Current challenges in cardiac rehabilitation: strategies to overcome social factors and attendance barriers

ABSTRACT

Introduction

Cardiac rehabilitation (CR) significantly reduces secondary cardiovascular events and mortality and is a class 1A recommendation by the American Heart Association (AHA) and American College of Cardiology (ACC). However, it remains an underutilized intervention and many eligible patients fail to enroll or complete CR programs. The aim of this review is to identify barriers to CR attendance and discuss strategies to overcome them.

Areas covered

Specific barriers to CR attendance and participation will be reviewed. This will be followed by a discussion of solutions/strategies to help overcome these barriers with a particular focus on home-based CR (HBCR).

Expert opinion

HBCR alone or in combination with center-based CR (CBCR) can help overcome many barriers to traditional CBCR participation, such as schedule flexibility, time commitment, travel distance, cost, and patient preference. Using remote coaching with indirect exercise supervision, HBCR has been shown to have comparable benefits to CBCR. At this time, however, funding remains the main barrier to universal incorporation of HBCR into health systems, necessitating the need for additional cost benefit analysis and outcome studies. Ultimately, the choice for HBCR should be based on patient preference and availability of resources.

KEYWORDS:

• Barriers
• cardiac rehabilitation
• home-based cardiac rehabilitation
• strategies
• tele-rehabilitation

Article highlights

• Cardiac Rehabilitation is an important component in the continuum of care for patients with cardiovascular diseases and provides numerous benefits including increased functional capacity, decreased hospitalizations, secondary cardiovascular events, and mortality.

• Despite these benefits and the increasing burden of cardiovascular disease, participation and completion of CR programs by eligible patients remain low.

• Physician barriers to CBCR include low referral rates and inadequate physician endorsement.

• Patient barriers to CBCR include gender bias, racial, socioeconomic, and psychological factors, language barriers, and poor physical health.

• Systemic barriers to CBCR include distance to CR centers, cost of CR, and fragmented care between CBCR programs and referring physicians.

• Potential solutions to these barriers include standardized or automated referrals to CR, increasing exposure to CR during medical training, increasing CR staff diversity, travel reimbursements, providing financial incentives for CR completion, and enrolling appropriate patients in HBCR.

• HBCR circumvents many barriers to traditional CBCR participation by utilizing remote monitoring and personalized risk factor management to engage patients to improve their cardiovascular health.

• The use of HBCR, either alone or in combination with CBCR, represents a potential alternative that may improve the delivery of CR to eligible patients.

• Additional research is needed on HBCR outcomes and per-patient cost analysis before Medicare and third-party insurers consider coverage for these interventions.

• With the Coronavirus (COVID-19) pandemic and need for social distancing, HBCR provides a unique opportunity for patients to continue receiving CR despite closure of CBCR programs.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose. 

Additional information

Funding

This paper was not funded.