Cardiac Rehabilitation Services Insufficiently Utilised

A new study published in Circulation: Journal of the American Heart Association suggests that less than one in five people receive rehabilitation services following a heart attack or coronary bypass surgery. These numbers are shocking as there is strong evidence that cardiac rehabilitation reduces disability and increases life expectancy.

This largest and most comprehensive of its kind study was carried out by Dr. Jose A. Suaya and colleagues at the Brandeis University in Waltham, Massachusetts. The researchers studied Medicare claims data on 267,427 men and women over the age of 65. All study subjects had survived at least 30 days after being hospitalised and discharged for a heart attack or coronary bypass surgery in 1997.

The researchers found that in the year after the patients were discharged from hospital, only 18.7% or one in five patients had at least one session of cardiac rehabilitation. There was also a vast difference in the likelihood of bypass patients and heart attack patients receiving rehabilitation – 31% of bypass patients got rehabilitation services compared to only 13.9% of heart attack patients.

Despite cardiac rehabilitation sessions being covered by Medicare, the researchers found that women above the age of 65 used rehabilitation services less than men. Non-whites too were significantly less likely to participate in rehabilitation than whites.

Overall, men – 22.1% were significantly more likely to used cardiac rehabilitation than women – 14.3%. This difference increased with age with both higher aged men and women being much less likely to take full benefit of cardiac rehabilitation services.

“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 Dr. Suaya, a lecturer and scientist at the Schneider Institutes for Health Policy, Heller School, at Brandeis University.

“Almost all patients with stable angina or a recent heart attack, bypass surgery, or a coronary stent could benefit from cardiac rehabilitation,” Dr. 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 study co-author Dr. Donald S. Shepard, a Professor at the Heller School. “This is particularly important for patients with other medical conditions, who are less likely to receive a referral.”

“Coronary bypass surgery is a big event for most patients and cardiac rehab has been adopted as a very important component of recovery,” said Dr. William B. Stason, another 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 includes supervised and monitored exercise sessions that help improve cardiovascular fitness. It also covers help with changes in lifestyle such as smoking cessation, improvement in diet and learning how to reduce stress.

When the study was conducted, Medicare – the primary health insurer in the US for people over 65 provided coverage for up to 36 sessions of cardiac rehabilitation after a heart attack, bypass surgery, or stable angina. This meant three sessions each week for three months.

The researchers found that on average, the patients covered under the study went through 24 sessions only. In 2006 the coverage was 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,” Dr. Stason said. “I think differences in the use of cardiac rehabilitation for different age groups reflect 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,” Dr. Stason added.

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