Cardiac Rehabilitation: Clinical Performance and Quality Measures

Thomas RJ, Balady G, Banka G, et al.
2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol 2018;Mar 29:[Epub ahead of print].

The following are key points to remember about the 2018 American College of Cardiology (ACC)/American Heart Association (AHA) Clinical Performance and Quality Measures for Cardiac Rehabilitation (CR):

  1. The 2018 ACC/AHA Task Force convened the writing committee in 2016 to begin the process of revising the existing performance measures set for CR of 2007, and for which a focused update was issued in 2010. The writing committee also was charged with the task of developing new quality measures (QMs) to benchmark and improve the quality of care for patients eligible for CR.
  2. The 2017 AHA Heart Disease and Stroke Statistics report highlights the large number of patients who need CR each year, including 625,000 patients discharged from US hospitals after an acute coronary syndrome, 954,000 patients who underwent percutaneous coronary interventions (PCIs), 500,000 patients discharged with a new diagnosis of heart failure (HF), and 397,000 who underwent coronary artery bypass grafting (CABG).
  3. CR is a multidisciplinary, systematic approach to applying secondary prevention therapies of known benefit. After a myocardial infarction (MI), CR decreases recurrent MI and mortality rates based on a meta-analysis of 34 randomized trials. CR can also improve a patient’s quality of life and facilitate return to work more quickly. One observational study within a community demonstrated a 10-year absolute risk reduction in all-cause mortality of >12% in patients with CABG who participated in a CR program. Studies have also found that CR participation is associated with a 20-30% reduction in hospital readmission during the year after a cardiac event.
  4. Yet data from the ACTION-Get With The Guidelines registry (2014) on the ST-segment elevation MI (STEMI)/non-STEMI measures related to CR find only 76% of patients with non-STEMI and 85% of STEMI are referred. CR referral is only about 60% following a PCI, and only 12.2% in patients hospitalized for HF with reduced ejection fraction (HFrEF) received CR referral at discharge.
  5. Just under 35% of patients with an acute MI surveyed received CR. Certain subpopulations, including ethnic minorities, women, and those with caregiver-related responsibilities, multiple comorbidities, limited program access, and inadequate health insurance coverage, are less likely to receive CR. In addition to a referral gap, an enrollment gap also exists in CR, with only about 50% of patients referred to CR actually enrolling and participating in CR. In addition, completion rates of CR are suboptimal. If CR participation rates were improved to at least 70%, it is estimated that approximately 25,000 deaths and 180,000 hospitalizations could be prevented each year.
  6. CR QMs of physician and institutional compliance were designed to cover two specific aspects of CR services: 1) referral of eligible patients to a CR program, and 2) delivery of CR services through multidisciplinary CR programs. The measures also were designed to include all eligible patients who did not have a valid reason for exclusion from the measure. For example, in the case of the CR referral from an inpatient setting, a physician who recommends CR referral to an eligible patient is considered to have met performance even if the patient refuses, at the time of referral, because of one or more reasons (e.g., lack of transportation, patient preference). In such a case, the physician would receive credit for the measure. If the patient has told the physician that he/she does not wish to enroll in a CR program, the physician can document in the medical record that he/she has recommended referral, but that the patient has refused CR.
  7. A CR program may include a traditional center-based CR program that incorporates face-to-face interactions and supervised exercise training sessions or, importantly, may include other alternative CR delivery models that meet all criteria for a safe and effective CR program, as specified by American Association of Cardiovascular and Pulmonary Rehabilitation CR practice guidelines. Such alternative CR program models are defined as hospital outpatient-based programs. These programs may include traditional and/or novel delivery options (e.g., home-based CR models, remote monitoring, or mobile health strategies to link patients with CR professionals, either alone or in combination with center-based CR) as part of the program.
  8. Earlier enrollment in CR (i.e., within the first 21 days after the qualifying event) is a safe and important goal to help optimize enrollment, participation, and eventual patient outcomes of CR. There is a graded dose response in which attending 36 sessions is associated with lower risks of death and MI at 4 years, compared with attending fewer sessions. Although a challenging goal, the writing committee proposed that this full-dose measure be introduced as a QM, which CR programs and patients are encouraged to ideally achieve.
  9. CR communication to referring/primary healthcare providers is not part of Class I clinical practice recommendations. However, such care coordination is considered a standard of care and is included as a QM that CR programs are encouraged to ideally achieve.
  10. Areas of research that will potentially impact CR participation, performance, and QMs include: 1) relative performance of racial/ethnic minorities, women, and the elderly; 2) impact on health care expenditures; 3) effectiveness of center-based versus novel CR delivery model adherence and related outcomes; 4) impact of the inclusion of CR performance measures in the pay-for-performance strategies on CR participation, adherence, and outcomes; 5) novel measures to stimulate higher CR participation and adherence rate; 6) impact of CR on long-term compliance with secondary prevention efforts; and 7) role of CR performance measures in new cohorts including HF with preserved EF (HFpEF), peripheral arterial disease, and atrial fibrillation.

Keywords: Acute Coronary Syndrome, Atrial Fibrillation, Cardiology, Coronary Artery Bypass, Exercise, Heart Failure, Insurance Coverage, Motor Activity, Myocardial Infarction, Patient Compliance, Patient Discharge, Patient Preference, Patient Readmission, Percutaneous Coronary Intervention, Peripheral Arterial Disease, Primary Prevention, Quality Improvement, Quality of Life, Rehabilitation, Referral and Consultation, Secondary Prevention, Standard of Care, Stroke, Stroke Volume, Telemedicine

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