Despite a 30% decline in heart disease mortality from 2001 to 2011, heart disease prevalence is on the rise, responsible for 1 of every 3 deaths in the U.S.1 Cardiac rehabilitation (CR) is an evidence-based, secondary prevention strategy that has been proven effective in preventing future cardiovascular events and decreasing heart disease mortality.2-4 The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) is the leading authority on CR and provides guidelines for CR programs. The AACVPR and the American Heart Association (AHA) published core components for CR programs deemed essential for all CR/secondary prevention programs, including evaluations, interventions, and expected outcomes.5 These core components are aimed at promoting a healthy lifestyle and increasing function and well-being while reducing injury, death, and the reoccurrence of disease.6
In a meta-analysis of 47 trials with 10,794 participants, CR reduced cardiovascular disease (CVD) mortality and hospital admissions by 26% and 18%, respectively.2 Performance measures (Class 1, Level A) recommend the following types of patients should be referred from the inpatient setting: “all patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina, or who during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation.”7 However, despite overwhelming evidence and widespread endorsement (Class 1, Level A), service utilization, uptake, and patient adherence to CR programs remain suboptimal. In a U.S. study of claims from > 250,000 Medicare beneficiaries, < 30% of eligible patients participated in some type of CR program.8 In response to poor participation, a presidential advisory from the AHA in 2011 stated, “the remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehabilitation and clinical implementation of rehabilitation programs is unacceptable.”9
This treatment gap is echoed throughout the VHA. Schopfer and colleagues found that only 28% of the 124 VAMCs that provide inpatient care also offer a supervised, facility-based CR program.10 Furthermore, only 10.3% of eligible veterans participated in at least 1 CR session (VA or non-VA). On a systemic level, low patient referral rates and inadequate third-party reimbursement were the most common barriers to participation in CR.10,11 On a patient level, distance was by far the largest barrier to veterans receiving CR. Currently, 74% of the 9.3 million VA-enrolled veterans live at least 1 hour by car from a VA facility that offers CR.9 Within some regions of the VHA, there are no VA facility-based CR programs. For example, VISN 21 has no facility-based CR programs. At the same time, referral of eligible veterans to facility-based CR outside the VA remains low. Prior to April 2013, < 2% of qualified patients residing in VISN 21 were being referred to Non-VA CR programs, making it the VISN with the lowest participation rate for CR.
One potential solution that addresses both systemic and patient barriers to CR utilization is home-based CR. Veterans within the wide geographic area of VISN 21 are referred to San Francisco VAMC (SFVAMC) for ischemic heart disease, cardiovascular revascularization, and cardiac valve surgeries. In 2013, a comprehensive home-based CR program named The Healthy Heart Program was developed based on a successful evidence-based CVD secondary prevention program. The Healthy Heart Program is designed to be a physician-directed, nurse case-managed, customized exercise and lifestyle program that provides a safe and convenient way for veterans to participate in CR. Exercise and disease self-management education are the cornerstones of the Healthy Heart Program. The program’s multidisciplinary team includes physicians, nurses, a dietician, an exercise physiologist, and a health behavior psychologist.
An Alternative Approach
DeBusk and colleagues demonstrated that a physician-directed, nurse-managed, home-based cardiac risk-factor modification program improved smoking cessation, reduced low-density lipoprotein cholesterol, and increased exercise capacity compared with usual care.12 The results of this study helped pave the way for one of the first CR programs with a strong home-based element. The MULTIFIT program was jointly developed by the Stanford Coronary Rehabilitation Program and Kaiser Permanente (Oakland, CA) in 1995. MULTIFIT is a nurse-based care model for CVD prevention.
Further research that evaluated other home-based programs showed similar promise. A Cochrane review demonstrated that home- and facility-based CR programs were equal in cardiac risk factor reduction, reduced hospital readmissions and mortality rates, and improved quality of life (QOL).13 Cost-effectiveness also seemed to be similar in both home- and hospital-based CR programs.14 A meta-analysis of telephone support interventions for coronary artery disease demonstrated a 38% decrease in rehospitalizations and a 32% increase in the number of participants who stopped smoking.15 In addition, patients with time constraints (eg, work, family obligations) preferred home-based CR programs for the convenience and accessibility that these programs offer.16 Home-based CR programs may have better completion rates compared with that of facility-based programs.17 The American College of Cardiology and AHA updated guidelines for CR include home-based CR as a substitute for facility-based CR for low-risk patients (Class 1, Level A).18