Cardiopulmonary rehab is routinely recommended for thousands of cardiac patients every year—and for good reason. A rich body of evidence shows that supervised exercise programs reduce the mortality rate and hospitalization rates for heart attack patients, heart disease patients, and patients who have undergone heart surgery.[1] Other studies have shown that pulmonary rehabilitation has benefits for patients with lung disease, especially COPD.[2]

These programs are typically administered either in a clinic setting. A typical rehab program combines supervised and monitored exercise with education on risk factor modification and healthy living. Patients may be exposed to education on healthy eating and nutrition, exercising safely, smoking cessation, and other disease-management tools.

The issue? Running a profitable rehab program for a hospital is challenging, resulting in the closure of many internal rehab programs. This is partly due to the challenges of successfully referring patients to rehab programs and keeping them engaged through the entire 36-session program. Referral rates vary depend on the disease and healthcare facility, but they can be below 20% in some cases.[3] [4] Worse, these numbers mask a sobering truth: in many cases, the sickest and poorest patients who need rehab the most are the ones who don’t enroll or can’t complete the program. The issues are often practical: lack of transportation, conflicting work schedules, and cost.

To address these challenges, various groups are looking at ways to finally make remote cardiac rehab a reality, using a combination of digital tools and evidence-based approaches. In 2019, the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology issued a joint statement supporting the development of home-based cardiac rehabilitation (HBCR) programs, with a special focus on underserved groups including older adults, women, minorities and high-risk patients.[5] Although HBCR is largely uncovered by insurance, that hasn’t stopped start-ups and research groups from developing ways to build effective HBCR programs. While there isn’t yet a consensus on the best design for a HBCR program, there are several models being tested:

  • Asynchronous: Materials are delivered to the patient, including print and video educational material and instructions, and the patient moves through the program at their own pace. There is no real-time communication with a care provider, but progress is tracked.
  • Synchronous: Patients have real-time communication with the provider, often through video conference during live sessions. These programs can be conducted in the home, or sometimes classes are arranged through local facilities like community centers where patients gather to participate.

Many HBRC programs also include hardware like digital scales and blood pressure cuffs, in addition to the printed or video educational material.

While there are significant challenges to implementing HBRC and the research is still in its infancy, the good news is that we have models to rely on. Counties including the United Kingdom, Canada, and Australia all have national healthcare coverage that includes HBRC, so adoption rates overseas are much higher than in the United States, where HBRC is not yet covered by Centers for Medicare & Medicaid Services and most private insurers.[6]

In the future, it seems assured that viable models for HBRC will be developed and expand the pool of patients who can benefit from this powerful therapeutic approach.


References

[1] Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, Taylor RS. Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis. J Am Coll Cardiol. 2016 Jan 5;67(1):1-12.

[2] Hanekom S, Gosselink R, Dean E, van Aswegen H, Roos R, Ambrosino N, Louw Q.The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion and its translation into practice. Clin Rehabil. 2011 Sep;25(9):771-87.

[3] Rengo JL, Savage PD, Barrett T, Ades PA. Cardiac Rehabilitation Participation Rates and Outcomes for Patients With Heart Failure. J Cardiopulm Rehabil Prev. 2018 Jan;38(1):38-42.

[4] Ambrosetti M, Faggiano P, Greco C, Mureddu GF, Temporelli PL, Pedretti RFE.Referral from vascular surgery to cardiovascular rehabilitation and relatedoutcomes in patients with peripheral arterial disease: the THINKPAD-RELOADEDsurvey. Monaldi Arch Chest Dis. 2019 Sep 18;89(3).

[5] Randal J. Thomas, Alexis L. Beatty, Theresa M. Beckie, LaPrincess C. Brewer, Todd M. Brown, Daniel E. Forman, Barry A. Franklin, Steven J. Keteyian, Dalane W. Kitzman, Judith G. Regensteiner, Bonnie K. Sanderson, Mary A. Whooley. J Am Coll Cardiol. 2019 Jul, 74 (1) 133-153.

[6] Thomas RJ, Beatty AL, Beckie TM, Brewer LC, Brown TM, Forman DE, Franklin BA, Keteyian SJ, Kitzman DW, Regensteiner JG, Sanderson BK, Whooley MA. Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. Circulation. 2019 Jul 2;140(1):e69-e89.