Implementing a Home-based Cardiac Rehabilitation Program Among Rural Patients With Heart Failure

Background and Significance:

Rural communities in the United States experience a disproportionate burden of cardiovascular disease and associated adverse outcomes, with recent epidemiological data demonstrating a widening mortality gap compared to urban populations. These disparities are particularly pronounced in cardiovascular care delivery, where rural-residing adults demonstrate significantly lower rates of guideline-directed therapies for coronary heart disease, heart failure, and stroke. Among the most substantial gaps identified is the utilization of cardiac rehabilitation services, with total participation among Medicare beneficiaries reaching only 5% in rural areas. This disparity is compounded by the intersection of multiple risk factors including reduced access to healthcare services, lower socioeconomic status, and geographic barriers to specialized care.

The emergence of telemedicine platforms presents a novel opportunity to address these healthcare access disparities through innovative service delivery models. The COVID-19 pandemic has catalyzed the adoption of digital health technologies, with telemedicine visits among rural Medicare beneficiaries increasing nearly 100-fold between 2019 and 2020. Concurrent improvements in rural broadband access, with over 70% of rural adults reporting home broadband availability in 2021, have created an infrastructure foundation supporting telehealth interventions. Mobile health (mHealth) interventions have demonstrated efficacy in cardiovascular care through patient monitoring, medication adherence support, and risk factor management, with preliminary evidence suggesting effectiveness in reducing rehospitalizations and increasing patient participation in cardiac rehabilitation programs.

Study Design and Methodology:

This investigation employs a randomized, open-label, Type 1 hybrid effectiveness-implementation trial design to evaluate the efficacy and implementation characteristics of an mHealth-enabled home-based cardiac rehabilitation program. The study will enroll 332 adult participants with recent hospitalization for heart failure with ejection fraction ≥35%, stratified with 70% recruitment from rural hospitals and 30% from urban centers to enable comparative analysis of implementation challenges across geographic settings. Participants will be randomized in a 1:1 ratio to receive either the mHealth cardiac rehabilitation intervention or attention control, with outcomes assessed over a 6-month follow-up period.