Rehabilitation significantly underused after heart attack and bypass surgery

Sep 26 2007

Despite strong evidence that cardiac rehabilitation reduces disability and prolongs life, fewer than one in five people receive rehabilitation services after a heart attack or coronary bypass surgery, according to a Brandeis study in Circulation: Journal of the American Heart Association.

“We need to find ways to increase the use of cardiac rehabilitation, because it is used very little by patients who could benefit a lot,” said Jose A. Suaya, M.D., Ph.D., lead author of the study and a lecturer and scientist at the Schneider Institutes for Health Policy, Heller School, at Brandeis University in Waltham, Mass.

Overall, the study found that, despite Medicare coverage of cardiac rehabilitation sessions, among Medicare beneficiaries aged 65 and above, women participated less than men, older people less than younger, and non-whites significantly less than whites. Additionally, the researchers noted striking geographic differences in the use of cardiac rehabilitation after cardiac hospitalizations, ranging from 53.5 percent of patients in Nebraska to 6.6 percent in Idaho. The accompanying map shows rates by state.

“Almost all patients with stable angina or a recent heart attack, bypass surgery, or a coronary stent could benefit from cardiac rehabilitation,” Suaya said. “Importantly, this benefit applies regardless of age, gender or race.”

“Patients and their families should ask for referral to cardiac rehabilitation before they are discharged from the hospital,” said co-author Donald S. Shepard, Ph.D., professor at the Heller School. “This is particularly important for patients with other medical conditions, who are less likely to receive a referral.”

In the largest and most comprehensive study of its kind, researchers evaluated Medicare claims data on 267,427 men and women aged 65 and above who survived at least 30 days after hospital discharge following a heart attack or coronary bypass surgery in 1997.

In the year following hospital discharge, fewer than one in five (18.7 percent) patients in the study had at least one session of cardiac rehabilitation. Bypass patients (31.0 percent) were far more likely to receive rehabilitation than patients who had had a heart attack (13.9 percent).

“Coronary bypass surgery is a big event for most patients and cardiac rehab has been adopted as a very important component of recovery,” said William B. Stason, M.D., M.Sci., study co-author and senior scientist at the Heller School. “In contrast, the condition of patients after heart attack varies widely and there is less agreement among physicians about the value of cardiac rehab compared with medications and lifestyle changes.”

Cardiac rehabilitation sessions include supervised and monitored exercise to improve cardiovascular fitness, as well as assistance in making lifestyle changes such as smoking cessation, improving diet and learning to reduce stress.

At the time of the study, Medicare (the primary health insurer for people age 65 and older) provided coverage for up to 36 sessions (three per week for three months) of cardiac rehabilitation after heart attack, bypass surgery, or stable angina. Rehabilitation patients in this study had an average of 24 sessions. In 2006, Medicare expanded to include patients undergoing heart and lung transplants, heart valve surgery and procedures such as stenting and angioplasty.

“Every patient who has had a myocardial infarction or is hospitalized for coronary disease should at least be considered as a candidate for rehab at the time of discharge,” Stason said.

In the study, use of cardiac rehabilitation differed by age and gender. Overall, the use of cardiac rehab in men (22.1 percent) was significantly higher than in women (14.3 percent). Compared with men age 65 – 74, the likelihood of receiving cardiac rehab was:

• 2 percent lower in women age 65–74;
• 13 percent lower in men and 31 percent lower in women age 75–84;
• 71 percent lower in men and 83 percent lower in women age 85 and older.

“I think differences in the use of cardiac rehabilitation for different age groups reflects physicians' preconceptions about less value in older people rather than a careful look at the clinical evidence. There is an increasing body of research showing that increased exercise is just as valuable, if not more so, in older people, and is important in preserving their ability to function,” Stason said.

Overall, use of cardiac rehab was twice as great in white as in non-white patients. Lower-income elders who were eligible for Medicaid as well as Medicare, were far less likely (5.2 percent) to receive rehabilitation than those not on Medicaid (20.3 percent). Furthermore, patients with co-existing medical conditions, such as diabetes, a previous stroke, congestive heart failure or cancer, were significantly less likely to participate in cardiac rehab, according to the report.

Shepard said that further study is needed of potential approaches to increase use of this effective service. These include analyzing reimbursement rates for cardiac rehabilitation in relation to their costs, studying referral patterns in high use states, and seeing whether the utilization rate of rehabilitation services among Medicare patients should be made a quality indicator for cardiac care.