A Comparison of Barriers to Use of Home- Versus Site-Based Cardiac Rehabilitation

Abstract

STRUCTURED ABSTRACTPurpose-Despite the established benefits of cardiac rehabilitation (CR), it remains significantly underutilized. It is unknown whether patient barriers to enrollment and adherence are addressed by offering choice of program type. The purpose of this study was to examine barriers to participation in CR by program type (site vs. home-based), and the relation of these barriers to degree of program participation and exercise behavior.Method-1809 cardiac patients from 11 hospitals across Ontario completed a sociodemographic survey in-hospital, and clinical data were extracted from charts. They were mailed a follow-up survey one year later, which included the Cardiac Rehabilitation Barriers Scale and the Physical Activity Scale for the Elderly. Participants were also asked whether they attended CR, the type of program model attended, and the percentage of prescribed sessions completed.Results-Overall, 939 (51.9%) patients participated in CR, with 96 (10.2%) participating in a home-based program. Home-based participants reported significantly greater CR barriers compared to site-based participants (p<0.001), including distance. Mean barrier scores were significantly and negatively related to session completion and physical activity among site-based (ps<0.05), but not home-based CR participants (p>0.05). To address many of the CR barriers such as lack of transportation access and distance to program facilities, home-based CR programs have been developed. Home-based CR programs offer the same core CR components as site-based programs, 5,6 but communication occurs through telephone or internet contact, education occurs through provision of written materials, and exercise is undertaken in the patient's community environment. Home-based and site-based programs do not differ in terms of mortality rates, cardiac events, exercise capacity, smoking cessation, or health-related quality of life. 7 Conclusion-ThePatients reporting greater barriers to CR use are significantly less likely to enrol, and are more likely to dropout, ultimately not achieving the health benefits of CR. 8 Yet, many patient barriers to CR could be addressed by appropriate allocation to site or home-based programs, although this has yet to be investigated. Thus, the objectives of this study were to:(1) describe and compare barriers to participation, and (2) investigate whether these barriers are related to (a) program adherence (percentage of site or phone CR sessions attended) and (b) exercise behavior, among patients participating in site versus home-based CR programs. METHOD Design and ProcedureThis is a secondary analysis of a larger study 9 for which cardiac in-patients from 11 hospitals in Ontario were recruited. CR services were provided through provincial healthcare at no cost to patients (although patients pay for transportation and/or parking at each visit). Ethics approval was granted from all participating institutions. After obtaining consent, clinical data were extracted from medical charts, and a self-report survey was prov...

Geographic Variation in Cardiac Rehabilitation Participation in Medicare and Veterans Affairs Populations

“…Home cardiac rehabilitation can be administered remotely and has the potential to better meet the needs of rural patients, patients with work or caregiving responsibilities, or those served by facilities without an existing cardiac rehabilitation center. 30, 31 However, home-based programs are unlikely to be widely adopted unless payment reform is enacted to include reimbursement for non-traditional cardiac rehabilitation. Medicare is considering programs for incentives to hospitals based on cardiac rehabilitation participation and bundled payment initiatives with an aim toward reducing rehospitalizations, at least in part by increasing use of cardiac rehabilitation.…”

Home- and Hospital-Based Cardiac Rehabilitation Exercise

“…Of patients who receive a physician referral to Phase II CR, only 30% to 34% enroll and participate (Mazzini, Stevens, Whalen, Ozonoff, & Balady, 2008;Suaya et al, 2007). There are multiple predictors of poor participation in Phase II CR, including lack of physician referral (Cortés & Arthur, 2006;Gurewich, Prottas, Bhalotra, Suaya, & Shepard, 2008) or perceived low levels of physician endorsement (Cortés & Arthur, 2006;Tsui, Shanmugasegaram, Jamnik, Wu, & Grace, 2012), lower socioeconomic status, limited education, racial/ethnic minority status (Valencia, Savage, & Ades, 2011), travel constraints (McDonall, Botti, Redley, & Wood, 2013;Shanmugasegaram, Oh, Reid, McCumber, & Grace, 2013), a preexisting home-based exercise routine (Shanmugasegaram et al, 2013), advanced age (McDonall et al, 2013), female sex (Beckstead et al, 2014;McDonall et al, 2013), being unpartnered (McDonall et al, 2013, and depression (McGrady, McGinnis, Badenhop, Bentle, & Rajput, 2009).…”

“…Home-based CR exercise optimally takes the form of a structured program that establishes clear guidelines for patients and may include monitoring and follow-up visits with health care professionals either in person (Balady et al, 2011) or via telephone or Internet (Shanmugasegaram et al, 2013). Many patients who participate in a home-based CR program report doing so because of barriers to participating in a hospital-based Phase II CR program, including travel constraints or a preexisting exercise routine (Shanmugasegaram et al, 2013).…”

Cross-cultural adaptation and psychometric validation of the Persian version of the Cardiac Rehabilitation Barriers Scale (CRBS-P)

“…The CR adherence tool, while valid, does not consider factors that may impede initial enrolment. 20 The Cardiac Rehabilitation Barriers Scale (CRBS) is arguably the most widely administered, [21][22][23][24][25][26][27] comprehensive and psychometrically validated tool to assess patient barriers to CR enrolment and participation from the patient to health system levels. 28 It was developed following a review of the literature and revised with input from healthcare providers including CR staff.…”