Two few Medicare patients, women and non-white patients, participated in outpatient cardiac rehabilitation after a heart attack or acute heart event or surgery, says findings in a recently published study in American Heart Association’s journal Circulation: Cardiovascular Quality and Outcomes.
This observational studies and identified the populations and regions most at risk for suboptimal cardiac rehabilitation.
According to the researchers, although 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, about 1.3 million U.S. adults with heart disease may qualify for cardiac rehabilitation (this number does not include those with qualifying heart failure).
The research study reviewed more than 366,000 patients covered by Medicare who were eligible for outpatient cardiac rehabilitation in 2016. They found that only about 25 percent (approximately 90,000) participated in a cardiac rehabilitation program. Among those patients who participated in cardiac rehabilitation, only 24 percent began the program within 21 days of the acute cardiac event or surgery. Among those who participated in cardiac rehabilitation, only about 27 percent completed the full course of the recommended 36 or more cardiac rehabilitation sessions, which have been shown to improve health outcomes.
Participation Remains Low Among Medicare Patients
“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,” said lead study author Matthew D. Ritchey, P.T, D.P.T., O.C.S., M.P.H., a researcher at the Centers for Disease Control and Prevention’s Division for Heart Disease and Stroke Prevention, in a statement issued January 14, 2020. “The low participation and completion rates observed translate to upward of 7 million missed opportunities in this study to potentially improve health outcomes if 70 percent of them covered by Medicare who had a heart attack or acute heart event or surgery participated in cardiac rehabilitation and completed 36 sessions,” says Ritchey.
Researchers also noted other findings in this published article. They reported that participation in outpatient cardiac rehabilitation decreased with increasing age, with only about 10 percent of patients age 85 and older participating, versus about 32 percent of those age 65 to 74. They noted that participation was lower among women than men, about 19 percent versus about 29 percent, respectively.
The study’s findings also indicated that over half of the cardiac rehab eligible patients had less than 5 comorbid conditions.Non-Hispanic whites also had the highest participation rate at about 26 percent, versus 16 percent for Asians, 14 percent for non-Hispanic blacks and 13 percent for Hispanics.
Participation also varied by region, with cardiac rehabilitation being lowest in the Southeastern United States and the Appalachian region, say the researchers. They also found that 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.
“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,” adds 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,” he says.
The researchers also noted study limitations including 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 also 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. Finally, the authors said they were unable to control for factors that may have affected their findings such as the availability of cardiac rehabilitation programs in certain communities.
Ritchey stated, “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.”
Co-authors of this study include: Sha Maresh, Dr.P.H.; Jessica McNeely, Ph.D.; Thomas Shaffer, M.H.S.; Sandra L. Jackson, Ph.D., M.P.H.; Steven J. Keteyian, Ph.D.; Clinton A. Brawner, Ph.D.; Mary Whooley, M.D.; Tiffany Chang, M.P.H.; Haley Stolp, M.P.H.; Linda Schieb, M.P.H.; and Janet Wright, M.D.