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Research Letter |

Cardiac Rehabilitation Use Among Veterans With Ischemic Heart Disease FREE

David W. Schopfer, MD, MAS1; Steven Takemoto, PhD1; Kelly Allsup, BS2; Christian D. Helfrich, PhD3; P. Michael Ho, MD4,5; Daniel E. Forman, MD2,6,7,8; Mary A. Whooley, MD1,9,10
[+] Author Affiliations
1Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
2New England Geriatric Research, Education, and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
3Northwest Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
4Division of Cardiology, Denver Veterans Affairs Medical Center, Denver, Colorado
5Department of Medicine, Division of Cardiology, University of Colorado Health Sciences Center, Denver
6Division of Cardiovascular Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
7Department of Medicine, Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
8Department of Medicine, Harvard Medical School, Boston, Massachusetts
9Department of Medicine, University of California, San Francisco
10Department of Epidemiology and Biostatistics, University of California, San Francisco
JAMA Intern Med. 2014;174(10):1687-1689. doi:10.1001/jamainternmed.2014.3441.
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Published online

Referral to exercise-based cardiac rehabilitation (CR) is 1 of 9 performance measures for secondary prevention after hospitalization for myocardial infarction (MI), percutaneous coronary intervention (PCI), and/or coronary artery bypass graft (CABG).1,2 Although CR programs significantly reduce morbidity and mortality in patients with ischemic heart disease (IHD),3 they are vastly underused among US Medicare beneficiaries.4 The use of CR programs in the Veterans Health Administration (VA) has not been described. Therefore, we sought to determine (1) the proportion of eligible veterans with IHD who participate in CR, (2) whether the presence of an on-site CR program is associated with greater participation, and (3) the characteristics of the CR participants.

National VA inpatient files were used to identify all patients discharged from VA facilities with a diagnosis of MI, PCI, and/or CABG during fiscal years 2007 to 2011 (eMethods in the Supplement). The number of patients who participated in VA CR programs during the 12 months following hospitalization was determined from VA outpatient files. The number of eligible patients who participated in non-VA CR programs was determined from non-VA care files and from the Centers for Medicare and Medicaid Services data. Institutional review board approval was obtained from the San Francisco Veterans Affairs Medical Center and the University of California, San Francisco.

Between October 1, 2006, and September 30, 2011, a total of 47 051 unique patients were hospitalized for MI, PCI, or CABG at 124 VA facilities. Of these, 3955 patients (8.4%) participated in 1 or more sessions of outpatient CR during the 12 months after hospitalization (eTable 1 in the Supplement). Overall, there was no significant difference in participation by sex or race: 8.4% of men (3893 of 46 271) and 7.9% of women (62 of 780) received CR (P = .64), and 8.0% of whites (2093 of 26 150) and 8.3% of nonwhites (587 of 7068) received CR (P = .41). However, whites were more likely than nonwhites to attend non-VA CR programs (P = .001) and less likely than nonwhites to attend on-site VA CR programs (P = .02).

From fiscal years 2007 to 2011, participation rates increased from 7.5% to 9.4% (P < .01). There was a significant interaction between the presence of an on-site CR program and the distance to the closest VA medical center (P = .02 for interaction). Therefore, we stratified analyses by the presence (35 VA facilities) or absence (89 VA facilities) of an on-site CR program (eTable 2 and eTable 3 in the Supplement).

Overall, patients were more likely to participate in CR if they had been hospitalized at a VA facility with vs a facility without an on-site CR program (10.9% vs 6.8%; P < .001). Facilities with vs those without on-site CR programs had higher rates of participation (Figure). In multivariable models, the characteristics associated with greater participation were younger age, marriage, higher body mass index, living closer to a VA facility, hyperlipidemia, absence of heart failure, absence of chronic kidney disease, and hospitalization for CABG (vs PCI or MI) (Table). After controlling for these variables, the presence of an on-site CR program was associated with a 75% greater odds of attending a CR program (odds ratio, 1.75; 95% CI, 1.62-1.90; P < .001).

Place holder to copy figure label and caption
Figure.
Proportion of Eligible Patients Participating in Cardiac Rehabilitation (CR) at Veterans Health Administration (VA) Facilities With and Without CR Programs

The study was conducted from October 1, 2006, to September 30, 2012. All differences were significant at P < .001. CABG indicates coronary artery bypass graft; IHD, ischemic heart disease; MI, myocardial infarction; and PCI, percutaneous coronary intervention.

Graphic Jump Location
Table Graphic Jump LocationTable.  Factors Associated With Participation in Cardiac Rehabilitation Among 9636 Veterans With Ischemic Heart Diseasea

In this study of 47 051 veterans hospitalized for MI, PCI, or CABG, 8.4% of eligible patients participated in 1 or more sessions of outpatient CR. Both the presence of an on-site CR program and patient proximity to a VA facility were associated with greater participation in CR. However, participation was low regardless of the presence (10.9%) or absence (6.8%) of an on-site program. These findings suggest that new patient-centered delivery strategies must be developed to solve the seemingly intractable challenge of CR underuse.5

Corresponding Author: David W. Schopfer, MD, MAS, San Francisco Veterans Affairs Medical Center, 4150 Clement St (111A1), San Francisco, CA 94121 (david.schopfer@gmail.com).

Published Online: August 18, 2014. doi:10.1001/jamainternmed.2014.3441.

Author Contributions: Drs Schopfer and Whooley had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Schopfer, Takemoto, Allsup, Helfrich, Forman, Whooley.

Acquisition, analysis, or interpretation of data: Schopfer, Takemoto, Ho, Whooley.

Drafting of the manuscript: Schopfer, Takemoto.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Schopfer, Takemoto, Whooley.

Obtained funding: Schopfer, Forman, Whooley.

Administrative, technical, or material support: Allsup, Helfrich.

Study supervision: Forman, Whooley.

Conflict of Interest Disclosures: Dr Whooley has received research funding from Janssen Healthcare Innovations.

Funding/Support: This study was supported by grant QUERI RRP 12-232 from the Veterans Health Administration (VA) Office of Health Services Research and Development. Dr Schopfer was supported by the VA Quality Scholars Fellowship Program.

Role of the Sponsor: The VA had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: John Rumsfeld, MD, PhD, administered the VA Survey of Cardiovascular Specialty Care Services and provided critical comments on the manuscript. No financial reimbursement was provided.

Drozda  J  Jr, Messer  JV, Spertus  J,  et al; American Academy of Family Physicians; American Association of Cardiovascular and Pulmonary Rehabilitation; American Association of Clinical Endocrinologists; American College of Emergency Physicians; American College of Radiology; American Nurses Association; American Society of Health-System Pharmacists; Society of Hospital Medicine; Society of Thoracic Surgeons.  ACCF/AHA/AMA-PCPI 2011 performance measures for adults with coronary artery disease and hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association–Physician Consortium for Performance Improvement. J Am Coll Cardiol. 2011;58(3):316-336.
PubMed   |  Link to Article
Thomas  RJ, King  M, Lui  K, Oldridge  N, Piña  IL, Spertus  J; American Association of Cardiovascular and Pulmonary Rehabilitation/American College of Cardiology/American Heart Association Cardiac Rehabilitation/Secondary Prevention Performance Measures Writing Committee.  AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. Circulation. 2007;116(14):1611-1642.
PubMed   |  Link to Article
Heran  BS, Chen  JM, Ebrahim  S,  et al.  Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011;(7):CD001800. doi:10.1002/14651858.
PubMed
Suaya  JA, Shepard  DS, Normand  SL, Ades  PA, Prottas  J, Stason  WB.  Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2007;116(15):1653-1662.
PubMed   |  Link to Article
Balady  GJ, Ades  PA, Bittner  VA,  et al; American Heart Association Science Advisory and Coordinating Committee.  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(25):2951-2960.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Proportion of Eligible Patients Participating in Cardiac Rehabilitation (CR) at Veterans Health Administration (VA) Facilities With and Without CR Programs

The study was conducted from October 1, 2006, to September 30, 2012. All differences were significant at P < .001. CABG indicates coronary artery bypass graft; IHD, ischemic heart disease; MI, myocardial infarction; and PCI, percutaneous coronary intervention.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Factors Associated With Participation in Cardiac Rehabilitation Among 9636 Veterans With Ischemic Heart Diseasea

References

Drozda  J  Jr, Messer  JV, Spertus  J,  et al; American Academy of Family Physicians; American Association of Cardiovascular and Pulmonary Rehabilitation; American Association of Clinical Endocrinologists; American College of Emergency Physicians; American College of Radiology; American Nurses Association; American Society of Health-System Pharmacists; Society of Hospital Medicine; Society of Thoracic Surgeons.  ACCF/AHA/AMA-PCPI 2011 performance measures for adults with coronary artery disease and hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association–Physician Consortium for Performance Improvement. J Am Coll Cardiol. 2011;58(3):316-336.
PubMed   |  Link to Article
Thomas  RJ, King  M, Lui  K, Oldridge  N, Piña  IL, Spertus  J; American Association of Cardiovascular and Pulmonary Rehabilitation/American College of Cardiology/American Heart Association Cardiac Rehabilitation/Secondary Prevention Performance Measures Writing Committee.  AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. Circulation. 2007;116(14):1611-1642.
PubMed   |  Link to Article
Heran  BS, Chen  JM, Ebrahim  S,  et al.  Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011;(7):CD001800. doi:10.1002/14651858.
PubMed
Suaya  JA, Shepard  DS, Normand  SL, Ades  PA, Prottas  J, Stason  WB.  Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2007;116(15):1653-1662.
PubMed   |  Link to Article
Balady  GJ, Ades  PA, Bittner  VA,  et al; American Heart Association Science Advisory and Coordinating Committee.  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(25):2951-2960.
PubMed   |  Link to Article

Correspondence

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Multimedia

Supplement.

eMethods. Study participants, outcome assessment, and data analysis

eTable 1. Patient participation in cardiac rehabilitation (CR) by qualifying diagnosis (10/06-9/11)

eTable 2. Patient characteristics associated with participation in cardiac rehabilitation following hospitalization for ischemic heart disease (10/1/06-9/30/11) at 35 VA medical centers with an on-site CR program

eTable 3. Patient characteristics associated with participation in cardiac rehabilitation following hospitalization for ischemic heart disease (10/1/06-9/30/11) at 89 VA medical centers without an on-site CR program

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