RESUMEN
Objective: Studies have shown that both home-based cardiac rehabilitation (HBCR) and center-based cardiac rehabilitation (CBCR) exhibit comparable efficacy in reducing mortality during short-term follow-up periods of up to 12 months. However, research on sex- and race-specific outcomes associated with HBCR is limited. This study examines all-cause mortality and hospital readmission among patients referred to HBCR, with stratification by sex and race. Methods: This Kaiser Permanente Southern California (KPSC) retrospective cohort study followed 6,868 patients from HBCR referral until death, disenrollment, or December 31, 2021. There were 3,835 HBCR graduates, 722 non-graduates, and 2,311 non-enrolled patients. Cox models were used to estimate hazard ratios (HR) and 95 % confidence intervals (CI) comparing 1) HBCR graduates vs. non-enrolled, and 2) HBCR graduates vs. non-graduates, stratified by sex and race. Differential outcomes among strata were analyzed using Kaplan-Meier curves. Results: Among the 6,868 patients referred to HBCR, 4693 (68.3 %) were male, 2,175 (31.7 %) female, 870 (12.7 %) Asian/Pacific Islander, 731 (10.6 %) African American, 1,612 (23.6 %) Hispanic/Latino, and 3,646 non-Hispanic White (53.1 %). Over a mean follow-up period of 2.28 years, HBCR graduates, compared to patients who did not enroll in HBCR, had overall significantly lower risks of all-cause mortality and hospitalization. These results remained significant with stratification by sex and race. Compared to HBCR non-graduates, HBCR graduates overall had significantly lower risks of all-cause mortality and hospitalization. In the same comparison, mortality risk was significantly reduced for male and White patients; risk of hospital readmission was significantly reduced in both sexes, African American, and White patients. Among HBCR graduates, no significant differences in all-cause mortality or hospital readmission were observed across sexes and races. Conclusion: HBCR participation is associated with reduction of all-cause mortality and hospital readmission rates across sexes and races. Notably, we observed benefits at varying levels of engagement, which suggests that even partial completion of HBCR is associated with risk reduction. Among HBCR graduates, we found similar outcomes across sexes and races, which suggests that the program can be effective among diverse patient groups.
RESUMEN
Importance: Prior studies have suggested that participation in home-based cardiac rehabilitation (HBCR) vs center-based cardiac rehabilitation (CBCR) results in similar clinical outcomes in patients with low to moderate risk; however, outcome data from demographically diverse populations and patients who are medically complex are lacking. Objective: To compare hospitalizations, medication adherence, and cardiovascular risk factor control between participants in HBCR vs CBCR. Design, Setting, and Participants: This retrospective cohort study was conducted among patients in Kaiser Permanente Southern California (KPSC), an integrated health care system serving approximately 4.7 million patients, who participated in CR between April 1, 2018, and April 30, 2019, and with follow-up through April 30, 2020. Data were analyzed from January 2021 to January 2022. Exposures: Participation in 1 or more HBCR or CBCR sessions. Main Outcomes and Measures: The primary outcome was 12-month all-cause hospitalization. Secondary outcomes included all-cause hospitalizations at 30 and 90 days; 30-day, 90-day, and 12-month cardiovascular hospitalizations; and medication adherence and cardiovascular risk factor control at 12 months. Logistic regression was used to compare hospitalization, medication adherence, and cardiovascular risk factor control, with inverse probability treatment weighting (IPTW) to adjust for demographic and clinical characteristics. Results: Of 2556 patients who participated in CR (mean [SD] age, 66.7 [11.2] years; 754 [29.5%] women; 1196 participants [46.8%] with Charlson Comorbidity Index ≥4), there were 289 Asian or Pacific Islander patients (11.3%), 193 Black patients (7.6%), 611 Hispanic patients (23.9%), and 1419 White patients (55.5%). A total of 1241 participants (48.5%) received HBCR and 1315 participants (51.5%) received CBCR. After IPTW, patients who received HBCR had lower odds of hospitalization at 12 months (odds ratio [OR], 0.79; 95% CI, 0.64-0.97) but similar odds of adherence to ß-blockers (OR, 1.18; 95% CI, 0.98-1.42) and statins (OR, 1.02; 95% CI, 0.84-1.25) and of control of blood pressure (OR, 0.98; 95% CI, 0.81-1.17), low-density lipoprotein cholesterol (OR, 0.98; 95% CI, 0.81-1.20), and hemoglobin A1c (OR, 0.98; 95% CI, 0.82-1.18) at 12 months compared with patients who received CBCR. Conclusions and Relevance: These findings suggest that HBCR in a demographically diverse population, including patients with high risk who are medically complex, was associated with fewer hospitalizations at 12 months compared with patients who participated in CBCR. This study strengthens the evidence supporting HBCR in previously understudied patient populations.
