Too few people covered by Medicare participated in outpatient cardiac rehabilitation after a heart attack or acute heart event or surgery, particularly women, the elderly and non-white patients, according to new research published today in the American Heart Association's journal Circulation: Cardiovascular Quality and Outcomes.
Every year, an estimated 1.3 million U.S. adults with heart disease may qualify for cardiac rehabilitation (this number does not include those with qualifying heart failure). Outpatient cardiac rehabilitation has been shown to improve health outcomes among patients who have heart failure, have suffered heart attacks or have undergone a cardiac procedure such as coronary artery bypass surgery. This observational study measured participation rates and identified the populations and regions most at risk for suboptimal cardiac rehabilitation.
In the review of more than 366,000 patients covered by Medicare who were eligible for outpatient cardiac rehabilitation in 2016, researchers found:
- only about 25% (approximately 90,000) participated in a cardiac rehabilitation program;
- among those who participated in cardiac rehabilitation, only 24% began the program within 21 days of the acute cardiac event or surgery; and
- among those who participated in cardiac rehabilitation, only about 27% completed the full course of the recommended 36 or more cardiac rehabilitation sessions, which have been shown to improve health outcomes.
Cardiac rehabilitation has strong evidence demonstrating its lifesaving and life-enhancing benefits, and Medicare Part B provides coverage for the program. However, participation in cardiac rehabilitation programs remains low among people covered by Medicare. The low participation and completion rates observed translate to upwards of 7 million missed opportunities in this study to potentially improve health outcomes if 70% of them covered by Medicare who had a heart attack or acute heart event or surgery participated in cardiac rehabilitation and completed 36 sessions."
Matthew D. Ritchey, P.T, D.P.T., O.C.S., M.P.H., lead study author, researcher at the Centers for Disease Control and Prevention's Division for Heart Disease and Stroke Prevention
Additional study findings included:
- Participation in outpatient cardiac rehabilitation decreased with increasing age, with only about 10% of patients age 85 and older participating, versus about 32% of those age 65 to 74.
- Participation was lower among women than men, about 19% versus about 29%, respectively.
- Over half of the cardiac rehab eligible patients had less than 5 comorbid conditions.
- Non-Hispanic whites had the highest participation rate at about 26%, versus 16% for Asians, 14% for non-Hispanic blacks and 13% for Hispanics.
- Participation also varied by region, with cardiac rehabilitation being lowest in the Southeastern United States and the Appalachian region.
- Patients who had a procedure such as coronary bypass surgery were more likely to participate in cardiac rehabilitation than those who had a heart attack with no procedure performed.
Researchers noted that patients face systematic, logistical and cultural barriers to attending and completing an outpatient cardiac rehabilitation program. At the system level, there are no universally accepted, automated, electronic referral processes for cardiac rehabilitation services. On a personal level, patients may not complete rehabilitation due to the costs and/or the time needed to participate in the program versus returning to work and other personal commitments.
"Improving awareness of the value of cardiac rehabilitation, increasing referral of eligible patients and reducing system and patient barriers to participation are all critical steps in improving the referral, enrollment and participation rates, which, in turn, can improve patient outcomes," said Ritchey. "For example, the Agency for Healthcare Research and Quality, recently launched the TAKEheart initiative to implement automatic referral processes with care coordination to increase cardiac rehabilitation referrals, enrollment and retention across hundreds of hospitals. Each of these programs are important building blocks for continued improvement for patients."
This study had the following limitations:
- Billing codes were used to identify patients eligible for cardiac rehabilitation, however, referral rates cannot be assessed with use of billing data.
- Clinical information was not available for patients; therefore, the authors were unable to validate the billing codes used or to exclude patients who may not have been appropriate for cardiac rehabilitation.
- This study was restricted to assessing cardiac rehabilitation use among older patients with Original Medicare coverage, therefore, the findings may not be generalizable to Medicare Advantage members or to younger patients.
- The authors were unable to control for factors that may have affected their findings such as the availability of cardiac rehabilitation programs in certain communities.
"It is also important to improve the capacity within existing cardiac rehabilitation programs and to address shortages in available programs, especially in rural areas. One strategy for addressing these shortages could be to increase the use of home-based or tele-cardiac rehabilitation, which have been shown to achieve similar health outcomes as compared to center-based rehabilitation care," said Ritchey.
In 2019, the American Heart Association issued a new Scientific Statement, a collaboration with the American Association for Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology, detailing the need for and benefits of home-based cardiac rehabilitation programs to improve patient access and health outcomes. The American Heart Association also supports the Increasing Access to Cardiac Rehabilitation Care Act of 2019 (H.R. 3911), introduced in the U.S. House of Representatives in July 2019. The 2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation, published in April 2018, provide a comprehensive report on the performance and quality measures that can assess and improve the quality of care for patients eligible for cardiac rehabilitation.
"This study's findings confirm the urgent need to increase participation in and access to cardiac rehabilitation programs - especially since they are covered by Medicare and many insurance companies," said Randal J. Thomas, M.D., M.S., chair of the ACC/AHA Writing Committee for the joint Scientific Statement and Performance Measures Report, and medical director of the Cardiac Rehabilitation Program and Professor of Medicine at the Mayo Clinic in Rochester, Minnesota. "Cardiac rehabilitation provides essential supports, services and health care guidance that are proven to be critical to the optimal recovery of patients after a major cardiovascular event and reducing the incidence of secondary events and long-term disability. We must find ways to improve patient access to cardiac rehabilitation."
Ritchey, M. D., et al. (2020) Tracking Cardiac Rehabilitation Participation and Completion Among Medicare Beneficiaries to Inform the Efforts of a National Initiative. Circulation: Cardiovascular Quality and Outcomes. doi.org/10.1161/CIRCOUTCOMES.119.005902.