Cardiac Rehabilitation:

Low Cost, Low Technology, Great Medicine!

Why you should write

the “Prescription”

TODAY!

The Cardiac Rehabilitation Mission

To restore and maintain an individual’s optimal physiological, psychological,

social and vocational status.

Goals of Cardiac Rehab

Identify, modify, and manage risk factors to reduce disability, morbidity & mortality

Improve functional capacity

Alleviate/lessen activity related symptoms

Educate patients about the management of heart disease

Improve quality of life

Core Program Components

Baseline & ongoing patient assessment

Risk factor management

Exercise/activity training

What is Cardiac Rehabilitation?

Medically supervised

Lifestyle modification

Monitored progressive exercise/activity

Inpatient ► Outpatient ► Lifetime Maintenance

Individualized, typically 3x/week, up to 12 weeks

Physician Referral Required!

Disease Management Components

Population Identification processes

Evidence-based practice guidelines

Collaborative practice models

Patient self-management education

Process and outcomes measurement, evaluation, and management

Routine reporting/feedback loop

What Diagnoses are Covered? Medicare Guidelines:

− Stable Angina − s/p Myocardial Infarction − s/p PCI − s/p Coronary Artery Bypass Graft − s/p Valve repair or replacement − s/p Heart Transplant

Private insurance carriers generally follow Medicare eligibility guidelines but MAY also provide coverage benefits for patients with:

− PAD − CHF − Cardiomyopathy

Utilization Benefits: Reduced risk of fatal MI (≥ 25%)

Decreased severity of angina & need for anti-angina medications

Decreased hospitalizations

Decreased cost of physician office visits & hospitalizations (≤35%)

Fewer ER visits

Decreased cardiac event rates

Decreased all-cause mortality

Physician Benefits:

Partnership in case management provides:

Enhanced access to physician services

Reliable surveillance for improved clinical outcomes

Improved patient satisfaction

Patient education for self directed care

Enhanced medication compliance, safe exercise behavior and long term health benefits

Patient Benefits:

Improved functional capacity

Increased knowledge of heart disease

Improved adherence to positive lifestyle changes

Enhanced compliance with medical regime

Increased self-esteem and confidence

Reduced subsequent morbidity & mortality

Superior Psychosocial benefits

Lifestyle Benefits: Risk Factor and Lifestyle Modification

Lipid improvement

Blood pressure control

Work capacity

Weight management

Diabetes control

Stress management

Smoking cessation

Significant Statistics

Cardiovascular disease accounts for almost 50% of all deaths in the U.S.

Coronary Artery Disease affects 13.5 million Americans each year

Nearly 1.5 million Americans sustain myocardial infarctions each year

American Heart Association, Dallas Texas

Utilization Trends

Greater than 2 million Americans are eligible for cardiac rehab (secondary prevention) post ACS, MI, PCI or CABG

On average, only 10% to 30% of eligible patients receive cardiac rehabilitation

− Ranges vary between 11% and 38% depending on the area of the country

The Cornerstone of Cardiac Rehabilitation

Exercise Research

Direct relation between inactivity and cardiovascular mortality. Inactivity is an independent risk factor for of CAD

Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for CAD

Physical fitness has been unmistakably associated with improvements in lipid profiles

* Coronary Artery Disease Cardiac Rehabilitation and Survival in Older Coronary Patients. Suaya, JA., et al. J Am Coll Cardiol 2009;54:25–33

Methods: Studied 601,099 Medicare beneficiaries Examined 1 to 5 year mortality rates in CR users & nonusers Compared 70,040 propensity-based matched groups (CR

participation versus non-participation) after extensive analyses to control for potential confounding

Results: Only 12.2% of the cohort used Cardiac Rehabilitation Significantly lower (p 0.001) 1- to 5-year mortality rates in CR

users than nonusers

A Landmark Study!*

Coronary Artery Disease Cardiac Rehabilitation and Survival in Older Coronary Patients. Suaya, JA., et al. J Am Coll Cardiol 2009;54:25–33

Subsequent to extensive analyses to control for potential confounding:

Post 1 year, Cardiac Rehabilitation participants (more than 24

sessions) had a 58% relative risk reduction for mortality

At 5 years, Cardiac Rehabilitation participants had a 34% relative

risk reduction for mortality

“Mortality reductions extended to all demographic and clinical

subgroups including patients with acute myocardial infarctions, those receiving revascularization procedures, and those with congestive heart failure”

Dose Response Relationship for CR Sessions and Risk of Death / MI *

Sessions Attended

36 vs 24 Sessions

36 vs 12 Sessions

36 vs 1 Sessions

Death - 14% - 22%

- 47%

Myocardial Infarction

- 12% - 23%

- 31%

*Relationship Between Cardiac Rehabilitation and Long-Term Risks of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries. Hammill, BG. et al. Circulation. 2010;121:6370

Cost-effectiveness / Cost-efficiency

Medicare payments in hospital for CAD in 1999 was $26.3 billion!

Studies, adjusted for quality of life, show savings of $4,950-$9,200 per year of life saved

Reduction in re-hospitalizations and medical costs are well documented

Cardiac Rehab Professionals Team Partners in Patient Care:

CR Medical Director

Referring Physician

Registered Nurses

Exercise Physiologists

Physical Therapists

Dieticians/Nutritionists

Psychosocial Professionals

Pharmacists

Case Managers

Who can Refer a Patient?

Site-specific Policy:

Primary Care Physician

Internist

Cardiologist

NP’s & PA’s (State specific)

Communication with Rehab?

Collaborative Approach:

Initial referral

Individualized treatment plan

Periodic Progress reports

Program oversight by Medical Director

Open ended lines of communication

Cardiac Rehab adds Value Cardiac patients have many disease processes

and lifestyle concerns that have contributed to their heart disease.

Cardiac rehab serves the needs of each cardiac patient and works toward secondary prevention.

Cardiac rehab adds VALUE to your patient care and increases QUALITY OF LIFE !

Improving CR Participation

“Cardiac Rehabilitation participation rates were the recent subject of both an American Heart Association Presidential Advisor (1) and a Scientific Advisory (2) and is an ongoing national Performance Measure priority for improvement (3)

1. Balady GJ, et al.. Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: A presidential advisory from the American Heart Association. Circulation. 2011;124:2951-2960.

2. Arena R, et al.. Increasing referral and participation rates to outpatient cardiac rehabilitation: The valuable role of healthcare professionals in the inpatient and home health settings: A science advisory from the American Heart Association. Circulation. 2012;125:1321-1329.

3. Thomas Rjet al. J. AACVPR/ACCF/AHA 2010 update: Performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services. Circulation. 2010;122:1342-1350.

Sooner is Better !!

The secret to getting cardiac patients into outpatient rehabilitation programs is scheduling their first appointment soon after they leave the hospital (1)

Compared with the standard median time from hospital discharge (35 days), enrolling patients into cardiac rehabilitation 10 days after discharge significantly improved patient attendance.

1. An Early Appointment to Outpatient Cardiac Rehabilitation at Hospital Discharge Improves Attendance at Orientation: A Randomized, Single-Blind, Controlled Trial. Quinn R. Pack, Mouhamad Mansour, Joaquim S. Barboza, et al. Circulation. published online December 18, 2012

CARDIAC REHABILITATION

A REFERRAL IS A

PHONE CALL

AWAY!