USA needs to put greater emphasis on home-based cardiac rehabilitation

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A Scientific Statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology has called for greater use of home-based cardiac rehabilitation as a secondary prevention tool in the USA to bring it into line with common practice in other countries.

Published in Circulation, the statement from Randal J Thomas (Mayo Clinic, Rochester, USA) et al says that although cardiac rehabilitation programmes have been shown to reduce morbidity and mortality in adults with ischaemic heart disease, heart failure, or cardiac surgery, they are significantly underused in the USA, and that “new delivery strategies are urgently needed to improve participation”. It adds: “Home-based cardiac rehabilitation has been incorporated into the healthcare systems of several countries, including Australia, Canada, and the UK. The British Heart Foundation recently reported that in the UK >50% of eligible patients are now participating in cardiac rehabilitation after a cardiac event or procedure. Unfortunately, home-based cardiac rehabilitation faces substantial challenges to implementation in the USA, most notably a lack of reimbursement by the Centers for Medicare & Medicaid Services and other third party payers. Of interest, in a recent study of cardiac rehabilitation-eligible patients, when given the option to receive cardiac rehabilitation through a home-based or a centre-based approach, nearly half preferred a home-based approach.”

Thomas et al carried out a systematic review of published studies that compared home-based cardiac rehabilitation with centre-based cardiac rehabilitation to assess the comparative effectiveness and potential benefits of home-based programmes and to explore implementation strategies for their development. A literature search identified 23 studies that used randomised, experimental designs that directly compared outcomes, and the authors used these as the primary scientific basis of the statement. They excluded meta-analyses, systematic reviews, qualitative studies, published letters, editorials, and case reports, as well as studies that compared home-based cardiac rehabilitation with usual care. Patient populations included adults with myocardial infarction, stable angina, or heart failure and those who had undergone coronary revascularisation.

The included studies assessed at least one of the following health outcomes: mortality, morbidity (defined as reinfarction, revascularisation, or cardiac-related hospitalisation), exercise capacity, modifiable cardiovascular risk factors (for example, smoking, lipids, blood pressure, blood glucose, exercise capacity), health related quality of life (HRQOL), adverse events, health services use, cost, or intervention adherence.

The statement recommends: “Although home-based cardiac rehabilitation appears to hold promise in expanding the use of cardiac rehabilitation to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the home-based cardiac rehabilitation evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups.”
Thomas told Cardiovascular News: “We present evidence and limitations of home-based cardiac rehabilitation, and suggest that the evidence supports its use in patients who are at low-to-moderate risk who cannot attend a centre-based program. There are a number of unanswered questions about home-based cardiac rehabilitation, including its longer-term impact on cardiovascular disease outcomes, its impact in the elderly and underserved populations, and so on. But current evidence is sufficient to suggest it can be considered for lower-risk patients who cannot attend a centre-based program.

The statement was co-published in the Journal of Cardiopulmonary Rehabilitation and Prevention and the Journal of the American College of Cardiology.

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