Elsevier

Mayo Clinic Proceedings

Volume 92, Issue 2, February 2017, Pages 234-242
Mayo Clinic Proceedings

Special article
Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative

https://doi.org/10.1016/j.mayocp.2016.10.014Get rights and content

Abstract

The primary aim of the Million Hearts initiative is to prevent 1 million cardiovascular events over 5 years. Concordant with the Million Hearts' focus on achieving more than 70% performance in the “ABCS” of aspirin for those at risk, blood pressure control, cholesterol management, and smoking cessation, we outline the cardiovascular events that would be prevented and a road map to achieve more than 70% participation in cardiac rehabilitation (CR)/secondary prevention programs by the year 2022. Cardiac rehabilitation is a class Ia recommendation of the American Heart Association and the American College of Cardiology after myocardial infarction or coronary revascularization, promotes the ABCS along with lifestyle counseling and exercise, and is associated with decreased total mortality, cardiac mortality, and rehospitalizations. However, current participation rates for CR in the United States generally range from only 20% to 30%. This road map focuses on interventions, such as electronic medical record–based prompts and staffing liaisons that increase referrals of appropriate patients to CR, increase enrollment of appropriate individuals into CR, and increase adherence to longer-term CR. We also calculate that increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the United States.

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

References (58)

  • A.L. Beatty et al.

    Trends in referral to cardiac rehabilitation after myocardial infarction: data from the National Cardiovascular Data Registry 2007 to 2012

    J Am Coll Cardiol

    (2014)
  • D.E. Gaalema et al.

    Financial incentives to promote cardiac rehabilitation participation and adherence among Medicaid patients

    Prev Med

    (2016)
  • P. Lounsbury et al.

    Text-messaging program improves outcomes in outpatient cardiovascular rehabilitation

    Int J Cardiol Heart Vasculature

    (2015)
  • S.J. Wyer et al.

    Increasing attendance at a cardiac rehabilitation programme: an intervention study using the Theory of Planned Behaviour

    Coronary Health Care

    (2001)
  • S.L. Grace et al.

    Systematizing inpatient referral to cardiac rehabilitation 2010: Canadian Association of Cardiac Rehabilitation and Canadian Cardiovascular Society joint position paper endorsed by the Cardiac Care Network of Ontario

    Can J Cardiol

    (2011)
  • J.S. Wright et al.

    Million hearts—where population health and clinical practice intersect

    Circ Cardiovasc Qual Outcomes

    (2012)
  • Million Hearts website. http://millionhearts.hhs.gov/. Accessed October...
  • T.R. Frieden et al.

    The “Million Hearts” initiative—preventing heart attacks and strokes

    N Engl J Med

    (2011)
  • G.J. Balady et al.

    Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association

    Circulation

    (2011)
  • 42 CFR Parts 510 and 512. Medicare program; advancing care coordination through episode payment models (EPMS); cardiac rehabilitation incentive payment model; and changes to the comprehensive care for joint replacement model (CJR); proposed rule

    Fed Regist

    (2016)
  • B.G. Hammill et al.

    Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries

    Circulation

    (2010)
  • B.S. Heran et al.

    Exercise-based cardiac rehabilitation for coronary heart disease

    Cochrane Database Syst Rev

    (2011)
  • G.T. O'Connor et al.

    An overview of randomized trials of rehabilitation with exercise after myocardial infarction

    Circulation

    (1989)
  • N.B. Oldridge et al.

    Cardiac rehabilitation after myocardial infarction: combined experience of randomized clinical trials

    JAMA

    (1988)
  • P.A. Ades

    Cardiac rehabilitation and secondary prevention of coronary heart disease

    N Engl J Med

    (2001)
  • C.J. Lavie et al.

    Exercise and the cardiovascular system: clinical science and cardiovascular outcomes

    Circ Res

    (2015)
  • R. Hambrecht et al.

    Effect of exercise on coronary endothelial function in patients with coronary artery disease

    N Engl J Med

    (2000)
  • P.A. Ades et al.

    High-calorie–expenditure exercise: a new approach to cardiac rehabilitation for overweight coronary patients

    Circulation

    (2009)
  • W. Linden et al.

    Psychosocial interventions for patients with coronary artery disease: a meta-analysis

    Arch Intern Med

    (1996)
  • 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.

    View full text