Exercise-based cardiac rehabilitation (CR) programs reduce morbidity and mortality in patients with ischemic heart disease (IHD). Referral of patients with IHD to a CR program is a performance measure highlighted in recent guidelines for secondary prevention. Although CR programs are underutilized among Medicare beneficiaries, utilization of CR has not been evaluated in the Veterans Health Administration (VA).
We performed a mixed-methods study to determine the proportion of VA facilities that offer CR programs and to identify factors associated with referral to these programs.
In 2011, the VA conducted a survey of cardiovascular specialty care services that included the question "Does your facility have a cardiac rehabilitation program?" We interviewed key informants (physicians, nurses, and physical therapists) at each CR program at each VA facility that answered affirmatively to this question. We determined the number of patients hospitalized for acute myocardial infarction (MI) and number of patients treated for IHD in 2010 based on VA administrative data. Our goals were (1) quantify the burden of IHD in VA, (2) to confirm the existence of unique CR programs and (3) determine barriers and facilitators associated with referral.
Between 10/1/06 and 9/30/11, 47,051 unique patients were hospitalized for MI, PCI or CABG at 124 VA facilities. Of these, 4080 (8.7%) participated in one or more sessions of outpatient CR during the 12 months after hospitalization. Patients were more likely to participate in CR if they had been hospitalized at one of the 35 VA facilities with an on-site CR program vs. one of the 89 VA facilities without an on-site CR program (11.4 vs 6.9%; p<0.001), but participation was low regardless of the presence or absence of a program.
In multivariable models, the characteristics associated with greater participation were younger age, being married, higher body mass index, living closer to a VA facility, hyperlipidemia, absence of heart failure, absence of chronic kidney disease, and hospitalization for CABG (vs. PCI or MI). After controlling for these variables, the presence of an on-site CR program was associated with an 84% greater odds of attending a CR program (Odds Ratio 1.84, 95% CI, 1.70-1.99, p<0.001).
Geographic distance is by far the largest barrier to patient participation in CR programs. This demonstrates that building more CR programs will not solve the problem of under-utilization. The published findings are informing current efforts to develop and test additional modalities for delivering CR, such as tele-CR and mobile apps.
- 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.