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Cardiac Rehabilitation:
Low Cost, Low Technology, Great Medicine!
Why you should write
the “Prescription”
TODAY!
The Cardiac Rehabilitation Mission
To restore and maintain an individual’s optimal physiological, psychological,
social and vocational status.
Goals of Cardiac Rehab
Identify, modify, and manage risk factors to reduce disability, morbidity & mortality
Improve functional capacity
Alleviate/lessen activity related symptoms
Educate patients about the management of heart disease
Improve quality of life
Core Program Components
Baseline & ongoing patient assessment
Risk factor management
Exercise/activity training
What is Cardiac Rehabilitation?
Medically supervised
Lifestyle modification
Monitored progressive exercise/activity
Inpatient ► Outpatient ► Lifetime Maintenance
Individualized, typically 3x/week, up to 12 weeks
Physician Referral Required!
Disease Management Components
Population Identification processes
Evidence-based practice guidelines
Collaborative practice models
Patient self-management education
Process and outcomes measurement, evaluation, and management
Routine reporting/feedback loop
What Diagnoses are Covered? Medicare Guidelines:
− Stable Angina − s/p Myocardial Infarction − s/p PCI − s/p Coronary Artery Bypass Graft − s/p Valve repair or replacement − s/p Heart Transplant
Private insurance carriers generally follow Medicare eligibility guidelines but MAY also provide coverage benefits for patients with:
− PAD − CHF − Cardiomyopathy
Utilization Benefits: Reduced risk of fatal MI (≥ 25%)
Decreased severity of angina & need for anti-angina medications
Decreased hospitalizations
Decreased cost of physician office visits & hospitalizations (≤35%)
Fewer ER visits
Decreased cardiac event rates
Decreased all-cause mortality
Physician Benefits:
Partnership in case management provides:
Enhanced access to physician services
Reliable surveillance for improved clinical outcomes
Improved patient satisfaction
Patient education for self directed care
Enhanced medication compliance, safe exercise behavior and long term health benefits
Patient Benefits:
Improved functional capacity
Increased knowledge of heart disease
Improved adherence to positive lifestyle changes
Enhanced compliance with medical regime
Increased self-esteem and confidence
Reduced subsequent morbidity & mortality
Superior Psychosocial benefits
Lifestyle Benefits: Risk Factor and Lifestyle Modification
Lipid improvement
Blood pressure control
Work capacity
Weight management
Diabetes control
Stress management
Smoking cessation
Significant Statistics
Cardiovascular disease accounts for almost 50% of all deaths in the U.S.
Coronary Artery Disease affects 13.5 million Americans each year
Nearly 1.5 million Americans sustain myocardial infarctions each year
American Heart Association, Dallas Texas
Utilization Trends
Greater than 2 million Americans are eligible for cardiac rehab (secondary prevention) post ACS, MI, PCI or CABG
On average, only 10% to 30% of eligible patients receive cardiac rehabilitation
− Ranges vary between 11% and 38% depending on the area of the country
Exercise Research
Direct relation between inactivity and cardiovascular mortality. Inactivity is an independent risk factor for of CAD
Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for CAD
Physical fitness has been unmistakably associated with improvements in lipid profiles
* Coronary Artery Disease Cardiac Rehabilitation and Survival in Older Coronary Patients. Suaya, JA., et al. J Am Coll Cardiol 2009;54:25–33
Methods: Studied 601,099 Medicare beneficiaries Examined 1 to 5 year mortality rates in CR users & nonusers Compared 70,040 propensity-based matched groups (CR
participation versus non-participation) after extensive analyses to control for potential confounding
Results: Only 12.2% of the cohort used Cardiac Rehabilitation Significantly lower (p 0.001) 1- to 5-year mortality rates in CR
users than nonusers
A Landmark Study!*
Coronary Artery Disease Cardiac Rehabilitation and Survival in Older Coronary Patients. Suaya, JA., et al. J Am Coll Cardiol 2009;54:25–33
Subsequent to extensive analyses to control for potential confounding:
Post 1 year, Cardiac Rehabilitation participants (more than 24
sessions) had a 58% relative risk reduction for mortality
At 5 years, Cardiac Rehabilitation participants had a 34% relative
risk reduction for mortality
“Mortality reductions extended to all demographic and clinical
subgroups including patients with acute myocardial infarctions, those receiving revascularization procedures, and those with congestive heart failure”
Dose Response Relationship for CR Sessions and Risk of Death / MI *
Sessions Attended
36 vs 24 Sessions
36 vs 12 Sessions
36 vs 1 Sessions
Death - 14% - 22%
- 47%
Myocardial Infarction
- 12% - 23%
- 31%
*Relationship Between Cardiac Rehabilitation and Long-Term Risks of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries. Hammill, BG. et al. Circulation. 2010;121:6370
Cost-effectiveness / Cost-efficiency
Medicare payments in hospital for CAD in 1999 was $26.3 billion!
Studies, adjusted for quality of life, show savings of $4,950-$9,200 per year of life saved
Reduction in re-hospitalizations and medical costs are well documented
Cardiac Rehab Professionals Team Partners in Patient Care:
CR Medical Director
Referring Physician
Registered Nurses
Exercise Physiologists
Physical Therapists
Dieticians/Nutritionists
Psychosocial Professionals
Pharmacists
Case Managers
Who can Refer a Patient?
Site-specific Policy:
Primary Care Physician
Internist
Cardiologist
NP’s & PA’s (State specific)
Communication with Rehab?
Collaborative Approach:
Initial referral
Individualized treatment plan
Periodic Progress reports
Program oversight by Medical Director
Open ended lines of communication
Cardiac Rehab adds Value Cardiac patients have many disease processes
and lifestyle concerns that have contributed to their heart disease.
Cardiac rehab serves the needs of each cardiac patient and works toward secondary prevention.
Cardiac rehab adds VALUE to your patient care and increases QUALITY OF LIFE !
Improving CR Participation
“Cardiac Rehabilitation participation rates were the recent subject of both an American Heart Association Presidential Advisor (1) and a Scientific Advisory (2) and is an ongoing national Performance Measure priority for improvement (3)
1. Balady GJ, 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;124:2951-2960.
2. Arena R, et al.. Increasing referral and participation rates to outpatient cardiac rehabilitation: The valuable role of healthcare professionals in the inpatient and home health settings: A science advisory from the American Heart Association. Circulation. 2012;125:1321-1329.
3. Thomas Rjet al. J. AACVPR/ACCF/AHA 2010 update: Performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services. Circulation. 2010;122:1342-1350.
Sooner is Better !!
The secret to getting cardiac patients into outpatient rehabilitation programs is scheduling their first appointment soon after they leave the hospital (1)
Compared with the standard median time from hospital discharge (35 days), enrolling patients into cardiac rehabilitation 10 days after discharge significantly improved patient attendance.
1. An Early Appointment to Outpatient Cardiac Rehabilitation at Hospital Discharge Improves Attendance at Orientation: A Randomized, Single-Blind, Controlled Trial. Quinn R. Pack, Mouhamad Mansour, Joaquim S. Barboza, et al. Circulation. published online December 18, 2012