Cardiovascular disease is the number one cause of mortality in the U.S., attributing to approximately one of every six deaths. In addition, nearly one of every three individuals has been diagnosed with some form of cardiovascular disease. As recommended by numerous professional organizations, cardiac rehabilitation (CR) is an established component of preventive medical care after the diagnosis of coronary artery disease or an acute cardiac event (5,15,27,33). Although CR programs vary in size and scope, the core components include individualized exercise training, patient evaluation, medical surveillance, lifestyle modification, and psychosocial counseling.
BENEFITS ACHIEVED FROM CARDIAC REHABILITATION PARTICIPATION
The core components, when used appropriately, demonstrate well-established benefits in the recovery from cardiovascular disease. Those who participate in CR after an acute cardiac event or diagnosis of cardiovascular disease demonstrate fewer recurrent cardiac events and a reduced need for repeat interventional procedures. CR also has been shown to increase exercise capacity, reduce angina symptoms, improve blood lipid profiles, reduce other risk factors associated with disease development, improve psychosocial well-being, and decrease overall mortality. In fact, those who participate in CR demonstrate an approximate 25% reduction in cardiac mortality during 3 years of follow-up versus those who do not attend (23,24,28,29) while decreasing the risk of several important cardiovascular outcomes, particularly nonfatal myocardial infarction (MI), during that same period (16). In Medicare beneficiaries who undergo percutaneous coronary interventions (PCIs) or cardiac surgery and attend CR, mortality rates have been shown to be up to 34% lower (vs. no CR) (8). Moreover, those who adhere to the significant lifestyle modification taught in traditional CR programs demonstrate a 50% lower chance of a recurrent cardiac event in the first 6 months of recovery (9). CR also is cost-effective, with the cost per year life saved ranging from $4,950 to $9,200 in 1995 dollars (2). Based on these strong outcomes, CR is considered as a class I indication in the management of acute MI (AMI) and other cardiovascular events or conditions (4,12,14,26).
CARDIAC REHABILITATION IS UNDERUTILIZED
Despite the widespread benefits associated with CR, it remains underutilized after the diagnosis of cardiovascular disease or a cardiac intervention. A recent evaluation of Medicare beneficiaries in the United States showed a utilization rate approximating only 14% for patients after an AMI and 31% after a coronary artery bypass surgery (27). Overall, CR is associated with a wide range of utilization (14% to 55%) after AMI (13,18,19,28,34). In addition, older adults, nonwhites, patients with comorbidities, patients with a low socioeconomic status, the unemployed, and single patients, are significantly less likely to participate in CR (13,28).
One additional population demonstrating a reduced likelihood for participation in CR is women (28,32). This is primarily a result of women being less likely to be referred to outpatient CR than men (7,13). This gap in referral is particularly true when racial background is considered because a nearly 60% reduction in referral to outpatient CR is noted in black women when compared with white women (3). Furthermore, women are less likely than men to enter CR, even if a referral has been provided (7). These reasons are multifactorial and can be seen in the Table.
UNDERUTILIZATION OF CARDIAC REHABILITATION TIED TO PHYSICIAN REFERRAL
The American Association of Cardiovascular and Pulmonary Rehabilitation/American College of Cardiology/American Heart Association (AHA) performance measures for CR state that all hospitalized patients with a qualifying cardiovascular event or diagnosis, including AMI, coronary artery bypass surgery (CABG), PCI, cardiac valve surgery, cardiac transplantation, or chronic stable angina, should be referred to CR before hospital discharge (30). Despite these and other guideline recommendations, referral rates to CR remain low. A recent study of 72,817 patients with coronary artery disease reported an overall CR referral rate of 56%. Referral rates ranged from 53% for patients with AMI and 58% for PCI patients to 74% for patients undergoing CABG surgery (8). These rates were lower than those of other AMI quality-of-care performance measures (e.g., medication use), most of which — unlike CR — are publicly reported by the Centers for Medicare/Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations (22). Although several barriers exist to patient participation in CR, physician referral and encouragement have been shown to be a strong motivating factor for patients to attend (1,25). Yet, although this lack of initial referral by the health care provider represents one of the most important impediments to enrollment into a CR program, it also is the most correctable (30). In fact, a recent study of 179 patients with AMI showed that participation in CR is greatly enhanced when the referral by the health care provider comes while the patient is in the hospital, second only to having a cardiologist as the primary provider (11).
Physicians’ attitudes about CR also affect their referral practices (17,18), and the type of provider has a significant effect on the rate of CR referral (6). Aside from the physician’s attitude, four major predictors have been identified for referral by a physician to a CR program. These include prior AMI, insurance coverage, being English speaking, and being admitted to a hospital with existing CR programs (10,20). Other predictors of referral included younger age, CABG surgery, cardiac catheterization, hypertension, hypercholesterolemia, and smoking (21). Similarly, in a more recent study involving hospitals affiliated with the American Heart Association “Get With the Guideline” program, younger age, PCI, CABG surgery, smoking, and dyslipidemia were all associated with increased referral to CR, whereas most other comorbidities were associated with a decreased likelihood of referral (8).
In an effort to address the variability in health care quality and delivery that has been realized during the past decade, performance measures for cardiovascular disease were developed in 2007 (30). Attempting to further improve on the disparity in care that remains relative to CR and, in particular, the gap in referral rates, these performance measures were updated in 2010 to address inpatient and outpatient referral patterns (31). It is anticipated that these quality measures will help address the identified barriers to CR entry while providing easier access and improved delivery to patients. CR professionals can influence this process by working directly with hospital administration to establish automatic referral process upon discharge. The institution of this process can help increase patient participation in CR programs and improve the overall quality of care received after an acute cardiac event. In addition, CR professionals can educate low-referring and non-engaged physicians on the importance of CR and remove barriers that inhibit the referral to outpatient CR. Through process improvements, enhancements to the referral process will help make available consistent and high-quality programming that has been found to greatly enhance the recovery from cardiovascular disease.
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