Many patients feel nervous about transitioning from hospital to home after being hospitalized for a myocardial infarction (heart attack), percutaneous coronary intervention (stent placement), or coronary artery bypass surgery. This period immediately after hospital discharge, when patients feel particularly vulnerable and highly motivated to make lifestyle changes, represents a huge opportunity to improve health. Teaching patients new habits for keeping active and eating healthy foods during the weeks following a myocardial infarction, stent placement, or bypass surgery can have a formative impression that results in lifelong changes. Exercise-based cardiac rehabilitation (CR) programs decrease mortality and improve quality of life after hospitalization for coronary heart disease by providing individually tailored exercise training, education, risk factor management, and psychosocial support. However, CR programs are vastly underutilized, with less than a third of eligible patients participating in the United States. The largest barrier to patient participation is that CR must be provided in a physician’s office or hospital setting to qualify for reimbursement. Virtually all existing CR programs require that the patient travel to a CR center three times per week for 12 to 36 weeks. Most patients live too far from a CR center to enroll, and even when nearby programs are available, few patients have the time, flexibility, transportation, social support, and/or financial resources to attend.
A recent Presidential Advisory from the American Heart Association concluded, “The remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehabilitation and clinical implementation is unacceptable.” One promising solution to the problem of CR under-utilization is greater implementation of home-based CR programs. Both home- and center-based CR programs have equal benefits on cardiovascular risk factors, mortality, and quality of life. However, similar efficacy does not necessarily translate into similar effectiveness. If patients are more likely to participate in home- versus center-based therapy, then greater participation could lead to greater effectiveness. We are therefore proposing to compare the clinical effectiveness of home- versus center-based CR following hospitalization for myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery.
We hypothesize that referral to home-based CR will have greater effectiveness than center-based CR as measured by
- greater participation;
- similar patient-centered outcomes; and
- similar cost.
Our ultimate goal is to demonstrate that administering a 12-week home CR program will cost less than (and prevent at least) one day of re-hospitalization per patient.
In Care Transitions, a Chance to Make or Break Patients' Recovery - A narrative on what happens when patients are harmed by poorly executed transitions between healthcare settings.