Ischemic heart disease (IHD) is the leading cause of death among Veterans, particularly as more adults are surviving into old age when prevalence of IHD increases. Efforts to moderate IHD progression, as well as increase quality of life have become leading Veterans Health Administration (VHA) priorities. Cardiac rehabilitation (CR) is a composite program of education, diet and lifestyle modification, stress reduction, and exercise training that has been shown to reduce morbidity and mortality among IHD patients, as well as improve their quality of life, independence, self-efficacy, and therapeutic adherence. CR has been established as one of nine performance measures recommended for patients with IHD by the American College of Cardiology Foundation, the American Heart Association, and The American Medical Association Physician Consortium for Performance Improvement. Yet in spite of such compelling rationale and mandate, CR utilization by eligible IHD patients remains low. In the VHA, approximately 26% of facilities report having CR programs, suggesting there are fundamental referral constraints for an expanding population of eligible Veterans. Furthermore, studies show under-utilization of CR in non-VHA healthcare systems even when resources are available, suggesting that simply increasing numbers of CR programs will not achieve robust referral and enrollment: there are other reasons underlying this performance gap that are not clear. Therefore, the long-term goal to promote CR in the VHA requires, as a first step, delineation of system- and patient-level factors that influence its utilization. This project constituted a key step towards promoting CR in VHA by focusing on better understanding the factors that impact CR utilization.
The objective of this study was to describe the state of CR within VHA and determine gaps. In particular, we wanted to identify characteristics of VHA CR programs that make them more or less successful (i.e. practices that are conducive to increased patient CR referral or enrollment). Therefore, the aim of this study was to compare qualitative factors between VHA facilities with high utilization of on-site CR and VHA facilities with low utilization of on-site CR programs.
This was a qualitative study. We conducted telephone interviews with 15 cardiology and other providers associated with CR services, and 16 patients who were eligible for CR services across six sites (i.e. three VHA facilities with high utilization of on-site CR programs and three VHA facilities with low utilization of on-site CR programs). Our semi-structured interview guide was based on the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Provider interviews were structured to learn about current enrollment practices and processes, and identify potential (personal and organizational) barriers and facilitators to cardiac rehabilitation enrollment. Patient interviews were structured to explore motivations and barriers to enrolling in CR, and identify possible interventions or ways to promote enrollment. Interviews were audio-recorded, transcribed and analyzed qualitatively using an emergent, thematic approach based on tenets of grounded theory.
Patient enrollment in CR services is primarily contingent on patients receiving a CR referral. VHA facilities with high utilization of on-site CR programs have established departmental standard operating procedures that result in systematic CR referrals to all eligible patients, or have a strong culture among referring providers to make these referrals. Patient characteristics (e.g. distance to CR program and comfort-level with physical activity) and CR program characteristics (e.g. patient-centeredness of CR program) also influence utilization of CR programs, but only if CR referrals are made. To promote VHA CR services, departmental-level processes that "hard-wire" referrals for eligible patients should be considered.
By identifying factors that influence patient utilization of VHA on-site CR programs the VHA may better understand ways to increase enrollment in CR programs.
- McIntosh N, Fix GM, Allsup K, Charns M, McDannold S, Manning K, Forman DE. A Qualitative Study of Participation in Cardiac Rehabilitation Programs in an Integrated Health Care System. Military medicine. 2017 Sep 1; 182(9):e1757-e1763.
- Schopfer DW, Takemoto S, Allsup K, Helfrich CD, Ho PM, Forman DE, Whooley MA. Cardiac rehabilitation use among veterans with ischemic heart disease. JAMA internal medicine. 2014 Oct 1; 174(10):1687-9.
- Allsup KL, McIntosh NM, McDannold S, Fix GM, Manning K, Schopher DW, Whooley MA, Charns MP, Forman DE. Patient Perceptions of Cardiac Rehabilitation within Veterans Health Administration (VHA) Facilities with High Verses Low Program Utilization. Paper presented at: American Association of Cardiovascular and Pulmonary Rehabilitation Annual Meeting; 2016 Sep 7; New Orleans, LA.
Health Systems, Cardiovascular Disease