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Cardiac rehabilitation referrals for HF slowly increasing
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Relatively few patients hospitalized for HF received referrals for cardiac rehabilitation on discharge during a 10-year period, but the number of referrals slowly increased during that time, according to a recent analysis.
Gregg C. Fonarow, MD, Eliot Corday Chair in cardiovascular medicine and science at David Geffen School of Medicine at UCLA, and colleagues evaluated data on 105,619 patients with HF collected from the observational, prospective American Heart Association Get With the Guidelines – Heart Failure registry.
Gregg C. Fonarow
Incidence of referrals for cardiac rehabilitation over time were evaluated among patients with HF with reduced ejection fraction (HFrEF; 48% of patients) and those with preserved ejection fraction (HFpEF; 52% of patients) between 2005 and 2014. All patients were eligible for cardiac rehabilitation.
Referral occurred in 12.2% of patients with HFrEF and 8.8% of patients with HFpEF. The frequency of referrals increased over time, both overall (9.6% to 13.3%) and in the HFrEF (9.6% to 15.5%) and HFpEF (9.6% to 11.6%) populations separately (P < .0001 for all). Fonarow and colleagues noted that the frequency of referrals also varied by region, with a 49% referral rate at participating facilities located in the southern United States compared with a 14% rate among Midwestern centers.
Multivariable analysis indicated that advanced age significantly reduced the likelihood of referral for cardiac rehabilitation (adjusted OR = 0.97; 95% CI, 0.95-0.98 per 5-year increase) as did the presence of comorbidities, including hypertension (OR = 0.92; 95% CI, 0.87-0.98), anemia (OR = 0.92; 95% CI, 0.86-0.97), cerebrovascular accident/transient ischemic attack (OR = 0.94; 95% CI, 0.9-0.99) and chronic obstructive pulmonary disease (OR = 0.94; 95% CI, 0.89-0.99). Elevated systolic BP (OR = 0.99; 95% CI, 0.99-1 per 5 mm Hg increase) and ejection fraction (OR = 0.98; 95% CI, 0.97-0.99 per 5% increase) also were associated with lower likelihood of referral.
Factors significantly associated with increased likelihood of referral included smoking (adjusted OR = 1.1; 95% CI, 1.04-1.16) and undergoing in-hospital procedures such as CABG (OR = 3.24; 95% CI, 2.4-4.37), cardiac valve surgery (OR = 1.76; 95% CI, 1.31-2.38) and PCI, both with a stent (OR = 2.36; 95% CI, 1.91-2.9) and without (OR = 1.88; 95% CI, 1.46-2.42).
“Although we expected some under-referral to cardiac rehabilitation in the HF population, the results of this study are startling,” Fonarow said in a press release. “Our findings point to the need for better strategies to increase physicians’ and patients’ awareness about the importance of cardiac rehabilitation.”
However, in a related editorial, Philip A. Ades, MD, cardiac rehabilitation and preventive cardiology, University of Vermont College of Medicine, wrote that cardiac rehabilitation referrals were not likely to be given during the evaluated period.
“From 2005 to 2014, [cardiac rehabilitation] for [chronic] HF would have been by self-pay, and few physicians or hospitals would have established a systematic referral policy for a treatment that was self-pay and therefore unlikely to be pursued,” Ades wrote. “A major value of the data … is as a baseline and springboard to setting up [cardiac rehabilitation] referral and uptake processes that optimize [cardiac rehabilitation] participation processes for inpatients or outpatients with HFrEF now that insurance coverage is broadly available.” – by Adam Taliercio
Disclosure: Fonarow reports receiving research funding from the NIH and the Agency for Healthcare Research and Quality, as well as consulting fees from Amgen, Baxter, Bayer, Janssen, Medtronic and Novartis. Please see the full study for a list of all other authors’ relevant financial disclosures.
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