Cardiac Rehab After Acute MI Still Underutilized in Older Patients

Though cardiac rehabilitation has repeatedly been shown to improve survival and quality of life after acute MI, less than two-thirds of such patients are referred for rehab programs, according to a research letter published online August 3, 2015, ahead of print in JAMA Internal Medicine. Notably, only one-third of those referred actually attend a single session, much less the recommended 36 appointments.

“Quality improvement efforts should focus not only on increasing referral rates but also on addressing barriers to attending rehabilitation sessions, such as travel distance, copayments, and lack of coordination between inpatient and outpatient clinicians,” write Jacob A. Doll, MD, of the Duke Clinical Research Institute (Durham, NC), and coauthors.

“Alternative methods of providing cardiac rehabilitation, such as home-based programs, may be needed to improve participation rates,” they advise.

Lack of Referral, Low Participation

The researchers culled data from Medicare records and from the National Cardiovascular Data Registry ACTION Registry-Get With the Guidelines database on 58,269 acute MI patients (mean age 75 years) eligible for cardiac rehab between 2007 and 2010.

Overall, 62.4% were referred to cardiac rehab at discharge, but only 32.6% of those referred opted to attend at least 1 session within the next year. Additionally, 8.2% of those not initially referred wound up receiving some level of rehab. The median number of sessions attended was 26 among all patients, with 24.2% attending at least the recommended 36 sessions and 8.7% attending fewer than 5.

Compared with patients who did not participate in rehab, those who attended at least 1 session were younger and more likely to be men, white, and nonsmokers; to present with STEMI; and to have fewer baseline comorbidities. Moreover, those treated with CABG (48.8%) were more likely than those who underwent PCI (36.0%) or received medical therapy (16.3%) to schedule and keep their appointments.

Alternative Strategies to Encourage Rehab

In an invited commentary, Donna M. Polk, MD, MPH, and Patrick T. O’Gara, MD, of Brigham and Women’s Hospital (Boston, MA), write: “System-based mechanisms to improve referral rates are needed but are unlikely to meaningfully narrow this treatment gap unless they are supplemented by other efforts.”

It is clear from the data, they say, that “referral to cardiac rehabilitation does not assure that a patient will enroll or complete a recommended treatment course.” Thus, other initiatives should be put in place to encourage patient participation, they write.

One proposed strategy is the selective use of home-based exercise programs coupled with smartphone apps that can track physiological responses and coaching sessions via the internet or phone. Social media also has the potential to “optimize patient adherence and may provide a platform for friendly competition among participants who keep track of their weekly step counts outside of the program,” Drs. Polk and O’Gara say.

Another way to lower costs could be to have nurses, exercise physiologists, and case managers oversee rehab care as opposed to physicians, they suggest.

More Than Physical Exercise

The onus of improvement falls on the system as a whole, according to Ajay J. Kirtane, MD, SM, of NewYork-Presbyterian Hospital/Columbia University Medical Center (New York, NY). “In an ideal world, once the patient becomes a coronary or [acute MI] patient, there ought to be some triggers that then are followed up on outside the hospital after they are discharged…. Those types of systems would at least help patients to make that initial visit.”

According to Dr. Kirtane, a rehab referral may not in itself be sufficient to persuade patients. “They get this referral or a phone number on discharge without clear knowledge about what it’s going to entail,” he said. “Some don’t want to go because they had an MI and they are afraid to go. There are several barriers to it, but rehab is an invaluable resource for these patients.”

Carl J. Lavie, MD, of Ochsner Medical Center (New Orleans, LA), told TCTMD in an email that while everyone shares the responsibility, cardiovascular and primary care physicians are the most important players in making sure that patients not only are referred but also participate in the recommended 36 sessions. It is up to these doctors to explain the survival benefit associated with rehab and convince patients with higher copays that it is worth the cost, said Dr. Lavie, who serves as the medical director of a cardiac rehab program.

Dr. Kirtane explained that the benefits of rehab extend beyond physical exercise to issues such as “smoking cessation and weight loss and even things that are harder to talk about in the office like sexual activity… and that can be very beneficial for patients.”

Today physicians are being encouraged by declining reimbursements to move acute MI patients out of the hospital faster than in the past, Dr. Kirtane noted. That trend needs to be counterbalanced by outpatient programs that can provide some of the education that would otherwise have been offered in the hospital, he said.

 

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Sources: 
1. Doll JA, Hellkamp A, Ho PM, et al. Participation in cardiac rehabilitation programs among older patients after acute myocardial infarction [research letter]. JAMA Internal Med. 2015;Epub ahead of print.
2. Polk DM, O’Gara PT. Closing the treatment gap for cardiac rehabilitation [invited commentary]. JAMA Internal Med. 2015;Epub ahead of print.

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