London, UK – Participating in a cardiac rehabilitation program after a cardiac event yields well-established benefits in reducing cardiac and noncardiac mortality as well as reducing morbidity and cardiac risk factors [1,2]. But uptake of this service is notoriously low. Some countries are slowly managing to remove barriers to rehabilitation programs, but experts say the profound impact of rehab services will be felt only if physicians themselves start thinking beyond drugs and procedures and take a more active role in promoting these programs and changing attitudes.
Cardiac rehabilitation is a structured program to help patients make changes in lifestyle and learn about the appropriate use of medication after a cardiac event. Patients are normally asked to attend 36 sessions over a three-month period, where they partake in supervised exercise sessions and undergo nutritional counseling and receive advice on lipids, diabetes, blood pressure, smoking cessation, and psychological support.
Attendance rates at such programs vary enormously between and within countries but are generally below half of eligible patients.
Slow improvement in UK
The most recent figures for the UK , where there is a national audit of cardiac rehabilitation, show that for the year 2008-2009, 41% of eligible patients in England, Northern Ireland, and Wales took part in cardiac rehabilitation. This was an improvement in the 38% figure for the previous year, and there were also significant reductions in waiting times. The figures show that while 76% of bypass patients attended a cardiac-rehabilitation program in 2008-2009, numbers following MI and angioplasty were much lower, at 40% and 28% respectively.
The British Heart Foundation (BHF) notes: “Cardiac rehabilitation remains a Cinderella service, with patchy distribution and large disparities in staffing and uptake. However, this year there are signs of an improvement in the number of people taking part and for the third year a further reduction in waiting times.” These improvements are attributed to an injection of extra funding for cardiac rehabilitation in 2006. But the BHF adds: “Once again, there was evidence of a ‘postcode lottery’ in both patients’ opportunity to attend and the level of staff support they received.”
It points out that although the National Institute for Clinical Excellence (NICE) has recently recommended cardiac rehabilitation for many heart-failure patients, few patients with this condition have received such care, with 2009 figures showing that only 1% of those taking part in cardiac-rehabilitation programs were referred because of heart failure and only 4% were referred for angina, with many programs actually excluding patients with these indications. The organization adds: “It is clear that there is a long way to go before cardiac rehabilitation is part of the routine treatment pathways for the majority of cardiac patients.”
However, the figures demonstrate yet again the benefits that can be achieved from these programs, with a 20% increase in the number of people exercising five or more times a week and a 28% reduction in those who never exercised. The number of people who reported smoking also decreased, from 12% to 7%, and quality-of-life scores improved significantly.
The data suggest that women are less likely to go to cardiac-rehabilitation classes than men. The BHF reports that if men and women were taking part in proportion to the case rates for MI, there should be 63% men and 37% women, but in practice, women made up 32% of referrals but only 26% of participants.
Another issue that appears not to be addressed adequately is help for anxiety and depression that often accompany heart disease. The latest UK figures showed that 17% of patients were borderline or clinically depressed and 28% had anxiety. Despite this, fewer than 3% of patients were recorded as having had individual psychological help or counseling. There was only a small improvement in these figures three months after starting cardiac rehabilitation, and no sign of any further improvement at 12 months. And 90% of programs in the survey reported having no dedicated psychology time for their patients.
Medicare reimbursement helping situation in US
The UK appears to be doing relatively well compared with North America, where attendance rates at cardiac rehabilitation programs are dawdling at around 30%. A study published in 2007 found that cardiac-rehabilitation use varied ninefold among US states, ranging from 6.6% in Idaho to 53.5% in Nebraska .
American Association of Cardiovascular and Pulmonary Rehabilitation president-elect Dr Steven Lichtman says, as in the UK, figures in the US are also improving. “In my opinion, things are getting a bit better. We are definitely on an upswing,” he commented to heartwire.
He explained that this is partly due to improvements in Medicare funding of cardiac rehabilitation, noting that in January 2010, reimbursement for this service in patients aged over 65 became part of the federal statute. “It is thus now a requirement that Medicare patients get reimbursed. It is a much more permanent law than it was before. And the indications recognized for reimbursement are gradually increasing,” he said. Cardiac rehabilitation has also been endorsed as a performance indicator.
And while Medicare has accepted more indications for cardiac rehabilitations, these do not yet include heart failure.
Lichtman thinks this is disappointing, since there are several studies showing benefits of exercise in at least a subset of CHF patients. “We believe exercise is beneficial for all CHF patients. But some studies have suggested that CHF patients tend not to complete the program. So we are still fighting that fight with Medicare.”
But not everyone who needs cardiac rehabilitation is covered by Medicare. Dr Neil Oldridge (University of Wisconsin School of Medicine & Public Health, Madison), who has been involved in cardiac rehabilitation for 40 years, notes that most private insurance companies follow Medicare reimbursement roughly but may require a copayment from the patient. But for the under-65s without health insurance, there is no financial help for such classes. “And at around $75 a session, those without health insurance probably won’t go,” he adds.
Selling it to the patient
But it is not all about money. The main barrier to boosting cardiac-rehabilitation attendance rates is actually persuading patients that they need to go to the classes.
Dr Margaret Cupples (Queens University Belfast, Northern Ireland) says this is a major issue. “Patients have often been in the hospital for only a short time, and they don’t feel they have had a significant illness. Entering a cardiac-rehabilitation program reinforces to them they have a serious condition, which they may not want to accept. The attitude of the doctors and nurses in the hospital is key. But doctors tend to advocate the importance of adhering to drug regimes more than lifestyle changes. While it is always advocated that lifestyle advice be given, everyone seems to leave this to someone else to actually do. Changing lifestyle is much more difficult to achieve than taking a tablet. It involves hard work and for the patient to take responsibility for their own health. In today’s society, many people don’t want to do that.” She adds that people are busy and don’t want to take time out for the classes.
American Heart Association (AHA) spokesperson on the subject, Dr Gerald Fletcher (Mayo Clinic College of Medicine, Jacksonville, FL), concurs with this view. “People go home from the hospital, then feel better. There is a break in care, and they don’t feel the need to go to classes. Two to three weeks after discharge is a good time to start. Any longer than this, and the memory of the event is diminished and the urgency to go becomes less. If a patient has had an MI, they like to try to forget about it when they get home. They don’t understand that it is a progressive disease and they need long-term follow-up.”
Physician endorsement is the crux
Oldridge says physician endorsement is the crux when it comes to getting patients to go to cardiac rehabilitation. “If a doctor tells you that you really must not smoke, you are more likely to quit. It is the same for cardiac rehabilitation. If a doctor stresses to you how important it is, you are more likely to go. Once a clinician believes and reinforces the value of cardiac rehabilitation, we see a higher attendance and adherence rate.”
But Oldridge points out that this is often not the first priority for most doctors. “Doctors themselves need to be better educated as to the benefits of cardiac rehabilitation. How much time in medical schools is given to lifestyle? Not very much. But things are changing. Younger doctors today are more aware of the health benefits of physical activity than they used to be. And the public is also more aware.”
Lichtman agrees with this stance. “We are seeing a huge turnaround in acceptance by physicians,” he says.
Cupples adds that one of the difficulties is poor communication between the primary- and secondary-care teams . “An automatic referral service on discharge should occur, but this doesn’t always happen. If this hasn’t happened, and the discharge team has not referred, then it may be up to the patient’s GP. But patients don’t always see their GP straight away, and there can be a long delay in records being sent from the hospital to the GP. So the referral may get lost in all this. There is a huge need for better integration of services.”
Fletcher reinforces this view. “Referral to cardiac rehabilitation is normally the last thing the physician does before the patient is discharged, but it doesn’t seem to be a priority. If it doesn’t happen, the GP should pick this up and refer, but often it gets lost in the shuffle. A good system is where the [cardiac rehabilitation] nurses make rounds in the hospital and sign the patients up before they go home.”
But Cupples also believes things are getting very slowly better in the UK. “There is more publicity. Attitudes are changing. Doctors and governments are thinking more about lifestyle, encouraging exercise and healthy eating and discouraging smoking.” Consequently, cardiac-rehabilitation uptake is gradually improving by about 1% to 3% per year. “The national audit in the UK started only about five years ago. This has triggered some changes. But these things take a long time. Change happens slowly.”
A perfect storm in Canada
But these positive messages don’t seem to have reached Canada yet. Dr David Alter (University of Toronto, ON) says that cardiac rehabilitation is still significantly underfunded in Canada, and he can’t see any improvements on the horizon. “If anything, the spaces are decreasing despite the fact that the number of people eligible is rising. While the number of MIs is coming down, the number of angioplasties is going up, and the population is aging and people are surviving longer after MI, so we have more people living with heart disease. But funding for cardiac rehabilitation is not increasing. While we have made a shift in the acute management of MI, there is not enough interest in the ‘nonsexy’ nature of prevention.”
He reports that there are 55 000 people hospitalized for cardiac illness eligible for cardiac rehabilitation each year in Ontario, but there are only 18 000 spaces. “There is a massive unmet need, and this is just for the highest-risk patients—those who have had cardiac surgery, MI, or angioplasty. If others are included who could benefit, such as those with heart failure, angina, diabetes, etc, there could be millions of patients who are not getting valuable intervention.”
Alter says there are many factors that together are causing “a perfect storm” in cardiac rehabilitation. “The first is policy, so there is not enough funding to cover everyone who needs it. Then there is the problem of physicians not referring enough. This is partly because they know there is not enough capacity, so they just refer some patients, but this is not consistent, and it is not always the right patients who get referred. And then the patients themselves often do not go or just go once or twice. We need an automatic referral mechanism that captures all patients, but such a system cannot be set up, as there are not enough places. It is a chicken-and-egg situation.” He adds that in the US, there seem to be some rainbows on the horizon, but these are not apparent yet in Canada.
He makes the point that cardiac rehabilitation is equally as cost-effective as most technologies and drug therapies that are used in these high-risk patients if not more so, a stance recently underscored by an AHA policy paper addressing the cost-effectiveness of prevention . “So inadequate funding is counterintuitive from an economic argument. For low-risk patients, it might take a long time to see the benefit, but for high-risk patients benefits are seen with six months to a year.”
The other problem, Alter says, is advocacy. “Unlike drugs and technologies, no one is pushing cardiac prevention. There is no big industry, and it doesn’t have the critical mass of physician involvement, as cardiac rehabilitation is run mainly by allied health professionals” (eg, nurses, kinesiologists, exercise physiologists). While they do a fantastic job, the doctors themselves are not engaged in the process and so are often unaware of the massive benefits.”
Rewards for referrals?
As well as educating doctors better on the benefits, Alter wants services to be better integrated so that doctors are more involved in the flow of patients through to cardiac rehabilitation. “Doctors are in the business of prescribing drugs; they don’t really prescribe exercise. They think lifestyle is out of their control. But I do believe we can shape behavior. We need doctors to get more involved and to provide more incentive for them to refer to cardiac rehabilitation, such as performance-driven fee codes.”
Cupples agrees with this idea. She says in the UK the British Association for Cardiovascular Prevention & Rehabilitation (BACPR) sets out excellent standards, but sometimes the priorities of local health authorities are different, and everyone’s budget is limited. “Although cardiac rehabilitation is part of the national service framework for coronary heart disease, there are no direct rewards for doctors or hospitals if they refer patients, but I think it might go in this direction in the future.”
Australia on right track
Of all the countries surveyed, Australia seems to be doing best, with attendance rates at rehabilitation classes of about 50%. Paula Candlish, president of the Australian Cardiovascular Health and Rehabilitation Association (ACRA), told heartwire: “There is a driving force from state government to grow cardiac rehabilitation. They are well aware that this will reduce hospitalizations and costs. Our attendance figures range from 30% to 60% of those eligible. We are striving to get more places up to 60%. And some states are aiming for 90%.”
She notes that cardiac rehabilitation in Australia is generally funded by the government, with no cost to the patient, like the system in the UK and Canada. She says that cardiac rehabilitation is usual care in Australia, with all high-risk patients automatically referred on discharge. While that is positive in that everyone gets a letter inviting them to a program, she points out that this system totally lacks physician involvement. “We’ve cut doctors right out of the loop, and maybe that’s not such a good thing, as having a doctor tell you that you really have to go is often what makes the patient attend.”
She adds: “We are making a concerted effort to recruit patients, reinforcing the necessity for them to go. But around 50% still don’t go or just go to the first assessment and then don’t continue. It is easy to be in denial.”
As with all the other countries, capacity is also an issue in Australia. Candlish says that ACRA is trying to attract funds dedicated to cardiac rehabilitation to make more spaces available. She notes at present the service is funded by individual hospitals, which can decide to divert staff to other areas as they see fit. “If we had dedicated funding and staffing, they couldn’t do that.”
There is also a move under way to deliver more cardiac-rehabilitation services by telephone or computer, especially for those who live in remote areas, which is a big issue in Australia. “It isn’t quite as effective as a face-to-face group, but we need to compromise.” Around 30% of the service in Australia is delivered this way.
Distance to be traveled to the classes is a key issue in all countries. Lichtman says that if patients have to drive for more than 30 minutes, they probably won’t go. And Oldridge adds: “It needs to be accessible for all. There should be classes in every town, with sessions at different times of day to accommodate people who work.”
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