Cardiac Rehab Rates Still Low in Medicare and VA Populations

Only about one in six Medicare patients and even fewer of those treated in Veterans Affairs hospitals who are eligible for cardiac rehabilitation services participate in such programs after discharge, a new study concludes. Patients in West North Central states like Nebraska and the Dakotas were found to have the highest rates of participation.

The rate of cardiac rehab among the Medicare population is even lower than it was in an analysis conducted 10 years prior, said the study’s lead author, Alexis Beatty, MD, MAS (VA Puget Sound Health Care System, Seattle, WA), in an interview with TCTMD.

“So, despite the fact that cardiac rehab has been included in hospital performance measures and professional society performance measures and guidelines, we’re still not seeing any improvement in participation overall,” she added.

South Dakota and Nebraska Lead the Way

Beatty’s study, published online January 5, 2018, ahead of print in Circulation, looked at data on 143,756 Medicare patients and 88,826 veterans in the VA system who were hospitalized for MI, PCI, or CABG. The rate of participation in cardiac rehab was 16.3% among the Medicare group and just 10.3% among the Veterans Affairs group. Some variation was seen by ethnicity, with white patients being more likely than black or Hispanic patients to attend rehab.

Large, academically affiliated hospitals with on-site cardiac rehabilitation were the most likely to be in the higher quartiles of patient participation.

Looking regionally, Iowa, Nebraska, Kansas, North Dakota, Minnesota, South Dakota, and Missouri were the states with the highest overall participation rates. As a region—categorized as West North Central—those states had participation rates of 33.7% among Medicare patients and 16.6% among VA patients. Individually, South Dakota came out on top in the Medicare population, while among the VA group it was Nebraska in the top spot. The Mid Atlantic (New Jersey, New York, Pennsylvania), West South Central (Arkansas, Louisiana, Oklahoma, Texas), and Pacific (Alaska, California, Hawaii, Oregon, Washington) regions were the three lowest among both groups in participation.

The hope is that we can learn from the high-performing sites to improve performance at the low-performing sites. Krishna G. Aragam

“There are a few areas of the country that appear to be doing better than others at getting their patients to participate in cardiac rehab,” Beatty noted.

Answers to the big question of why and how they are doing that are elusive. While individual patient factors, hospital factors, and socioeconomic status each may play a small role in rehab patterns, Beatty said the overall conclusion of her group is that more research is needed to understand and even out the variability.

Learning From High Performers

Speaking with TCTMD, Krishna G. Aragam, MD (Massachusetts General Hospital, Boston), agreed, adding that the study provides “more weight” to the theory of regional trends in cardiac rehab, especially since it shows these trends are consistent in both the Medicare and VA populations.

“It tells us there is something there in terms of where you are potentially going to be engaging in cardiac rehab and how that might influence your likelihood to follow up after an event and participate in one or more sessions,” noted Aragam, who was not involved in the study. “The hope is that we can learn from the high-performing sites to improve performance at the low-performing sites.”

Both Beatty and Aragam said the regional variation could be influenced by referral patterns. “But, it could also be something more downstream like accessibility of the cardiac rehab sites and how easily you can get to one, or how many of them there are in your area,” Aragam added. “Trying to get at some of those details is a key next step to addressing disparities in care and performance.”

The issue is particularly relevant in light of efforts such as the Million Hearts Cardiac Rehabilitation Collaborative, which has set a goal of increasing cardiac rehab participation to 70%. In a recent paper, the group estimated that 25,000 lives could be saved and 180,000 hospitalizations prevented annually in the United States by achieving that goal.

“It’s about taking that deeper dive into not just particular hospitals that are doing well but [also researching] what is it about Nebraska, for instance, that confers a two-and-a-half-fold greater odds of participating in rehab? The goal is quite high and . . . we need to identify the barriers and address them,” Aragam said.

At the same time, alternatives may be needed to increase rehab participation in certain regions or certain patient populations. One example is mobile programs that potentially could be used for patients who can’t or won’t go to rehab on their own. “Some of these things may be things we can overcome, and then again some of them may not,” Aragam added.