New Standards Aim to Boost Enrollment in Cardiac Rehab

ROCHESTER, Minn., Sept 20 -- A new set of rehabilitation standards for patients recovering from a serious cardiac event is designed to get more patients into rehab programs and to standardize their care.

The majority of patients who have a heart attack or a serious coronary event leave the hospital without referral to a cardiac rehabilitation program, said Randal J. Thomas, M.D., of the Mayo Clinic here.

The detailed document aimed at repairing this gap is a three-way collaborative effort by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American College of Cardiology, and the American Heart Association. It has been endorsed by nine other medical societies specializing in cardiac care and rehabilitation. Dr. Thomas chaired the writing committee for the document.

There is plenty of evidence that cardiac rehabilitation is extremely beneficial for patients who have had a heart attack, coronary artery bypass surgery, percutaneous coronary intervention, or transplant or valve surgery, Dr. Randall said. Others for whom it is appropriate are patients with acute coronary syndrome and stable angina.

Rehab programs can reduce the risk of death from a second event by 20% to 25%, a level of benefit similar to that of statin drugs, beta-blockers, and aspirin, he said.

Cardiac rehab can also boost physical strength and endurance by 20% to 50%, an improvement that could determine whether a patient is able to return to an active life, he added.

But the intervention is vastly underutilized, with less than 30% of eligible patients participating in a rehab program after a cardiovascular event, the authors wrote.

The document "Cardiac Rehabilitation Performance Measurement Sets for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services" appears in the Oct. 2 issues of the Journal of the American College of Cardiology and Circulation and the Sept/Oct. issue of the Journal of Cardiopulmonary Rehabilitation and Prevention.

Although cardiac rehab is often thought of as medically supervised exercise, physical conditioning is just one component, the authors wrote.

According to the definition of these services, by the U.S. Public Health Service and other organizations, cardiac rehabilitation involves medical evaluation, prescribed exercise, risk-factor modification, education, and counseling.

The new standards apply to both inpatient and outpatient settings, with performance measures for hospitals, office practices, and rehabilitation programs.

One goal of the new standards is to make referral to cardiac rehab as automatic as giving aspirin during a heart attack, the authors said. To that end, the 30-page document provides sample referral forms and outlines the best approach for collecting and analyzing data on patient referral.

The authors developed two basic sets of performance measures, one related to referral of patients to rehab programs, the other to the optimal performance of a cardiac rehabilitation program.

Of two measures related to early referral, the first is designed to assure that all hospitalized patients with a qualifying event are referred to a cardiac rehabilitation program while still in the hospital.

The second seeks to capture outpatients who have fallen into a preventive-care gap. These patients should be referred by their healthcare provider in an outpatient setting, the authors said.

To ensure the safety and excellence of the rehabilitation programs, the document urges use of standards for safety, physician involvement, intervention for risk factors, and outcomes analysis previously developed by major organizations. A sample tracking tool is included in the document to help rehabilitation programs track their own performance.

The measures include appropriate emergency response during exercise sessions, adherence to evidence-based guidelines, individualized assessment of adverse events, individual assessment and intervention for modifiable cardiac risk factors, and communication with patients and the treating physicians.

In addition, rehab programs are encouraged to monitor response to therapy and undertake quality-improvement methods.

In conclusion, the authors wrote, the recommendations "will need to be adapted, adopted, and implemented by health care systems, health care providers, health insurance carriers, chronic disease management organizations, and other groups in the health care field that have responsibility for the delivery of care to persons with cardiovascular disease."