Underutilization of Cardiac Rehab Despite Guidelines and Reimbursement

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October 1, 2007 By Grendel Burrell [1]

After an acute myocardial infarction (AMI) or coronary artery bypass surgery (CABG), cardiac rehabilitation (CR) reduces all-cause mortality by 15% to 28% and cardiac mortality by 26% to 31%. However, only 18.7% of patients had at least one cardiac rehab session in the year following an AMI or coronary artery bypass graft, despite recommendations according to a recent analysis of Medicare claims by Dr. JA Suaya and authors in Circulation (1). Meta-analyses have found 15% to 28% reduction in all-cause mortality and 26% to 31% reduction in cardiac mortality for patients who participated in cardiac rehabilitation (2).

In 2001,13 million people in the US had CHD, ~ 860 000 people suffered AMIs, and 480 000 people died of CHD (3). Patients aged ≥ 65 years account for > 55% of AMIs and 86% of CHD deaths (4). A disproportionate economic burden for this disease falls on the elderly.

Since 1982, Medicare has provided coverage for up to 3 outpatient CR sessions per week for 3 months after AMI, CABG surgery, or stable angina pectoris, if these sessions are prescribed and supervised by a physician (http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part1.pdf). CMS expanded coverage in March 2006, to include percutaneous revascularization procedures, heart valve surgery, and heart or heart-lung transplant (http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id_164.)

Published in 1995 and subsequently endorsed by a number of professional associations (5, 6) and the Centers for Medicare and Medicaid Services (CMS) (http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part1.pdf), clinical practice guidelines for cardiac rehab include an exercise plan, nutritional counseling, management of blood lipid levels, diabetes mellitus, high blood pressure, and weight, smoking cessation instruction, and psychosocial interventions (7). Hospitalizations for acute myocardial infarction frequently provide patients with inpatient or phase I cardiac rehab and this includes supervised early mobilization and education on controlling risk factors and physical activities after discharge. The duration of hospitalization for AMI has shortened (8), and thus, outpatient rehab has become increasingly important but perhaps overlooked. Outpatient (phase II) CR can be initiated as soon as 3 weeks after hospital discharge, generally in a supervised hospital- or community-based ambulatory setting, and includes supervised exercise, counseling on nutrition and other lifestyle modification interventions with a goal of cardiac risk factor reduction. After supervised CR, in phase III CR, patients are encouraged to maintain healthy lifestyles and unsupervised exercise with periodic checks of symptoms, risk factors, and medications by healthcare professionals.

Using Medicare claims for 1997, Dr. Suaya and authors analyzed outpatient (phase II) cardiac rehab use after hospitalizations for AMI or coronary artery bypass graft surgery in 267,427 patients aged 65 years who survived for at least 30 days after hospital discharge. They utilized multivariable analyses to identify predictors of cardiac rehab use and to quantify geographic variations in its use. The authors divided the cardiac rehab candidates into 2 main groups: AMI or CABG surgery without AMI. Patients with AMI were then subdivided into 3 s: medical treatment only, percutaneous coronary intervention (PCI) without CABG, or CABG. Patients who received both CABG and PCI were classified as CABG.

Of the 267,427 patients, 18.7% (49,877) received at least 1 session of outpatient CR after hospital discharge. Recipients of CR had an average of 24 sessions. Men were more likely to receive CR than women (22.1% versus 14.3%). Sex differences increased with age. Men and women aged 75 to 84 years were only 87% and 69%, respectively, as likely to receive CR as men aged 65 to 74 years despite research showing that increased exercise is valuable for older people, to preserve functional capabilities. Furthermore, even after adjusting for age and sex, whites were 33% more likely to receive CR than nonwhites (OR=1.33 versus 1.00). Overall, CR was used in 13.9% of patients hospitalized for acute myocardial infarction and 31.0% of patients who underwent coronary artery bypass graft surgery. Of patients with an AMI and no subsequent revascularization procedure during the index hospitalization, 11.1% of received CR.

Patients were more likely to receive CR if they had been admitted from home (19.3%) than if they had been transferred from another acute care hospital (13.2%) or nursing home (5.6%). If the Index admission was to a hospital with cardiac catheterization, angioplasty, and CABG capabilities, CR use increased to 22.4% from 13.8% in hospitals lacking these facilities. Slightly higher CR rates were observed in hospitals affiliated with medical schools (20.5%) versus those not affiliated (17.1%). The analysis showed that patients with congestive heart failure, diabetes mellitus with complications, cerebrovascular disease, chronic pulmonary disease, or renal disease had moderate reductions in any CR use (0.69 to 0.77).

A strong predictor of cardiac rehab use was having CABG surgery during the index whether or not CABG was performed after an AMI (OR=3.5). Higher rates of CR use in patients undergoing CABG surgery than in those with AMIs may be a reflection of the high level of patient awareness of the surgical procedure systematic referral to rehab by cardiac surgeons. AMI patients who received PCI after an AMI were nearly 2 times more likely to receive CR than those with no revascularization procedure (OR=1.8). Higher level of education and shorter distance to the nearest CR facility were both important predictors of higher CR use. Patients living in zip codes with the highest levels of median household income and education were 23% and 33% more likely to experience CR than those living in zip codes with the lowest income and education (P < 0.001).

There was a wide variance in the adjusted CR use across states, ranging from 6.6% in Idaho to 53.5% in Nebraska. Cardiac rehab rates were 4-fold higher in Nebraska, Iowa, North and South Dakota, Minnesota, and Wisconsin (north central states) than in southern states. Highest rates of CR use were found in the north central states of the United States. If 53.5% rate in Nebraska were achieved in other states, 93,000 additional Medicare beneficiaries would have received rehab and cardiac mortality would have decreased 26% to 31% in these individuals, the researchers wrote.

Dr. Harlan Krumholz

Asked for his thoughts on this analysis of the Medicare data that demonstrated underutilization of yet another evidence based therapy, Dr. Harlan Krumholz, Harold H. Hines, Jr. Professor of Medicine and Epidemiology and Public Health (Cardiology), Yale University, stated, “Cardiac rehabilitation is a wonderful, low risk intervention that is far too often overlooked for patients who have just experienced a cardiovascular event or who have heart failure. This patient-centered approach needs to have a higher profile as a tool to reduce risk and improve outcomes. Also, variation in the use of cardiac rehabilitation may be contributing to some disparities in outcomes among various patient groups.”

The authors made several recommendations for improving rehabilitation use. These included improving methods of referring patients to rehab facilities after hospitalization using automatic referrals, an increase reimbursement rates, installation of referral-to and completion-of programs as quality indicators in cardiovascular care to be used by organizations such as the American College of Cardiology, the American Heart Association, and the National Committee for Quality Assurance, adoption of those measures by Medicare in its pay-for reporting and pay for-performance initiatives, and separate payments for key components, such as nutritional counseling and stress management.


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