NCDR Study Finds Low Referral Rates, Low Participation in Cardiac Rehab Among MI Patients

Although current guidelines recommend cardiac rehabilitation following acute myocardial infarction (MI), rates of participation are low even among those referred to these programs, according to a research letter published Aug. 3 in JAMA: Internal Medicine

Cardiac rehabilitation programs are multifaceted outpatient interventions that include individualized exercise programs, health education, and support focused on cardiovascular risk reduction and medication adherence. Patients typically attend two-to-three sessions weekly for up to 36 sessions.

Using data from the ACC’s ACTION Registry-GWTG linked with Centers for Medicare and Medicaid Services data between January 2007 and December 2010, researchers examined records from 58,269 eligible patients age 65 or older. Of those patients, 36, 376 (62 percent) were referred to cardiac rehabilitation at the time of hospital discharge. Of those referred, 11,862 (about 33 percent) attended at least one session within the following year. Among those not initially referred, 1,795 (8 percent) attended at least one session.

The median number of sessions attended among patients participating in rehab was 26, with 3,305 (24 percent) attending at least 36 sessions and 1,188 (about 9 percent) attending fewer than five sessions. Among the 58,269 patients in the cohort, 13,657 (about 23 percent) attended one or more cardiac rehabilitation sessions, and 3,175 (about 5 percent) completed 36 sessions or more. 

Patients who participated in at least one session tended to be younger, male, white, and nonsmokers, with fewer comorbidities. Participation in cardiac rehab was also more common among patients treated with coronary artery bypass graft (about 49 percent) than among those treated with percutaneous coronary interventions (36 percent) or medical management (16 percent).

“Our analysis identifies opportunities to improve the use of cardiac rehabilitation by older adults,” says  Jacob A. Doll, MD, the research letter’s lead author and a fellow at the Duke Clinical Research Institute. “Quality improvement efforts should focus not only on increasing referral rates but also on addressing barriers to attending sessions, such as travel distance, co-payments, and lack of coordination between inpatient and outpatient clinicians. Alternative methods, such as home-based programs, may be needed to improve participation rates.”

In an accompanying commentary, Donna M. Polk, MD, MPH, FACC, and Patrick T. O’Gara, MD, MACC, both of the Cardiovascular Division at Brigham and Women’s Hospital, write that cardiac rehabilitation programs are “grossly underused,” adding that referral, while important, does not guarantee that a patient will attend all 36 sessions, even though the survival of those patients is better than for those who leave the program prematurely.

To address this problem, they point to patient-centered approaches, including the selective use of home-based exercise programs coupled with smartphone applications to monitor heart rate, blood pressure, and other vital signs. Such programs also include Internet, mobile phone, and/or text-based coaching. Social media, they say, “adds another layer of communication to optimize patient adherence and may provide a friendly competition among participants.” Early research on these innovations shows significantly higher rates of participation and completion than for traditional programs.

Polk and O’Gara stress the importance of moving toward digital and e-health strategies. “Wide-scale change,” they emphasize, “will require patients, clinicians, insurers, and health systems to adopt and catch up with what is already digitally achievable.” 

Keywords: ACTION Registry, National Cardiovascular Data Registries, Centers for Medicare and Medicaid Services, U.S., Rehabilitation, Myocardial Infarction, Quality Improvement, Referral and Consultation

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