by Mary Ann Compton
An article in The Journal of Cardiovascular and Pulmonary Rehabilitation caught my eye recently both because of the subject matter and because I recognized several of the investigators and their ties to UNC. The lead investigator, Montika Bush, PhD, surveyed program directors in our state last year and will soon be submitting information from that survey for publication.
The article reviewed here is the “Effect of Initiating Cardiac Rehabilitation after Myocardial Infarction on Subsequent Hospitalization in Older Adults.”
As we all know, there is a gradual shift in our country from fee-for-service care towards value-based care. If value-based care comes to fruition, providers and hospitals will be financially compensated for keeping patients well and out of the hospital. In addition, hospitals and providers would pay a penalty for exceeding “standard” costs to care for a patient. We all know that Cardiac Rehabilitation helps to not only decrease mortality, but also helps to keep our patients well. But knowing something is not always enough. If scientific studies show that participation in Cardiac Rehab will improve the health of our patients while also saving the hospital money (i.e. keeping patients out of the hospital), then the value of Cardiac Rehab increases and the support we will get in our larger organizations should be immense.
This study looked back at 32,851 Medicare beneficiaries in 2008 and compared those patients who initiated CR within 60 days post-discharge with those patients who did not. The study was limited to those patients age 65-88 years of age who were hospitalized with an AMI, had a revascularization, and had not previously experienced an MI. It is one of the few studies to look at readmissions after cardiac rehabilitation in an older population.
While the article is dense with statistical analysis, the conclusions are fairly succinct. The authors were primarily looking to see if there was a difference between the two groups (CR initiators vs CR noninitiators) in admission for AMI in the year following discharge. There was not a substantial difference for AMI admission between the two groups, but there was a difference for all-cause hospital admissions. The CR initiators had a lower risk of hospital admission for a major cardiac event (MACE) and for all-causes compared to the CR noninitiators. Of note, the older beneficiaries (>75 years) had a greater reduction in all-cause hospitalization risk than MACE risk.
The authors made several references in the paper regarding the need for more information on the effects of cardiac rehab, or exercise therapy, on nonmortality outcomes. This study noted, that “the risk of each study outcome for CR initiators with 1 to 2 medications at day 60 is similar to the risk of that same outcome in CR noninitiators with 3 to 4 medications at day 60” and that since older patients are not always able to tolerate medication therapy, the exercise therapy could be even more important. This finding, if repeated in other studies, could greatly enhance the value of cardiac rehabilitation.
Similar to other studies, the mortality rate was lower for initiators than noninitiators, and the participation rate for cardiac rehab was 21%. This low percentage of participation has got to improve, and should be a focus of our programs. I suspect, also, it will be a focus as we learn from changes we have all had to implement in our programs due to the COVID pandemic.
Bush, Montika; Kucharska-Newton, Anna; Simpson, Ross J. Jr; More
Bush, Montika; Kucharska-Newton, Anna; Simpson, Ross J. Jr; Fang, Gang; Stürmer, Til; Brookhart, M. Alan Less
Journal of Cardiopulmonary Rehabilitation and Prevention. 40(2):87-93, March 2020.