Nearly 90% of patients with heart failure are not referred to cardiac rehabilitation

Only 10 percent of patients with heart failure were referred to cardiac rehabilitation after hospital discharge between 2005 and 2014, according to a database analysis.

Although the referral rates were higher in recent years, researchers noted that they expected more people to be told to attend cardiac rehabilitation sessions. They said the sessions have been proven to be effective at improving the quality of life and reducing readmissions.

Lead researcher Harsh Golwala, MD, of the University of Louisville, and colleagues published their results online in the Journal of the American College of Cardiology on Aug. 17.

Cardiac rehabilitation typically consists of medically supervised exercise that takes place in 36, one-hour sessions over three months. During the sessions, patients often receive instructions regarding lifestyle modifications such as a healthy diet and smoking cessation as well as the importance of medication adherence and following up with physicians.

This analysis included 105,619 patients with heart failure who were discharged from 338 hospitals between Jan. 1, 2005, and June 30, 2014. The researchers analyzed information from the AHA’s Get With The Guidelines–Heart Failure database, a prospective registry and quality improvement program.

Of the patients, 10.4 percent overall were referred to cardiac rehabilitation. In 2014, 13.3 percent of patients were referred to cardiac rehabilitation, up from 9.6 percent in 2005.

“Given all the evidence, guidelines and Medicare coverage decision regarding cardiac rehab, we certainly expected over the course of the study to have seen much higher rates of referral and a much greater improvement over time than we saw,” Gregg C. Fonarow, MD, a study author and director of the Ahmanson-UCLA cardiomyopathy center in Los Angeles, told Cardiovascular Business. “In many ways, these results are quite surprising.”

More than 6.5 million Americans have heart failure, and more than 650,000 patients are diagnosed with heart failure each year. In addition, heart failure accounts for more than 43 percent of Medicare spending. There are more than one million heart failure hospital admissions each year among people who are 65 or older.

Guidelines from the American College of Cardiology and American Heart Association (AHA) recommend cardiac rehabilitation for heart failure patients with reduced ejection fraction and New York Heart Failure Association class II to III symptoms. Meanwhile, the Centers for Medicare & Medicaid Services in 2013 approved cardiac rehabilitation coverage for stable outpatients with heart failure with reduced ejection fraction.

In this study, 48 percent of patients had heart failure with reduced ejection fraction and 52 percent had heart failure with preserved ejection fraction. At baseline, the mean age was 74, and 48 percent of patients were female.

The researchers noted that patients referred to cardiac rehabilitation were younger and had fewer comorbidities than patients who did not receive a referral after discharge. They were also more likely to be male and use in-hospital procedures such as coronary angiography, PCI with stent and CABG.

Among patients with reduced ejection fraction heart failure, 15.5 percent were referred to cardiac rehabilitation in 2014 compared with 9.6 percent in 2005. During that same time period, the proportion of patients with preserved ejection fraction who were referred to cardiac rehabilitation increased from 9.6 percent to 11.6 percent.

Although this study could not determine the reasons for the low referral rates, Fonarow said doctors may not understand the benefits of cardiac rehabilitation.

“There are a lot of barriers that do exist regarding changing physician practice patterns,” Fonarow said. “In general, there may be a lack of awareness regarding the benefits of cardiac rehab in heart failure patients and how the guidelines have evolved. There are a lot of other issues going on with heart failure patients – adjusting all their medications, arranging for early follow-up. In this setting, the opportunity to refer patients for rehabilitation may have been overlooked. This really highlights that there’s a very important opportunity here to recognize the benefits of cardiac rehabilitation.”