Abstract
This study examines whether implementing new home-based cardiac rehabilitation programs is associated with cardiac rehabilitation participation in the Veterans Health Administration.
Performance measures recommend referral to cardiac rehabilitation (CR) after acute myocardial infarction (AMI), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG),1 but CR is vastly underused.2 Lack of transportation and limited access to CR programs have been identified as 2 of the largest barriers to participation.3 To address this issue, the Veterans Health Administration (VHA) has started implementing new home-based CR (HBCR) programs.4,5 Therefore, we examined whether implementation of new HBCR programs is associated with improved CR participation in the VHA.
Methods
We conducted a prospective cohort study of 151 VHA facilities at which 99 097 patients were hospitalized for MI, PCI, or CABG (based on national electronic health records) from January 1, 2010, through December 31, 2015. Sixty-four VHA facilities were excluded from the analysis because they had fewer than 10 patients hospitalized for ischemic heart disease (IHD). During the 6-year study period, the number of VHA facilities that offered HBCR increased from 1 to 12. This study, including a waiver of the requirement to obtain informed consent, was approved by the institutional review board at the University of California, San Francisco.
We compared CR participation across 3 groups of facilities. The 3 groups of facilities offered referral to: (1) offsite facility-based CR programs reimbursed by the VHA, (2) either offsite CR or VHA onsite CR programs, or (3) offsite CR or VHA onsite CR or HBCR programs. Participation was defined as participating in at least 1 outpatient CR session within 12 months after the discharge date based on electronic health records from VHA facilities, non-VHA facilities that were reimbursed by the VHA, and Medicare claims data. The number of sessions was determined using Current Procedural Terminology codes (93797, 93798) and/or VHA Stop Code 231. We used mixed-effects logistic regression with clustering by facility to determine the association of offering HBCR and participation, adjusted for patient and hospital characteristics. We used 2-sided t tests for continuous variables and χ2 tests for dichotomous variables. P < .05 was considered to be statistically significant.
Results
From January 1, 2010, through December 31, 2015, a total of 99 097 patients were hospitalized for IHD (AMI, PCI, or CABG). Participation in at least 1 CR session increased from 8.1% to 13.2% overall (P < .001). At the 12 facilities that began implementing HBCR programs, participation increased from 6.0% (14 of 234) to 24.6% (724 of 2941) (P < .001) (Figure). At the 23 facilities that offered referral to offsite CR or VHA onsite CR, participation increased from 10.9% (815 of 7463) to 17.6% (928 of 5266) (P < .001). At the 52 facilities that offered referral to offsite CR only, there was no detectable change in CR participation (from 6.4% [752 of 11 771] to 6.6% [561 of 8504]; P = .63). In a sensitivity analysis that required 3 or more CR sessions, participation increased from 5.1% (12 of 234) to 16.6% (489 of 2941) at facilities that offered HBCR (P < .001), 8.3% (621 of 7463) to 9.6% (504 of 5266) at facilities that offered offsite or VHA onsite CR (P = .01), and 5.2% (615 of 11 771) to 6.0% (511 of 8504) at facilities that offered offsite CR only (P = .02).
Figure. Participation in Cardiac Rehabilitation (CR) by Type of Program Available, 2010-2015.
Compared with patients hospitalized at a facility that offered referral to offsite CR only, those hospitalized at a facility that offered HBCR had 4-fold greater odds of participating, and those hospitalized at a facility that offered VHA onsite CR had 3-fold greater odds of participating in CR (Table). No significant difference was found in the number of weeks of CR completed among patients offered HBCR vs those not offered HBCR (median, 7.6 vs 8.7 weeks; P = .60). However, patients offered HBCR were less likely to drop out after the first session than were those for whom HBCR was not available (423 [16.8%] vs 1741 [20.2%]; P < .001).
Table. Factors Associated With Patient Participation in Cardiac Rehabilitation.
| Factor | Adjusted OR (95% CI) | P Value |
|---|---|---|
| Patient-specific factors | ||
| Age per decade | 0.80 (0.78-0.82) | <.001 |
| Distance to VHA greater than median (65.6 km) | 0.65 (0.62-0.68) | <.001 |
| Hypertension | 1.16 (1.08-1.25) | <.001 |
| Hyperlipidemia | 1.58 (1.48-1.69) | <.001 |
| Heart failure | 0.82 (0.78-0.87) | <.001 |
| Valvular heart disease | 1.22 (1.16-1.29) | <.001 |
| Peripheral vascular disease | 0.93 (0.88-0.99) | .01 |
| Arrhythmia | 1.29 (1.23-1.36) | <.001 |
| Diabetes | 1.12 (1.00-1.17) | <.001 |
| Stroke | 0.90 (0.82-0.97) | .01 |
| Chronic obstructive pulmonary disease | 0.94 (0.89-0.99) | .03 |
| Chronic kidney disease | 0.83 (0.78-0.88) | <.001 |
| Hospital-specific factors | ||
| Admissions greater than mean (5387 admissions) | 0.72 (0.33-1.56) | .40 |
| Cardiothoracic surgery on site | 1.47 (0.65-3.34) | .35 |
| PCI capability on site | 1.37 (0.49-3.88) | .55 |
| Year of IHD hospitalization | ||
| 2010 | 1 [Reference] | NA |
| 2011 | 1.04 (0.95-1.13) | .32 |
| 2012 | 1.09 (1.00-1.18) | .04 |
| 2013 | 1.50 (1.38-1.62) | <.001 |
| 2014 | 1.85 (1.72-2.00) | <.001 |
| 2015 | 1.88 (1.74-2.03) | <.001 |
| CR program available | ||
| Offsite facility-based only | 1 [Reference] | NA |
| Offsite or onsite facility-based | 3.28 (1.56-6.91) | .002 |
| Offsite, onsite, or home-based | 4.11 (1.43-11.85) | .01 |
Abbreviations: CR, cardiac rehabilitation; IHD, ischemic heart disease; NA, not applicable; OR, odds ratio; PCI, percutaneous coronary intervention; VHA, Veterans Health Administration.
Discussion
In summary, veterans hospitalized with IHD were more likely to participate in CR when a home-based program was available. We recognize that results may be biased because facilities that developed HBCR programs were likely to be stronger proponents of CR, and overall CR participation remained low. Nonetheless, these findings demonstrate that HBCR may be an effective tool for increasing CR participation among patients who would otherwise decline to participate.
References
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