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Effect of a Home-Based Exercise Intervention of Wearable Technology and Telephone Coaching on Walking Performance in Peripheral Artery Disease: The HONOR Randomized Clinical Trial McDermott MM, Spring B, Berger JS, Treat-Jacobson D, Conte MS, Creager MA, et al. JAMA 2018;319:1665-76. Study design: Randomized clinical trial conducted at threeU.S.medical centers between June 18, 2015 andApril 4, 2017. Key findings: A total of 200 patients with peripheral arterial disease (PAD) were randomized to home-based exercise consisting of on-site sessions for the first month, active exercise, and coaching (99 patients) vs usual care (101 patients) for 9 months. The mean change in walking distance was better in the usual care group than in the exercise group. Conclusion: A home-based exercise program consisting of a wearable activity monitor and telephone coaching did not improve walking performance at 9-month follow-up. These results do not support home-based exercise program of wearable devices and telephone counseling without periodic on-site medical center visits to improve walking performance in patients with PAD. Commentary: Clinical practice guidelines recommend either supervised treadmill exercise (class IA recommendation) or home-based walking exercise (class IIA recommendation) as first-line therapy to improve walking in patients with lower extremity PAD. But importantly, both programs required frequent visits to the medical center. But, how often should these visits be required? In this randomized study, the exercise group received four weekly medical center visits during the first month, followed by 8months of a wearable activity monitor and telephone coaching. The authors suggest increased frequency of periodic on-site visits might have yielded improvedresults. I assume that they mean that if the subjects had visited the medical center three or four times a week instead of once a week, or if they continued to visit the medical center for the full 9-month trial, the exercise program would have resulted in improved walking distances. The study emphasizes that simply telling patients to walk more or involving them in a less than strenuous walking program to improve claudication will not do much good. The problem is that not many vascular surgeons have access to rigorous exercise programs to treat claudication. Until that happens, and until reimbursements for such exercise programs become widespread, the only realistic noninterventional options to treat disabling claudication due to PAD are cilostazol and smoking cessation programs.