Alexis Beatty, MD, MAS, has received a $6.8 million grant from the Patient-Centered Outcomes Research Institute in Washington, D.C., to study strategies for optimal delivery of cardiac rehabilitation. Beatty, a UC San Francisco cardiologist and associate professor in the Department of Epidemiology and Biostatistics, also directs the UCSF MD/Masters in Advanced Studies program, which trains medical students in patient-oriented research methodologies.
Beatty’s team’s study will compare the efficacy of traditional, in-person cardiac rehabilitation with that of telehealth rehab. Because only about 25 percent of eligible patients attend in-person cardiac rehab, the telehealth approach may help reach those who otherwise might not enroll.
“Cardiac rehabilitation is one of the most underused, highly recommended therapies we have for people with heart disease,” Beatty said. “But people from socioeconomically disadvantaged groups, people of color, and women are less likely to be referred to it. Even when they are, they’re less likely to participate.”
Much of this disparity results from well-known societal challenges. For example, to attend cardiac rehab, a working mother might have to take time off from her job or arrange childcare – or both. If she lived in San Francisco, she might need to ride two or three buses to get to her care facility. Such factors present significant barriers to people struggling to attend rehab appointments three times a week for 12 weeks.
“As a result of the COVID pandemic, we have more experience delivering cardiac rehab with telehealth,” Beatty said. “A patient still has that relationship with the rehab center, but we can check in with them via telehealth to ensure that they’re progressing through their exercise program and working on their other goals like healthy eating and managing their medications and stress. We hope this will improve access.”
The multi-center study will be conducted jointly with researchers from the University of Michigan, the University of Pittsburgh, and Johns Hopkins, in addition to those at UCSF. Beatty and her team will also collaborate with an expert in cardiac rehab and health equity at the Mayo Clinic, and a Harvard specialist in health economics who plans to investigate the role of out-of-pocket costs such as copays, transportation, and missed work in patients’ rehab attendance. The goal is to enroll roughly 516 subjects, of whom at least 40 percent will be women, at least 40 percent will identify as racial or ethnic minorities, and at least 50 percent will be older than 65.
Guidelines recommend cardiac rehab for long-term management of people who have had a heart attack, coronary interventions or surgeries, or for those with chronic heart failure or stable angina – roughly 2 million people annually in the United States. Studies show that rehab improves functional capacity and quality of life (QOL) and lowers the relative risk of hospitalization by 18 percent to 30 percent. In patients with coronary disease, rehab reduces cardiovascular mortality by 26 percent. Such promising numbers support Beatty’s urgency about improving attendance.
“We’ve set national participation goals,” she said. “An organization I work with, Million Hearts, wants to achieve seventy percent participation, which means we have a lot of work to do. Our hope is that expanding access will help us achieve that goal.”
Although studies estimate that improved access could save 25,000 lives every year in the United States, if all in-person cardiac rehab programs were at full capacity, they’d still be able to accommodate only about 45 percent of eligible patients. In other words, innovation in delivery is critical. Moreover, the study’s primary outcome measures – exercise capacity and 12-month QOL – may predict better clinical results across the board.
“We mainly want to make sure we’re providing care that’s at least equivalent to in-person rehab,” Beatty explained. “We know those programs result in lower risks of hospitalization and death. When we look long-term at people who participate, whether in person or by telehealth, we think we’ll see that they have better overall outcomes than those who weren’t able to participate.”
Study subjects randomized to receive telehealth rehab will initially meet with rehab center staff in person for an interview and a variety of assessments. They will also be eligible to receive up to 12 in-person visits if their providers deem it important to their care. Beatty and her team will allow for this variable in their analysis, and hope to determine whether the number of in-person sessions affects outcomes.
“Ultimately this will be patient-centered,” Beatty said. “Those for whom in-person cardiac rehab will achieve the best outcomes will participate that way; those who can only manage telehealth rehab will do that. And for some, it will be a hybrid approach.”
Beatty developed her enthusiasm for cardiac rehabilitation during her UCSF cardiology fellowship. Her research mentor, Mary Whooley, MD, was studying the interplay between depression and heart-disease outcomes. It came down to poorer health behaviors, particularly regarding physical activity.
“It was obvious that cardiac rehabilitation was the perfect intervention for this problem,” Beatty said. “It includes exercise and a variety of psychosocial approaches. That led us to study the underuse problems with rehab delivery and to seek solutions. When you get into cardiac rehabilitation, you see how much it affects patients’ lives, how much it means to people. It’s a great cause to fight for and it just feels good.”