Studies point out future growth potential of cardiac rehab services
Move now to get your program ready to take advantage of latest trends
Experts who monitor the rehab industry are urging you to heed recent studies that show cardiopulmonary rehab programs save money by improving patient outcomes and reducing rehospitalization.If you have such a program, market it. If you don’t, you might consider establishing one because the cost savings will justify it, particularly under capitation.
"All you have to do is avoid a couple of days of hospitalization, and that pays for the whole cost of the program," said John Hodgkin, MD, in a recent speech to the Cardiopulmonary Rehabilitation Symposium in Orlando, FL. Hodgkin is a pulmonary rehabilitation specialist at St. Helena Hospital in Deer Park, CA.
According to a recent study conducted at Wake Forest University in Winston-Salem, NC, patients who remained in outpatient cardiac rehab programs for an average of 2.5 years were in better condition than patients who quit their programs after three months.
Patients who continued the cardiac rehab programs did better on treadmill exercise testing, weighed less, and had higher blood levels of "good cholesterol," the study concluded.1
Dropouts lose most of their rehab gains
The study also showed that the patients were generally successful in retaining their post-rehab gains, such as functional capacity and triglyceride and body fat levels.By contrast, people who dropped out after the standard three-month cardiac rehab program lost many of the gains they achieved during rehab, the study concluded.
Although the differences could be explained by continued participation in a structured exercise program, the researchers suggested that periodic evaluations and feedback from the cardiac rehab staff may have been responsible for helping patients maintain their body weight and blood lipid levels. The patients who participated in a three-month program claimed to be exercising regularly, the researchers said, adding "our data suggest it was inadequate to alter factors essential in the secondary prevention of coronary artery disease."
The Wake Forest researchers called for greater efforts to encourage compliance in long-term rehab center-based cardiac rehab programs.
Other researchers discovered that cardiac rehab patients returned to work more frequently and had less sick leave, resulting in an overall cost savings of $12,250 per patient.2
That study supported Hodgkin’s assertion, showing the costs of a rehabilitation program are balanced over a five-year period by reduction in readmissions for cardiovascular disease.
But even though these and other studies point out the benefits of cardiac and cardiopulmonary rehabilitation, less than a third of all heart patients participate in such programs, concluded a report by the Washington, DC-based Agency for Health Care Policy and Research (AHCPR).3
Opportunities in cardiopulmonary rehab
Cardiopulmonary rehab offers a niche for providers who may be losing some patients to subacute rehab or home health. (For details on some inpatient programs, see related article, p. 60.)The AHCPR reports that more than 13.5 million patients have coronary heart disease, an additional 4.7 million patients experience heart failure, and an additional several thousand patients undergo heart transplantation each year.
The researchers explained that most outpatient cardiopulmonary rehabilitation is limited by third-party payers to 36 sessions over a 12-week period. But even limited participation is beneficial, the researchers learned. The patients attending the shorter sessions still received health benefits, including improved exercise capacity, less body fat, and lower lipid levels in the blood.
The safety of exercise rehabilitation is well-established. The rates of myocardial infarction and cardiovascular complications during exercise training are very low, the AHCPR report says.
Its research panel reviewed more than 400 scientific reports on the benefits of cardiac rehabilitation.
A survey of adverse experience in 142 cardiac rehabilitation programs showed a rate of nonfatal reinfarction of one per 294,000 patient-hours.
AHCPR recommends multilevel approach
The AHCPR report recommends a comprehensive approach that includes exercise training to improve exercise tolerance and stamina, and education, counseling, and behavioral interventions to assist patients in achieving optimal health.Here are some excerpts from the guidelines:
• The most substantial benefits from cardiac rehabilitation services include improvement in exercise tolerance, improvement in symptoms, improvement in blood lipid levels, reduction in cigarette smoking, improvement in psychosocial well-being, reduction in stress, and reduction in mortality.
• The most consistent benefit of exercise training appeared to occur with exercise training at least three times weekly for 12 or more weeks. The duration of sessions ranged from 20 to 30 minutes at an intensity approximating 70% to 85% of the baseline exercise test heart rate.
• The limited data available did not demonstrate the efficacy of education, training, counseling, and behavioral interventions as sole interventions, independent of exercise training. Education and behavioral interventions may improve morale, self-esteem, and adherence to exercise.
• Clinically stable coronary patients can safely perform training measures designed to increase skeletal muscle strength if they receive appropriate instruction and monitoring.
• Patients should be encouraged to participate in exercise activities that they enjoy and can continue long-term. Older women, in particular, should be encouraged to participate in cardiac rehabilitation to enhance exercise capacity and physical activity.
• Smoking cessation and relapse prevention programs should be offered to patients who are smokers to reduce their risk of further coronary problems.
• Intensive nutrition education, counseling, and behavioral interventions improve dietary fat and cholesterol intake and can result in significant improvement in blood lipid levels.
• Rehab studies that reported the most favorable impact on lipid levels provided a combination of exercise training, dietary education, and counseling, and in some cases, pharmacologic treatment, psychological support, and behavioral training.
• Education as a sole intervention is unlikely to achieve and maintain weight loss. Instead, a combination of education, counseling, behavior modification, and exercise training is most successful.
• Hypertension can best be managed by a combination of education, counseling, behavioral, and pharmacological intervention. Comprehensive educational programs should include information about weight management, exercise, and nutrition, as well as information on medication, potential side effects, and strategies to improve medication adherence.
• Education, counseling, and/or psychosocial interventions to improve psychological well-being are recommended to complement the benefits of exercise training.
References
1. Brubaker PH, Warner JG, Rejeski WJ, et al. Am J Cardiol 1996; 78:769-773.
2. Levin LA, Perk J, Hedback B. Cardiac rehabilitation — cost analysis. J Intern Med 1991; 230:427-434.
3. Wenger NK, Froelicher ES, Smith LK, et al. Cardiac Rehabilitation as Secondary Prevention: Clinical Practice Guideline. Quick Reference Guide for Clinicians. No. 17. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, and National Heart, Lung, and Blood Institute. AHCPR Pub. No. 96-0673; October, 1995.
[Editor’s Note: AHCPR’s full guideline, Cardiac Rehabilitation, the Quick Reference Guide for Clinicians; Cardiac Rehabilitation: Exercise Training and Education, Counseling, and Behavioral Interventions; and the patient guide, Recovering from Heart Problems through Cardiac Rehabilitation are available free of charge from the AHCPR Publications Clearinghouse, P. O. Box 8457, Silver Spring, MD 20907. Telephone: (800) 358-9295. They also are available 24 hours a day, seven days a week through AHCPR InstantFAX: (301) 594-2800. Or on the Internet at http://text.nlm.nih.gov.]You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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