Top Things to Know: Home-Based Cardiac Rehabilitation
Published: May 13, 2019
Prepared by By Jay A. Pandit, MD, Clinical Assistant Professor, Feinberg School of Medicine, Northwestern University
- Referral to cardiac rehabilitation (CR) is an American Heart Association/ American College of Cardiology Class IA recommendation in myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft surgery, stable angina, symptomatic peripheral arterial disease, heart valve surgery, cardiac transplantation and chronic heart failure with reduced ejection fraction.
- Despite the well-established benefits of CR, >80% of eligible patients in the U.S. do not participate in center based cardiac rehabilitation (CBCR). Home-based cardiac rehabilitation (HBCR) may be an alternative option to recommend for selected patient to potentially reduce this gap.
- The primary difference between HBCR and CBCR is that CBCR programs require direct face-to-face observation of patients, whereas HBCR programs rely on remote coaching with indirect exercise supervision.
- The purpose of this statement is to identify core components, efficacy, strengths, limitations, evidence gaps and research necessary to guide the future delivery and potential reimbursement of HBCR in the U.S.
- Studies comparing CBCR and HBCR for low- to moderate-risk patients, showed no statistically significant difference in 12-month mortality, improvement in exercise capacity, modifiable risk factors and health related quality of life, however inferences are limited by heterogeneous data quality.
- Although studies of HBCR are underpowered to assess the risk of severe cardiovascular events, particularly in higher risk patients, available evidence suggests that HBCR may provide an alternative option for CR services for stable, low-to-moderate risk patients with CVD who lack available CBCR services. Further research in women, minority groups, the elderly and higher risk population, along with hybrid models of HBCR and CBCR and their impact on clinical outcomes and costs are warranted to truly understand the impact of a standardized HBCR program.
- Potential advantages of HBCR include reduced enrollment delays, expanded capacity/access, individually tailored programs, flexible, convenient scheduling, minimal travel/transportation barriers, greater privacy while receiving CR and integration with regular home routine. Potential disadvantages include lack of reimbursement, less intensive exercise training, lower social support, lower patient accountability, lack of published standards, less face to face monitoring and communication and safety concerns for higher risk populations.
- Patient motivation, self-efficacy and engagement are the most important predictors of healthy long-term lifestyle changes and adherence. Providers serve the critical role of sources for referral, positive reinforcement and proponents of long-term lifestyle changes.
- Endorsement of HBCR and reimbursement at the health system level are critical to the success or failure of an HBCR program and a major barrier to adoption in the U.S.
- In selected, clinically stable, low- to moderate-risk patients who cannot attend a CBCR program, HBCR has the potential to harness the power of technology in remote monitoring to improve CV outcomes and expand the benefits of CR.
Citation
Citation Thomas RJ, Beatty AL, Beckie TM, Brewer LC, Brown TM, Forman DE, Franklin BA, Keteyian SJ, Kitzman DW, Regensteiner JG, Sanderson BK; Whooley MA. Home-based cardiac rehabilitation: a scientific statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology [published online ahead of print May 13, 2019]. Circulation. doi: 10.1161/CIR.0000000000000663.