The candidate for this mentored patient-oriented research career development award is David Schopfer, MD MAS, Assistant Professor of Medicine (Cardiology) at the University of California, San Francisco (UCSF). The primary goal of this award is to facilitate development of the candidate into an independent investigator with the training necessary to evaluate implementation of secondary prevention programs among patients with ischemic heart disease (IHD). Specifically, the training aims of this award will provide the candidate with mentoring and instruction in cardiovascular outcomes research (primary mentor, Mary Whooley MD), qualitative research methods (Carol Dawson-Rose PhD), implementation science (John Fortney PhD), secondary CV disease prevention (Dan Forman MD), and econometric analysis (Todd Wagner PhD). The proposed research seeks to catalyze implementation of home-based cardiac rehabilitation (CR) programs for secondary prevention of IHD. CR programs are multi-disciplinary interventions, involving exercise training, risk factor management, patient education, and counseling, that reduce morbidity and mortality in patients with IHD. Despite its compelling benefits and the widespread recommendations for its use, less than 20% of eligible Medicare patients, and only 10% of Veterans, receive CR. Because virtually all CR programs require attendance at 12 or more in person sessions, the largest barriers to patient participation are logistical. The Department of Veterans Affairs (VA) has begun to address this quality gap by developing a small number of home-based CR programs. Importantly, meta-analyses have demonstrated that home-based and facility-based programs have similar benefits on quality of life, clinical events, and mortality. During the past 4 years, 20 (of 124) VA facilities have successfully developed and implemented new home-based CR programs modeled on the AHA ?Active Partnership for the Health of your Heart? manual. Between 2011 and 2015, participation in CR among eligible patients more than doubled (from 10% to >25%) at VA facilities that developed home-based CR programs, but stayed flat (10%) at VA facilities that did not offer home-based CR. However, there was marked variation in participation rates (ranging from 3% to 43%) across home-based CR sites, and the reasons for these differences are unknown. The proposed research will address three specific aims:
(Aim 1) Determine the key factors of home- based CR programs associated with higher participation rates;
(Aim 2) Identify barriers to adopting the best practices identified in Aim 1, and develop a home-based CR program implementation plan that addresses those barriers;
and (Aim 3) Conduct a pilot study to evaluate the effect of implementing this tailored home- based CR program (vs. usual care) on rates of CR participation and retention in patients with IHD. The activities performed under this award will prepare the candidate to conduct a multi-center, cluster randomized controlled trial of implementing home-based programs to improve participation in CR.
Cardiac rehabilitation comprehensive lifestyle program that reduces symptoms and improves clinical outcomes, such as hospitalization, in patients with ischemic heart disease; however, it is tremendously underutilized (~10-20% of patients) primarily due to the lack of patient-oriented accessibility with limited scheduling and in facilities not easy for everyone to reach. Home-based cardiac rehabilitation is a modern approach to healthcare which can overcome these critical barriers and increase access for thousands of patients who would otherwise not participate. The results of this proposal will determine the best practices essential for effective home-based cardiac rehabilitation programs in anticipation of wider dissemination.
