More Diverse, Medically Complex Patients Hospitalized Less Often After Home-Based Cardiac Rehab

Patients, including those from diverse backgrounds and with more complex medical conditions, who participated in in-home cardiac rehabilitation had fewer hospitalizations over 12 months than patients who participated in center-based cardiac rehabilitation, according to a study published Thursday in JAMA Network Open.

Prior studies have suggested that participation in home-based and center-based cardiac rehabilitation results in similar clinical outcomes in patients with low-to-moderate risk. However, outcomes from demographically diverse populations and patients who had other chronic illnesses and other complex comorbidities had not been studied.

To add to what is known about in-home cardiac rehabilitation, researchers from Kaiser Permanente analyzed patients from Kaiser Permanente Southern California (KPSC), an integrated health care system that serves 4.7 million members in racially and ethnically diverse Southern California.

They compared 12-month hospitalizations, medication adherence, and cardiovascular risk factor control in higher-risk, complex patients. The 2556 patients participated in cardiac rehabilitation from April 1, 2018, to April 30, 2019, with follow-up through April 30, 2020. Data were analyzed from January 2021 to January 2022.

Mean (SD) age was 66.7 (11.2) years; nearly 30% were women. Close to 47% had Charlson Comorbidity Index ≥4. More than half (55.5%) of the patients were White; 11.3% were Asian or Pacific Islander; 7.6% were 193 Black; and 3.9% were Hispanic.

Participants were split between home-based cardiac rehabilitation (HBCR) vs center-based cardiac rehabilitation (CBCR), with 1241 participants (48.5%) receiving HBCR and 1315 participants (51.5%) receiving CBCR.

Logistic regression was used to compare hospitalization, medication adherence, and cardiovascular risk factor control, with inverse probability treatment weighting (IPTW) to adjust for demographic and clinical characteristics.

Patients who participated in HBCR had a 21% less chance of experiencing a hospitalization in the 12 months after cardiac rehab compared with patients who participated in CBHR (odds ratio [OR], 0.79; 95% CI, 0.64-0.97).

However, other results between the 2 groups receiving different types of therapies similar:

• Adherence to beta blockers (OR, 1.18; 95% CI, 0.98-1.42) and statins (OR, 1.02; 95% CI, 0.84-1.25)
• Control of blood pressure (OR, 0.98; 95% CI, 0.81-1.17)
• Low-density lipoprotein LDL-cholesterol low-density lipoprotein cholesterol (OR, 0.98; 95% CI, 0.81-1.20),
• Hemoglobin HbA1c (OR, 0.98; 95% CI, 0.82-1.18)

In addition, the HBCR participants, who lived farther from their nearest available center, were more likely to complete their program.

Although cardiac rehabilitation is recommended after a cardiovascular event, past studies have shown that up to 80% of eligible patients do not take part, with women, individuals with multiple chronic illnesses, and members of certain racial and ethnic groups more likely not to participate.

HBCR was developed to increase the diversity of participants by improving accessibility. Kaiser Permanente’s 8-week HBCR includes weekly nurse calls, education, and unsupervised exercise monitored with a smart watch. Providers can review data, including step counts and heart rate, through a dashboard in the electronic health record and adjust the program as needed.

The authors said that to their knowledge, theirs is the largest study of cardiac rehabilitation and “the first study to report superior clinical outcomes in HBCR compared with CBCR and the first to examine hospitalizations as the primary outcome.”

They noted that one limitation that may have affected outcomes is that the decision to refer patients to either HBCR or CBCR was up to the patient’s cardiologist, which may have introduced physician referral bias.

“The remarkable thing we found in this study of more than 2,500 diverse patients was that health advantages of home-based cardiac rehabilitation applied to both patients with low and moderate risk, as well as those with higher risk due to poor health, age, or chronic health conditions,” lead author Chileshe Nkonde-Price, MD, a cardiologist at the Kaiser Permanente West Los Angeles Medical Center, a clinician investigator with the Kaiser Permanente Southern California Department of Research & Evaluation, and an assistant professor at the Kaiser Permanente Bernard J. Tyson School of Medicine, said in a statement.

Reference

Nkonde-Price C, Reynolds K, Najem M, et al. Comparison of home-based vs center-based cardiac rehabilitation in hospitalization, medication adherence, and risk factor control among patients with cardiovascular disease. JAMA Netw Open. 2022;5(8):e2228720. doi:10.1001/jamanetworkopen.2022.28720