The Past, Present, and Future of Cardiac Rehabilitation

Cardiac rehabilitation is defined as “the provision of comprehensive long-term services involving medical evaluation; prescriptive exercise; cardiac risk factor modification; and education, counseling, and behavioral interventions.¹

In the 1960s and 1970s, residential rehabilitation in the countryside, typically following a several-month hospitalization for myocardial infarction, was characteristic in many European nations. It included supervised (but not monitored) exercise, patient education, and psychosocial counseling. Concerns included costs, availability, question of subsequent readjustment to society, and variability of return to work.

In the 1970s and 1980s, cardiac rehabilitation in North America involved hospital-based or community-based outpatient rehabilitation, initially begun 4-6 weeks after hospital discharge for myocardial infarction. There was exercise testing for exercise prescription and, typically, electrocardiogram (ECG) monitoring. This engendered the initial clinical practice guidelines.²

During the 21st century, exercise rehabilitation was undertaken for patients previously arbitrarily excluded, such as those with heart failure, arrhythmias, pacemakers, and implanted defibrillators. Exercise training was seen also viewed as antianginal therapy. Cardiac rehabilitation was a Class IA recommendation in most cardiovascular clinical practice guidelines. There was a changing scope of patients, with more elderly and more diverse populations. The emphasis persisted that exercise training did not equate with cardiac rehabilitation, but that rehabilitation involved education and counseling, psychosocial issues, and in some instances return to work as an economic imperative. Performance measures were developed regarding appropriate personnel and equipment (structure-based) and process-based aspects of cardiac rehabilitation designed for a hospital setting, a physician’s office, and a cardiac rehabilitation program setting.3 Nonetheless, only a small percentage of eligible patients participated (14-31% of eligible Medicare beneficiaries and 10% of Veterans), prompting exploration of barriers to participation and potential solutions.

Home-based cardiac rehabilitation was one such solution, with evidence in low- to moderate-risk patients of similar adherence to that of supervised exercise programs, and that working patients preferred medically directed home-based compared with center programs.^4,5

The AHA/AACVPR/ACC Scientific Statement on Home-based Cardiac Rehabilitation addresses the future of cardiac rehabilitation.⁶ The authors have highlighted the documented safety and efficacy of traditionally medically-supervised, center-based cardiac rehabilitation as effective in reducing hospitalizations, secondary events, and mortality in patients with cardiovascular disease. Concomitantly, they have highlighted the low percentage of eligible patients participating in cardiac rehabilitation, particularly those in vulnerable subgroups. Home-based cardiac rehabilitation refers to systematic, multidisciplinary, team-based, patient-centered care external to a traditional medical setting. The manuscript compared published studies of home-based and center-based cardiac rehabilitation based on 23 randomized trials of patients with myocardial infarction, stable angina, heart failure, or coronary revascularization in a systematic review encompassing 2,951 patients. Five of the 23 studies were in the U.S., the others were worldwide. Some involved comprehensive cardiac rehabilitation and others involved an exercise only intervention. All included the 5 core components preciously identified by the AHA and the AACVPR of: patient assessment, exercise training, dietary counseling, risk factor management, and psychosocial intervention.

Most studies were characterized by a walking program and none formally evaluated the effect of supplying exercise equipment. A variety of strategies were involved to improve lifestyle habits and adherence to prescribed medications, and 2 studies offered support group sessions. One addressed the important question as to whether greater self-monitoring-management in home-based rehabilitation may facilitate the transition from the active intervention program to lifelong preventive care. Importantly, the data are very limited for the most vulnerable populations – non-white ethnic minorities, individuals of lower socioeconomic status, uninsured or underinsured individuals, women, and elderly, all significantly underrepresented in the 23 data base studies.

The safety seems reasonable for low- to moderate-risk patients, but the data for more complex patients must be subjected to future scrutiny. No statistically significant mortality differences were reported in any of the studies providing such data, but the shorter term follow up may limit this ascertainment. In one study, rehospitalizations were greater in center-based than in home-based cardiac rehabilitation. Improvement in exercise capacity was comparable in the 2 populations, as was risk factor modification and improvement in overall health-related quality of life. Adherence, in general, seemed comparable in both groups, although several studies suggested a higher level of adherence and completion with home-based cardiac rehabilitation.

Of interest is a recent Veterans Health Administration study⁷ defining that patients offered either option were 4 times more likely to participate in a home-based cardiac rehabilitation program; a Kaiser Permanente Colorado study found that 41% of eligible patients participated in home-based cardiac rehabilitation.

Costs of the intervention are difficult to ascertain, in that many countries with national health insurance systems provide reimbursement, whereas in the U.S. this is extremely rare. It is uncertain whether home-based cardiac rehabilitation will lower costs, but the increased application of technology, limiting the need for specific healthcare personnel, can be anticipated to be cost-saving – a theory that must be validated.

A number of patient-based factors, provider-based factors, and system-based factors have been shown to limit the utilization of cardiac rehabilitation. In this regard, the increased temporal availability of home-based cardiac rehabilitation may be valuable, whereas the effect of lack of face-to-face interactions remains to be ascertained. Obviously, the endorsement and reimbursement at the health system level will be the most influential factors in determining the adoption of home-based cardiac rehabilitation.

Important practical considerations are explored in the manuscript, including the roles and competencies of personnel, the provision of durable medical equipment, and a valuable resource list of patient education materials.

A list of the challenges and potential solutions to home-based cardiac rehabilitation offers a research agenda for the next decade. Whether the improved access of home-based cardiac rehabilitation will truly increase participation and completion remains to be ascertained, as does the safety, particularly for higher risk patients. Further efficacy data and metrics regarding personnel and program details may overcome the challenge of lack of reimbursement by third party payers in the U.S. The convenience and flexibility may enhance participation and adherence, but unknown factors are motivation and interest. Whether access to a health coach, i.e., a hybrid program, is more beneficial remains to be ascertained, as are the challenges of communication, counseling, and education. Social support and group-based dynamics appear important, and the suggested potential of smartphone-based rehabilitation to initiate “chat rooms” for patients may provide a solution, as may the health coach in a hybrid program.

The most important is the standardization and codification of interventions with guidelines and standards specifically for home-based rehabilitation as they have been promulgated for center-based rehabilitation.

Longer term follow up for the impact on clinical cardiovascular events requires ascertainment. Quality metrics suggested by the authors include referral, enrollment, and maintenance; effect on health behaviors; effect on cardiovascular risk factors; functional capacity, quality of life, and anxiety/depressive symptoms; and effect on readmission to hospital, recurrent cardiovascular events, and mortality rates.

The technology-facilitated home-based cardiac rehabilitation has the most exciting potential to expand access to cardiac rehabilitation, promote patient engagement, and enable increased patient/provider communication. Devices to transmit data, text message, and enable other communication, and the potential for social support “chat rooms” appears exciting, although none of the studies compared home-based cardiac rehabilitation with or without the use of technology, which has the potential to improve uptake and adherence.

As previously noted, specific vulnerable populations must be examined as must higher risk populations. Hybrid models of cardiac rehabilitation require study, and staffing and programming needs require standardization, as does the ascertainment of long-term clinical outcomes. In summary, this document is the first step toward expanding the underutilized lifesaving cardiac rehabilitation approach, currently limited by patient, provider, and system-based barriers. The limited trial data reported suggested that the core components of home-based cardiac rehabilitation are similar to those for center-based, as are short-term outcomes, but process and outcome metrics are needed for standards, guidelines, quality metrics, and outcome results, with emphasis on more diverse and higher risk groups of patients.