In this era of healthcare financial reform, there is a growing consensus that treatments should be cost-effective, decrease disability, and improve survival. There is also increasing recognition that healthcare should be co-ordinated among clinicians and care settings, and that patients should be involved in the decision-making process. Cardiac rehabilitation (CR) programs are ideally situated to help physicians and patients individualize and optimize secondary prevention, as well as decrease disability, across the care continuum.
Phases of Cardiac Rehabilitation
CR is an integral component in the overall management of patients with cardiovascular disease and begins during the acute care hospitalization. Typically, patients are referred to early outpatient CR at discharge, which includes supervised, monitored exercise along with education and counseling related to secondary prevention issues. Selected elderly patients may be referred for intensive inpatient rehabilitation to improve mobility and function, typically in an acute inpatient rehabilitation facility.
Upon ‘graduation’ from early outpatient CR, patients are encouraged to continue lifelong regular physical activity and compliance with secondary prevention activities. Many CR programs offer maintenance courses for these patients—typically self-pay supervised exercise, education, and support. Alternative delivery models have been developed in research settings but are not widely used at this time, often due to limited reimbursement (see Figure 1).
CR programs provide multidisciplinary and multidimensional lifestyle and medical therapies for patients who are recuperating from a cardiovascular event. Recent evidence clearly shows that patients who participate in CR have reduced all-cause mortality. In a study of five-year mortality data in 601,099 Medicare beneficiaries who had suffered a cardiac event, Suaya et al. demonstrated that those who attended CR had significantly decreased mortality compared with those who did not. This ranged from a 34% decrease using propensity-based matching to a 21% decrease including instrumental variables. Patients who attended 25 or more sessions had a 19% lower likelihood of dying over five years relative to matched CR users who attended 24 or fewer sessions (p<0.001).1
Underutilization of Cardiac Rehabilitation
The biological, psychological, and clinical benefits of CR were reviewed in US Cardiology in 2008 by Lavie and Milani.2 Despite clear and consistent evidence that CR improves health status, decreases disability, and improves survival,1,3,4 underutilization remains an issue, particularly for minority, elderly, and female patients. Approximately 20–30% of eligible patients participate in CR following a qualifying cardiovascular disease event, with significant geographical variation in CR participation across the US.5,6 Professional associations including the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), American College of Cardiology (ACC), and American Heart Association (AHA) have recognized this treatment gap. They have published joint performance measures related to CR referral and programming in order to promote quality improvement efforts by healthcare systems and professionals.7 These measures were intended to enhance care co-ordination by promoting referral to CR as well as by defining minimal standards for quality CR programming.
CR begins during the acute care hospitalization of patients with cardiovascular disease. As length of stay has decreased, by necessity inpatient CR has focused on mobilization and identification of high-risk behaviors, such as tobacco use. Often there is insufficient time and opportunity to address other secondary prevention issues during inpatient rehabilitation, such as nutrition, weight loss, adherence to preventive medications, and regular aerobic exercise. Fortunately, these issues are stressed during outpatient CR programs.8 Systems are often lacking, however, to ensure that patients enroll in CR after discharge.
Effective referral includes communication between the referring healthcare provider, the patient, and the CR program organizer that a referral has been made. Sufficient information needs to be given to the patient to allow him or her to easily enroll in CR. Unfortunately, earlier versions of referral measures did not include the requirement for adequate communication and did not effectively increase CR participation. For example, data from a large teaching hospital in Boston revealed that although referral to CR increased to 55% during a quality improvement project, only 19% actually enrolled.9 Approximately 25% of patients, when contacted after hospital discharge, did not remember being referred to CR.9 For this reason, the current CR performance measures define a referral as: “an official communication between the health care provider and the patient to recommend and carry out a referral order to an early outpatient CR program. This includes the provision of all necessary information to the patient that will allow the patient to enroll in an early CR program. This also includes a communication between the health care provider or health care system and the CR program that includes the patient’s referral information for the program.”7
These referral-to-CR performance measures have been incorporated into the ACC/AHA Performance Measure Set for Non-STEMI/STEMI10 and into quality improvement registries such as the National Cardiovascular Data Registry (NCDR).11 AACVPR has provided members with a referral enhancement toolkit that includes sample order sets, scripts, data tracking, marketing tools, and PowerPoint presentations to use with professional and lay audiences.12
Some healthcare systems use CR staff to evaluate and mobilize patients after acute cardiac events or open-heart surgery, which can enhance understanding about the importance of participating in CR. Other centers are incorporating a referral to CR field in electronic discharge order sets for patients with qualifying discharge diagnoses.13
Barriers to Enrollment in Cardiac Rehabilitation
Despite progress in developing systems to enhance referral, however, significant barriers to enrollment remain, especially for the elderly, women, and minorities.
Increasing Enrollment of Elderly Patients
Elderly patients clearly benefit from CR and the percentage improvement actually exceeds that for younger individuals.1,14,15 There is often an under-referral bias, in part because physicians and other healthcare providers are not aware of the benefits and do not realize that newer treadmills and recumbent bicycles provide low-intensity exercise appropriate for elderly patients.
Depression, social isolation, decreased endurance and strength, and decreased functional capacity for activities of daily living are real problems for these patients. CR programs address and improve all of these issues.14,15 Family support and transportation are often barriers to participation and creative use of community resources may be needed.
Fortunately, Medicare recognizes the benefits of CR, including its comprehensive nature. The most recent coverage determination policy includes patients with recent open-heart surgery, including valve or coronary bypass surgery, percutaneous intervention, myocardial infarction, or transplantation.16 This policy also extends the maximum duration of CR from 12 to 18 weeks (with a maximum of 36 sessions covered). It recognizes that sessions without telemetry monitoring may be appropriate for some patients, which allows programs to be more flexible and to for programming to be individualized. Despite this, underutilization remains a problem.
Nurse-led co-ordination of care before and after hospital discharge may be a strategy to increase enrollment in CR for older patients. Case management systems for high-risk patients, follow-up telephone contact by the CR program, and involvement of CR staff in inpatient rounds and rehabilitation care have been described as potential strategies to increase enrollment.17,18 Carroll et al. used a collaborative peer advisor/advanced practice nurse intervention in 247 unpartnered older adults following myocardial infarction or coronary artery bypass graft to improve enrollment in CR.19 Treatment consisted of a home visit within 72 hours after discharge and follow-up telephone calls from an advanced practice nurse and a peer advisor. Compared with usual care, significantly more patients were participating in CR after three months in this treatment group and there was a trend toward fewer re-hospitalizations.
Inpatient Rehabilitation for Elderly Patients
Some elderly patients are not appropriate for referral to an outpatient CR program immediately after discharge from acute care, especially those over 75 years of age who have had open-heart surgery. They have significant medical deconditioning and are often unable to dress, shower, walk around the house, or cook meals. These patients can benefit from transfer to an inpatient rehabilitation facility (IRF). Typically, they participate in three or more hours of physical and occupational therapy per day, working on independence in activities of daily living, independent ambulation, understanding medications and self-management principles, and increasing physiological ability and psychological confidence for return to home, often alone. Medical issues are also monitored and addressed, including fluid status, wound care, arrhythmias, diabetes, blood pressure, and pulmonary status.14
Facilities providing this care track outcomes for quality improvement. Data from eRehab, one of the large IRF data registries, show that in 2008 the average length of stay for these patients (n=4,786) was 10.7 days. Percentage gain in functional independence measure was 28% at discharge and an additional 18% at three months. Seventy-nine percent were discharged home and 82% were still living at home at three months, with 4.5% three-month mortality.20 Unless patients have significant barriers to enrollment, such as dementia, all patients should be referred to an outpatient CR program close to their home at discharge.
Barriers to Cardiac Rehabilitation Utilization in Women
Women are 50% less likely to participate in CR compared with men21 despite equal benefit1 and endorsement in clinical practice guidelines.22 Again, some of this underutilization may be related to referral bias,23 since CR programs were originally designed to return young men to work. Over the past three decades, however, CR has progressed to a comprehensive program for all patients. CR includes individualized treatment plans that address secondary prevention issues and promote lifelong exercise, communication with other healthcare providers about issues such as depression or uncontrolled risk factors, and use of exercise equipment more appropriate for women and elderly patients.7,8,24,25
In addition to provider, system, and environmental barriers common to all patients, women have additional unique barriers to enrollment in CR. Women have the same misconceptions about CR as providers, often considering CR to only include exercise in a gym environment, which is an unfamiliar culture for many middle-aged and elderly women. Some are embarrassed by exercising in a group setting or have co-morbidities, such as obesity, arthritis, osteoporosis, or urinary stress incontinence, that require special attention during exercise. They also have conflicting attitudes about attending CR, often concerned that this may take them away from their responsibilities at home.17
Recently, investigators have been studying innovative CR program models specifically designed for women. Davidson et al. described a Heart Awareness for Women Program, consisting of a six-week program in which groups of five to 10 women met weekly for two hours in the CR department for a facilitated session designed to promote education and awareness, social support, and strategies for behavior change.26
A nurse facilitator promoted mutual support and sharing of commonality of experience, views, and emotions. Participants also attended CR exercise sessions. At the end of the program, participants (n=48) completed questionnaires to evaluate psychosocial outcomes. Although results were not statistically significant for changes in depression, stress, or anxiety scores from pre-intervention to post-intervention, they were able to identify four themes from qualitative data:
- lack of understanding/awareness of symptoms prior to participation in CR;
- feelings of isolation following the event;
- not prioritizing their own health, putting the needs of other family members ahead of their own; and
- appreciating the benefits of supportive education/awareness.
Other investigators have described innovative program models such as women’s-only exercise sessions and peer support activities. A recent article by Parkosewich is an excellent summary of barriers and opportunities for women in CR. 17
Underutilization of Cardiac Rehabilitation by Minority Patients
Despite receiving similar mortality benefit from participation in CR, minority patients are less likely to participate.1,5,27 Non-white women are less likely to be referred to CR and are more likely to report financial barriers.27 Barriers to access for minority patients with socioeconomic challenges include unavailability of CR programs in cities and rural areas, few minority professionals in CR, inconsistent reimbursement by Medicaid programs, transportation issues, and programs that are perceived as culturally insensitive. Inner-city hospitals often struggle financially and concentrate resources on high-volume or higher-profit activities rather than on innovative CR programming. Increasing participation in CR by minority patients and training minority CR professionals should be priority areas for research and quality improvement in the future.
The Role of Cardiac Rehabilitation in Co-ordination of Care
CR professionals are often the link between patients and their healthcare providers after an acute cardiac event and during continued secondary prevention efforts. Patients are often confused and frightened, but are unable to admit this or to articulate it during a 10- minute office visit. During intake evaluations at a CR program, patients are assessed for knowledge about their condition and medications, continued unhealthy behaviors such as tobacco use and poor nutritional habits, and psychosocial dysfunction.8
Quality improvement programs, such as the AACVPR program certification process28 and the CR performance measures,7 stress the importance of:
- development of individualized treatment programs;
- communication with referring and other healthcare professionals when appropriate; and
- measuring and assessing individual and program outcomes.
In addition, CR professionals are trained to assess patients for signs and symptoms suspicious for recurrent unstable cardiac conditions, helping patients receive prompt medical attention. CR professionals also serve as informal health coaches, using basic principles of readiness-to-change and motivational interviewing techniques to help patients alter unhealthy behaviors and learn self-management techniques. They often help patients improve communication skills to use with their healthcare providers, teaching them to distinguish individual important issues that need medical attention or discussion.
The Future of Cardiac Rehabilitation—Alternative Delivery Models
Alternative models of delivering CR will be needed in the future to provide effective services to all patients. Some of these models have been described above. For several years, AACVPR has sponsored an Innovation Award to encourage CR professionals to think ‘outside the box’ to improve service delivery.29 Some of the winners of the award have expanded services beyond traditional CR to include long-term case management, heart failure exercise programs, and provision of rehabilitation and secondary prevention services to patients with ‘cardiovascular disease equivalents,’ such as diabetes and peripheral arterial disease. Many other CR programs also provide supervised maintenance or wellness programs, community outreach activities, and co-ordinated services with heart failure, bariatric, and diabetic exercise programs.30
Many patients are unable to come to CR facilities for supervised exercise and education due to transportation issues, distance, or disability. The Agency for Health Care Policy and Research clinical practice guidelines for CR31 recognized this issue and advocated transtelephonic and other means of monitoring, surveillance, and education/counseling to extend services beyond traditional facility-based programs. Although there have been several studies demonstrating that Internet-based, transtelephonic, community-based, and nurse-managed delivery models are effective,32,33 unfortunately there is currently no reimbursement for these models and they are not widely used for early outpatient CR.
Not only does CR improve functional capacity and decrease morbidity/ mortality, it also improves care co-ordination for patients after an acute cardiac event and during their recovery period. Unfortunately, CR is underutilized, especially by the patients who can achieve the most benefit. Professional organizations such as the AACVPR, ACC, and AHA are promoting quality improvement efforts related to CR enrollment and programming. Future work includes the development of cost-effective alternative delivery models that extend participation to currently underserved populations.