Cardiac Rehabilitation: Changes, Challenges, and Clinician Perspectives
Referral for cardiac rehab has been historically poor, despite American College of Cardiology/American Heart Association recommendations.
For individuals who have suffered a cardiovascular event, cardiac rehabilitation (CR) can lead to significant improvements. This comprehensive, multidisciplinary approach that includes exercise, psychological support, lifestyle education, and more has been found to decrease morbidity and improve health-related quality of life.1 However, despite such benefits, as well as recommendation by the American College of Cardiology/American Heart Association,2 evidence suggests the service is underused, partly because of provider factors and partly because of patient factors.3
A new study published by researchers at the University of Washington and the University of Colorado, for example, reported CR referral rates of 48% among patients with percutaneous coronary intervention (PCI) and 91% among patients who underwent cardiac surgery.3 The researchers found that the strongest predictor of referral was the hospital performing the procedure, more so than patient characteristics for PCI (hospital referral range, 3%-97%; median odds ratio [OR], 5.94; 95% CI, 4.10-9.49) or cardiac surgery (range, 54%-100%; median OR, 7.09; 95% CI, 3.79-17.80). Only 10% of the variation in PCI referral was accounted for by hospitals having an outpatient CR program.
For the latest CR updates, Cardiology Advisor spoke with Jonathan Ledyard, MS, RCEP, director of cardiopulmonary rehabilitation at the University of Pittsburgh Medical Center Heart and Vascular Institute in Pennsylvania, and Monica Mukherjee, MD, MPH, FACC, FASE, an assistant professor of medicine at Johns Hopkins University Division of Cardiology in Baltimore, Maryland.
Cardiology Advisor: Some data show that physician referral of patients to CR is poor. What are your thoughts on potential reasons for that?
Dr Mukherjee: Although referrals for CR have improved significantly since EPIC electronic health record (EHR) implementation, we may be missing many patients. A reason for this is the assumption by the primary providers that the discharging physicians have ordered CR, and vice versa. There is also a lack of education in both inpatient and outpatient providers on the importance of CR in improving outcomes in cardiac patients. CR encompasses more than physical activity, it is a comprehensive approach to lifestyle modification, with medication reconciliation, nutritional classes, smoking cessation, heart health, risk factor education, and psychosocial support.1 There also tends to be a bias that CR is only for older patients with physical limitations, when it has much to offer to all patients, regardless of age, comorbid conditions, and physical ability.
Mr. Ledyard: According to a study published in the Journal of the American College of Cardiology in 2009, 1 of the strongest factors for patient participation in CR is the strength of conviction of the physician making the referral.4 If the physician believes and conveys the importance passionately, patients are more likely to participate.
The next most significant barriers are copays and other costs followed by access: there are not enough programs within a reasonable distance from patients' homes. [Editor's note: Home-based programs are on the rise, and a recent review revealed few differences in outcomes between patients who attended home-based vs center-based programs. Additional research in this area is warranted.5]
Cardiology Advisor: How has cardiac rehab changed over the years in terms of recent developments, discoveries, or trends?
Dr Mukherjee: The structure of CR has changed over the years as the American Association of Cardiovascular and Pulmonary Rehabilitation has placed more emphasis on patient-centered outcomes and a comprehensive treatment plan that encompasses concomitant psychosocial treatment. Since Medicare began covering heart failure with reduced ejection fraction a little more than 3 years ago, our volumes, and therefore focus, have also shifted. Last, the demographics of patients have also changed, with younger patients now participating in CR more often.
Mr. Ledyard: The Cardiac and Pulmonary Rehabilitation Act was passed by Congress in 2008. Since then:
- Centers for Medicare & Medicaid Services (CMS) reimbursement has increased more than 130%.
- The American College of Cardiology PCI registry is now expecting that patients leaving the hospital after a PCI receive a referral to an outpatient CR or a documented reason as to why they did not.
- The Society of Thoracic Surgery registry is now expecting that patients who have had bypass surgery and valve replacement or repair leave the hospital with an outpatient CR referral or a documented reason as to why they did not.
- Covered diagnoses expanded to include chronic systolic heart failure (left ventricular ejection fraction <35%) in February 2014.
- About 3 weeks ago, coverage was expanded to include supervised exercise therapy for patients with symptomatic peripheral artery disease.
- CMS is now evaluating the possibility of offering a financial incentive to hospitals that get more patients to participate and stay longer in CR.
Cardiology Advisor: What are some of the challenges that clinicians face in getting patients to participate in cardiac rehab?
Mr. Ledyard: Having an inpatient program with adequate staffing is very important. Every patient with a qualifying diagnosis should have standing order sets that include an automatic order for inpatient CR staff to see. We also give every patient a brochure, explain the program, and put the location and telephone number of the closest center on their discharge instructions.
In addition, there are not enough programs to refer patients to, leaving many people and communities underserved. For those that do exist, there is a lack of transportation for some elderly or low-income patients. In addition, getting insurance companies to drop copays for these patients [is an issue]. Most payers, including Medicare, charge a copay, while most Medicare Advantage plans pay in full since the supplement picks up the copay.
Dr Mukherjee: Many patients are limited by transportation to and from rehab facilities, parking fees, insurance copays and expense, limitations related to CR operating times and patient working hours, and lack of engagement from referring physicians. In fact, we have found that patients who have received encouragement from their primary and referring physicians to participate in rehab have had the most benefit.
Cardiology Advisor: What are other issues or needs in this area?
Mr. Ledyard: At UPMC, we are beginning to use technology to both supplement and provide alternative models of CR delivery. We have an app that many patients use to get more education, medication reminders, and feedback to their therapist in many different areas. We need more resources to [perform] research and implement the use of technology and alternative methods of delivery. Also, up to 20% of post-MI patients are depressed.6 We do depression screenings on every patient, and [the incidence] runs about 12% for patients who attend. This leads me to believe that depression is likely a barrier for some patients.
Dr Mukherjee: The growth of CR programs is largely reliant on space, physician coverage, and operating times to accommodate the working patient. The last component to CR that would help attendance would be support and encouragement from the primary physicians and cardiologists to attend rehab consistently as part of their longitudinal care.
Please note: This interview was edited for clarity.
- Taylor RS, Dalal H, Jolly K, Moxham T, Zawada A. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2010;(1):CD007130. doi:10.1002/14651858.CD007130.pub2
- Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147-239.
- Beatty AL, Bradley SM, Maynard C, McCabe JM. Referral to cardiac rehabilitation after percutaneous coronary intervention, coronary artery bypass surgery, and valve surgery: data from the clinical outcomes assessment program. Circ Cardiovasc Qual Outcomes. 2017;10(6):e003364.
- Brown TM, Hernandez AF, Bittner V, et al. Predictors of cardiac rehabilitation referral in coronary artery disease patients. J Am Coll Cardiol. 2009;54(6):515-521.
- Anderson L, Sharp GA, Norton RJ, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2017;6:CD007130. doi:10.1002/14651858.CD007130.pub4
- Kala P, Hudakova N, Jurajda M, et al. Depression and anxiety after acute myocardial infarction treated by primary PCI. PLoS One. 2016;11(4):e0152367. doi:10.1371/journal.pone.0152367