Exercise-based cardiac rehabilitation (CR) has been a Class I indication in clinical guidelines for patients with chronic stable angina, STEMI and NSTEMI, and patients undergoing PCI and CABG for more than a decade. Most recently it has been added as a Class I indication for heart failure and lower extremity peripheral arterial disease. Enrolling patients and coaching them to completion of a CR program can reduce the risk of death from future cardiac events and all-cause mortality.

The benefits are well documented – CR has been shown to reduce odds of mortality by more than 50% compared with no CR. It can also improve risk factors, functional status, quality of life and mood and keep patients out of the hospital. Simply stated, we could save lives, improve quality of life and reduce costs to the health care system if we coach our patients to enroll in and complete CR.

Yet, incredibly, only a fraction of eligible patients in the U.S. enroll in a CR program after a major cardiovascular event or diagnosis. In a study assessing Medicare enrollee demographics in 2016-2017, 18.9% of eligible women and 28.6% of eligible men enrolled in Phase II CR. In addition to the gender disparity, the study reflects a disturbing pattern of disparity in access for minority enrollment, with 13.6% of eligible non-Hispanic Blacks, 13.2% of eligible Hispanics, and 16.3% of eligible Asians enrolled in 2016-2017. Recognizing the magnitude of this issue prepandemic gives perspective to the challenges we now face to assure CR is not erased as a means to improve the cardiovascular health of the communities we serve.

The Referral – Enrollment Gap

Historically, hospital-based CR programs provided Phase I CR in the inpatient setting. While time and budget constraints have unfortunately eliminated the Phase I program in most hospitals, the rate of eligible patients referred to CR prior to hospital discharge remains a performance measure in NCDR and the Society of Thoracic Surgeons registries and CR may be used as one of the measures physician practices select for the Merit-based Incentive Payment System. CR also plays a role in the requirements for center of excellence designation for some large commercial payer plans. As is often the case, we have responded to a process-based measure by implementing lots of process-based tools, like automated orders embedded in postprocedure order sets, discharge order sets, or encounter templates.

Overcoming Barriers to Enrollment

As we address the structures in the practice setting to promote CR enrollment there are a number of socioeconomic barriers to address, including health plan coverage, co-pay, patients' commitment to follow-through, travel, and most recently the COVID-19 pandemic. All of these barriers can be overcome using the same approach we use to push patients forward for other evidence-based therapies.

Patient Cost

When speaking with physicians, the health care team and patients, cost and adequate insurance coverage typically come in at, or close, to the top of the list of barriers to referral and enrollment. Medicare covers CR on a per session basis for up to 36 traditional sessions or up to 72 intensive cardiac rehabilitation (ICR) sessions. For Medicare patients who have supplemental insurance, some portion of the co-pay responsibility may be covered, but supplemental coverage for the service and how much may be covered varies widely. Out-of-pocket cost is a barrier for low- and fixed-income patients and it may deter referral if assisting patients to find access to financial assistance is complex and time consuming.

Financial Assistance Programs – Creating Solutions Upfront

Getting patients enrolled in CR makes sense clinically and financially for health care systems. The Million Hearts Cardiac Rehabilitation Collaborative work has quantified potential savings for patients completing 36 one-hour CR sessions as $4,950 to $9,200 per year of life. Because CR also helps to reduce readmissions in the cardiovascular population improving enrollment and completion rates can have a positive impact on value-based purchasing measures, third-party designations and publicly reported outcome measures. It's crucial to create easy and dignified solutions to address financial barriers to CR enrollment for the patient.

Improving Patient Adherence to CR

The strength of the physician's recommendation is important to push patients toward enrollment and optimizing the CR program and infrastructure is important to mitigate potential socioeconomic barriers. However, keeping patients enrolled and engaged in CR is strongly influenced by the CR team. To support patients in maximizing the benefits from CR, the team can evaluate current and historic program statistics and create strategies to establish an expectation for all patients to complete 36 sessions (72 sessions for ICR). While this may be a cultural shift for some programs, designing improvement to achieve new goals for the average number of sessions completed is important as a parallel to improving enrollment.

Access

Work and family commitments, program capacity, location/travel distance, and operational hours complicate access to CR and create barriers to enrollment. A truly patient-centric approach to mitigating these types of barriers to enrollment requires an assessment of the socioeconomic demographics of the patient population served by a program. When possible, use of both ambulatory practice data and acute care discharge data can be helpful to developing strategies to increase enrollment. For example, if data reflect a substantial number of patients are working age, solutions may include expanded hours of operation or modifying existing schedules to ensure working patients receive priority for early or late sessions.

Optimizing CR Access and Enrollment

The COVID-19 pandemic has been an unprecedented and frightening time in health care, but it has also led to renewed innovation. Using lessons and experiences from this time can help define new goals to improve CR access and enrollment. For example, setting goals to achieve improvements by hardwiring referral and enrollment is an important first step, followed by evaluating the infrastructure of current CR programs to assess whether they are meeting the needs of eligible patient populations. Defining and implementing specific, actionable strategies to mitigate barriers to referral and enrollment is a third step and could include incorporating virtual options to meet patients where they are.

In general, communicating current and ongoing performance to the entire team, socializing improvement goals, and involving team members at all levels of the cardiovascular service line in improvement efforts have a real opportunity to ensure optimal use of CR and ultimately improve patient outcomes and save lives.

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