Special articleIncreasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative
Section snippets
Background
Benefits of CR participation are broad and compelling and include a 13% to 24% reduction in total mortality over 1 to 3 years, a 31% decrease in rehospitalizations over 1 year, and an increase in physical function and quality of life.9, 10, 11, 12, 13 Much of the clinical benefit of CR has been ascribed to increases in fitness from a structured exercise program14, 15 and the associated favorable physiologic effects on coronary endothelial function, insulin resistance, blood pressure,
Potential Impact
What would be the impact of increasing CR participation from 20% to 70% in terms of cardiovascular events prevented as a component of Million Hearts? We performed this calculation with a simple model using published literature. We first summed the annual number of CR-qualifying events: acute MI (735,000), CABG surgery (395,000), PCI (454,000), and new cases of systolic heart failure discharged from the hospital (504,000).27, 28, 29, 30 We then obtained contemporary 1-year mortality rates and
Improving CR Referral
Cardiac rehabilitation referral rates can be almost tripled by using the systematic approach to referral developed by Grace et al,38 which includes an automatic electronic medical record–based CR referral system. This “default” or “opt-out” order for patients with qualifying diagnoses results in efficient, systematic referral to outpatient CR during the hospital discharge process. Additionally, a staff member or “liaison” meets with each patient to introduce CR and help coordinate the referral
Improving CR Enrollment
The transition from CR referral to CR enrollment is a crucial step in the overall CR participation process. Systematic approaches to CR enrollment substantially increase CR participation rates (Table 1). First, the systematic CR referral strategy of Grace et al38 was also associated with a higher overall CR enrollment rate, 74% in centers that used a computerized automatic referral system with liaisons to help patients navigate the enrollment process vs 29% in centers using “usual care”
Increasing Adherence to CR
Another challenge and opportunity for CR programs is ensuring that all patients receive the largest “dose” possible of program participation. Specifically, several studies suggest that the magnitude of clinical benefit derived from participation in CR is related to the number of sessions completed by patients.8, 34, 35 Cardiac rehabilitation participants face a variety of barriers in attending and completing the program. Among these barriers are the need to return to work, the cost burden,
Instituting System-Based Approaches
The widespread use of system-based approaches for both CR referral and enrollment would improve CR participation rates substantially. If all hospitals adopted the systematic CR referral approach with liaisons, CR referral rates could approach 90%.38 If all hospitals and CR programs adopted the CR enrollment strategies outlined previously, then overall enrollment rates could exceed 70%, assuming the geographic availability of a CR program. Even if only half of US hospitals and CR programs
Implementation and Practical Considerations
Implementation of this road map should begin with CR programs and their affiliated hospitals instituting process improvements designed to accommodate more patients in an efficient manner, as well as working with their information systems department and electronic medical record personnel to develop an automated CR referral during the hospital discharge process. Patients with appropriate diagnoses should leave the hospital with a written CR referral and a scheduled individual or group visit at
Conclusion
The benefits of CR are broad and compelling, ranging from decreased mortality and decreased hospitalizations to improvements in functional capacity, insulin sensitivity, depression, and quality of life. Secondary prevention practices in CR support and align with the ABCS of Million Hearts. Improving CR participation from 20% to 70% in 5 years or less is achievable through individual and collective action to implement evidence-based strategies that increase CR referral, enrollment, and
Acknowledgments
The authors thank David Whellan, MD, for his helpful suggestions after reviewing the submitted manuscript. We also express gratitude for the commitment, expertise, and actions of members of the Million Hearts Cardiac Rehabilitation Collaborative, an outgrowth of the Million Hearts Cardiac Rehabilitation Leadership Summit held in November 2015 in Washington, DC, with representatives from over 30 organizations and agencies as well as CR graduates and their families. Represented organizations
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Cited by (0)
Grant Support: This work was supported in part by National Institutes of Health Center of Biomedical Research Excellence award P20GM103644 from the National Institute of General Medical Sciences (P.A.A., D.S.S.).
Potential Competing Interests: Dr Keteyian reports personal fees from NimbleHeart, Inc, unrelated to the submitted work. Ms Lui reports that GRQ, LLC, represents the American Association of Cardiovascular and Pulmonary Rehabilitation regarding regulatory and legislative issues that affect cardiac rehabilitation.