardiac rehabilitation program was voluntary, and only 44% (490 subjects) enrolled.
The home-based cardiac rehabilitation program lasted 12 weeks, during which participants received up to nine coaching calls, motivational interviews, a workbook, and a personal health diary to document vital signs, exercise, and diet. They also received a blood pressure monitor, scales and (if desired) a stationary bike. A nurse or exercise physiologist worked one-on-one with participants to create achievable physical activity goals. Participants received follow-up phone calls from program staff three and six months after completion of the program and were followed up an average of 4.2 years after hospitalization.
Among the researchers’ findings:
- The one-year mortality rate after hospitalization was 4% among those who did not participate in cardiac rehabilitation versus 2% among those who participated in home cardiac rehabilitation.
- Overall, those who participated in the cardiac rehabilitation program were associated with a 36% reduction in the odds of dying from complications compared to those who did not.
- Deaths during the entire follow-up period occurred in 12% of rehabilitation participants versus 20% of nonparticipants.
The researchers note that scientists do not yet know the optimal number of home cardiac rehabilitation sessions needed to achieve lasting success for people with heart disease, and this requires further research. Additionally, compared to traditional facility-based programs, the researchers believe that home-based cardiac rehabilitation may lead to more lasting behavioral changes that improve outcomes because incorporating healthy behaviors into a participant’s routine from the start has been associated with better compliance rates.
Although there is no standardized approach to providing home cardiac rehabilitation, it is generally shorter than on-site care, and “as technology expands, behavior modification in participants’ home environments may help make cardiac rehabilitation more accessible and change lifestyles more sustainably,” Whooley said.
Another advantage of home cardiac rehabilitation is that, because capacity is not limited by the availability of facility-based programs, it has shorter wait times to start treatment (average of 25 days versus 77 days after a heart attack).
“Our biggest challenge in the US is that home cardiac rehabilitation is not covered by many health insurers,” he said. “Currently, Medicare only pays for on-site cardiac rehabilitation or facility-based cardiac rehabilitation.”
The American Heart Association supports legislation from Congress, such as the bipartisan Increasing Access to Quality Cardiac Rehabilitation Care Act, which calls for expanding cardiac rehabilitation resources.
Randal J. Thomas, MD, chair of the 2019 American Heart Association/American College of Cardiology Joint Statement on the Effectiveness of Home Cardiac Rehabilitation called this study a “unique, landmark report.”
“This study shows that home cardiac rehabilitation is associated with a lower mortality rate compared to people who do not receive cardiac rehabilitation,” said Thomas, who is a professor of medicine at the Mayo Clinic Alix School of Medicine that collaborates with the Mayo Clinic Cardiac . Rehabilitation program in Rochester, Minnesota. “Previous studies of home cardiac rehabilitation have not been designed to address this significant benefit. Additional studies are needed, but this study strongly suggests a mortality benefit from home cardiac rehabilitation.
“Although the study did not determine whether home cardiac rehabilitation affects mortality rates as well or even better than in-center rehabilitation, it does show that home cardiac rehabilitation reduces mortality rates compared to those patients who do not participate in cardiac remodeling.”
The joint statement strongly recommends cardiac rehabilitation in people diagnosed with a heart attack, chest pain, heart failure, or after bypass surgery, percutaneous coronary intervention, heart valve surgery, or a heart transplant. Additionally, an American Heart Association scientific statement notes that home rehabilitation is an effective alternative to cardiac rehabilitation for those unable to participate in an on-site cardiac rehabilitation program.
The study has several limitations, including that there was no comparison with facility-based cardiac rehabilitation. Participants were not randomized. and most were English-speaking, older men. The researchers note that it is unclear whether the benefits of home cardiac rehabilitation would have similar benefits in women or non-English speakers.
The Veterans Health Care Quality Improvement Research and Development Initiative funded the study.
(tagsTo Translate)Heart disease? Stroke Prevention? COPD? Elderly care; Today