Cardiac Rehabilitation for
Ambulatory Care Providers
What
is cardiac rehabilitation (CR)?
-
CR is a
comprehensive intervention that includes medical evaluation, exercise,
cardiac risk factor modification, and education. The goals is to reduce the risk of
death, control cardiac symptoms, and improve the psychosocial and vocational
status1
-
CR typically
includes exercise sessions 2-3 times per week for 12-18 weeks
o
Most also include
counseling on diet, smoking cessation, medication adherence, and psychosocial
support
-
CR is endorsed by
the American Heart Association (AHA), American College of
Cardiology2, CMS/HHS3 &
AHRQ4
-
Despite strong
evidence, it is an underused resource:
o
Less than 30% of
eligible patients participate in CR after a CV event nationwide5-7
o
Only about 12% of
eligible New York State Medicare patients had CR after a CV event in
19978
o
Women, the elderly,
and non-whites are less likely than whites to be referred and enroll in
CR5, 9
What
is the evidence for CR?
-
The benefit of CR
in secondary cardiovascular disease prevention is well established with a
mortality benefit of 20-25%2
o
A meta-analysis of
48 randomized control trials (RCT) with a median follow-up of 15 months showed
in patients with coronary heart disease, compared to usual care participation in
CR was associated with10:
§
20% reduction in
all-cause mortality (OR 0.80; 95% CI:
0.68-0.93)
§
26% reduction in
cardiac mortality (OR 0.74; 95% CI:
0.61-0.96)
§
Greater
reductions in total cholesterol level,
triglyceride level, systolic blood pressure, and lower rates of
self-reported smoking
o
A meta-analysis of
63 RCTs showed a 17% reduction in recurrent MI
over a median 12-month follow-up11
Who
should be referred?
-
According to the AHA, all patients evaluated in the outpatient
setting who in the last 12 months have experienced2
:
o
MI/acute coronary
syndrome
o
CABG
o
PCI/PTCA
o
Chronic stable
angina
o
Heart valve
surgical repair or replacement
o
Heart or heart/lung
transplantation
-
There is growing
evidence for the benefit of CR in chronic heart failure and peripheral arterial
disease
-
Those with
contraindications to exercise or existing high-risk condition should not be
referred
How
do I refer a patient?
-
Encourage your
patient to follow-up: A main predictor
of patient participation in CR is strong physician endorsement
12
-
Identify and
contact a cardiac rehab facility
o
Choose a facility
close to the patient’s home to promote patient
follow-up12
o
Facilities vary on
their referral processes; many require a standard form that must be faxed
-
How do I know if
my patient’s insurance covers cardiac rehab?
o
Most CR facilities
have billing departments that will contact the insurance provider to determine
eligibility and obtain prior authorization. They CR facility may contact you if your
patient is ineligible or if more information is needed for authorization.
o
Insurance carriers
vary by qualifying conditions, number of sessions allowed, and the time frame
for referral after an event; some only accept referral from a
cardiologist
o
Medicare covers
referral for all AHA recommended conditions. Patients with MI must referred within
one year of the event, but there is no time limit on other
diagnoses
o
A list of ICD-9
codes covered by most Medicare programs are found above
-
Include
necessary documents in the referral to facilitate insurance
approval
□
Recent clinical
note or hospital discharge summary documenting medical
necessity
□
Cardiac
catheterization report, stress test, relevant laboratory studies (lipid panel,
HbA1c)
□
Recent stress test
is often needed to qualify for coverage for stable angina
References:
1.
Wenger NK, Foelicher ES, Smith
LK, Ades PA, et al. Cardiac Rehabilitation: Practice Guideline 17: U.S.
Department of Health and Human Services; 1995.
2.
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 Oct 2;116(14):1611-42.
3.
Centers for
Medicare and Medicaid Services Decision Memo for Cardiac Rehabilitation Programs
(CAG-00089R)U.S. Department of Health & Human
Services; 2006.
4.
Agency for Health
Care Research Technology Assessment Program. Randomized trials of secondary
prevention programs in coronary artery disease: a systematic review. Agency for Health Care Research and
Quality. 2005.
5.
Thomas RJ, Miller NH, Lamendola
C, et al. National survey on gender
differences in cardiac rehabilitation programs: patient characteristics and
enrollment patterns. J Cardiopulm Rehabil 1996;16:402–12.
6.
Receipt of cardiac
rehabilitation services among heart attack survivors—19 states and the District
of Columbia, 2001
MMWR Morb Mortal
Wkly Rep 2003;52:1072-1075.
7.
Cortes O, Arthur
HM. Determinants of referral to cardiac rehabilitation programs in patients with
coronary artery disease: a systematic review Am Heart J 2006;151:249-256.
8.
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
Oct 9;116(15):1653-62.
9.
Witt BJ. Jacobsen SJ. Weston SA.
Killian JM. Meverden RA. Allison TG. Reeder
GS. Roger VL. Cardiac rehabilitation after myocardial infarction in the
community. Journal of the American College of Cardiology. 44(5):988-96,
2004 Sep 1.
10.
Taylor RS, Brown A,
Ebrahim S, et al. Exercise-based rehabilitation for
patients with coronary heart disease: systematic review and meta-analysis of
randomized controlled trials Am J Med 2004;116:682-692.
11.
Clark AM, Hartling L, Vandermeer B, McAlister FA. Meta-analysis: secondary
prevention programs for patients with coronary artery disease Ann Intern
Med 2005;143:659-672.
12.
Jackson et al. Getting the most out of cardiac
rehabilitation: a review of referral and adherence predictors. Heart 2005;91:10-14.