Comparing Cardiac Rehabilitation at Home or in a Clinic after Hospitalization

This project has results

Results Summary and Professional Abstract

Results Summary

What was the research about?

Doctors often recommend cardiac rehabilitation, or CR, for patients who have been in the hospital for heart problems, such as a heart attack. CR programs include exercise, changes in diet, and avoiding behaviors like smoking. CR can help prevent future heart problems.

CR programs usually take place in clinics. But patients may find it hard to go to the clinic for CR two or three times a week. Having CR at home may be easier.

In this study, the research team compared two types of CR programs:

Home CR. Patients exercised at home and checked their blood pressure and heart rate. A clinic staff member called once a week to check patients’ health, provide coaching, and give information about diet and exercise.
Facility CR. Patients visited a clinic two or three times a week to exercise under a staff member’s supervision. They also received information on diet and exercise.

The research team looked at how the two CR programs affected the distance patients could walk in a short time. Walking tests are a way to measure heart health.

What were the results?

After three months, compared with patients in facility CR, patients in home CR could walk further in six minutes. They also had more improvement than patients in facility CR in quality of life, physical activity, and symptoms of anxiety.

But patients in facility CR felt more confident in their ability to exercise and had more improvement in their memory and reasoning than patients in home CR.

After six months, each group had similar improvement in walking distance.

Who was in the study?

The study included 235 patients who received care for heart problems at one of three Veterans Affairs, or VA, medical centers. The average age was 65, and 99 percent were men. Of those in home-based CR, 78 percent were white, 11 percent were black, and 9 percent were Hispanic. Of those in facility-based CR, 77 percent were white, 19 percent were black, and 2 percent were Hispanic.

What did the research team do?

Patients receiving care at the San Francisco VA received home CR. Patients receiving care at the Pittsburgh and Ann Arbor VAs received facility CR. After three and six months, medical center staff tested patients to see how far they could walk in six minutes. Patients also filled out surveys about their health at three months.

Patients, patient advocates, healthcare providers, policy makers, and community members gave input on the study.

What were the limits of the study?

Doctors at the three VAs used different ways to refer patients for CR. This difference could have affected whether patients joined the study. At six months, 72 percent of patients in home CR and 39 percent of patients in facility CR left the study. Results may have differed if more patients had stayed in the study.

Future research could study patients’ health over the long term after CR.

How can people use the results?

Medical centers can use these results when considering what kind of CR to offer patients with heart problems.

Professional Abstract

Objective

To compare the effectiveness of home-based cardiac rehabilitation (CR) and facility-based CR on increasing patients’ timed walking distance

Study Design

Design Elements	Description
Design	Quasi-experimental
Population	235 adult patients recently hospitalized at three VA medical centers for myocardial infarction, coronary bypass surgery, or percutaneous revascularization
Interventions/ Comparators	Home-based CR program Facility-based CR program
Outcomes	Primary: distance in 6-minute walk test Secondary: physical activity and function, health-related quality of life, self-efficacy, depression, anxiety, cognitive function
Timeframe	6-month follow-up for primary outcome

This natural experiment compared the effectiveness of home-based versus facility-based CR on increasing timed walking distance in patients with ischemic heart disease.

The research team enrolled patients who were referred to CR from three Veterans Affairs (VA) medical centers. At all three sites, CR included exercise guidance, guidance on medication, and education regarding cardiac risk factors. For patients receiving care at the San Francisco VA, the referral was for 12 weeks of home-based CR. In home-based CR, patients exercised using equipment delivered to their homes and learned to use other equipment to monitor their heart rate, blood pressure, weight, and blood sugar. In weekly calls with individual patients, clinical staff provided education on medication, diet, and lifestyle changes; answered questions; and monitored physical activity.

Patients at the Pittsburgh VA and the Ann Arbor VA received referrals for facility-based CR three times per week for 12 weeks and 6 weeks, respectively. At each session, these patients received health education and exercised under staff supervision.

The study included 235 adults recently hospitalized for myocardial infarction, coronary bypass surgery, or percutaneous revascularization. The average age was 65, and 99% were male. Of those in the home-based-CR program, 78% were white, 11% were black, and 9% were Hispanic. Of those in the facility-based CR program, 77% were white, 19% were black, and 2% were Hispanic.

At baseline and three and six months later, the research team used the six-minute walk test to assess improvement in cardiac function in all participants. Patients completed surveys about cardiac and exercise self-efficacy, quality of life, functional status, depression, anxiety, cognitive function, and diet. At the completion of CR, the team followed a subset of patients for an additional three months to assess change in walking ability and other patient-reported outcomes.

Patients, patient advocates, clinicians, policy makers, and community members gave input on the study protocol.

Results

Compared with facility-based CR, home-based CR was associated with greater improvement in walking ability at three-month follow-up (324 feet versus 128 feet, p<0.001). At six months, the two groups did not differ significantly. Both continued to have improvement compared with baseline.

At three months, patients in home‐based CR had greater improvement in quality of life (p<0.001), physical activity (p=0.03), and anxiety symptoms (p=0.01) than patients in facility-based CR. Facility‐based CR participants had greater improvement in exercise self‐efficacy (p=0.03) and cognitive function (p=0.05) than patients in home‐based CR.

Limitations

The CR referral process differed across sites, which could have influenced patients’ decisions to participate in the study and introduced selection bias. At six months, 72% of patients in home-based CR and 39% in facility-based CR had been lost to follow-up, which may have affected the research team’s ability to detect a statistical difference in walking ability at six months.

Conclusions and Relevance

In this study, home-based CR and facility-based CR resulted in similar improvements in patients’ walking ability. Home-based CR may be considered as an alternative to facility-based CR, especially for patients who live far away from a facility.

Future Research Needs

Future research could further investigate six-month and longer outcomes for patients in home-based and facility-based CR.

Journal Articles

Circulation

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

Journal of Cardiopulmonary Rehabilitation and Prevention

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

Journal of the American College of Cardiology

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

Circulation

Geographic Variation in Cardiac Rehabilitation Participation in Medicare and Veterans Affairs Populations: Opportunity for Improvement

Journal of the American College of Cardiology

Limitations of Treating Heart Rate as the Primary Outcome Determinant in Older Adults

Circulation. Cardiovascular Interventions

Gait Speed Assessment in Transcatheter Aortic Valve Replacement: A Step in the Right Direction

Federal Practitioner

The design and implementation of a home-based cardiac rehabilitation program

Journal of Cardiac Failure

Participation in Cardiac Rehabilitation Among Patients With Heart Failure

Mayo Clinic Proceedings

Decisive Bearing of Organizational Dynamics on the Application and Success of Hospital-Based Cardiac Rehabilitation

Journal of Cardiopulmonary Rehabilitation and Prevention

Factors Associated With Utilization of Cardiac Rehabilitation Among Patients With Ischemic Heart Disease in the Veterans Health Administration: A QUALITATIVE STUDY

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.

Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:

Reviewers commented on the presence of multiple differences among the three study sites that could have affected study outcomes, differences that went beyond the fact that one site offered home-based rehabilitation services and the two other sites offered facility-based rehabilitation services. The researchers added Table 1 to clarify the differences across the intervention sites and explained the reasons for some of the differences.
Among the differences across sites, reviewers noted differences in the average time between clinical events and the initiation of rehabilitation services, suggesting that the analyses control for these differences. The researchers clarified that the shorter time between the clinical event and rehab initiation is an important outcome of the study rather than a difference in the interventions. They also added a multivariable model, (Table 9, Model 3) that did control for number of days to enrollment.
Reviewers noted that patients dropping out of the study undermined the value of the longest follow-up interval, 6 months. The researchers acknowledged that this was a limitation of the study despite their best efforts to retain participants. However, the researchers also noted that since there were no differences in baseline characteristics between the participants who were and were not lost to follow up at 6 months, there was no reason to believe that patients who dropped out were either sicker or more functionally impaired than those who remained in the study.

Conflict of Interest Disclosures

The Conflict of Interest Disclosures for this project will be posted here soon.

Project Details

Principal Investigator

Mary Whooley, MD

Project Status

Completed; PCORI Public and Professional Abstracts Posted

Project Title

Improving Delivery of Patient-Centered Cardiac Rehabilitation

Board Approval Date

September 2013

Project End Date

April 2019

Organization

University of California San Francisco

Year Awarded

2013

State

California

Year Completed

2019

Project Type

Research Project

Health Conditions

Cardiovascular Diseases

Coronary or Ischemic Heart Disease

Intervention Strategies

Behavioral Interventions
Other Clinical Interventions
Incentives for Behavior Change
Training and Education Interventions

Populations

Individuals with Multiple Chronic/co-morbid Conditions
Low Income
Racial/Ethnic Minorities
Rural
Veterans

Funding Announcement

Improving Healthcare Systems

Project Budget

$1,932,960

Study Registration Information

HSRP20143559

NCT02105246

Page Last Updated:

September 2, 2019