Research Supporting the Pritikin Program
The Latest Research
Traditional cardiac rehabilitation (CR) improves cardiovascular outcomes and reduces mortality, but less is known about the relative benefit of intensive cardiac rehab (ICR), which incorporates greater lifestyle education. This retrospective cohort study of Medicare Fee-For-Service beneficiaries found that ICR was associated with 12% lower all-cause mortality when compared with CR.
Circulation:
Cardiovascular Quality and Outcomes
Published December 2023
"Intensive Versus Traditional Cardiac Rehabilitation: Mortality and Cardiovascular Outcomes in a 2016-2020 Retrospective Medicare Cohort"
Nature Metabolism
Published June 2023
“Dietary Weight Loss-Induced Improvements in Metabolic Function Are Enhanced by Exercise in People with Obesity and Prediabetes”
Journal of the Endocrine Society
Published June 2023
"Short-Term Intensive Lifestyle Therapy in a Worksite Setting Improves Cardiometabolic Health in People With Obesity"
Journal of Cardiopulmonary Rehabilitation and Prevention
Published November 2022
"Benefits of the First Pritikin Outpatient Intensive Cardiac Rehabilitation Program"
Research Library
The subsequent sections provide an in-depth review of key research supporting the following:
- Intensive Cardiac Rehab (ICR)
- Virtual Cardiac Rehab (VCR) and Virtual Intensive Cardiac Rehab (VICR)
- The Pritikin Program
Each section begins with a brief introduction followed by a complete chronological listing of related research studies, all of which feature a condensed abstract and a link to the full article.
Intensive Cardiac Rehabilitation
Traditional cardiac rehabilitation (CR) is a medically supervised, 36-session treatment program for patients with cardiovascular disease designed to promote optimal recovery after a cardiac event or procedure and to reduce the risk for future cardiac events. As a class 1a recommendation, its results have been proven through decades of research. While cardiac rehabilitation programs do offer patients some instruction on the impact of lifestyle factors such as diet and stress management as they relate to cardiac recovery, exercise is the primary focus.
However, Intensive Cardiac Rehabilitation (ICR) programs, such as that for which Pritikin received CMS approval in 2010, take recovery a step further. Pritikin ICR features the same 36-session exercise regimen as traditional CR, plus 36 education sessions which address the key components of a healthy lifestyle – exercise, nutrition, and mind-set – for a total of 72 sessions. This comprehensive approach equips patients with the tools and knowledge they need for success, both during cardiac rehabilitation and long after the program is complete.
“Intensive Versus Traditional Cardiac Rehabilitation: Mortality and Cardiovascular Outcomes in a 2016-2020 Retrospective Medicare Cohort”
Circulation: Cardiovascular Quality and Outcomes AHA Journal; Vol. 16, Issue 12
Published 1 December 2023
Traditional cardiac rehabilitation (CR) improves cardiovascular outcomes and reduces mortality, but less is known about the relative benefit of intensive cardiac rehab (ICR), which incorporates greater lifestyle education through 72 sessions (versus 36 in CR). This retrospective cohort study of Medicare Fee-For-Service beneficiaries found that ICR was associated with 12% lower all-cause mortality when compared with CR.
“Benefits of the First Pritikin Outpatient Intensive Cardiac Rehabilitation Program”
Journal of Cardiopulmonary Rehabilitation and Prevention; Vol. 42, Issue 6
Published November 2022
Intensive cardiac rehabilitation (ICR) is a comprehensive, medically supervised exercise treatment program covered by Medicare for patients with approved cardiac diagnoses. The aim of this study was to determine the benefits of the first Pritikin outpatient ICR program. The Pritikin outpatient ICR program resulted in improvements in several cardiovascular health indices, including dietary patterns, 6MWT distance, all SPPB components, grip strength, and health-related quality of life. The improvements in anthropometrics and dietary patterns were greater in ICR than in CR.
In this MedAxiom webinar, primary author, Susan B. Racette, Ph.D, reviews this research.
Virtual Cardiac Rehab and Virtual Intensive Cardiac Rehab
Heart disease is the leading cause of death in the United States, and cardiac rehabilitation (CR) offers a proven solution for those who have suffered a cardiac event or undergone a cardiac procedure. Unfortunately, despite decades of research demonstrating that cardiac rehab participation reduces the risk of hospital readmissions and death, it is significantly underutilized during the recovery process.
Past and emerging research has confirmed what we have learned from Pritikin Intensive Cardiac Rehab (ICR) licensed facilities currently utilizing our virtual cardiac rehab platform: home-based cardiac rehabilitation improves clinical outcomes, and it is as safe and effective as facility-based CR and ICR.
- ➨ Home‐Based vs. Center‐Based Cardiac Rehab
- ➨ In-Person and Virtual Cardiac Rehab: Post-Pandemic Update
- ➨ A New Era in Cardiac Rehab Delivery
- ➨ Telehealth Before and After COVID-19
- ➨ In-Person, Hybrid, and Virtual Cardiac Rehab
- ➨ Comparison of Home-Based vs. Center-Based Cardiac Rehab
- ➨ Design and Implementation of a Hybrid Cardiac Rehab Program
- ➨ Disparities in Cardiac Rehab
- ➨ COVID-19 Program Flexibilities
- ➨ Home-Based Cardiac Rehab at the Veterans Affairs
- ➨ Cardiac Rehab During COVID-19
- ➨ Remote Cardiac Rehab as an Alternative to On-Site Services
- ➨ Effects of Home‐Based Cardiac Rehab for Patients with Ischemic Heart Disease
- ➨ Cardiac Rehab Participation and Completion Among Medicare Beneficiaries
- ➨ Home-Based and Hybrid Cardiac Rehab for Heart Failure Patients
- ➨ Home-Based Cardiac Rehab: A Scientific Statement
- ➨ The Veterans Health Administration’s Home-Based Cardiac Rehab Program
- ➨ Hospital vs. Home-Based Exercise Training After CABG Surgery
- ➨ Cardiovascular Complications of Outpatient Cardiac Rehab
“Home‐Based Versus Center‐Based Cardiac Rehabilitation”
Cochrane Database of Systematic Reviews
Published 27 October 2023 (update of a review previously published in 2009, 2015, and 2017)
This review now includes 24 trials which randomized a total of 3,046 participants undergoing cardiac rehabilitation. The review found no evidence of a difference between home‐ and center‐based cardiac rehabilitation in primary outcomes, including total mortality and exercise capacity, for up to twelve months of follow-up. This update supports previous conclusions that home‐ (± digital/telehealth platforms) and facility-based forms of cardiac rehabilitation seem to be similarly effective in improving clinical and health‐related quality-of-life outcomes. This finding supports the continued expansion of home‐based cardiac rehabilitation programs (± digital/telehealth platforms), especially in the context of the COVID-19 pandemic that limited in-person patient access to hospital and community health services.
“Availability and Use of In-Person and Virtual Cardiac Rehabilitation Among US Medicare Beneficiaries: A Post-Pandemic Update”
Journal of Cardiopulmonary Rehabilitation and Prevention; Vol. 43, Issue 4
Published July 2023
The COVID-19 pandemic is associated with persistent declines in cardiac rehabilitation (CR) use among Medicare FFS beneficiaries, which may be partly explained by a reduction in the number of available CR centers. The authors have previously reported that pandemic-related declines of in-person CR disproportionately affected low-income patients, patients residing in rural areas, and patients from the most socially vulnerable communities. Accelerating the uptake of novel models of CR delivery will require policies to ensure continued insurance coverage after the end of the public health emergency, coupled with evaluations of the real-world scalability and cost-effectiveness of these care models in diverse populations.
“A New Era in Cardiac Rehabilitation Delivery: Research Gaps, Questions, Strategies, and Priorities”
Circulation; Vol. 147, Issue 3
Published 17 January 2023
The emergence of new virtual and remote delivery models has the potential to improve access to and participation in cardiac rehabilitation (CR) and ultimately improve outcomes for people with cardiovascular disease (CVD). Although data suggest that new delivery models for CR have safety and efficacy similar to traditional in-person CR, questions remain regarding which participants are most likely to benefit from these models, how and where such programs should be delivered, and their effect on outcomes in diverse populations. This review describes important gaps in evidence, identifies relevant research questions, and proposes strategies for addressing them.
“The State of Telehealth Before and After the COVID-19 Pandemic”
Primary Care: Clinics in Office Practice; Vol. 49, Issue 3
Published 1 December 2022
Telemedicine was underused and understudied until the COVID-19 pandemic, during which reduced regulations and increased payment parity facilitated a rapid increase in telemedicine consultation. Research supports telemedicine's role in acute care and chronic disease management and suggests that it is non-inferior to in-person care for health outcomes in certain conditions. The author outlines several key benefits of telemedicine for both patients and healthcare providers, including convenient and timely access to care that overcomes geographic barriers and reduced burden on medical infrastructure.
“Clinical Outcomes and Qualitative Perceptions of In-person, Hybrid, and Virtual Cardiac Rehabilitation”
Journal of Cardiopulmonary Rehabilitation and Prevention; Vol. 42, Issue 5
Published September 2022
This study of 187 cardiac rehabilitation (CR) patients compared the association of in-person, hybrid, and virtual CR with change in performance on the 6-minute walk test (used to assess exercise capacity) between enrollment and completion. When compared to in-person CR, hybrid and virtual delivery models were associated with similar improvements in functional capacity, and therefore, have the potential to expand availability of cardiac rehabilitation without compromising outcomes.
“Comparison of Home-Based vs Center-Based Cardiac Rehabilitation in Hospitalization, Medication Adherence, and Risk Factor Control Among Patients with Cardiovascular Disease”
JAMA Network Open; Vol. 5, Issue 8
Published 25 August 2022
This cohort study examined the associations of home-based cardiac rehabilitation (HBCR) versus center-based cardiac rehabilitation (CBCR) with hospitalizations, medication adherence, and cardiovascular risk factor control among 2,556 diverse patients with cardiovascular disease and high risk. Results 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 evidence supporting HBCR in previously understudied patient populations.
“A Review of the Design and Implementation of a Hybrid Cardiac Rehabilitation Program: An Expanding Opportunity for Optimizing Cardiovascular Care”
Journal of Cardiopulmonary Rehabilitation and Prevention; Vol. 42, Issue 1
Published January 2022
A facility-based cardiac rehabilitation (FBCR) program is often the first choice for patient participation in cardiac rehabilitation (CR), as it is supported by an extensive evidence base demonstrating effectiveness in decreasing cardiac and overall mortality, as well as improving functional capacity and quality of life. However, to attain the CR participation rate goal of 70% set by the Million Hearts Initiative, CR programming will need to be expanded beyond the confines of FBCR. In particular, hybrid cardiac rehabilitation (HYCR) programs will be necessary to supplement FBCR and will be particularly useful for the many patients with geographic or work-related barriers to participation in an FBCR program.
“A Review of Disparities in Cardiac Rehabilitation: Evidence, Drivers, and Solutions”
Journal of Cardiopulmonary Rehabilitation and Prevention; Vol. 41, Issue 6
Published 1 November 2021
Despite the proven benefits of cardiac rehabilitation (CR) – including functional status, quality of life, and recurrent cardiovascular disease (CVD) events – it is vastly underutilized. There are significant disparities in patient referrals, enrollment, and completion of CR, particularly by race, ethnicity, sex, and socioeconomic status. To incentivize healthcare organizations to reduce these care disparities, the authors identified interventions such as mitigation of economic barriers, novel delivery mechanisms, community partnerships, and health equity metrics.
“COVID-19 Program Flexibilities and Considerations for Their Continuation”
United States Government Accountability Office (goa.gov)
Published 19 May 2021
During the COVID-19 pandemic, the federal government increased funding for Medicare and Medicaid and took steps to ensure that beneficiaries could get health care safely. In its assessment of these COVID-19 flexibilities, the GAO testified that they have benefitted both providers and beneficiaries and confirmed the positive effects of telehealth on patient access.
“Home-Based Cardiac Rehabilitation: Experience from the Veterans Affairs”
Journal of Cardiopulmonary Rehabilitation and Prevention; Vol. 41, Issue 2
Published March 2021
This study of 923 participants evaluated the effectiveness and safety of the Veterans Affairs (VA) national home-based cardiac rehabilitation (HBCR) program. Findings included significant improvements in exercise capacity, depression, cardiac self-efficacy, body mass index, and eating habits. No safety issues were related to HBCR participation, and participants were highly satisfied. The VA HBCR program demonstrates strong evidence of effectiveness and safety to a wide range of patients, including those with high clinical complexity and risk.
“Cardiac Rehabilitation and Implications During the COVID-19 Era”
American College of Cardiology (acc.org)
Published 4 January 2021
Available data suggest that home‐based cardiac rehabilitation (HBCR) is equivalent to center-based cardiac rehabilitation (CBCR). As COVID-19 disrupted the traditional CBCR model, HBCR has been shown to be an effective alternative. Cardiovascular providers must continue to innovate by defining and monitoring patient and CR program outcomes, integrating technology to improve care delivery, assimilate HBCR with CBCR, and ultimately plan for a hybrid model of CR.
“Remote Cardiac Rehabilitation Programs Are Effective Alternatives to On-Site Services”
American Heart Association Scientific Sessions 2020, Presentation P2365 and P664
Published 9 November 2020
According to two studies conducted in Canada and Japan during the COVID-19 pandemic, remote or virtual cardiac rehabilitation programs are effective alternatives to on-site hospital outpatient programs and could help to increase equitable access and participation rates for cardiac patients. In the Japanese study specifically, results indicated that remote cardiac rehabilitation is as effective as outpatient rehab for improvements in short-term prognosis after hospital discharge for patients hospitalized with heart failure. In addition, patients’ quality of life scores one month after discharge were higher in the remote group than the patients in the standard outpatient group.
“Effects of Home‐Based Cardiac Rehabilitation on Time to Enrollment and Functional Status in Patients with Ischemic Heart Disease”
Journal of the American Heart Association, Vol. 9, Issue 19
Published 21 September 2020
Cardiac rehabilitation is an established performance measure for adults with ischemic heart disease, but patient participation is remarkably low. Home-based cardiac rehabilitation (HBCR) may be more practical and feasible, but evidence regarding its efficacy is limited. This study sought to compare the effects of HBCR versus facility-based cardiac rehabilitation (FBCR) on functional status in patients with ischemic heart disease. The study found that patients enrolled in HBCR achieved greater 3-month functional gains than those enrolled in FBCR. This data suggests that HBCR may safely derive equivalent benefits in exercise capacity and overall program efficacy in selected patients.
“Tracking Cardiac Rehabilitation Participation and Completion Among Medicare Beneficiaries to Inform the Efforts of a National Initiative”
Circulation: Cardiovascular Quality and Outcomes AHA Journal; Vol. 13, Issue 1
Published 14 January 2020
Outpatient cardiac rehabilitation is a multidisciplinary, evidence-based intervention shown to improve health outcomes and quality of life when used among patients who have had a qualifying heart disease event or procedure. However, participation in cardiac rehabilitation among eligible patients and completion of the program among those who initiate it has historically been low, with considerable disparities observed by geography and patient characteristics. In 2016, only one in four CR-eligible Medicare beneficiaries participated in CR. Reinforcement of current effective strategies and development of new strategies, including the use of telehealth, will be critical to address the noted disparities and achieve the 70% cardiac rehab participation goal of the Million Hearts Initiative.
“Home-Based Cardiac Rehabilitation Alone and Hybrid with Center-Based Cardiac Rehabilitation in Heart Failure: A Systematic Review and Meta-Analysis”
Journal of the American Heart Association; Vol. 8, Issue16
Published 17 August 2019
Center‐based cardiac rehabilitation (CBCR) has been shown to improve outcomes in patients with heart failure. This study sought to compare CBCR with home-based cardiac rehabilitation (HBCR) and hybrid cardiac rehabilitation, which combines short‐term CBCR with HBCR, potentially allowing both flexibility and rigor. This meta‐analysis concluded that hybrid cardiac rehab significantly improved functional capacity, but only home-based cardiac rehabilitation improved health‐related quality of life (hr‐QOL) over usual care. However, both are potential alternatives for patients who may not have access to center‐based cardiac rehabilitation.
“Home-Based Cardiac Rehabilitation: A Scientific Statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology”
Journal of the American College of Cardiology; Vol. 74, Issue 1
Published 9 July 2019
The purpose of this scientific statement was to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of home-based cardiac rehabilitation (HBCR) in the United States. Its authors state that new cardiac rehabilitation (CR) delivery strategies are urgently needed for the >80% of eligible patients in the United States who do not participate in CR. They identify HBCR as a potential approach to help overcome common barriers to participation, including geographic, logistical, and other access-related barriers.
“Association of Veterans Health Administration Home-Based Programs with Access to and Participation in Cardiac Rehabilitation”
JAMA Internal Medicine; Vol. 178, Issue 5
Publication May 2018
Performance measures recommend referral to cardiac rehabilitation (CR) after acute myocardial infarction (AMI), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG), but CR is vastly underused. Lack of transportation and limited access to CR programs have been identified as two of the largest barriers to participation. To address this issue, the Veterans Health Administration began implementing home-based CR (HBCR) programs and found that, compared with patients hospitalized at a facility that offered referral to offsite CR only, those hospitalized at a facility that offered HBCR had 4-fold greater odds of participating. Additionally, patients offered HBCR were less likely to drop out after the first session than were those for whom HBCR was not available.
“Six-Year Follow-Up of a Randomised Controlled Trial Examining Hospital Versus Home-Based Exercise Training After Coronary Artery Bypass Graft Surgery”
Heart (published by BMJ and BCS)
Published 10 May 2011
This study compared the long-term effectiveness of hospital versus telephone-monitored home-based exercise training during cardiac rehabilitation (CR) on exercise capacity and habitual physical activity. Exercise training initiated in the home environment in low-risk patients undergoing coronary artery bypass graft surgery conferred greater long-term benefit on Vo2 and persistent physical activity compared with traditional hospital-based CR. The total number of hospitalizations (cardiac and non-cardiac) was greater in center-based patients than in the home-based group participating in virtual cardiac rehabilitation; there were no significant between-group differences in clinical events.
“Cardiovascular Complications of Outpatient Cardiac Rehabilitation Programs”
Journal of the American Medical Association
Published 5 September 1986
Research since the 1980s has demonstrated the low risk of major cardiovascular complications in cardiac rehabilitation: only one cardiac arrest per 111,996 patient-hours, 3.4 myocardial infarctions per 293,990 patient-hours, and one death per 783,972 patient-hours.
The Pritikin Program
More than four decades ago, research on the Pritikin program began at UCLA, leading to more than 100 peer-reviewed published scientific studies. It was this research which resulted in Pritikin’s 2010 Medicare approval for a new benefit class called Intensive Cardiac Rehab (ICR), which was developed as CMS recognized the importance of consistent, thorough, evidence-based patient education.
ICR is a benefit class with such stringent requirements that CMS has only approved three programs since its inception. Pritikin not only met, but exceeded its rigorous approval criteria:
- Slowed progression of coronary heart disease.
- Reduced the need for coronary bypass surgery.
- Reduced the need for percutaneous coronary interventions.
- Reduced LDL, triglycerides, BMI, systolic blood pressure, diastolic blood pressure, and the need for cholesterol, blood pressure, and diabetes medications.
Today, ongoing research underscores the power of Pritikin in addressing chronic diseases – including heart disease, hypertension, diabetes, obesity, and cancer – and the significant impact that positive lifestyle interventions and education can have upon their development.
“Dietary Weight Loss-Induced Improvements in Metabolic Function Are Enhanced by Exercise in People with Obesity and Prediabetes”
Nature Metabolism, Vol. 5, Issue 7, 1221-1235
Published 26 June 2023
This study demonstrated that whole-body (primarily muscle) insulin sensitivity (primary outcome) was 2-fold greater after 10% weight loss induced by calorie restriction plus exercise training than 10% weight loss induced by calorie restriction alone in participants. The greater improvement in insulin sensitivity was accompanied by increased muscle expression of genes involved in mitochondrial biogenesis, energy metabolism, and angiogenesis (secondary outcomes) in the Diet+EX group. These results demonstrate that regular exercise during a diet-induced weight loss program has profound additional metabolic benefits in people with obesity and prediabetes.
In this Educational Spotlight from MedAxiom’s 2023 Fall Transforum, primary author Joseph W. Beals, PhD, reviewed this research.
“Short-Term Intensive Lifestyle Therapy in a Worksite Setting Improves Cardiometabolic Health in People with Obesity”
Journal of the Endocrine Society, Vol. 7, Issue 6
Published June 2023
The Pritikin Program, which provides intensive lifestyle therapy, had already been shown to improve cardiometabolic outcomes when provided as a residential program. This short-term, randomized, controlled trial sought to evaluate the feasibility and clinical efficacy of treatment with the Pritikin Program in an outpatient worksite setting. Results demonstrate the feasibility and clinical effectiveness of short-term, intensive outpatient lifestyle therapy in people with overweight/obesity and increased risk of coronary heart disease when all food is provided and the intervention is conducted at a convenient worksite setting.
In this Educational Spotlight from MedAxiom’s 2023 Fall Transforum, primary author David C. Beckner, MD, reviewed this research.
Research Compendium
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