In a recent study published in the Journal of the American Heart Association, researchers comparatively evaluated death rates among home-based cardiac rehabilitation (HBCR) participants and non-participants.
Study: Association of Home‐Based Cardiac Rehabilitation With Lower Mortality in Patients With Cardiovascular Disease: Results From the Veterans Health Administration Healthy Heart Program. Image Credit: REDPIXEL.PL / Shutterstock
Cardiac disease is a leading cause of hospital admissions among United States (US) veterans, and cardiac rehabilitation programs can improve the quality of life of hospitalized cardiac patients. In case of issues in transportation or accessibility to center-based CR (CBCR) programs, HBCR programs are essential in improving patient survival following hospitalization for cardiovascular diseases.
The American Association of Cardiovascular and Pulmonary Rehabilitation, American Heart Association, and the American College of Cardiology recommended HBCR referrals for cardiac rehabilitation-eligible and low-risk to medium-risk individuals with clinical stability who are not able to access CBCRs. Both CR types have shown similar efficacy against deaths in clinical efficacy trials. However, the impact of HBCR participation on cardiac outcomes in clinical settings is unclear.
About the study
In the present study, researchers evaluated cardiovascular disease-associated deaths among individuals who participated in HBCRs and those who did not.
Cardiac patients admitted to the hospital for myocardial infarction, percutaneous coronary intervention (PCI), valvular surgery, or coronary artery bypass grafting and suitable for cardiac rehabilitation in the outpatient settings were recruited between 1 August 2013 and 31 December 2018 from the Veterans health administration of San Francisco. Patients opting for CBCR, who were to receive staged PCI, who were discharged to nursing facilities, and individuals who were dead within 30.0 days of hospital admission were excluded from the analysis.
In addition, individuals with cognitive impairments and movement disorders that could interfere with fitness training were excluded. HBCR participants received ≤9.0 telephonic coaching sessions with motivational interviewing for 12.0 weeks, and follow-up assessments were performed until 30 June 2021. For all patients, the Healthy Heart Program nurses completed in-depth chart reviews and interviews to evaluate patient requirements and assess HBCR indications, feasibility and appropriateness.
Data on demographics, vital signs, and comorbidities were obtained from chart reviews and the VA corporate data warehouse. The study approach was informed using three theoretical models, including the health belief model, the social cognitive theory, the predisposing reinforcing and enabling constructs in educational diagnosis and evaluation policy, regulatory and organizational constructs in the educational and environmental development implementation planning model.
Health journals were distributed to all participants to record activities, vital signs, and nutritional intake. In addition, all participants were provided with equipment for the relevant measurements, and exercise physiologists and nurses aided in devising attainable strategies to improve cardiac health. The Healthy Heart program emphasizes behavioral health components such as physical fitness, good nutrition, quitting smoking, medication compliance and managing stress.
The prime study outcome was one-year mortality rates, and the secondary study outcome was mortality during the study period. Cox proportional hazards-type regression modeling was performed using the inverse probability treatment weighting (IPTW) method to comparatively assess death rates among individuals participating in HBCR vs. those who did not, and hazard ratios (HR) were calculated.
Out of 1,120 cardiovascular patients with ischemic heart disease who were offered HBCR (average age of 68.0 years, 98.0% were men, and 76.0% were Whites), 44% (n=490) individuals attended HBCR. Among the patients, 68% resided in urban locations, and 50% were admitted to the hospital for PCI prior to the CR referral. In the follow-up period of 4.20 years (median), 17% (n=185) died.
Mortality was lesser in the HBCR group vs. the non-participating individuals (12.0% versus 20.0%). Overall death rates were 3.0% (n=38) within a year of hospital admission and 17.0% (n=133) during follow-up. The one-year death rates were 4.0% (n=28) and 2.0% (n=10) among non-participants and HBCR participants, respectively.
HBCR was related to a 33.0% reduction in the risk of death within a year; however, the relationship was insignificant (HR 0.7). Of the 490 participating individuals, 43% (n=209) patients completed ≥9.0 HBCR sessions, and the mean number of completed sessions was 7.20. The findings indicated a reducing trend in mortality with an increase in the number of attended sessions.
Overall, the study findings showed that cardiovascular patients participating in home-based cardiac rehabilitation had a 36.0% lesser mortality risk within four years of follow-up. In addition, the findings indicated that HBCR could benefit cardiovascular patients who are not able to participate in CBCR, especially in the coronavirus disease 2019 (COVID-19) scenario.
Compared to CBCR, a notable benefit of HBCR is the significantly smaller duration between index event to recruitment. In addition, HBCR programs offer motivational coaching for modifying lifestyle in the environment of patients’ homes. Therefore, HBCRs can create sustainable lifestyle modifications, which are critical for the completion and long-lasting success of the programs.
- Association of Home-Based Cardiac Rehabilitation With Lower Mortality in Patients With Cardiovascular Disease: Results From the Veterans Health Administration Healthy Heart Program. Nirupama Krishnamurthi, MBBS, MPH; David W. Schopfer, MD, MAS; Hui Shen, MS; Gregory Rohrbach, DNP; Abdelaziz Elnaggar, MBBS, MPH; Mary A. Whooley, MD, DOI: doi.org/10.1161/JAHA.122.025856, www.ahajournals.org/doi/10.1161/JAHA.122.025856