From Referral to Recovery: Maximizing Enrollment and Participation in Cardiac Rehabilitation.

Background Cardiac telerehabilitation is proven to be equally safe and effective as center-based cardiac rehabilitation. Nevertheless, some real-world barriers significantly impact the adoption and successful implementation of cardiac rehabilitation as well as cardiac telerehabilitation. Purpose This study assesses willingness and actual participation in cardiac (tele)rehabilitation, examining key influencing factors (i.e. digital health readiness, health literacy, patients’ awareness). It explores the relation between digital health readiness and patients’ awareness concerning their intention to participate in cardiac telerehabilitation. Additionally, it investigates the relation between intention and actual participation in cardiac rehabilitation, considering the impact of health literacy and patients’ awareness. Methods In this prospective single-center survey study, patients with cardiovascular disease were asked to fill in questionnaires. Digital health readiness was measured by Digital health readiness questionnaire (DHRQ), and health literacy was assessed with the Health Literacy Scale (HLS-EU). Patients' awareness of their cardiovascular disease was determined by the accuracy of their understanding of their specific cardiovascular condition. Results A total of 72 patients (mean age 62.7 ± 13.3; 33.3% is women) were included in this survey. 81.7% and 50% patients have respectively the intention to participate in cardiac rehabilitation and telerehabilitation. Additionally, 50,7% patients actually participated cardiac rehabilitation. There is a negative correlation between age and digital health readiness (r = -0.05, p < 0.001)/learnability ( r= -0.26, P = 0.025). There is no correlation between digital health readiness (r= 0.011, P= 0.931) and patients’ awareness with the intention to participate in cardiac telerehabilitation (r = -0.045, P = 0.733). Furthermore, there is also no correlation between health literacy (r = 0.196, P= 0.123) and patients’ awareness (r = 0.002, P = 0.086) with the intention to participate in cardiac rehabilitation. Lastly, no correlation between health literacy and actual participation in cardiac rehabilitation is detected (r = -0.115, P = 0.375), but it has been established that there is a relationship between patients’ awareness and actual participation in cardiac rehabilitation (r = -0.266, P = 0.033). Conclusion Cardiovascular patients express a moderate intention to participate in cardiac terehabilitation, and there is no relation between digital health readiness and this intention, suggesting that digital health readiness is not a barrier to the willingness to participate cardiac telerehabilitation. Additionally, higher levels of patients’ awareness of their cardiovascular disease appears to result in increased engagement in cardiac rehabilitation program. However, further research is necessary to explore the barriers in participation to cardiac (tele)rehabilitation.

Aims:To estimate the participation in, and the comparative effectiveness of, short-term residential and comprehensive outpatient cardiac rehabilitation (CR), after the latter was introduced in Slovenia by establishing dedicated regional CR centers.Methods:We extracted and analyzed data on all patients hospitalized for myocardial infarction in Slovenia (n = 15,639), focusing on CR participation – either comprehensive outpatient (introduced in 2017) or short-term residential (available throughout the study period 2015–2021). Impact on nation-wide CR participation rates was assessed by interrupted time series analysis; impact on patient-level outcomes (all-cause mortality and cardiovascular hospitalizations) was assessed using Kaplan Meier estimators and ‘doubly robust’ Cox regression with propensity score-derived inverse probability of treatment weighting.Results:Of the 11,815 eligible patients (event-free after 180-day landmark), 3819 (32.3%) attended CR. Nation-wide CR participation rates increased both in level (9.7%, 95% CI 6.3–3.1) and in trend (0.41% per month, 95% CI 0.22–0.60) after outpatient CR was introduced in 2017. After propensity score-based adjustment, participation in either CR was associated with lower event rates (12.8%, 17.2%, and 21.0% at 3-year follow-up for outpatient, residential, and no CR, respectively; p < 0.001). Risk reductions were significant for composite outcomes (outpatient: HR 0.58, 95% CI 0.47–0.70; residential: HR 0.79, 95% CI 0.68–0.93) and all-cause mortality (outpatient: HR 0.56, 95% CI 0.38–0.83; residential: HR 0.59, 95% CI 0.45–0.77), whereas the risk reduction for cardiovascular hospitalizations was only significant for outpatient CR (HR 0.60, 95% CI 0.48–0.74). The incremental cost-effectiveness ratio per life-year gained was €6421 and €7381 for outpatient and residential CR, respectively.Conclusions:Participation in either CR improves outcomes after myocardial infarction, but comprehensive outpatient CR conveys superior risk reductions, primarily through reduced cardiovascular hospitalizations.Lay SummaryOur study highlights the importance of expanding cardiac rehabilitation services (by setting up dedicated regional comprehensive outpatient centers) and provides new evidence on improved outcomes in patients after myocardial infarction, who undergo cardiac rehabilitation. While previous studies have demonstrated the efficacy and effectiveness of cardiac rehabilitation, ours is the first to compare two distinctive cardiac rehabilitation modalities – comprehensive outpatient (introduced in 2017) and short-term residential (available throughout the study period 2015–2021).In our nationally representative population of patients after myocardial infarction (n = 15,639), participation in cardiac rehabilitation increased both in level (by ~10%) and in trend (by ~0.4% per month) after dedicated cardiac rehabilitation centers were established. Participation in either comprehensive outpatient or short-term residential cardiac rehabilitation was associated with a significant 42% and 21% risk reduction in the primary outcome (death or cardiovascular hospitalization) respectively, after propensity score-based adjustment. Mortality was also reduced (by 46% and 41%, respectively), whereas the risk reduction for hospitalization was only significant in patients undergoing comprehensive cardiac rehabilitation (by 60%).Participation in either cardiac rehabilitation program improves cardiovascular outcomes, but comprehensive outpatient cardiac rehabilitation yields superior risk reductions, primarily through reduced cardiovascular hospitalizations.Key Learning PointsWhat is already known?Cardiac rehabilitation improves outcomes in patients with coronary artery disease.Despite its established efficacy, cardiac rehabilitation participation remains suboptimal. Improving access to cardiac rehabilitation through establishing dedicated regional centers may improve participation, but also crowd-out existing options of cardiac rehabilitation.The comparative effectiveness of different cardiac rehabilitation modalities (e.g., comprehensive outpatient versus short-term residential cardiac rehabilitation) remains understudied.What does this study add?Expanding cardiac rehabilitation services (by setting up dedicated regional comprehensive outpatient centers) significantly improves participation in cardiac rehabilitation after myocardial infarction.Participation in either comprehensive outpatient or short-term residential cardiac rehabilitation after myocardial infarction is associated with improved outcomes (i.e., a significant 42% and 21% risk reduction in death or cardiovascular hospitalization, respectively).Comprehensive outpatient cardiac rehabilitation yields superior risk reductions primarily through reduced cardiovascular hospitalizations.

Background: Regional quality improvement collaboratives may provide one solution to improving cardiac rehabilitation (CR) participation through performance benchmarking and provider engagement. The objective of this descriptive study was to evaluate the feasibility of the Michigan Cardiac Rehab Consortium to improve CR participation Methods and Results: Multipayer claims data from the Michigan Value Collaborative were used to identify hospitals and CR facilities. Univariate analyses described participating hospital characteristics and hospital-level rates of CR enrollment within 1-year. A total of 95 hospitals and 85 CR facilities with 48 hospitals (51%) providing interventional cardiology services and 33 (35%) provided cardiac surgical services. The overall consortium-wide enrollment rate into CR across all conditions was 19.8% (26,398 of 133,641 eligible admissions), which was highest for CABG (58.4%), followed by SAVR (54.8%), PCI (34.6%), TAVR (33.1%), AMI (12.7%), and CHF (3.4%). There was wide variation in CR participation across participating eligible admissions and hospitals (Figure). A 17-member multidisciplinary stakeholder group was assembled representing 12 institutions and diverse roles, including exercise physiologists, cardiologist, program directors, and patients. Three diverse CR facilities participated in virtual site visits, which revealed individual successes in improving CR participation, but a variety of barriers to participation related to referrals, capacity and staffing constraints, and geographic and financial barriers. Conclusions: This study demonstrated the feasibility of a statewide collaboration centered around the goal of equitably improving CR enrollment for all eligible patients that is supported by a multidisciplinary stakeholder group and performance benchmarking. Future work will seek to continuously improve and evaluate the impact of this consortium on CR participation in Michigan.

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Background: Participation in cardiac rehabilitation (CR) is enhanced by proximity to CR facilities and communication between inpatient and outpatient settings but may become fragmented when patients are distant from their discharging hospital and nearest CR facility. Research Question: This study investigates how patient distance to both hospitals and CR facilities impacts the rates of CR participation. Methods: This study included 100% Medicare fee-for-service claims for beneficiaries with 12 months of continuous Part A/B coverage who had coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or surgical or transcatheter aortic valve replacements (SAVR or TAVR) between 07/2016-12/2018, excluding patients discharged to hospice or died within 30 days. Google Maps defined travel distances from the patient to hospital and CR facility locations using geographic centroids of ZIP codes, which were then categorized into quartiles. CR enrollment was defined as attending at least one session within one year of discharge. Logistic regression models estimated marginal CR enrollment rates across both hospital and CR facility distance categories adjusting for patient, hospital, and regional factors. Results: The study included a total sample of 501,049 beneficiaries undergoing PCI (62%), CABG (19%), SAVR (7%), and/or TAVR (15%). The median travel distance to the hospital was 18.6 miles (IQR 8.2-43.3 miles) and to the CR facility was 7.7 miles (IQR 2-15.3 miles). A total of 188,963 (37.7%) beneficiaries attended at least one CR session, which varied across categories of distance to hospital (Q1: 36.8% to Q4: 37.5%) and CR facility (Q1: 44.7% to Q4: 30.0%, p&lt;0.01). Adjusted CR enrollment rates improved when beneficiaries lived farther from their admitting hospitals but closer to CR facilities (Figure 1), with the highest enrollment for those located farthest from their admitting hospital but closest to the CR facility (47.5%) and lowest enrollment among those closest to the hospital but farthest from the CR facility (20.6%). Conclusions: Greater distance to the admitting hospital was associated with higher CR enrollment, while greater distance to the CR facility was associated with lower enrollment among eligible Medicare beneficiaries. Addressing geographic barriers to CR participation may require tailored solutions based on patient proximity to hospitals and CR facilities.

For patients hospitalized for a cardiac event, an earlier appointment to outpatient cardiac rehabilitation (CR) increases participation. However, it is unknown what effect hastening CR enrollment might have among employed patients planning to return to work (RTW). Using 2 complementary data sets from Henry Ford Hospital (HFH) and Mayo Clinic, we assessed when employed patients eligible for CR anticipated a RTW, the impact of an earlier appointment on CR enrollment, and the effect of employment status on the number of CR sessions attended. Patients at HFH attended CR at either 8 or 42 days (through randomization), whereas Mayo Clinic patients attended 10 days after hospital discharge per standard routines. Among 148 patients at HFH, 65 (44%) were employed and planned to RTW. Of these, 67% desired to RTW within 1 to 2 weeks, whereas 28% anticipated an RTW within 1 to 3 days. Home financial strain predicted nonparticipation in CR (P < .001) and was associated with an earlier planned RTW. Among 1030 patients at Mayo Clinic, 393 (38%) were employed. Employed (vs nonemployed) patients enrolled in CR 3.3 days sooner (P < .001), but attended 1.6 fewer CR sessions (P = .04). In employed patients from both health systems, an earlier (vs later) appointment to CR did not result in additional exercise sessions of CR. Employed patients plan to RTW quickly, in part because of home finances. They also enroll earlier into CR than nonemployed patients. Despite these findings, earlier appointments do not seem to favorably impact overall CR participation.

Temporal Trends and Factors Associated With Cardiac Rehabilitation Participation Among Medicare Beneficiaries With Heart Failure

Background Research evidence shows that greater cardiac rehabilitation (CR) referrals and participation can reduce cardiovascular mortality and morbidity, which leads to social and economic benefits (1). It remains unknown, however, what the CR referrals and participation are for patients following elective percutaneous coronary intervention (PCI). Aim Our aim was to identify the prevalence, trends, and predictors of CR referrals and participation in patients undergoing elective PCI between July 2017 and December 2021 among six public hospitals in one of the Australian states. Methods A retrospective observational study was conducted. Data were extracted from a state-wide Cardiac Outcomes Registry for patients who underwent elective PCI. Patients were identified if they were referred to CR following hospital discharge. CR participation has two assessments. The initial assessment focuses on a comprehensive cardiovascular risk factor review that occurs before attending a CR program, whereas the final assessment represents CR completion. We conducted descriptive and inferential statistical analyses. Results Out of 3081 patients who underwent elective PCI, 1845 (59.9%) had CR referrals. Of the 1845 patients who had CR referred, 1022 (55.4%) completed an initial assessment, and 400 (21.7%) completed both an initial and final assessment. The rate of CR referrals increased from 12.0% in 2017 to 23.5% in 2018 before decreasing slightly in 2019 and 2020 (21.0% and 22.8%, respectively). There was a decline in the proportion of patients who had an initial assessment from 44.0% in 2017 to 29.0% in 2021. The rate of the final assessment showed a slight increase from 32% in 2017 to 41% in 2021. Multivariate logistic regression showed that of those patients undergoing PCI, patients who stayed overnight were 9.9 times more likely to receive a CR referral than those with same-day discharge. However, for those who had CR referrals, overnight stay was not a predictor in completing the initial assessment. Similarly, of those who completed an initial assessment, overnight stay was also not a predictor in completing the final assessment; rather, those with a positive family history were more likely to complete the final assessment. Conclusion Our findings reveal a low CR referral rate in patients undergoing elective PCI, and overnight stay is a strong predictor for CR referrals. As a referral is a gateway to CR participation (2), more work is needed to explore the options to increase CR referrals, particularly for patients discharged on the same day as their procedure. Following referrals, overnight stay did not predict completion of initial and final assessments, indicating that other strategies are required to promote CR participation.

Cardiac rehabilitation (CR) improves outcomes following percutaneous coronary intervention (PCI) but remains underutilized. A liaison-mediated referral (LMR), where a health care professional explains CR's benefits, addresses barriers to participation, and places a referral before discharge, may promote CR use. Our objective was to assess the impact of an LMR on CR participation after PCI. This was a retrospective study of patients who underwent PCI across 48 hospitals in Michigan between January 2021 and April 2022 and referred to CR before discharge. Clinical registry data were linked to administrative claims to identify the primary outcome, CR participation, defined as ≥1 CR session within 90 days of discharge. Bayesian hierarchical logistic regression was used to compare CR participation between patients with and without an LMR. For the secondary outcome, frailty proportional hazard modeling compared days elapsed between discharge and first CR session between liaison cohorts. Among 9023 patients referred to CR after PCI, 4323 (47.9%) underwent an LMR (mean age, 69.3 [SD=11] years; 68.3% male) and 3390 (36.7%) attended ≥1 CR session within 90 days of discharge. The LMR cohort had a higher unadjusted CR participation rate (43.1% [95% CI, 41.5%-44.6%] versus 32.4% [95% CI, 31.1%-33.8%]; P<0.001), a higher adjusted odds ratio of attending ≥1 CR session (adjusted odds ratio, 1.21; 95% credible interval, 1.07-1.38), and a shorter delay in attending the first CR session compared with the non-LMR cohort (28 [interquartile range, 19-42] versus 33 [interquartile range, 21-47] days; P<0.001). An LMR was associated with higher odds of CR participation and may mitigate delays in CR enrollment. This referral strategy may improve CR participation and patient outcomes after PCI.

Introduction: Barriers to referral, enrollment and participation in cardiac rehabilitation (CR) contribute to low rates of completion despite known benefits. Barriers are system, provider and patient related. We sought to examine the impact a non-integrated community health plan can have on addressing these barriers, given the absence of formal studies evaluating its impact. Hypothesis: Implementing evidence-based strategies would increase CR participation. Methods: Between October 2019-October 2022, The Capital District Physicians’ Health Plan (CDPHP) developed and implemented an enhanced cardiac rehabilitation initiative (ECRI) to increase CR rates using evidence-based strategies. CDPHP: 1) eliminated patient cost-share, 2) covered home-based cardiac rehabilitation (HBCR), 3) implemented physician valued-based incentives, 4) presented metrics to providers, 5) educated providers and patients, and 6) dedicated staff to facilitating enrollment. CR rates were evaluated between Q2 2021 and Q2 2022. Results: Time from ECRI program conception to implementation was 18 months. Enrollment in HBCR went from 4% (19/485) (Q2, 2021) to 7.8% (33/422) (Q2, 2022). Enrollment in center-based cardiac rehab (CBCR) went from 11% (53/485) to 11.4% (48/422) respectively. Total enrollment in CR increased from 14.8% (72/485) to 19.2% (81/422). Conclusions: The ECRI created a call-to-action among providers to address modifiable barriers such as patient identification for CR and referral and enrollment processes. The introduction of HBCR increased CR rates and were additive to CBCR rates, suggesting the introduction of HBCR can increase CR rates and not displace CBCR. Increasing CR engagement and amplifying the results found in this demonstration, requires coordinated effort from all stakeholders-cardiology providers, hospitals, CR providers and health plans.

To examine the effectiveness of cardiac rehabilitation on health status following coronary artery bypass surgery. A prospective cohort study of patients having coronary artery bypass surgery at 14 centers in the state of Washington. Baseline clinical and demographic data were collected, as was information from the Rand Short Form, 36 (SF-36), the Seattle Angina Questionnaire, and other questions regarding health status before surgery and at 6 and 12 months after surgery. In the 12-month follow-up survey, subjects were asked to complete questions pertaining to their participation in postdischarge cardiac rehabilitation programs. A total of 947 subjects from 13 centers received 1-year follow-up surveys, with 75% responding. Of these, 691 (95%) answered questions about participation in cardiac rehabilitation programs. SF-36 and Seattle Angina Questionnaire scores improved significantly after surgery for both cardiac rehabilitation participants and nonparticipants. Although more than 90% of subjects who participated in the cardiac rehabilitation programs stated that they were beneficial, for eight SF-36 domains and five Seattle Angina Questionnaire domains, no significant associations were found with participation in cardiac rehabilitation. When the participation status was defined as only those participants who completed at least 8 weeks of cardiac rehabilitation, only 1 of 13 health status domains favored cardiac rehabilitation. Responses to a series of questions about perceptions of change in general and cardiac-specific health did not differ among participants and nonparticipants. Although patients report favorable impressions of cardiac rehabilitation after coronary artery bypass surgery, it does not appear to provide a measurable benefit in self-reported health status beyond that achieved from the revascularization procedure itself.

Poor implementation and variable quality of cardiac rehabilitation (CR) for coronary heart disease (CHD) have been a global concern. This nationwide study aimed to clarify the implementation of and participation in CR among CHD patients and associated factors in Japan. We conducted a retrospective cohort study using data extracted from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in 2017–2018 were included. Aspects of CR were assessed in terms of (1) participation in exercise-based CR, (2) pharmacological education, and (3) nutritional education. Of 87,829 eligible patients, 32% had participated in exercise-based CR, with a mean program length of 40 ± 71 days. CABG was associated with higher CR participation compared to PCI (OR 10.2, 95% CI 9.6–10.8). Patients living in the Kyushu region were more likely to participate in CR (OR 2.59, 95% CI 2.39–2.81). Among patients who participated in CR, 92% received pharmacological education, whereas only 67% received nutritional education. In Japan, the implementation of CR for CHD is insufficient and involved varying personal, therapeutic, and geographical factors. CR implementation needs to be promoted in the future.

Introduction: Cardiac rehabilitation is a guideline-recommended therapy for patients after acute myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass surgery (CABG). However, participation in cardiac rehabilitation is notoriously poor. Evaluating variation in health care delivery can help to identify best practices that improve quality of care more broadly. Therefore, we sought to examine regional variation in the percent of patients who participate in cardiac rehabilitation across the United States. Methods: We used ICD-9 codes from Medicare and Veterans Health Administration (VHA) data to identify patients hospitalized for MI, PCI, or CABG between 1/1/2007 and 12/31/2009 (in a 5% Medicare sample) or 10/1/2006 and 9/30/2011 (in VHA). After excluding patients who died within 30 days of hospitalization, we calculated the percent of patients who participated in one or more outpatient visits for cardiac rehabilitation (CPT code 93797 or 93798) during the 12 months after hospitalization. We then compared the percent of patients who participated in cardiac rehabilitation by state. Hawaii and Alaska were excluded from the analysis because they do not have VHA inpatient facilities. Results: Overall participation in cardiac rehabilitation was 20% (13,435/67,115) in Medicare and 8% (3,955/47,051) in VHA. Similar regional variation was observed, with the North-Central United States having the highest participation in both health care systems (Figure). Within Medicare, participation in cardiac rehabilitation ranged from 10% (Nevada) to 52% (Nebraska). Within VHA, participation ranged from 0 (Delaware, New Jersey) to 30% (Nebraska). Conclusion: Similar regional variation in participation in cardiac rehabilitation was observed in two separate health care systems. Nebraska had the highest rate of participation in both Medicare and VHA populations. Further study of reasons for regional variation and differences in regional variation in these populations may reveal opportunities for improving delivery of cardiac rehabilitation.

Cardiac rehabilitation after myocardial infarction in the community

Introduction: Cardiac rehabilitation (CR) participation reduces the likelihood of major adverse cardiovascular events (MACE), but is limited by structural factors, including race or ethnicity and annual income. We investigated (1) associations between CR participation and MACE, and (2) how structural disadvantage modifies this association, focusing on the intersection between race or ethnicity and household income. Hypotheses: We hypothesized that (1) CR participation would be inversely associated with MACE, and (2) this association would attenuate differences in MACE by race or ethnicity, as well as by household income. Methods: We identified 212,744 individuals with a CR-qualifying event between 1/1/16 and 12/31/20 in Optum’s de-identified Clinformatics® Data Mart database. We evaluated associations between CR sessions attended (0 to 36) and MACE (cardiac arrest, heart failure, myocardial infarction, or stroke hospitalizations) using a proportional hazards model for recurrent events, and assessed the three-way interaction between CR participation, race or ethnicity, and household income. Results: We included 212,744 individuals (age 70.8±11.3 years; 37.8% female sex; 71.9% White race) of whom 26.0% attended ≥1 CR sessions. Overall, we observed a dose-response association between CR participation and MACE. After adjustment, those who did not attend CR were 2.9 times as likely to experience MACE as those who attended ≥36 sessions (95% CI: 2.71, 3.03, P &lt;0.0001), for whom there were no significant differences by race or ethnicity ( Figure ). Associations between CR participation and MACE were similar both across race or ethnicity and by household income ( P , interaction=0.28). Conclusion: Greater CR participation is associated with lower risk of MACE, regardless of (1) race or ethnicity and (2) household income. Because participation in CR remains low, particularly in socially disadvantaged populations, interventions to promote use of CR are critical to reduce disparities in cardiovascular outcomes.