By Annette M. Boyle
SAN FRANCISCO—Despite evidence that cardiac rehabilitation reduces morbidity and mortality, few patients with heart failure undertake it, including veterans who often have difficulty accessing center-based programs.
In the general population, insurance companies and Medicare did not cover cardiac rehabilitation until 2014, but the VA has offered cardiac rehabilitation to heart failure patients for years. A new study sheds light on veteran participation and identifies ways to increase the number who benefit from this effective outpatient program.
In a study published in the Journal of Cardiac Failure, researchers at the San Francisco VAMC looked at cardiac rehabilitation rates among veterans and Medicare beneficiaries who had been hospitalized for heart failure between Jan. 1, 2007, and Dec. 31, 2011. A random sample of 5% of Medicare claims obtained from multiple databases identified 243,208 unique Medicare beneficiaries and 66,710 veterans for the retrospective study.1
Of these heart failure patients, 2.3% of the veterans and 2.6% of the Medicare beneficiaries attended one or more rehabilitation sessions. Over the five-year period studied, rehab utilization rose steadily among Medicare beneficiaries, from 1.3% to 3.1%, while remaining relatively low, at about 2%, among veterans.
Male Medicare beneficiaries were more than twice as likely to participate in rehabilitation than female beneficiaries (3.7% vs. 1.8%), but little difference in participation rates between male and female veterans was determined. Married veterans and those with higher incomes were more likely to utilize rehabilitation services, according to the analysis.
The low rates of rehabilitation in both groups contribute to a poor prognosis. Heart failure has a 30% one-year mortality rate, but rehabilitation can tip the scales for some patients.
According to the VA, “studies have shown that people who complete a cardiac rehabilitation program can increase their life expectancy by up to five years and have 27% lower cardiac death rates, 25% fewer fatal heart attacks, 21% fewer nonfatal heart attacks and an improved quality of life.”
Not all heart failure patients are appropriate candidates for cardiac rehabilitation. Currently, only those heart failure patients who have stable, chronic disease with reduced left ventricular ejection fraction are eligible.
The reasons for the low rates of participation among eligible patients differ somewhat between Medicare beneficiaries and veterans, the researchers note.
“Since Medicare only covers center-based cardiac rehab, virtually all cardiac rehab programs are center-based, and patients find it too difficult to come to a facility three times per week” because of distance and transportation issues, explained lead author Linda Park, PhD, NP, of the San Francisco VAMC and assistant professor at the University of California, San Francisco. In addition, patients may not receive referrals to rehabilitation because providers may not be aware of the expansion of cardiac rehabilitation services to include heart failure patients, the study pointed out.
Veterans face significant logistical barriers to accessing the enhanced care. Nearly 24% of veterans in VA care live in rural areas, and 76% of them live more than an hour from a VA cardiac rehabilitation (CR) center, the authors said. “A lot of other barriers are involved, too,” Park told U.S. Medicine, including “lack of knowledge in both providers and patients, poor motivation, poor self-efficacy and depression.”
Low participation rates were also associated with diabetes, cerebrovascular disease, chronic obstructive pulmonary disease and chronic kidney disease. The authors also suggested that the cost of copayments might reduce participation as might fear of stressing the heart.
Education and Availability
Increasing utilization rates requires a multifaceted approach, the authors suggested. Providers need education on the benefits of cardiac rehabilitation for heart failure patients and the cost-effectiveness of rehab programs. Referrals could be stimulated by creation of automated discharge orders for rehab in the electronic medical record of heart failure patients.
Individual patients might be more likely to utilize rehabilitation services if they have lay volunteers and nurse liaisons who encourage them to participate and if they learn motivational and self-management strategies, according to the study. Working to remove barriers such as chronic pain, disabilities and transportation issues can also lead to higher participation levels.
On a system level, the authors recommended tackling access issues by thinking beyond hospital-based cardiac rehabilitation programs. “Cardiac rehab for heart failure is extremely underutilized,” Park said. “We hope these findings will encourage other facilities to start home-based programs like we have in San Francisco.”
The San Francisco VA’s Healthy Heart Program is a free, home-based, 12-week customized exercise and lifestyle program that addresses nutrition, medication adherence, risk factor management—including weight, blood pressure, cholesterol, diabetes and smoking—and offers psychological support. In addition to serving heart failure patients, it is offered to veterans who have had cardiac stent placement, coronary artery bypass surgery, heart valve replacement or chronic angina.
The program brings together the expertise of a physician director, registered nurses, registered dietician, exercise physiologist and a cardiologist who jointly develop an individual plan for each patient. Team members stay in touch with participants through regular phone calls. Participants have regular assessments and the team adjusts therapies to ensure the exercises are effective, therapeutic and safe. Participants may receive exercise equipment for their use.
The authors note that “home and center-based CR appear to be equally effective in improving clinical and health-related quality of life outcomes.” Nonhospital-based programs, whether home-based or offered via telemedicine, could dramatically reduce logistical issues for patients while keeping down the cost of expanded services.
- Park LG, Schopfer DW, Zhang N, Shen H, Whooley MA. Participation in Cardiac Rehabilitation Among Patients With Heart Failure. J Card Fail. 2017 Feb 14. pii: S1071-9164(17)30036-2.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.