Digital Technology-Enabled Hybrid Model for Equitable Delivery of Cardiac Rehabilitation

From the 2023 HVPA National Conference

Chang Kim MD PhD (Johns Hopkins School of Medicine), Mansi Nimbalkar MS-EP, Nino Isakadze MD MHS, Zane MacFarlane BA, Yumin Gao ScM, Jennifer Ding PhD, Ashley Broderick MS, Alex Bush MS, Jeanmarie Gallagher MS MBA, Preeti Benjamin MS, Brittany Neigh MS, Kerry Stewart EdD, Lena Mathews MD MHS, Erin Spaulding PhD RN, Seth Martin MD MHS, Francoise Marvel MD

Background:
Cardiac rehabilitation (CR) is a comprehensive secondary prevention program consisting of supervised exercise and education about medications, healthy living, and cardiovascular risk factor modification. Despite the well-established cost-effectiveness and benefits of reducing readmissions, lowering mortality, and improving functional status following a cardiac event, CR participation remains low due to limited availability and barriers to access that disproportionately impact underrepresented minorities. To expand the availability and accessibility of CR, we developed a hybrid CR program that combines traditional, center-based CR with technology-enabled, home-based CR.

Objective:
To assess the characteristics and experience of patients who engaged with our hybrid CR program with a focus on health equity.

Methods:
From November 2022 to February 2023, we enrolled 16 patients with a clinical indication for CR into our program. Our hybrid CR program combines center-based CR sessions with home-based CR sessions delivered through a digital health platform (Corrie Health) over 12 weeks. The Corrie Health platform integrates a smartphone app, smartwatch, and wireless blood pressure monitor and enables tracking of individual health data on a clinician dashboard, based on which data-driven health coaching is delivered on a weekly basis. We examined the demographic distribution, clinical characteristics, and financial burden of our participants to assess our hybrid CR program from a health equity perspective.

Results:  
Sixteen patients were enrolled in our program, among which 10 were highly engaged, defined as utilizing the Corrie Health platform 2 or more times per week and completing 2 or more coaching sessions. For these 10 highly engaged patients, mean age was 60.5 ± 9.4 years (range: 41 to 74 years), 30% were female, and 50% were non-Caucasian (20% Black, 10% Asian, 10% other-Hispanic, 10% other-non-Hispanic), compared to 6 less engaged patients who were aged 64.5 ± 7.5 years (range: 57 to 74 years), 33% female, and 17% Black. Indications for CR included coronary artery bypass surgery (56%), acute coronary syndrome with percutaneous coronary intervention (38%), and stable ischemic heart disease with percutaneous coronary intervention (6%). For the highly engaged group, medical comorbidities included coronary artery disease (100%), hyperlipidemia (70%), hypertension (20%), diabetes (10%), atrial fibrillation (30%), tobacco use (20%), and obesity (50%; mean BMI 29.5 ± 4.4), and they received mean 7.5 ± 3.3 coaching calls with 31.8 ± 10.3 minutes per call. Among 4 patients willing to share financial information, the average out-of-pocket cost to complete a 1-hour session of center-based CR included $14 (range: $11-$20) for travel with 55 minutes (range: 45-90 minutes) of travel time, and copay of $25. For reference, the three CR centers within the Johns Hopkins system reported an average charge of $177.73 (range: $112.71-$280.49) per session.

Conclusions:
CR is a life-saving and cost-effective program but remains underutilized and unavailable for many patients in the U.S. Our results suggest that a hybrid CR program can be successfully implemented at a large academic medical center for a diverse group of patients across a range of cardiovascular conditions, with greater engagement in individuals of underrepresented ethnic backgrounds. This pilot study demonstrates the potential for a digital technology-enabled hybrid CR model to deliver CR to patients in an equitable manner.

Clinical Implications:
Hybrid CR may be considered as a practical option to increase participation in CR, especially for patients with significant financial or logistical barriers to care.

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