Referrals for Cardiac Rehab Are Too Low Despite Major Benefits Backed By Science

I served as medical director of several large cardiac rehabilitation (CR) programs in Michigan and have a special place in my heart and practice for getting all qualifying patients into a CR program. When I can, I try to refer to an intensive CR program or ICR using the principles of Pritikin and Ornish. They provide important lifestyle and nutrition education that standard CR does not cover. A new study points out some of the roadblocks to CR utilization. 

Consistent evidence gathered over many years supports the benefits of CR including reductions in mortality and hospitalizations and an increase in quality of life. Typical patients who qualify for CR have had a recent heart attack (MI), bypass surgery, stent, surgical or transcatheter valve replacement, or chronic stable angina pectoris. Some patients with congestive heart failure qualify and benefit from CR. 

In one study of 601,099 Medicare patients older than 65 years with coronary disease, 5-year mortality was lower in patients who participated in CR than those who did not (16% versus 25%). Another study has shown significantly fewer hospitalizations for heart failure among patients who participated in CR than those who did not.  The patients who underwent CR had 11 admissions for a total of 41 hospitalized days over a 24-week period, whereas those who did not had 33 admissions for a total of 187 hospitalized days. The clinical benefits of cardiac rehabilitation, as documented in both young and older participants, include increased exercise capacity, energy, and total quality of life.

Although cardiac rehabilitation is a class 1 indication for patients who have sustained acute coronary syndrome as well as those with heart failure, it is grossly underused. In one study, only 24% of a cohort of 366,103 Medicare patients with a qualifying diagnosis for cardiac rehabilitation assessed from 2016 to 2017 participated in CR. Of those who participated, only 27% completed the program.

Multiple hurdles contribute to poor CR availability, referral and participation. One major factor is the lack of referrals. In a 2017 meta-analysis of 26 studies including 297,719 participants, significantly fewer women than men were enrolled (45% men, 39% women. Moreover, in an evaluation of 48,993 patients referred to CR had 12% less participation in CR than men. The investigators also noted that Black, Hispanic, and Asian patients were 20%, 36%, and 50% less likely than white patients, respectively, to be referred for CR.

At the Kahn Center, we strive to refer every qualifying patient, including chronic angina patients, to a CR program. Ideally, we try to refer to an ICR program guided by the Pritikin or Ornish teachings.