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2023 HSR&D/QUERI National Conference Abstract

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1056 — Home-based cardiac rehabilitation associated with lower mortality in patients with heart disease: Results from the VA Healthy Heart Program

Lead/Presenter: Nirupama Krishnamurthi,  San Francisco VA Medical Center
All Authors: Krishnamurthi N (Mount Sinai Morningside Hospital, San Francisco Veterans Affairs Medical Center), Schopfer, DW (National Institutes of Health) Shen, H (San Francisco Veterans Affairs Medical Center; Department of Medicine, University of California, San Francisco) Rohrbach, G (San Francisco Veterans Affairs Medical Center) Elnaggar, A (San Francisco Veterans Affairs Medical Center; Department of Medicine, University of California, San Francisco) Whooley, MA (San Francisco Veterans Affairs Medical Center; Department of Medicine, University of California, San Francisco)

Objectives:
Home-based cardiac rehabilitation (HBCR) and traditional facility-based cardiac rehabilitation (CR) programs have similar effects on mortality in clinical trials and meta-analyses. However, the effect of HBCR on mortality in clinical practice settings is less clear. Therefore, we sought to compare mortality rates in HBCR participants versus non-participants.

Methods:
We evaluated all patients who were referred to and eligible for outpatient CR between 2013-2018 at the San Francisco Veterans Health Administration. Patients who chose to attend facility-based CR and those who died within 30 days of hospitalization were excluded. Patients who chose to participate in HBCR received up to 9 telephonic coaching and motivational interviewing sessions over 12 weeks. All patients were followed through June 30, 2021. We used Cox-proportional hazards regression models with inverse probability treatment weighting to compare mortality in HBCR participants vs. non participants.

Results:
Of the 1,120 patients (mean age 68, 98% male, 76% White) who were referred to and eligible, 490 (44%) participated in HBCR. During a median follow-up of 4.2 years, 185 patients (17%) died. Mortality was lower among the 490 HBCR participants vs. the 630 non-participants (12% vs. 20%; p < 0.01). In an inverse probability weighted cox regression analysis adjusted for patient demographics and comorbid conditions, mortality remained 36% lower among HBCR participants versus non-participants [HR 0.64, 95% CI 0.45, 0.90, p = 0.01].

Implications:
Among patients eligible for CR, participation in HBCR was associated with 36% lower mortality. Although unmeasured confounding can never be eliminated in an observational study, our findings suggest that HBCR may benefit patients who cannot attend traditional CR programs.

Impacts:
Ours is the first observational study that showed a mortality benefit with HBCR among US veterans. This a pivotal time in the era of tele-medicine and its diversifying use in bridging access to care. Our findings hope to provide an impetus to further expand HBCR and deliver CR to those that are unable to access CBCR programs.