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Providers and Patients Miss the Mark in Referrals and Participation in Cardiac Rehab

CardioSmart News

Exercise is an important element of a healthy lifestyle, but it is especially important after having a heart attack. By going to cardiac rehabilitation as part of recovery, patients have an opportunity to work with a professional on an individualized exercise program, as well as learn more about how to prevent further cardiac events. 

Despite these benefits—and that rehab is strongly recommended by current guidelines—participation rates are low even among those referred to these programs, according to a research letter and commentary published in the Journal of the American Medical Association: Internal Medicine

Using data from the National Cardiovascular Data Registry (NCDR) ACTION Registry-GWTG linked with Medicare data between Jan. 2007 and Dec. 2010, researchers looked at records from 58,269 eligible patients age 65 or older. Of those patients, 62% were referred to rehab at the time of hospital discharge. Of those referred, about 33% attended at least one session within the following year, while about 8% of patients not initially referred participated in rehab programs. 

Unfortunately, however, only about 5% of patients referred to rehab completed the full program of 36 sessions. Roughly another 23% attended at least one session. These participants tended to be younger, male, white, and nonsmokers, with less comorbidity. Another characteristic of participants was that they were more likely to have had bypass surgery (about 49%) than angioplasty (36%), or only medication to treat their condition (16%). 

“Our analysis identifies opportunities to improve the use of cardiac rehabilitation by older adults,” says Jacob A. Doll, MD, the research letter’s lead author and a fellow at the Duke Clinical Research Institute. “Quality improvement efforts should focus not only on increasing referral rates but also on addressing barriers to attending sessions, such as travel distance, co-payments, and lack of coordination between inpatient and outpatient clinicians.” 

In an accompanying commentary, Donna M. Polk, MD, MPH and Patrick T. O’Gara, MD, MACC, both of the Cardiovascular Division at Brigham and Women’s Hospital, write that cardiac rehabilitation programs are “grossly underused.” They add that referral, while important, does not guarantee that a patient will attend all 36 sessions, even though the survival of those patients is better than for those who leave the program prematurely. 

Patient-centered approaches may well be the wave of the future. Such approaches often include home-based exercise programs coupled with smartphone applications to monitor heart rate, blood pressure, and other vital signs. Mobile phone and/or text-based coaching are added elements that encourage participation. Early research on these innovations shows significantly higher rates of participation and completion than for traditional programs. 

Polk and O’Gara stress the importance of moving toward digital and e-health strategies. “Wide-scale change,” they emphasize, “will require patients, clinicians, insurers, and health systems to adopt and catch up with what is already digitally achievable.”
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