Only 1 in 10 With Heart Failure Referred for Postdischarge Cardiac Rehab: Analysis

Marlene Busko

August 20, 2015

LOUISVILLE, KY — Only 10.4% of patients who were hospitalized with heart failure from 2005 to 2014 and were part of a large national registry were referred for cardiac rehabilitation when they were discharged from the hospital, new research shows[1]. "Our study highlights a significant gap in contemporary clinical practice with respect to this key step," Dr Harsh Golwala (University of Louisville School of Medicine, Kentucky) and colleagues report in their study, published in the August 25, 2015 issue of the Journal of the American College of Cardiology.

This study shows that "there is an important need for targeted quality-improvement programs to improve use of cardiac rehabilitation for eligible patients with heart failure," senior author Dr Gregg C Fonarow (Ronald Reagan-University of California, Los Angeles Medical Center) told heartwire from Medscape.

The guidelines at the time of the study recommended "exercise training" as opposed to "cardiac rehabilitation" (exercise training plus counseling) and patients with traditional indications for cardiac rehabilitation—prior PCI/CABG, in-hospital PCI/CABG, or valve replacement, whether they had heart failure with preserved or reduced ejection fraction (HFpEF or HFrEF, respectively)—were covered by insurance, Fonarow clarified.

However, the AHA/ACC 2005 guidelines for heart failure only said that "exercise training . . . might have a favorable effect on the natural history of heart failure," whereas the latest 2013 guidelines strongly recommend cardiac rehabilitation, Dr Philip A Ades (University of Vermont, Burlington, VT), writes in an accompanying editorial[2]. Moreover, insurance coverage has changed now that as of February 2014, the Centers for Medicare and Medicaid Services (CMS) extended its coverage of cardiac rehabilitation.

To see an "uptick" in patients with heart failure who are sent for cardiac rehabilitation, a "multipronged approach" is needed, which can start with computerized prompts for referring patients, according to Ades. Since "the majority of patients with CHF eligible for [cardiac rehabilitation] are outpatients . . . efforts should not just focus on the hospital-discharge process."

Are HF Patients Being Referred for Cardiac Rehab?

Current ACC/AHA clinical practice guidelines recommend patients with symptomatic heart failure and reduced ejection fraction should receive cardiac rehabilitation to improve functional status (class 1, level of evidence A), Golwala and colleagues note.

They investigated the rates of referral of heart-failure patients to cardiac rehabilitation over the past decade, using data from 105,619 patients who had acute decompensated heart failure and were admitted to 338 hospitals that were part of the Get With the Guidelines–Heart Failure (GWTG-HF) registry. The patients were all eligible for referral for cardiac rehabilitation at the time of discharge from the hospital.

About half of the patients (48%) had HFrEF and half (52%) had HFpEF. At the time of hospital discharge, 12.2% of patients with HFrEF and 8.8% of the patients with HFpEF were referred for cardiac rehabilitation.

Compared with other patients, those who were referred for this treatment were younger (mean age 70 vs 74) with fewer comorbid conditions, and they were more likely to be men (57% vs 51%) and less likely to be covered by Medicare.

Younger age and CABG, PCI (with or without a stent), or cardiac valve surgery were associated with higher odds of being referred for cardiac rehabilitation, "consistent with guideline recommendations and insurance coverage," Golwala and colleagues write.

Ades points out that from 2005 to 2014, cardiac rehabilitation for CHF would have been by self-pay. "Indeed, as a longstanding director of a cardiac-rehabilitation program who has attended on the inpatient service over the time period in question, I would have rarely referred a CHF patient to early outpatient cardiac rehabilitation, knowing that self-pay was unrealistic, despite potential clinical benefits," he writes.

Typically, cardiac rehabilitation (exercise and counseling) may include 36 sessions over 3 months at a cost of $65 to $120 per session, Fonarow said.

"Although there is now substantial evidence that [cardiac rehabilitation], exercise training, and disease-related counseling are effective in reducing symptoms, hospitalizations, and mortality and in increasing exercise capacity and health-related quality of life in the setting of HFrEF (with similar but somewhat less evidence in HFpEF), these data were largely not available during the study period," Ades writes.

Fonarow disagrees. "Much of the evidence for benefit of formal exercise training in heart failure dates back to well before this study began," he said. "The HF ACTION study was published in 2009 at the midway point of this study." This trial, which was the major basis of the Medicare-coverage decision, enrolled only patients with HFrEF, and thus "there is an important need to further evaluate cardiac rehabilitation in patients with HFpEF," he said.

Ades agrees with the need for more study in HFpEF patients, so that they may be covered by CMS. The current study can act as a "springboard . . . to optimize [cardiac-rehabilitation] participation processes for inpatients or outpatients with HFrEF now that insurance coverage is broadly available" for them. "For patients with HFpEF, these data can stimulate further study . . . such that this patient category might be reconsidered for a CMS coverage determination in the future."

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