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Richard Soucier, M.D.
Fellow in Cardiology, University of Connecticut Health Center
An expert panel convened by the Agency for Health
Care Policy and Research and the National Heart, Lung, and Blood Institute
was given the charge to assess the clinical efficacy and cost-effectiveness
of cardiac rehabilitation. In October 1995, the Clinical Practice Guideline
for Cardiac Rehabilitation was published by the Department of Health and
Human Services and is available in several formats for clinicians, administrators
and patients.(1) In addition to documenting the benefits of program participation,
a number of shortcomings of the "traditional" cardiac rehabilitation program
were demonstrated. Prominent among these is the lack of availability for
patients who are unable to attend sessions at a hospital or free-standing
site because of location, lack of transportation, or financial considerations.
Furthermore, the focus of traditional programs has been on a limited scope
of cardiac disorders. A majority of participants have recently experienced
a myocardial infarction and/or surgical revascularization. Many patients
with symptomatic coronary disease, non-surgical revascularization, or
congestive heart failure are not considered for recruitment into programs
despite potential benefit in these populations.
Background
The benefit of cardiac rehabilitation for patients with coronary artery
disease has been well established. It has been demonstrated, however,
that this service tends to be underutilized. In fact, studies have shown
that only 11-20% of appropriate candidates for cardiac rehabilitation
are actually referred. This is compared with a 38% referral rate for patients
enrolled in the GUSTO trials.(1) Among the benefits of participation in
these programs are an increase in exercise tolerance, decrease in symptoms
of both angina and CHF, favorable changes in lipid profiles, decrease
in tobacco use, increase in a sense of well-being, and a decrease in mortality.(1)
The favorable effects of rehabilitation occur without significant risk
to the patient. In a recent study, it was demonstrated that post-myocardial
infarction patients participating in exercise rehabilitation had no increase
in early post-MI events when compared to non-participants. In over 1,600,000
patient-hours, there were 50 cardiac arrests and 7 myocardial infarctions.
There were 8 fatalities in the former group and 2 in the latter. This
corresponds to 1 fatal occurrence in over 116,000 patient-hours, similar
to the occurrence rate in the general post-MI population.(2) In another
group of 167 randomly selected cardiac rehabilitation programs, the event
rates per 1,000,000 patient-hours were 8.9 cardiac arrests, 3.4 myocardial
infarctions, and 1.3 fatalities.(3)
Additionally, there is a cost benefit to enrolling patients in adequate
cardiac rehabilitation programs. Perk and Hedback, in a five-year follow
up study, compared a group of 147 nonselected post-MI patients less than
65 years of age to 158 age-matched controls who were not involved in a
rehabilitation program. They demonstrated that the cost of the program
itself was offset by the increased tendency for the control patients to
be readmitted to the hospital for recurrent cardiac problems. This, coupled
with the fact that patients in cardiac rehab tended to return to work
earlier and more often than controls suggested that enrollment was the
cost-effective approach to post-MI care.(4) In a non-randomized study
of 580 patients having either a recent MI or CABG, the participants were
given the opportunity to participate in a supervised 12 week program of
exercise. The subjects exercised to 70-85% of their peak heart rate attained
on a graded exercise test for 1 hour per day, 3 days per week. Due to
study design, there were some differences in baseline characteristics
between the 230 participants and the remaining who declined participation.
It was of interest to note that the group taking part in the exercise
program incurred, per capita, an average of $739 lower rehospitalization
costs. (5)
Benefits of cardiac rehabilitation have also been demonstrated in selected
groups of cardiac patients, including those with "high" baseline exercise
tolerance. Although the relative improvement in exercise capacity in those
patients who were able to exercise to 6 METS was not as great as those
with less capacity, the changes noted in their lipid values were more
favorable.(6) The results of studies of women and cardiac rehabilitation
have revealed that participants have a 20-25% reduction in cardiovascular
and all-cause mortality, a decrease in resting blood pressure, decreased
weight, and a favorable change in lipid profiles. Also shown, however,
is a lower referral rate of women to programs and a significantly higher
dropout rate.(7)
The impact upon providers of services
The Clinical Practice Guidelines will challenge the flexibility and
creativity of those providing cardiac rehabilitation services. The traditional
four-phase program had been designed around predictable hospital lengths
of stay, standard methods of risk stratification, and third party reimbursement
for services that often dictated the length of time a participant spent
in rehabilitation. Rapid changes in the diagnosis and treatment of cardiac
disorders have already altered the landscape considerably and threaten
to make the programs of the 1980's and early 1990's old-fashioned if not
obsolete.
While there are distinct advantages to having on-site group exercise
and educational classes (social support, staff efficiency), a bulk of
the population at risk will not find their way into this setting. Innovative
approaches, including home- or community-based programs will allow a broader
participation and fulfill the mission of providing meaningful secondary
prevention to this large constituency. Bringing education into the home
will involve the cooperation of cardiac rehabilitation professionals and
home care agencies, as well as the development of unique and stimulating
teaching materials. The initiation of exercise training at home may be
helpful in encouraging a life-long commitment to increased physical activity,
but requires careful risk stratification and exercise prescription. Trans-telephonic
rhythm monitoring will have a role in the management of selected patients
involved in home-based exercise training, particularly those at moderate
risk for exercise.
Programs depending upon "reliable" insurance reimbursement for services
will be profoundly affected by the continued movement away from indemnity
coverage to managed care and capitation. Institutional reimbursement for
cardiovascular diagnosis-related groups will undoubtedly include a component
for post-hospitalization care - including cardiac rehabilitation. It will
be the responsibility of the service provider to implement a program that
is both efficient and effective. Diligent tracking of outcomes will be
as important during this phase of therapy as during acute hospitalization.
The Hoffman Heart Institute Experience
Saint Francis Hospital and Medical Center established the first cardiac
rehabilitation program in Hartford in 1976. Initially, a hospital-based
training and maintenance phase program was established with primarily
a low to moderate risk population. Separate convalescent phase and training
programs were developed in the mid-1980's as more "high risk" patients
were referred. The Mount Sinai Hospital program established an on-site
convalescent phase program and a busy training and maintenance phase program
at the Greater Hartford Jewish Community Center. Affiliation of the two
institutions fostered close cooperation between the cardiac rehabilitation
services and the development of a single program represented both on the
hospital campus and at the GHJCC.
Growth of the traditional outpatient program has been strong, with over
8,000 patient-hours of participation in fiscal year 1995. However, outcomes
data demonstrate that a majority of patients having myocardial infarction
or revascularization do not follow through with outpatient rehabilitation.
Efforts to increase the participation in program of secondary prevention
are being redoubled. Linkage between the inpatient critical pathways and
outpatient care plans will help to ensure continuity of care, including
post-discharge education and exercise rehabilitation. This will also provide
flexibility as lengths of stay continue to change. An upgrade of the monitoring
and data management system provide the capability for trans-telephonic
voice and ECG monitoring, facilitating continued contact between discharged
patients and the cardiac rehabilitation staff. It is clear that the new
practice guidelines provide not only challenges, but opportunities to
those willing to consider innovative approaches to rehabilitating and
educating the patient with heart disease.
I wish to acknowledge the assistance of Dr. Bernard Clark in the preparation
of this manuscript.
REFERENCES
- Wenger NK, et al. Cardiac Rehabilitation: Clinical
Practice Guidelines. AHCPR No. 96-0672. October 1995.
- Haskell, WA. Cardiovascular complications during
exercise training of cardiac patients. Circulation 1978; 57:920-4.
- Van Camp, SP, et al. Cardiovascular complications
of outpatient cardiac rehabilitation programs. JAMA 1986; 256:1160-3.
- Perk, LJ and Hedback, B. Cardiac rehabilitation -
a cost analysis. J of Int Med 1991; 230:427-34.
- Ades, PA et al. Cardiac rehabilitation participation
predicts lower rehospitalization costs. Am Heart J 1992;123:916-21.
- Lavie, CJ and Milani, RV. Patients with high baseline
exercise capacity benefit from cardiac rehabilitation and exercise training
programs. Am Heart J 1994;128:1105-9.
- Caras, DS and Wenger NK. Exercise rehabilitation
of women with coronary heart disease. J of Myocardial Ischemia 1993;5:42-52.
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