Cardiac Rehabilitation: Underutilized Care Offering Substantial Benefits.
Adam deJong, M.A., FACSM, is the cardiology manager at William Beaumont Hospital in Royal Oak, MI, and is a faculty lecturer in the School of Health Sciences at Oakland University in Rochester, MI. He earned his Bachelor of Applied Arts and Master of Arts degrees in Exercise Science from Central Michigan University. He currently serves as chair of the ACSM International Certification and Professional Education committees.
Disclosure: The author declares no conflict of interest and does not have any financial disclosures.
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.
1. Ades PA, Waldmann ML, Polk DM, Coflesky JT. Referral patterns and exercise response in the rehabilitation of female coronary patients aged greater than or equal to 62 years. Am J Cardiol
2. Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med
3. Allen JK, Benz Scott L, Stewart KJ, Rohm Young D. Disparities in women’s referral to and enrollment in outpatient cardiac rehabilitation. J Gen Intern Med
4. Anderson JL, Adams CD, Antman EM. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol.
5. Balady GJ, Williams MA, Ades PA, et al.
Core components of cardiac rehabilitation/secondary prevention programs: 2007 update. J Cardiopulmonol Rehabil Prev
6. Barber K, Stommel M, Kroll J, Holmes-Rovner M, McIntosh B. Cardiac rehabilitation for community-based patients with myocardial infarction: factors predicting discharge recommendation and participation. J Clin Epidemiol.
7. Benz Scott LA, Ben-Or K, Allen JK. Why are women missing from outpatient cardiac rehabilitation programs? A review of multilevel factors affecting referral, enrollment, and completion. J Women Health
8. Brown TM, Hernandez AF, Bittner V, et al.
Predictors of cardiac rehabilitation referral in coronary artery disease patients: findings from the American Heart Association’s Get With The Guidelines Program. J Am Coll Cardiol
9. Chow CK, Jolly S, Rao-Melacini P, Fox KA, Anand SS, Yusuf S. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation
10. Cortés O, Arthur HM. Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review. Am Heart J
11. Dunlay SM, Witt BJ, Allison TG, et al.
Barriers to participation in cardiac ehabilitation. Am Heart J
12. Eagle KA, Guyton RA, Davidoff R. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: summary article — A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). J Am Coll Cardiol
13. Evenson KR, Rosamond WD, Luepker RV. Predictors of outpatient cardiac rehabilitation utilization: The Minnesota Heart Survey Registry. J Cardiopulmonol Rehabil
14. Fraker Jr TD, Fihn SC, Gibbons RJ. 2007 Chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Group to Develop the Focused Update of the 2002 Guidelines for the Management of Patients With Chronic Stable Angina). J Am Coll Cardiol
15. Giannuzzi P, Mezzani A, Saner H, et al.
Physical activity for primary and secondary prevention. Position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. Eur J Cardiovasc Prev Rehabil
16. Giannuzzi P, Temporelli P, Marchioli R, et al.
Global secondary prevention strategies to limit event recurrence after myocardial infarction. Results of the Gospel study, a multicenter, randomized controlled trial from the Italian Cardiac Rehabilitation Network. Arch Intern Med
17. Grace SL, Evindar A, Abramson BL, Stewart DE. Physician management preferences for cardiac patients: factors affecting referral to cardiac rehabilitation. Can J Cardiol
18. Grace SL, Gravely-White S, Brual J, et al.
Contribution of patient and physician factors to cardiac rehabilitation enrollment: a prospective multilevel study. Eur J Cardiovasc Prev Rehabil
19. Grace SL, Scholey P, Suskin N, et al.
A prospective comparison of cardiac rehabilitation enrollment following automatic vs. usual referral. J Rehabil Med
20. Harlan WR III, Sandler SA, Lee KL, Lam LC, Mark DB. Importance of baseline functional and socioeconomic factors for participation in cardiac rehabilitation. Am J Cardiol
21. Homko CJ, Santamore WP, Zamora L, et al.
Cardiovascular disease knowledge and risk perception among underserved individuals at increased risk of cardiovascular disease. J Cardiovasc Nurs
22. Jha AK, Li Z, Orav EJ, et al.
Care in U.S. hospitals — the Hospital Quality Alliance program. N Engl J Med
23. O’Connor GT, Buring JE, Yusuf S, et al.
An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation
24. Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. JAMA
25. Shanks LC, Moore SM, Zeller RA. Predictors of cardiac rehabilitation initiation. Rehabil Nurs
26. Smith Jr SC, Feldman TE, Hirshfeld Jr JW, et al.
ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol
27. Stone JA, Arthur HM. Canadian guidelines for cardiac rehabilitation and cardiovascular disease prevention. 2nd ed. Executive summary. Can J Cardiol
. 2005;21(suppl D):3D–19D.
28. Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation
29. Taylor RS, Brown A, Ebrahim S, et al.
Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med.
30. Thomas RJ, King M, Lui K, et al.
AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. J Am Coll Cardiol
31. Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J. AACVPR/ACC/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services. J Cardiopulmonol Rehabil Prev
32. Thomas RJ, Miller NH, Lamendola C, et al.
National survey on gender differences in cardiac rehabilitation programs: patient characteristics and enrollment patterns. J Cardiopulmonol Rehabil
33. Williams MA, Ades PA, Hamm LF, et al.
Clinical evidence for a health benefit from cardiac rehabilitation: an update. Am Heart J
34. Witt BJ, Jacobsen SJ, Weston SA, et al.
Cardiac rehabilitation after myocardial infarction in the community. J Am Coll Cardiol