Cardiac Rehabilitation and Risk Reduction: Time to “Rebrand and Reinvigorate” | Ten Points to Remember

Sandesara PB, Lambert CT, Gordon NF, et al.
J Am Coll Cardiol 2015;65:389-395.

The following are 10 points to remember about cardiac rehabilitation (CR) and risk reduction:

  1. Since 1995, CR has been defined as “the provision of comprehensive long-term services involving medical evaluation; prescriptive exercise; cardiac risk factor modification; and education, counseling, and behavioral interventions.”
  2. Exercise-based CR programs are associated with a 47% lower risk of re-infarction, 36% reduction of cardiac mortality, and 26% all-cause mortality; a 20-50% reduction in all-cause mortality in those who undergo percutaneous coronary intervention and coronary artery bypass grafting; as well as improved exercise performance, health-related quality of life (QOL), decreased hospitalizations, and reduced depression and angina.
  3. Cardioprotective benefits of exercise and fitness include anti-inflammatory; anti-thrombotic; anti-arrhythmic; improved atherosclerotic cardiovascular disease risk factors including lipids, blood pressure, weight, and increased insulin sensitivity; anti-ischemic related to improved myocardial perfusion, raised ischemic threshold, and ischemic pre-conditioning; and anti-atherogenic.
  4. CR programs confer significant benefits to patients with heart failure through reduced mortality, enhanced QOL, and reduced hospitalizations. Medicare recently approved systolic heart failure as a reimbursable diagnosis for CR.
  5. While there are Class IA recommendations for CR in the American College of Cardiology/American Heart Association management guidelines and performance measures, up to 80% of eligible patients are not referred. Specific patient populations including the elderly, women, ethnic minorities, and people of lower socioeconomic status have especially low referral rates. There are at least four reasons why eligible patients are not referred for CR: 1) lack of standard and routine referral; 2) inadequate communication between treatment teams, patients, and CR facilities; 3) unfamiliarity with CR among physicians; and 4) limited access, competing responsibilities, and perceived inconvenience for the patient.
  6. Even among patients who are appropriately and/or automatically referred to CR within 1 and 6 months after acute myocardial infarction, only 29% and 48% of referred patients participated in CR. Predictors of suboptimal participation include: poor functional status, higher body mass index, tobacco use, depression, long distance to CR facilities, low health literacy, high costs (e.g., copays), and inflexible work schedules.
  7. The current model of CR delivery appears neither financially viable nor sustainable due to the barriers to consistent and appropriate referral, accessibility, and affordability. Some CR programs do not receive adequate referrals to maintain financial viability, and some do not generate revenues sufficient to cover costs.
  8. Increasing referral and participation will require: 1) educating providers, healthcare systems, patients, and their families about the benefits of CR; 2) reducing specific barriers to referral and participation in CR that are attributable to patients, physicians/health systems, and the community; 3) promoting a better understanding of CR as a cost-effective, multidisciplinary, secondary prevention treatment option and disease management service, rather than an exercise-only, gym-based therapy; 4) increasing insurance coverage and decreasing copays; and 5) increasing awareness of CR performance measures and use of system-based approaches such as automatic referral and discharge checklists for eligible patients.
  9. Regarding the use of innovative strategies to bring exercise-based CR to more patients, new delivery models must be adopted, especially for patients at low or low-intermediate risk. These include the use of telemedicine as well as Internet-based, home-based, and community-based programs to provide alternatives to traditional, medically supervised facility-based programs. Home-based programs using appropriately qualified nonphysician health professionals to supervise and monitor patient care are practical, feasible, and have shown outcomes in patients with coronary artery disease similar to those for traditional hospital-based programs.
  10. Given the increasing access of Americans to mobile phones and the Internet, telemedicine programs are emerging as promising alternatives to in-person programs, with improved accessibility and reduced costs. Home-based CR interventions are equally, if not more, cost-effective than traditional center-based programs. These new CR delivery models should not replace traditional programs, but should be used to help better meet the varying needs of individual patients, engage the many patients who currently do not participate, and provide ongoing monitoring and treatment after completion of a traditional CR program. Moreover, experimental or hybrid CR delivery models should not be widely adopted until they have been shown to be both clinically effective and cost-effective.

Keywords: Rehabilitation, Coronary Disease, Quality of Life, Risk Factors, Risk Reduction Behavior, Atherosclerosis, Referral and Consultation, Cell Phone, Checklist, Internet, Telemedicine, Secondary Prevention

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