In spite of growing scientific evidence of the benefits of cardiac rehabilitation and secondary prevention programs, these programs remain underutilized, with fewer than 30% of eligible patients participating. This occurs despite evidence that participation in cardiac rehabilitation is associated with a mortality benefit of approximately 20–25%.1 Although barriers to participation are multifaceted, a major first step is to correct problems with initial referral and to standardize the level of care provided to patients enrolled in cardiac rehabilitation. With this in mind, a writing committee combining experts from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACPR), the American College of Cardiology (ACC), and the American Heart Association (AHA) recently published a set of performance measures related to referral to cardiac rehabilitation and to delivery of cardiac rehabilitation and secondary prevention services. This article will summarize those recommendations, including the rationale and evidence base for these measures.
Definition of Cardiac Rehabilitation and Secondary Prevention Programs
When first developed over three decades ago, cardiac rehabilitation programs were supervised inpatient and outpatient exercise training programs for the physical rehabilitation of patients following a myocardial infarction or coronary artery bypass graft surgery. In recent years, cardiac rehabilitation programs have evolved into ‘secondary prevention’ centers that deliver a wide array of services aimed at both the rehabilitation of patients with significant cardiovascular diseases and the provision of preventive therapies to reduce the risk of recurrent cardiovascular disease events.
The writing committee used the US Public Health Service (PHS) definition of cardiac rehabilitation: “Cardiac rehabilitation services are comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk-factor modification, education, and counseling. These programs are designed to limit the physiological and psychological effects of cardiac illness, reduce the risk of sudden death or re-infarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients.”2
Cardiac rehabilitation and secondary prevention services are generally provided in three phases: inpatient cardiac rehabilitation, early outpatient cardiac rehabilitation (also known as phase 2), and long-term outpatient cardiac rehabilitation (also known as phases 3 and 4). The recently released performance measures are primarily related to early outpatient cardiac rehabilitation.
Several years ago, the ACC and AHA developed a strategy to facilitate the process of improving clinical care, which included the creation of clinical practice guidelines written to establish standards for the clinical care of patients with various cardiovascular disease conditions. While clinicians have become largely aware of these clinical guidelines, that awareness has not led to large-scale application of the guidelines and subsequent improvements in clinical care. With this in mind, new methods have emerged to stimulate the application of clinical care guidelines to clinical practice. One method that appears to hold promise is the use of performance measures, which are specific indicators that identify how well a clinician or group has applied practice guidelines.
The ACC/AHA Task Force on Performance Measures was developed in 2000 to spearhead the development of performance measures. This document, which sets a standard for the process of identifying, constructing, and refining measures, was used as the basis on which the cardiac rehabilitation/secondary prevention performance measures document was developed.3 The committee began by identifying 39 factors as potential performance measures from practice guidelines and other reports. Those measures deemed to be most evidence-based, interpretable, actionable, clinically meaningful, valid, reliable, and feasible were included in the final performance set. Two performance measure sets were created—one related to the appropriate referral of patients to cardiac rehabilitation and another related to the optimal performance of a cardiac rehabilitation program.
Performance Measures Related to Early Outpatient Cardiac Rehabilitation Referral
An important barrier to getting patients into cardiac rehabilitation programs is the lack of patient referral by the clinician at the time of the qualifying cardiovascular event. This barrier, thought to be the barrier that is most easily corrected of all potential barriers to cardiac rehabilitation participation, was the focus of the first set of performance measures developed by the writing committee. This brief set was designed so that it could be used as part of the cardiac rehabilitation and secondary prevention performance measures, and also so that it could be ‘plugged into’ other performance measure sets for certain cardiovascular conditions, acute myocardial infarction, percutaneous intervention, coronary artery bypass graft surgery, stable angina, heart-valve surgical repair or replacement, or heart or heart/lung transplantation (see Table 1).
The rationale for these measures is that referral to cardiac rehabilitation is an ACC/AHA Class I recommendation in clinical practice guidelines for these disease states. In addition, international guidelines, including the British Medical Journal: Clinical Evidence handbook, clearly recognize cardiac rehabilitation as a beneficial non-drug treatment.4,5
The first measure within this set is aimed at assessing the number of eligible patients who are referred to a cardiac rehabilitation or secondary prevention program from an inpatient setting. It is designed to ensure that all hospitalized patients with a qualifying cardiovascular event are referred to an early outpatient cardiac rehabilitation program prior to discharge. The second measure is targeted to the referral of outpatients who have not enrolled in a cardiac rehabilitation program after hospital discharge and, instead, have fallen into a gap in preventive care. This second performance measure is designed to ensure that all outpatients with qualifying diagnoses are being referred by their healthcare provider in the outpatient setting. Responsible parties for this measure set include the hospitals, healthcare systems, physician practices, and other healthcare settings with primary responsibilities for the care of patients after a cardiovascular event. Sample order sets with a suggested script are provided to facilitate appropriate referral and to encourage healthcare providers to develop systems that enhance the likelihood that patients will participate in cardiac rehabilitation programs.
Performance Measures to Define Quality Early Outpatient Cardiac Rehabilitation Programs
The second set of performance measures included in the cardiac rehabilitation/secondary prevention document is aimed at the appropriate delivery of services to patients who are enrolled in such programs. The set was designed to help assess the quality of services provided by a cardiac rehabilitation or secondary prevention program, using standards that have been developed previously by national and international healthcare organizations. The standards or core components of cardiac rehabilitation/secondary prevention programs have been described previously in a 2007 AHA/AACPR scientific statement, and include patient assessment, nutritional counseling, lipid management, hypertension management, tobacco-use cessation, weight management, diabetes management, psychosocial management, physical activity counseling, and exercise training.6 In addition, guidelines and consensus statements related to cardiac rehabilitation/secondary prevention stress the importance of physician leadership, communication with other healthcare practitioners, such as treating physicians, outcomes assessment and analysis, and provision of a safe exercise environment.7,8,9 The performance measures writing group used these publications as primary sources to develop measures to define quality cardiac rehabilitation/secondary prevention programming.
The performance measures from this set are briefly listed in Table 2. A set of structural measures (B-1) was developed to ensure appropriate emergency response during exercise sessions, and to stress oversight by a physician so that policies and procedures are consistent with evidence-based guidelines. Individualized assessment of patients for adverse cardiovascular events during the course of rehabilitation is stressed in measure set B-2. Set B-3 includes individualized assessment and intervention related to modifiable cardiovascular risk factors, and encourages a cycle of assessment, individualized treatment, communication with patients and treating physicians, continuous reassessment, and repeated communication as needed. Target goals and suggested intervention plans are based on clinical practice guidelines and scientific statements such as the AHA/ACC Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2006 Update.10 A sample tracking tool is included to encourage this process. The final measure set (B-4) encourages programs to monitor response to therapy, document program effectiveness, and initiate quality improvement strategies.
Cardiac rehabilitation performance measures were developed to help healthcare providers, healthcare systems, and cardiac rehabilitation programs bridge the treatment gaps that currently exist in the delivery of secondary prevention services for patients with cardiovascular disease. The first set of measures is related to cardiac rehabilitation referral, and was designed to be used separately or as ‘plug-ins’ for performance measure sets for other cardiovascular conditions. The second set of performance measures is focused on the appropriate delivery of cardiac rehabilitation/secondary prevention services by programs designed to carry out such services. The set is designed to encourage cardiac rehabilitation programs to assess their own performance related to safety, physician involvement, individualized assessment of and intervention for modifiable cardiovascular risk factors, communication with appropriate healthcare professionals, and outcomes assessment and analysis. These measures are intended to promote continuous quality improvement related to cardiac rehabilitation and secondary prevention programs in order to optimize composite and individual patient health-related outcomes.
The next step after the release of these performance measures will be for clinicians, group practices, healthcare systems, healthcare organizations, and other interested parties to monitor the acceptance, use, and impact of the performance measures on bridging the important treatment gap that currently exists in the delivery of life-saving secondary prevention services to patients with cardiovascular disease.