At-Home Cardiac Rehabilitation Just as Effective as Center-Based Programs

Reimbursement Enacted during Pandemic Set to Expire

At-home or hybrid cardiac rehabilitation (CR) programs are safe and work as well as or better than center-based programs for reducing risk and improving physical function, mood, and quality of life in patients with chronic heart disease, according to a recent ECRI Clinical Evidence Assessment.

However, at-home and hybrid CR therapy may no longer be available at the end of 2024 because reimbursement programs are set to expire. While legislative efforts are ongoing to enact permanent coverage, Medicare coverage provisionally enacted during the COVID-19 pandemic allowing for limited reimbursement for CR using assistive technologies and telemedicine ends in December.

ECRI’s evidence analysis found that assistive technology, including remote monitors, activity trackers, digital logs, and telemedicine consultations, help keep patients engaged and improve CR effectiveness during its analysis of studies from January 2021 through August 2024, including randomized controlled trials synthesized in 13 systematic reviews.

Traditional CR requires patients to attend a CR center several times a week, which may be difficult for many patients; fewer than 30% of eligible patients in the United States complete a CR program. Patients discontinue CR for a variety of reasons, including being unable to attend sessions at a CR center because of remoteness, lack of time or transportation means, or reduced mobility.

CR programs that take place fully or partially (hybrid CR) at the patient’s home feature standard CR components but rely on patients and caregivers for delivery and monitoring. Contemporary at-home CR programs also leverage telemedicine, remote physiologic monitors, and digital tools to facilitate care provider involvement and bridge the gaps between at-home and center-based CR, which may help address inequities in access to care.

CR is tailored to each patient's condition and needs but typically involves supervised aerobic and resistance training exercises that increase in intensity over time until patients reach recommended or best-achievable activity level. Patients also receive education or behavioral interventions to reduce or eliminate modifiable cardiovascular risk factors such as dyslipidemia, overweight, smoking, and stress. A critical CR goal is for patients to continue a heart-healthy lifestyle and receive consistent cardiovascular follow-up after the intervention.

Patients who adhere to CR and consequently make consistent lifestyle changes have their cardiovascular risk reduced by about 30% in addition to the reduction achieved by pharmacotherapy.

Key Findings on At-Home or Hybrid CR versus Traditional CR

• Six-minute walking distance exercise capacity: Five studies found that at-home or hybrid CR was better. Two studies found no statistical difference with traditional CR.
• Adherence to exercise: Three studies found at-home or hybrid CR was better. One study found no statistical difference with traditional CR.
• Blood pressure: One study found at-home or hybrid was better. Four studies found no statistical difference with traditional CR.
• Mortality and heart disease-related hospitalizations: Ten studies found no statistical difference.
• Mood and quality of life: Four studies found at-home or hybrid was better. Nine studies showed no statistical difference with traditional CR.
• Body composition: One study found at-home or hybrid was better. Two studies showed no statistical difference with traditional CR.
• Cholesterol: Two studies showed at-home or hybrid was better. One study showed no statistical difference with traditional CR.

Future of At-Home CR

ECRI’s analysis found that at-home CR remains in an early stage because of safety and effectiveness concerns and because of limited reimbursement and coverage for assistive technology availability. ECRI also identified four position statements and guidelines that are clearly supported by published SRs or that meet certain U.S. National Academy of Medicine criteria.

A scientific statement from the American Heart Association and American College of Cardiology reads: “Hybrid models, in which patients participate initially in medically supervised followed by home-based activities, may reduce cost and enhance accessibility for eligible patients. The widespread availability of activity trackers, smartphones, telehealth, and internet-based programs markedly enhances the ability to monitor patient adherence to, responses to, and progress in home-based CR programs. Future research is needed to evaluate integration of other technology applications and novel strategies and to assess their impact on patient adherence and outcomes.”

ECRI researchers concluded findings may not fully generalize to specific patient groups because patient characteristics and CR delivery varied across studies. Additional studies and focused review to validate CR in specific patient groups are warranted.

ECRI members may access this Clinical Evidence Assessment through ECRI’s web portal. Nonmembers may learn more about Clinical Evidence Assessment and request additional information.