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Evaluating Home-based Cardiac Rehabilitation Programs

Cardiac rehabilitation (CR) is an evidence-based, cost-effective intervention that uses exercise training and behavioral activation (i.e., healthy eating, medication adherence, smoking cessation, and stress management) to reduce morbidity and mortality in patients with cardiovascular disease. Current society guidelines and national performance measures state that all patients hospitalized for myocardial infarction or coronary revascularization should be referred to an outpatient CR program prior to hospital discharge.¹ However, despite its compelling benefits and evidence-based benefits on morbidity and mortality, CR is vastly under-utilized in the United States. Only 16% of eligible Medicare patients and 10% of eligible Veterans receive CR.^2,3 In a national qualitative study, QUERI investigators found that the largest barrier to patient participation is distance: more than 75% of Veterans live too far from a cardiac rehabilitation facility to enroll.⁴

To address this quality gap, VA’s Office of Rural Health (ORH) has supported the development and implementation of home-based CR programs at selected VA facilities. These programs are modeled on traditional facility-based CR programs but use telehealth, video technologies, and home exercise equipment (instead of facility-based supervised exercise sessions) to promote secondary prevention. At the San Francisco VA Health Care System, implementing bedside education plus referral to a home-based CR program was associated with an increase in CR participation from <5% to >40% of eligible patients within two years.⁵

Findings

In collaboration with Dr. Richard Schofield, National Program Director for Cardiology in the Office of Specialty Care, Patient Care Services (PCS), investigators from the Measurement Science QUERI have evaluated the implementation of home-based CR programs across the VA healthcare system. Between 2010 and 2015, the number of facilities offering home-based CR increased from 1 to 12, and participation rates at these facilities increased from 6% to 25% of eligible patients (see Figure). In 2015, eligible patients at VA facilities that had implemented new home-based programs were four times more likely to participate in CR than those at facilities offering (only) referral to traditional (community care) CR programs.⁶

From Schopfer et al, JAMA Internal Medicine, 2018.

Impact

Home-based CR programs are now spreading to other VA facilities and beyond. In connection with this work, QUERI researchers have been invited to coauthor a new American Heart Association scientific statement on home-based CR, and were asked to participate in the design of metrics for tracking national participation in CR programs as part of the CMS/CDC Million Hearts initiative. The goal of these efforts is to facilitate the impact and sustainability of home-based CR on a national scale. QUERI investigators also are evaluating new patient and provider-facing mobile applications⁷ to accelerate the scale-up and spread of this evidence-based intervention.

For more information about Measurement Science QUERI, please contact Mary Whooley, MD, at Mary.Whooley@va.gov .

References

1. Writing Committee Members, Thomas R, Balady G, et al. 2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Journal of the American College of Cardiology. March 19, 2018; Epub ahead of print.
2. Suaya J, Shepard D, Normand S, et al. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2007;116(15):1653-1662.
3. Beatty A, Truong M, Schopfer D, et al. Geographic Variation in Cardiac Rehabilitation Participation in Medicare and Veterans Affairs populations: An opportunity for improvement? Circulation. January 5, 2018; Epub ahead of print.
4. Schopfer D, Priano S, Allsup K, et al. Factors associated with utilization of cardiac rehabilitation among patients with ischemic heart disease in the Veterans Health Administration: A qualitative study. Journal of Cardiopulmonary Rehabilitation and Prevention. 2016; 36(3):167-173.
5. Rohrbach G, Schopfer D, Krishnamurthi N, et al. The design and implementation of a home-based cardiac rehabilitation program. Federal Practitioner. 2017;34:30-35.
6. Schopfer D, Krishnamurthi N, Shen H, et al. Association of Veterans Health Administration home-based programs with access to and participation in cardiac rehabilitation. JAMA Internal Medicine. January 22, 2018; Epub ahead of print.
7. Beatty A, Magnusson S, Fortney J,  et al. VA FitHeart, a mobile app for cardiac rehabilitation: Usability study. JMIR Human Factors.January 15,2018;15:5(1).