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Cardiac Rehabilitation and Decreased Hospitalization/Mortality After Valve Surgery
Study Questions:
What is the impact of cardiac rehabilitation (CR) enrollment after cardiac valve surgery and its association with outcomes, including hospitalizations and mortality?
Methods:
The observational cohort study included all fee-for-service Medicare beneficiaries undergoing cardiac valve surgery in 2014 and followed through 2015. Those persons with diagnosis codes for open replacement, repair, or valvuloplasty aortic, mitral, tricuspid, and pulmonary valve surgery were included. CR was defined with a continuous variable as number of sessions. Logistic regression was used to evaluate sociodemographic and clinical factors associated with CR enrollment. Andersen-Gill models were used to evaluate the association of CR enrollment with 1-year hospitalization risk and Cox regression models to evaluate the association of CR enrollment with 1-year mortality risk.
Results:
A total of 41,369 Medicare beneficiaries (median age, 73 [interquartile range, 68-79] years and 40.9% female) underwent open valve surgery in 2014. Fewer than half, (43%) who were referred following valve surgery enrolled in CR programs. The mean number of sessions attended was 32 of 36 and did not vary by valve site. Several racial/ethnic groups had a lower odds ratio (OR) of enrolling in CR programs after valve surgery compared with white patients, including Asian (OR, 0.36), Black (OR, 0.60), and Hispanic (OR, 0.36) patients. There was no difference regarding whether a CR program was present at the surgical hospital. Patients undergoing concomitant coronary artery bypass grafting (CABG) had a 26% greater enrollment than those without the concomitant CABG, and patients in the Midwest region had a 24% greater enrollment than those in the South (reference). CR enrollment was associated with 34% fewer hospitalizations within 1 year of discharge after multivariable adjustment. Enrollment was also associated with a 4.2% absolute decrease and a 61% decrease in 1-year mortality risk after multivariable adjustment. Among variables associated with reduced participation included alcohol dependence, chronic obstructive pulmonary disease, chronic heart failure, depression, diabetes, chronic kidney disease, weight loss, substance abuse, and obesity.
Conclusions:
Fewer than half of Medicare beneficiaries undergoing cardiac valve surgery enroll in CR programs, and there are marked racial/ethnic disparities among those that do. CR is associated with decreased 1-year cumulative hospitalization and mortality risk after valve surgery. These results invite further study on barriers to CR enrollment in this population.
Perspective:
The magnitude of benefit attributable to participation in CR within the first year following cardiac valve surgery is remarkable (1-year mortality 9.9% vs. 2.2% and about a 35% reduction in hospitalizations, which did not vary by replacement versus repair and multivalvular). About 50% of persons with an indication for CR are referred and less than half participate, with the greatest percentage of participants being CABG and valve surgery. Amongst the reasons for poor participation in CR by ethnic minorities regardless of indication includes lack of and cost of transportation, distance to site, social/family support, higher comorbidities and frailty, and language barriers.
Keywords: Cardiac Rehabilitation, Cardiac Surgical Procedures, Coronary Artery Bypass, Depression, Diabetes Mellitus, Ethnic Groups, Geriatrics, Heart Failure, Heart Valve Diseases, Kidney Diseases, Medicare, Obesity, Primary Prevention, Pulmonary Disease, Chronic Obstructive, Weight Loss
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