Predictors of Cardiac Rehabilitation Referral

(August 25, 2009) -- Recently, a group led by Todd Brown, MD, MSPH, analyzed data from 72,817 patients discharged alive after a myocardial infarction (MI), percutaneous coronary intervention (PCI), or coronary artery bypass graft surgery (CABG), between January 2000 and September 2007 from 156 hospitals participating in the AHA Get With the Guidelines Program.1 Overall, only 40,972 (56%) were referred to cardiac rehabilitation at discharge, ranging from 53% for MI, to 58% for PCI to 74% for CABG patients.  Analysis by institution revealed wide discrepancies:  35% of hospitals referred <20% of eligible patients, and only 22% of hospitals referred > 80%.  Older age, non-ST-segment elevation myocardial infarction, and the presence of most co-morbidities were associated with decreased odds of cardiac rehabilitation referral, despite the fact that the benefits of participation are proportionally greater in many of these patients.2

These results are especially problematic in light of the recent landmark study by the Brandeis group looking at more than 600,00 Medicare patients that showed that patients who enrolled in a cardiac rehabilitation program had substantially lower mortality than those who did not:  2.2% versus 5.3% at 1 year and 16.3% versus 24.6% at 5 years.3 There was a dose response relationship as well – patients who attended 25 or more sessions had approximately 20% lower 5 year mortality than those who attended 24 or less sessions.  Of note, this study used three sophisticated analytic techniques to control for diagnosis, co-morbidities, and demographics, and validated similar results from previous smaller studies and meta-analyses.

These studies are a call for action to healthcare professionals.  Participation in cardiac rehabilitation has similar mortality benefits as many of the other secondary prevention measures, yet many institutions continue to do poorly with this measure.  Healthcare providers and hospitals should feel confident that cardiac rehabilitation is a life saving intervention that should be provided to all of the appropriate patients whom they serve.  Barriers to referral should be eliminated, referral rates and enrollment monitored, and patients reassured that participation in cardiac rehabilitation will improve their quality and quantity of life.

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AACVPR Affirms Cardiac Rehabilitation Prolongs Life in Medicare Population

CHICAGO (June 24, 2009)— A study published in the current issue of the Journal of the American College of Cardiology, shows new evidence that cardiac rehabilitation, an under-utilized service, increases survival in a wide range of patients with heart disease. Philip Ades, MD, a past president of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), participated in a Brandeis University-led study that provides new evidence supporting the benefits of cardiac rehabilitation in older patients with heart disease.

Researchers from Brandeis University (Jose Suaya, MD; William Stason, MD; Donald Shepard, MD), the University of Vermont (Philip Ades, MD), and Harvard University (Prof. Sharon Lise-Normand) conducted an analysis of 601,099 Medicare beneficiaries who were hospitalized in 1997 for coronary heart disease, acute myocardial infarction, angioplasty, stent or bypass surgery and followed up through 2002. Their findings demonstrated that cardiac rehabilitation participation after one of these cardiac events was associated with a significant 21-34% increase in five-year survival rates, similar to that found with the use of other preventive therapies including cholesterol-lowering medications and beta blockers. Mortality reductions also extended to those with congestive heart failure. Ironically, despite these significant benefits, only 12% of eligible patients actually used cardiac rehabilitation services.

“This study clearly shows that cardiac rehabilitation works,” said Ades. “And although it is a covered benefit under Medicare, we can see that cardiac rehab is still severely underused in this population.”

Drs. Suaya, Ades and the other co-authors further commented: “These effects on survival are so convincing that expanded use of cardiac rehabilitation is critical. Cardiac rehabilitation is a low-cost, low-tech intervention that not only raises survival rates but also improves functional capacity, thereby decreasing disability. We should consider implementing quality-of-care performance measures for hospitals and physicians to encourage referral and utilization of cardiac rehabilitation.”

This study was funded by the Centers for Medicare & Medicaid Services.

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Study Shows Drastic Improvement Following Pulmonary Rehabilitation: Full Article Published in CHEST

(February, 2009) --  Pulmonary Rehabilitation has long been shown to improve symptoms and function in persons with disorders such as chronic obstructive lung disease or COPD. A recent study published in the February 2009 issue of CHEST, the journal of the American College of Chest Physicians provides evidence that other disorders such as interstitial lung disease and pulmonary fibrosis may benefit from Pulmonary Rehabilitation. Interstitial lung disease and pulmonary fibrosis usually involve inflammation of lung tissue that leads to scaring and shortness of breath with exercise. Pulmonary Rehabilitation includes supervised exercise and education to improve function and independence and control of symptoms caused by chronic lung disease. The study included three US Pulmonary Rehabilitation programs at the following sites:  Seton Medical Center in Daly City, California, John Muir Medical Center in Concord, California and Inova Medical Center in Fairfax, Virginia. The study of 99 persons with interstitial lung disease showed significant improvement in shortness of breath and function measured by walk distance after Pulmonary Rehabilitation. The study is the largest trial to date to look at the effect of Pulmonary Rehabilitation in persons with interstitial lung disease. The timing of the study is particularly important given the long struggle to establish Medicare coverage for Pulmonary Rehabilitation. Beginning January 2010, persons with chronic lung disease will be eligible to attend Pulmonary Rehabilitation under Medicare coverage.

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