The Healthy Heart Study

The long-term goal of this research is to improve patient-centered outcomes in patients with
coronary heart disease (CHD). CHD is the leading cause of death in the world. Exercise-based
cardiac rehabilitation (CR) programs decrease mortality and improve quality of life in
patients with CHD. Published guidelines recommend exercise-based CR following hospitalization
for myocardial infarction, coronary artery bypass grafting, or percutaneous coronary
revascularization, and referral to CR is one of nine performance measures established by the
American Heart Association and American College of Cardiology for patients with CHD.

Despite these compelling benefits, CR programs are vastly underutilized, with less than a
third of eligible patients participating. The largest barrier to patient participation is
that CR must be provided in a physician's office or hospital setting to qualify for
reimbursement. For this reason, virtually all existing CR programs require that the patient
travel to a CR center 3 times per week for 12 to 36 weeks. Unfortunately, many Americans live
too far from a CR center to enroll, and even when nearby programs are available, many
patients do not have the time, flexibility, transportation, social support, and/or financial
resources to attend.

One promising solution to the problem of CR under-utilization is greater implementation of
home-based CR. Both home and center-based CR programs have equal benefits on cardiovascular
risk factors and quality of life. However, similar efficacy does not necessarily translate
into similar effectiveness. If patients are more likely to participate in home- vs.
center-based therapy, then greater participation could lead to greater clinical
effectiveness. We are therefore conducting a quasi-experimental, controlled trial at two VA
medical centers to determine the comparative effectiveness of referral to home- vs.
center-based CR in patients with CHD.

Aim 1: Determine whether automatic referral to home- vs. center-based CR increases patient
participation in CR after hospitalization for myocardial infarction or coronary
revascularization.

Aim 2: Among patients who choose to participate in CR, compare the effectiveness of home- vs.
centerbased CR on six-minute walk distance, quality of life, and healthcare expenditures.

Aim 3: Determine whether the effects of home vs. center-based CR differ by age, gender, race,
ethnicity, employment, socioeconomic status, social support, comorbid conditions, or patient
preference.

Results from this study will (a) help policy makers determine the effect of covering home CR
on healthcare expenditures in patients with CHD; (b) help providers understand the potential
benefits and harms of home- vs. center-based CR; and (c) help patients answer questions like,
"Given my personal circumstances and preferences, which of these options will improve the
outcomes most important to me.

Inclusion Criteria:

Post MI, CABG, or PCI Able to speak, read and write in english

Exclusion Criteria:

Class IV CHF Unstable Angina Complex Ventricular Arrythmias EF <35% without AICD AICD
candidate Resting SBP >200mmHG Resting DBP>110mmHG Cognitive Impairment by MoCA Score <26
Life expectancy <1 year