A growing body of evidence shows that for patients who have been hospitalized for a cardiac event, participation in a supervised cardiac rehabilitation (CR) program after discharge reduces the risk of mortality.
In addition, the rehab programs, which typically include supervised exercise along with counseling and education about lifestyle changes, can reduce the risk that patients will return to the hospital.
Yet research also indicates that few eligible patients participate in a CR program following discharge. An October 2007 Circulation study of 267,427 Medicare beneficiaries found that only 18.7% received at least one session of outpatient CR after hospital discharge. Leading cardiology organizations—including the American College of Cardiology Foundation, the American Association of Cardiovascular and Pulmonary Rehabilitation and the American Heart Association—point to this low utilization rate as indication of a gap in the continuum of care that should be addressed before the patient leaves the hospital.
“Referral for cardiac rehab has been a challenge for all physicians, but in particular it can be a challenge for hospitalists,” says Gregg C. Fonarow, MD, professor of cardiovascular medicine at the University of California, Los Angeles. “Because hospitalists care for inpatients, they may not be familiar with the importance of cardiac rehab after discharge, and its impact on risk factor control and long-term outcomes.”
The scope of the problem
Even in hospitals participating in the Get with the Guidelines quality improvement initiative, only about half of eligible patients were referred to CR prior to discharge, according to a study by Dr. Fonarow and colleagues published in the Journal of the American College of Cardiology in August 2009.
“A lot of hospitalists are just too busy to remember to make the referral,” said Marjorie King, ACP Member, director of cardiac services at Helen Hayes Hospital in West Haverstraw, N.Y.
Cardiologists, too, have trouble staying abreast of the evidence, said Randal J. Thomas, FACP, director of the Cardiovascular Health Clinic at the Mayo Clinic in Rochester, N.Y.
“For example, most cardiologists are aware of reports that show a 20% to 25% reduction in mortality for patients who participate in cardiac rehab. But they may not know about new evidence showing even greater benefit after angioplasty and stent placement, or a study we just published showing improvement in medication adherence for patients who go to cardiac rehab,” he said. “For hospitalists, who have to keep up to date on a wide variety of topics, it would be understandable that they might not be up to speed on some of those details.”
Cardiologists cited a number of other factors that might prevent a hospitalist, or any discharging physician, from referring an eligible patient to a CR program. The possibilities include forgetting or neglecting to consider CR at all, misconceptions about what CR programs offer, lack of information about available programs, confusion about which patients are eligible, patient resistance or refusal to participate in CR, and reluctance to encroach on the territory of the primary care physician.
Strengthening the referral
A systematic approach that automatically prompts the hospitalist to refer eligible patients to outpatient CR programs is the first step in addressing underutilization, experts said.
Eligible patients include those who have had a myocardial infarction, coronary artery bypass surgery, stable angina, heart valve repair or replacement, percutaneous transluminal coronary angioplasty or coronary stenting, or heart or heart-lung transplants, according to the Centers for Medicare and Medicaid Services' list of clinical indications for cardiac rehabilitation coverage.
Contraindications would include “a patient who's completely immobile, who's had a significant stroke, or who is not clinically stabilized,” Dr. Fonarow said. A patient who is still somewhat unstable with an arrhythmia may need some time to recover before enrolling in a CR program, he added.
Methods of encouraging hospitalists to refer patients can range from a checkbox on an electronic or paper form to required documentation of an exchange of information with a specific CR program. Although research indicates that any form of automatic prompt increases referral rates, cardiologists said the checkbox method falls far short of what is needed to significantly improve both referral and enrollment.
“There needs to be a coordinated system in place so that once the hospitalist activates a referral, someone on the discharge planning team contacts the receiving program and provides some information about the patient,” said Dr. Thomas. “Many hospitals have set up a system in which staff members such as nurses and exercise specialists serve as a resource to hospitalists in completing the referral.”
To emphasize the importance of communication with the receiving CR program, he cited a study published in the April 15, 2008 American Journal of Cardiology of Boston hospitals participating in Get with the Guidelines.
The hospitals included CR on a checklist of evidence-based care indicated for selected cardiac patients. “They found there was indeed an increase in referral to cardiac rehab based on the checkmarks, but when they looked at actual enrollment in the programs, there was no change, and in fact about 20% to 30% of patients weren't even aware they had been referred,” Dr. Thomas said.
In addition to maintaining closer communication with CR programs, experts recommended a number of other steps hospitalists can take to overcome the most common barriers to CR referral and enrollment:
- Work with cardiologists and cardiac rehabilitation specialists within the hospital to identify patients who will be eligible for CR. “Our cardiovascular division has an excellent relationship with our hospitalists,” said Frederick Masoudi, FACP, associate professor of medicine at Denver Health Medical Center and the University of Colorado. “The hospitalists are familiar with our Healthy Hearts program, a set of services for the post-discharge care of cardiac patients. The program sends cardiology nurses to the floor to identify patients for the post-discharge clinic. Because of that close working relationship, we're successful in identifying patients with qualifying conditions to enroll in our cardiac rehabilitation program.”
- Learn about cardiac rehabilitation programs in the community and help patients find the program that's closest and most convenient. The availability of cardiac rehabilitation services varies greatly from region to region, Dr. Masoudi noted. “However, hospitalists have a responsibility to determine what's available in their community and, to the extent feasible, form a collaborative relationship with those who deliver cardiac rehabilitation services.” The effort at collaboration should go both ways, with hospital providers cultivating relationships with local CR programs, and the programs in turn reaching out to hospitals, according to Dr. Thomas. A searchable directory of programs is available from the American Association of Cardiovascular and Pulmonary Rehabilitation.
- Coordinate with primary care physicians and specialists in the process of referral to and enrollment in a CR program. “Some hospitalists are wary of stepping on the toes of the cardiologist who will take over the case,” said Murray Low, EdD, director of cardiac rehabilitation at Stamford Hospital in Stamford, Conn. “When I met with our hospitalists to talk about cardiac rehab, they expressed concern that they're not in charge of the patient once he or she leaves the hospital—the cardiologist or internist takes over.” In response, Dr. Low created a process in which the hospitalist makes the initial referral, the CR service contacts the patient and confirms his or her interest in joining the program, and the primary care physician gives final approval before the patient enrolls.
- Have a one-on-one conversation with the patient about the importance of CR services. “Hospitalists play a critically important role in helping to bridge the gap that's occurring in the care of patients with cardiac disease,” said Dr. Thomas. “The most important point for [hospitalists] to recognize is the power of their recommendation. If they say something as simple as, ‘You need to go to cardiac rehab. It will make you feel better and live longer. It's covered by insurance,’ those messages can help the patient gain the confidence they need to enter the program.”
Those last two points may also help with getting patients to continue, not just enter, cardiac rehab, which should also be a goal for discharging hospitalists. A study of 30,000 patients, published in Circulation last January, found that patients who attended all 36 sessions of CR that are reimbursed by Medicare had a 47% lower risk of death and a 31% lower risk of MI than those who attended only one session.