VA Home-Based Programs Increased Participation in Cardiac Rehabilitation

According to a recent study in JAMA Internal Medicine, cardiac rehabilitation is underused following acute myocardial infarction (MI), percutaneous coronary intervention, or coronary artery bypass grafting due to a lack of transportation and overall limited access to cardiac rehabilitation programs.

In an effort to address this growing issue, researchers examined whether implementation of new home-based cardiac rehabilitation by the Veteran Health Administration was associated with improved cardiac rehabilitation participation.

• Based on national electronic health records, researchers examined 151 VHA facilities, which included 99,097 patients who were hospitalized for MI, percutaneous coronary intervention, or coronary artery bypass grafting from January 1, 2010, through December 31, 2015.
• Cardiac rehabilitation participation was compared across 3 groups of facilities. Patient participation was defined as participating in at least 1 outpatient cardiac rehabilitation session within 12 months after hospital discharge.
• At the end of the study, patient participation in at least 1 cardiac rehabilitation session increased from 8.1% to 13.2%.
• During the study period, 12 facilities that began implementing home-based cardiac rehabilitation programs saw a participation increase from 6.0% to 24.6%. Further, 23 facilities that offered referral to offsite cardiac rehabilitation or VHA onsite cardiac rehabilitation, saw participation increase from 10.9% to 17.6%, and there was no detectable change in participation at 52 facilities that offered referral to offsite cardiac rehabilitation only.
• Participation in 3 or more cardiac rehabilitation sessions increased from 5.1% to 16.6% at facilities that offered home-based cardiac rehabilitation. The authors of the study noted that no significant difference was found in the number of weeks of cardiac rehabilitation completed among patients offered home-based cardiac rehabilitation compared to those not offered.
• Importantly, patients offered home-based cardiac rehabilitation were less likely to drop out after the first session compared to patients who did not have availability to home-based cardiac rehabilitation.

Based on their findings—veterans hospitalized with ischemic heart disease were more likely to participate in cardiac rehabilitation when a home-based program was available. Lead study author David Schopfer, MD, MAS, assistant professor at the UCSF School of Medicine, and co-author Daniel Forman, MD, director, cardiac rehabilitation and GeroFit, VA Pittsburgh healthcare system, recently spoke with First Report Managed Care about the benefits of widespread home-based cardiac rehabilitation participation.

Insight From The Authors

Dr Schopfer: We did not specifically investigate clinical outcomes among these patients in this study. We have an ongoing investigation of clinical outcomes. Because numerous studies have previously shown similar outcomes between facility-based vs. home-based programs, the current society recommendations are to implement changes that increase participation, since those who participate have improved outcomes compared to non-participants. Given these recommendations, we chose to focus on the impact of home-based programs on enrollment and on-going participation.

Dr Forman: Foremost, home-based cardiac rehabilitation improves access to care for Veterans. Thus, many more veterans use cardiac rehabilitation than would if home-based options were not available. Furthermore, since by definition, home-based cardiac rehabilitation enables a patient to achieve therapy on his/her own terms and schedule, it helps improve the effectiveness of cardiac rehabilitation; in other words, most people respond favorably to care that can be tailored to their personal needs and circumstances.

Are VA centers with higher cardiac patient populations more likely to participate in the program? Would widespread participation be beneficial?

Dr Schopfer: At the current time, VA medical centers with the highest population of cardiac patients are not more likely to have a home-based program. These programs are spread across large centers as well as smaller one with more limited resources. However, we definitely feel that more widespread use of home-based programs as an alternative mechanism to encourage participation would be beneficial.

Since they are more flexible to patients they can be more attractive. Also, home-based programs can be used to help transition patients from facility-based programs and thus open more space for new patient enrollment in a facility-based program.

Dr Forman: More VA centers are likely to use home-based cardiac rehabilitation for several reasons. First, the value of cardiac rehabilitation is well-substantiated and the VA leadership is more and more cognizant of the value of cardiac rehabilitation to improve fundamental aspects of care (adherence, healthful lifestyle, stress reduction, etc) to prevent rehospitalizations and improve quality of care. Second, home-based models enable access to care that transcends the limitations of a hospital-based footprint (i.e., transcends issues of access, physical space and other common impediments). Third, home-based responds to the fact that many Veterans live far from their VA centers…and/or have their cardiology administered at tertiary centers for which a site-based cardiac rehabilitation option is not practical or realistic. Fourth, home-based cardiac rehabilitation will likely become enhanced by proliferating telehealth options. Fifth, home-based cardiac rehabilitation is much less expensive than alternative options of sending Vets to non-VA care.

Are home-based initiatives for cardiac care cost effective or cost-neutral?

Dr Schopfer: We are currently conducting a cost-budget analysis of our home-based programs in VA, which will compare not only cardiac rehabilitation costs, but also subsequent cardiac care. Existing studies are a little mixed, but generally show that home-based programs are not more expensive than facility-based programs. However, the details of what costs are included in each study is quite variable. We are incorporating all related costs to get a more accurate answer to this question.

Dr Forman: Home-base options are cost-effective. Reduced hospitalizations in those participating saves money. Likewise, home-based care disseminated through the VA is less expensive than pursuing non-VA care options. --Julie Gould

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