Only 10 percent of patients hospitalized for heart failure (HF) receive referrals for cardiac rehabilitation (rehab), according to a study published Aug. 17 in the Journal of the American College of Cardiology.

The study, led by Harsh Golwala, MD, from the University of Louisville School of Medicine, used the Get With The Guidelines-Heart Failure database to determine the proportional use, temporal trends, and major factors associated with referral for cardiac rehab among HF patients at discharge. The study population included 105,619 patients with a HF-related diagnosis eligible for cardiac rehab at discharge. Of these, 48 percent had reduced ejection fraction (HFrEF) and 52 percent had preserved ejection fraction (HFpEF).

Results showed that overall, 10.4 percent of cardiac rehab eligible patients received a referral at discharge. Compared with patients discharged without referral, patients who were referred to cardiac rehab were younger, were predominantly men, and had a lower burden of comorbidities, a lower proportion of Medicare coverage, and a greater proportional use of in-hospital procedures such as coronary angiography, percutaneous coronary intervention with stent, and CABG. There was also significant regional variability, with higher referral raters among southern centers (49 percent) than mid-western centers (14 percent). Among patients eligible for use of pharmacotherapies for HF, patients referred to cardiac rehab had greater proportional use of evidence-based medical therapies at discharge. Over the study period, patients with HFrEF saw a greater increase in referral than patients with HFpEF. However, even with this increase, referral rates still remain low, despite favorable evidence and guideline-based recommendations.

The authors suggest that the lack of referrals could be due to multiple factors including the physician's perceived benefit of cardiac rehab as well as a lack of mortality benefit and concerns regarding safety of exertional training among HF patients. Patient-level factors such as patient demographics, older age, lower socioeconomic status, distance to travel to the cardiac rehab center, insurance status, higher copayments or pay from pocket, and higher comorbidity burden or cognitive dysfunction may also limit participation in cardiac rehab. Therefore, increased physician and patient awareness of the benefits of cardiac rehab in HF may increase referrals.

Moving forward, the authors note that the recent U.S. Centers for Medicare and Medicaid Services (CMS) approval of cardiac rehab for HFrEF patients may lead to improved referral trends in elderly patients with HF who have Medicare coverage. Additionally, with data supporting the benefit of cardiac rehab in HFpEF patients, further trials on the effectiveness of cardiac rehab and possibly similar CMS insurance coverage approval for cardiac rehab in HFpEF patients are needed to further improve the use of cardiac in this patient population as well.

In an accompanying editorial comment, Philip A. Ades, MD, FACC, writes that the findings are "a baseline and springboard for setting up [cardiac rehab] referral and uptake processes that optimize [cardiac referral] participation processes for inpatients or outpatients with HFrEF now that insurance coverage is broadly available." He adds that cardiac rehab referral "should include a direct, in-person physician recommendation to the patient that [cardiac rehab] is a part of the personalized treatment plan, because this physician recommendation has been shown to be a powerful predictor of [cardiac rehab] participation."

Listen to the audio commentary by JACC Editor-in-Chief Valentin Fuster, MD, PhD, MACC.

Keywords: Centers for Medicare and Medicaid Services, U.S., Comorbidity, Coronary Angiography, Cytarabine, Daunorubicin, Etoposide, Heart Failure, Inpatients, Medicaid, Medicare, Percutaneous Coronary Intervention, Stents

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