Barbra Fagan recently sat down with Dr. Todd Brown, an author of the recent joint scientific statement on Home-based Cardiac Rehab, to get his insights on the many questions surrounding this innovative delivery model.
This past May, a significant update occurred in the world of cardiac rehab delivery. After years of work, a joint scientific statement on the current state of Home-based Cardiac Rehab (HBCR) in the U.S. was released from the top three guideline organizations: the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association and the American College of Cardiology.
Perhaps the most striking takeaway from the paper was this conclusion:
Home-based Cardiac Rehab may be an alternative option to recommend for selected clinically stable low-to-moderate-risk patients who cannot attend center-based rehab.
Scientific Statement from AACVPR/AHA/ACC
The paper has generated a lot of interest and questions from clinicians delivering traditional Center-based Cardiac Rehab, so I spoke with Dr. Brown about some of them
Dr. Todd Brown is currently a cardiologist at the University of Alabama at Birmingham Hospital. He served as President of AACVPR in 2018 and currently Chairs the AACVPR Innovative Delivery Model Collaborative (IDMC)
Barbra: What is Home-based Cardiac Rehab (HBCR)?
Dr. Brown: Home-Based Cardiac Rehabilitation (HBCR) is a broad term that describes cardiac rehabilitation (CR) that is performed outside of the exclusive setting of a center-based program. So, this could include HBCR programs that are fully outside of a center or hybrid programs where some sessions occur in a traditional center and others occur outside of the center. Sessions that occur outside of the center could be done at home or in a gym or similar setting.
Barbra: Why should programs consider offering a HBCR program for patients?
Dr. Brown: Numerous barriers exist that make it difficult for patients to attend traditional center-based CR programs such as work or home responsibilities, difficulty with transportation, distance from the center, etc. The ability to complete CR sessions at home and potentially outside of usual office hours allows patients to overcome many of these barriers. Unfortunately, some of our most vulnerable patients, who stand the greatest opportunity for benefit from CR, are also the ones who have the greatest difficulty attending. So, having a HBCR option helps to get the benefits of CR to these patients by overcoming many of these barriers.
Barbra: How will this affect onsite cardiac rehab programs?
Dr. Brown: We view HBCR and traditional center-based programs as complimentary options. We still believe that center-based programs will always have a role. Some patients will choose to have a more personal relationship with the CR staff and prefer an onsite program. Other patients, particularly those at higher risk, may really need to be included in an onsite program for safety reasons. As I have already mentioned, HBCR does not fully exclude center-based sessions as many centers may choose to offer hybrid programs where some sessions might be completed in an onsite center while others are completed at home. Traditional center-based programs will also be able to address some of their largest challenges by incorporating HBCR into their programs. For instance, one major challenge for center-based programs is getting patients from hospital discharge to CR enrollment in a short period of time. In many centers, this can be a 3 or 4 week wait. If these centers could shift some patients into fully HBCR or hybrid programs, they could open up availability to more rapidly enroll new patients in their traditional center-based program. Given that about 80% of patients who qualify for, and would benefit from, CR do not enroll, there are plenty of patients to fill the slots of center-based and HBCR programs. In fact, if 100% of all patients who qualify for CR would suddenly show up to be enrolled, our current traditional center-based delivery method would be overwhelmed an unable to meet this surge in demand.
Barbra: How will this impact our patients?
Dr. Brown: As I mentioned earlier, the concept of HBCR allows us to get this valuable service to our patients and overcome some of our largest barriers to enrollment. We believe that recurrent events will be prevented and lives will be saved by enrolling more patients into CR.
Barbra: Is it safe?
Dr. Brown: The short answer is yes. Numerous publications have documented that the complication rates during CR exercise sessions are very low. Furthermore, in clinical trials that have been conducted on HBCR, event rates are similar to what has been observed in traditional center-based programs. That being said, most clinical trials have been conducted in low to moderate risk patients, not those at high risk. Some clinical judgement will need to be exercised when deciding who can perform CR at home. But, a substantial percentage of eligible patients would qualify.
Barbra: How is it paid for?
Dr. Brown: Currently, CMS does not provide reimbursement for HBCR. However, some individual health systems and private payors do provide reimbursement. In addition, hospitals that participate in a bundled care program may choose to implement HBCR as a way to improve care transitions and reduce readmission following hospitalizations for myocardial infarction, heart failure, etc. The financial benefits of this type of strategy might more than pay for the cost of providing HBCR, even if the program is not directly reimbursed.