Peek behind the paper: boosting participation in effective cardiac rehabilitation programs
In this feature, we peek behind the paper with lead study author Matthew Ritchey (Centers for Disease Control and Prevention; GA, USA) to further understand why almost three-quarters of eligible Medicare recipients do not participate in effective cardiac rehabilitation programs.
Earlier this year, we reported on some new research demonstrating that less than 25% of eligible Medicare beneficiaries successfully participate in outpatient cardiac rehabilitation programs following incidence of a heart attack or acute heart event, despite their effectiveness.
In this feature, we peek behind the paper with lead study author Matthew Ritchey (Centers for Disease Control and Prevention; GA, USA) to further understand why almost three-quarters of eligible Medicare recipients do not participate in these effective programs.
Please could you introduce yourself?
I am a Senior Scientist with the Centers for Disease Control and Prevention’s Division for Heart Disease and Stroke Prevention. I currently lead the Division’s Health Services and Systems Research Section and oversee multiple surveillance and research activities that support Million Hearts® – a national initiative with a network of partners focused on preventing 1 million heart attacks, strokes and other cardiovascular events by 2022.
What prompted you to conduct this research?
Cardiac rehabilitation is a comprehensive program that is typically delivered in an outpatient setting and is designed to improve cardiovascular health following a cardiac-related event or procedure. Participation in a cardiac rehabilitation program can reduce the risk of death from any cause and from cardiac causes, as well as decrease hospital readmissions. Cardiac rehabilitation participation also improves functional status, quality of life and mood. Despite these benefits, enrollment in cardiac rehabilitation remains low.
Participation in a cardiac rehabilitation program can reduce the risk of death from any cause and from cardiac causes, as well as decrease hospital readmissions."
This research was carried out as part of our progress tracking for reaching the Million Hearts Cardiac Rehabilitation Collaborative’s goal of increasing cardiac rehabilitation participation in the USA to 70% or higher by 2022.
The Million Hearts Cardiac Rehabilitation Collaborative includes over 400 representatives from organizations, agencies, institutions and clinics who are devoted to maximizing the health of people who have had a heart attack or other heart-related event or surgery.
What do you perceive to be some of the barriers towards individuals’ successful initiation in, and completion of, cardiac rehabilitation programs?
This study found that, from 2016–2017, approximately one-quarter (24%) of the 366,000 Medicare beneficiaries eligible for outpatient cardiac rehabilitation participated, and among those who participated, only 24% started in a timely manner (within 21 days) and 27% completed a full course of 36 or more sessions.
Cardiac rehabilitation use remains lowest among women, beneficiaries aged 85 years and older, and non-white, racial-ethnic groups. Its use was also observed to vary considerably based on where beneficiaries lived and what qualified them for receiving cardiac rehabilitation. For example, participation in cardiac rehabilitation was lowest in the southeastern states and Appalachia. Also, those who had a procedure performed, like coronary bypass surgery, were much more likely to use cardiac rehabilitation than those who had a heart attack and did not have a procedure performed.
Poor knowledge of the benefits associated with program participation and completion is a significant barrier towards individuals’ successful program initiation and completion."
Poor knowledge of the benefits associated with program participation and completion is a significant barrier towards individuals’ successful program initiation and completion. Improving awareness about the value of cardiac rehabilitation, increasing referral of eligible patients, and reducing system and patient barriers to participation are all critical steps in improving the referral, participation and completion rates for cardiac rehabilitation.
More importantly, effective remedies have been identified but are not being widely and systematically implemented.
What do you hope some of the implications of your research may be?
I hope that this work will encourage all patients who have had a heart attack or heart surgery performed, or who have heart failure or stable angina, to talk with their doctors about participating in cardiac rehabilitation. Every cardiac rehabilitation session that a patient doesn’t use is a missed opportunity for them to improve their health and reduce their risk for having a secondary heart attack or other heart-related event.
If a center-based cardiac rehabilitation program is not readily available in a patient’s community, they should talk with their doctor about other options to work towards improving their heart’s health. One strategy could be to use home-based or tele-cardiac rehabilitation – ways of providing cardiac rehabilitation that achieve similar health outcomes as those attained using center-based care. While health insurance coverage for receiving these types of services are currently limited, efforts are occurring across the country to increase their availability.
Every cardiac rehabilitation session that a patient doesn’t use is a missed opportunity for them to improve their health and reduce their risk for having a secondary heart attack or other heart-related event."
For clinicians and healthcare systems, a wealth of guidance exists that identifies the evidence-based strategies that can be used to increase cardiac rehabilitation use. However, they are not being widely and systematically implemented. As mentioned, improving awareness of its value and increasing referral of eligible patients are amongst the key steps that must be taken to improve program enrollment and participation rates.
What are the next steps for translating your findings into actionable outcomes?
To support clinicians, hospitals and cardiac rehabilitation programs, the American Association of Cardiovascular and Pulmonary Rehabilitation (IL, USA) teamed up with the Million Hearts initiative to develop the Million Hearts Cardiac Rehabilitation Change Package. This guide includes examples of interventions and strategies that have been effectively used throughout the country to improve cardiac rehabilitation use that other groups can lift and apply within their own settings.
In addition, the Agency for Healthcare Research and Quality (MD, USA) is leading the TAKEheart initiative to support hundreds of hospitals with the implementation of the Million Hearts Cardiac Rehabilitation Change Package.
Ricthey declares no disclosures relevant to this work.
The opinions expressed in this feature are those of the interviewee/author and do not necessarily reflect the views of The Evidence Base® or Future Science Group.