Cardiac Rehab Neglected After MI and Bypass Surgery

WALTHAM, Mass. -- Only about 19% of patients had at least one rehab session in the year after a heart attack or coronary artery bypass graft, despite recommendations by professional groups for rehab in that population.

WALTHAM, Mass., Sept. 26 -- Only about 19% of patients had at least one rehab session in the year after a heart attack or coronary artery bypass graft, despite recommendations by professional groups for rehab in that population.

Furthermore, coronary artery bypass graft (CABG) patients were far more likely to receive rehabilitation than those who'd had an MI, Jose A. Suaya, M.D., Ph.D., of Brandeis University here, and colleagues reported online in Circulation: Journal of the American Heart Association.

Rehab use also varied dramatically by state and region, the researchers said.

The low utilization rates reported in this study are discouraging in light of the considerable evidence that supports the effectiveness of cardiac rehab, the researchers noted. (See: New Standards Aim to Boost Enrollment in Cardiac Rehab)

Meta-analyses have found 15% to 28% reduction in all-cause mortality and 26% to 31% reduction in cardiac mortality for patients given cardiac rehabilitation, Dr. Suaya and colleagues wrote.

Their findings came from an analysis of national Medicare claims for 267,427 men and women admitted for MI or CABG to a nonfederal acute-care hospital in 1997, the researchers said.

Despite Medicare coverage for rehabilitation services, a year after hospital discharge only 18.7% of study patients had had at least one rehab session.

Of the bypass patients, 31% received rehab services compared with just 13.9% of the MI patients, the researchers reported.

Higher rehab rates for the CABG patients probably reflect the high significance of the surgical procedure in the patients' minds and the systematic referral by cardiac surgeons, the researchers said.

Least likely to receive rehab services were older patients, women, nonwhites, less educated patients, those of lower socioeconomic status, those with multiple co-morbidities, and those living in southern states or at greater distance from a cardiac rehab center, the researchers said.

Whites were more than twice as likely as nonwhites to receive rehab, and only 5.2% of individuals who were dual-eligible for Medicaid and Medicare received rehab services compared with 20.3% of Medicare-only patients.

Patients with co-morbidities, such as hypertension, diabetes, a previous stroke, congestive heart failure, or cancer were significantly less likely to have rehab.

Rehabilitation use also differed by gender and age. Overall, men were significantly more likely to have rehab than women (22.1% versus 14.3%).

And use was inversely related to age. For example, among those 75 to 84, rehab attendance was 13% lower in men and 31% lower in women than it was among their counterparts in the 65-to-74 age group.

Yet, said the investigators, there is an increasing body of research showing that increased exercise is just as valuable for older people, and is important in preserving their ability to function.

The researchers also found a nine-fold variation in use among states, ranging from 6.6% in Idaho to 53.6% in Nebraska. The highest use was clustered in the North-Central states and the lowest in the South.

Distance to the nearest rehab facility, as might be expected, was also an important factor. Patients living the farthest away from a facility were 71% less likely to go to rehab than those living closest, a finding consistent with other studies, the researchers said.

Payers may wish to explore the feasibility of reimbursing community- or home-based programs as supplements or alternatives to facility-based programs, particularly in rural and sparsely populated areas, they suggested.

A study limitation was its reliance on Medicare claims data and its focus on 1997 hospitalizations, the researchers said.

Although changes in medical practice may have affected the use of cardiac rehab, they noted, Medicare's eligibility criteria for rehab after MI and CABG remained unchanged until 2006. On balance, they said, they believe these findings closely mirror recent cardiac rehabilitation use among these patients.

Assuming that if 53.5% rate in Nebraska were achieved in other states, 93,000 additional Medicare beneficiaries would have received rehab and cardiac mortality would have decreased 26% to 31% in these individuals, the researchers wrote.

Dr. Suaya's team made several recommendations for improving rehabilitation use. These included:

  • Improve methods of referring patients to rehab facilities after hospitalization, such as automatic referrals.
  • Increase reimbursement rates.
  • Install referral-to and completion-of programs as quality indicators in cardiovascular care to be used by organizations such as the American College of Cardiology, the American Heart Association, and the National Committee for Quality Assurance.
  • Adoption of those measures by Medicare in its pay-for reporting and pay for-performance initiatives.
  • Separate payments for key components, such as nutritional counseling and stress management, might also be considered.