Refer Your Interventional Patient to Cardiac Rehab The Role of Cardiac Rehabilitation for Overall Cardiovascular Health

Abstract

Cardiac rehabilitation programs have historically been under-utilized as a treatment modality in cardiovascular health.  Issues such as lack of physician referral, financial burden to the patient, and limited awareness of the benefits of cardiac rehabilitation are major contributing factors regarding the under-utilization of cardiac rehabilitation. An automatic referral system and positive reinforcement by health care personnel to assist the patient in the enrollment process are shown to produce positive results in clinical outcomes. With recent changes in healthcare reform, promotion of cardiac rehabilitation programs may prove to be cost-effective for health care organizations and improve quality of life for patients living with cardiovascular disease.

Key words: Cardiac rehabilitation, minority patient, coronary heart disease

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Introduction

The number-one cause of morbidity and mortality worldwide is cardiovascular disease. More than two million people are affected annually in the United States with some form of cardiovascular disease. Of these, less than 20% of eligible patients per year having an acute myocardial infarction and/or coronary revascularization are enrolled in cardiac rehabilitation (CR) programs.¹ The referral rate of eligible patients for CR is between 7.5% to 29%.² These numbers are cause for alarm considering that the American Heart Association (AHA) has deemed CR an essential part of secondary prevention of coronary heart disease.¹ The factors that lead to low referral rates are unclear, although research has shown that being female, nonwhite, and elderly are associated factors with non-referral.²

Definition of cardiac rehabilitation

The following definition of cardiac rehabilitation is from the AHA council on clinical cardiology. 

“The term cardiac rehabilitation refers to coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality. As such, cardiac rehabilitation/secondary prevention programs provide an important and efficient venue in which to deliver effective preventive care”¹ (p. 369).          

In 1995, the U.S. Department of Health and Human Services, Agency for Healthcare Policy and Research (AHCPR), and the National Heart, Lung, and Blood Institute characterized cardiac rehabilitation as:

“The provision of comprehensive long-term services involving medical evaluation; prescriptive exercise, cardiac risk factor modification; and education, counseling, and behavioral interventions. The AHCPR guideline highlights the effectiveness of multifaceted and multidisciplinary cardiac rehabilitation services integrated in a comprehensive approach. The goal of this multifactorial process is to limit the adverse physiological and psychological effects of cardiac illness, to reduce the risk of sudden death or reinfarction, to control cardiac symptoms, to stabilize or reverse progression of the atherosclerotic process, and to enhance the patient’s psychosocial and vocational status”3 (p. 1619).   

Definition of minority patients

Minority patients in relation to CR for this article will be defined by race/ethnicity (non-white), sex (female), and age (75 years and over). The sociodemographic factors listed above are further broken down to examine nonwhites, women (especially elderly), and patients over 75 years of age.³ In one review of studies, patients between the ages of 45-59 had the highest rates of referral to CR. Patients who spoke English as a primary language were also referred more often, as were patients with a household income of more than $50,000 annually, a college education, and an urban residence.²

Prevalence of the problem

The lack of use of CR by minority patients (as defined by ethnicity, female gender, and advanced age) begins when the minority patient seeks initial care for a cardiovascular event.  Cardiac health disparities regarding minorities are well documented in research, starting with inadequate screening for cardiovascular risk factors. When dealing with nonwhite patients, mistrust of the medical profession can be an issue.⁴ Many patients from ethnic minorities harbor feelings of mistrust of the healthcare system due to unethical medical experiments that were conducted without consent many years ago.⁴ This can act as a hindrance to many ethnic minorities, who may enter the healthcare system with advanced complications such as a low ventricular ejection fraction from years of uncontrolled hypertension and with a higher rate of diabetes mellitus. 

Women, as a group, may not receive CR as often as men. Once diagnosed, women tend to be sicker, older and have more severe disease.⁵ Women may also suffer from psychosocial issues such as depression or guilt that may hinder enrollment into CR programs. Age is also a factor in whether or not patients receive CR. Patients over the age of 75 may be thought of as too old to achieve any benefit from a CR program. Yet the elderly actually gain the most from CR and have a significantly increased survival rate.⁶

Lack of referral from physicians

The literature indicates that there is a lack of referral for all cardiac patients to CR. In 2008, < 30% of patients in the United States who were eligible for CR were enrolled in CR programs following a cardiovascular event.³ Rozanski and Blumenthal reported that women and minorities were less likely to be referred for CR programs by their physicians.⁷ Mochari, Lee, Kligfield and Mosca conducted a study on 304 women with coronary heart disease and evaluated the barriers that they face, including referral to CR.⁸ Participants in the study were asked to rate how important their doctor’s referral was to their participation in a cardiac rehabilitation program. Ninety-one percent of white subjects and 93% of minority subjects rated physician referral a 3, 4, or 5 (with “1” as least agreement to “5” as most agreement) on a Likert-type scale. Only 17% of minority subjects, compared with 27% of white subjects, reported having been instructed to attend cardiac rehabilitation. The differences between the minority and white subjects were statistically significant (p = 0.048). According to Cortes and Arthur, the guidelines for CR referral, such as when, where, and how patients should be referred, and by whom, are not clear.² Jeger et al noted that the reasons for the referral bias in outpatient CR were not well understood.⁹ 

Lack of resources

Cardiac rehabilitation is limited in use by an overall lack of resources. Financial burden, whether due to limited resources or inadequate third-party reimbursements for CR, was reported by Wenger as a top barrier to CR.³ Personal financial burden may occur when the patient can no longer work due to disease status. Patients have to choose between paying their bills and attending CR. Mochari et al reported that minority patients were increasingly more likely to report finances as a barrier (p = 0.008) than whites.⁸ Historically, studies that have focused on race and medical procedures have shown that patients 65 years of age and older, and African Americans, are more prone to increased financial and organizational barriers. In comparison to whites, Hispanics and blacks often stated monetary issues, such as co-pays, as a barrier to being compliant with doctor visits.⁸ Minority women generally had similar insurance coverage to non-minority women; however, the insurance types of many minority women did not cover CR. Most insurance companies, including Medicare/Medicaid, cover 36 sessions (3 times weekly for 12 weeks) of rehabilitation, education, and counseling; however, patients are still not referred.³

Geographic locations of CR sites and transportation to CR sites were also identified as barriers to enrollment. Among women, transportation and the location of CR programs were the biggest determinants in seeking care.⁸ Cardiac rehabilitation programs are not available at all hospitals. This is related to supply and demand. Consistently low enrollment of patients to CR programs may not justify the establishment of CR sites within every healthcare facility. In addition to the previously mentioned barriers to CR, the public often does not recognize the positive impact that CR programs can have on the quality of life for cardiac patients.¹

Diagnosis eligibility for cardiac rehabilitation

Historically, myocardial infarction (MI) and coronary artery bypass grafting (CABG) were the primary diagnoses associated with CR enrollment. Today, patients who have undergone percutaneous coronary intervention, heart or heart/lung transplantation candidates/recipients, those with stable angina, stable chronic heart failure, peripheral arterial disease with claudication, and valvular disease necessitating repair or replacement are also eligible for CR.³ Cardiovascular prevention assistance provided thru CR is beneficial for women who may have CAD risk factors without the presence of disease.³ Cortes et al reviewed 10 published observational studies which included coronary artery disease (CAD) risk factors (e.g., hypercholesterolemia, current smoking, and hypertension) as diagnoses for eligibility for CR. Myocardial infarction (Q-wave) was the greatest CAD determinant for enrollment into CR. Patients having a more critical MI with the presence of stroke or shock were less likely to be candidates for CR. 

Benefits of cardiac rehabilitation

Cardiac rehabilitation as a method of secondary prevention has several benefits.^9-12 Post-MI, one-year survival increased from 74.7% with no treatment to 95.7% with CR.¹³ Overall morbidity and mortality are decreased with participation in CR. Elderly patients who partake in CR had mortality rates 21% to 34% lower over a five-year span post cardiovascular event.⁶ Cardiac rehabilitation programs are medically directed, with a multidisciplinary approach to care. Several physiological changes can be attributed to CR.¹² Research has shown that CR not only improves cardiovascular function, it can have an overall positive effect on quality of life (QOL), including an increase in functional capacity, improved cardiovascular efficiency, reduction in atherogenic and thrombotic risk factors, improvement in coronary blood flow, reduced myocardial ischemia, and severity of coronary atherosclerosis.¹²

Laux et al reported an increase in QOL with increased physical abilities as a result of exercise.¹¹ As patients proceeded with the exercise regimen, they expressed fewer feelings of pain, fewer limitations related to any pain that was present, and an overall more positive outlook on their disease process. In turn, participation in CR may enable a patient to return to work as a much more productive employee. 

Cardiac rehabilitation also offers psychosocial benefits. Many older adults live alone and CR may provide a social outlet that provides companionship. Coronary heart disease can psychologically predispose patients to anxiety or depression. Patients enrolled in CR typically have better overall mental health, enhanced self-efficacy and self-confidence. Most importantly, CR can be utilized to assess risk factors and tailor care to meet the needs of the patient and family. Fewer hospital admissions as a result of long-term behavioral changes that are learned in CR can ultimately decrease health care system costs.

Essentials of cardiac rehabilitation

In an optimal setting, CR begins while the patient is in the hospital with a cardiovascular disease process or associated risk factors (known as Phase I). Phase I may solely consist of walking around the hospital unit or receiving educational materials on diet and exercise. However, due to decreasing lengths of stay, often patients do not begin a CR program until after discharge. Phase II of CR is implemented in the outpatient setting and includes various core components for an overall comprehensive treatment plan for the prevention of future cardiovascular health concerns (Table 1).¹⁰ The core components and recommended interventions were designed by the AHA and the American Association of Cardiovascular and Pulmonary Rehabilitation to reduce cardiovascular risk factors, and encourage healthy behaviors, as well as active lifestyles for those living with cardiovascular disease.³

Promotion of cardiac rehabilitation programs

The most valuable tool in the promotion of CR programs is education. Healthcare providers from all disciplines should be knowledgeable regarding the benefits of CR. Physician endorsement and referral of CR is a critical factor in patient participation, as cited by many authors.^{1–3, 6, 8–9,14–16} Yet physicians are less likely to adhere to non-pharmacological secondary prevention methods such as CR even though initiatives such as the AHA’s Get With The Guidelines promote the use of CR. Physicians should be held accountable for prescribing CR for their patients who qualify as a means of secondary prevention of coronary heart disease. A possible solution regarding low referral rates to CR is to have an automatic referral system. An automatic referral system would enroll all patients with coronary heart disease without bias to race/ethnicity, gender, or age.^2,6,12

Patient education must be considered as an integral part in the utilization of CR programs. The best advertisement campaign for CR programs is patient testimonials. Patients who experience positive clinical and social outcomes from CR often share their story in the community. Patient education should be tailored to the needs of the individual and his/her diagnosis or risk factor(s). This can be achieved by healthcare providers practicing culturally competent care.¹⁵ Cultural competence enhances patient-provider relationships and is essential in the delivery of optimal clinical care. For individuals who lack healthcare insurance, insurance companies and healthcare professionals can collaborate to determine the systematic advantages of CR.¹⁴ Cardiac rehabilitation has been determined to significantly reduce health care expenditures and should be considered as an essential component in the reduction of national health care costs.¹⁷

Recommendations

The lack of physician referral is the biggest barrier to patient enrollment in CR. As a result, the rate of referral to CR programs varies across the United States, ranging from 5.2% to 42%.¹⁸ Many physicians simply forget to order CR as a component therapy in discharge planning. This can be eliminated by offering an automatic referral for CR on discharge planning documents for patients with cardiovascular disease and its associated risk factors.¹⁸ Physician as well as public awareness of CR programs must also be increased in order to raise awareness of the clinical benefits of CR.

Cardiac rehabilitation programs can be made more accessible thru a variety of ways. When a patient is identified with cardiac risk factors and/or coronary heart disease, the patient should be asked what their beliefs are about CR and any potential barriers to CR.¹⁴ This is a critical step in the utilization of CR due to the fact that more than fifty percent of patients referred to CR do not enroll.¹⁸ Minority patients should also be asked what type of interventions they would prefer in order to increase compliance. For example, cardiac rehabilitation programs are available in the following settings: inpatient acute care, outpatient (community-based) centers, home-based, and internet/transtelephonic programs.^1,3 Patients should be asked about their preferred setting for CR. Some minority patients state the public aspect of CR is a barrier to participation and would prefer to be monitored within the privacy of their homes. Once a patient-physician agreement is made regarding CR, reinforcement must be instituted through patient-centered education and allied health liaisons that have been equipped with motivational counseling techniques that assess readiness for change.¹⁷ The cost-effectiveness of CR programs as a secondary prevention modality is emphasized in the literature. Cardiac rehabilitation must be incorporated in the continuum of cardiovascular care and structured to compliment the lifestyles of all patients.

Kimberly Holmes, MSN, RN, can be contacted at: kimberly_holmes@bayhealth.org.

References

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