Cardiac rehab utilization for HFrEF remains low despite CMS expansion, but use growing
Despite low absolute enrollment, the 2014 expansion of CMS reimbursement for cardiac rehabilitation for patients with HF with reduced ejection fraction approximately doubled the yearly rate of rehabilitation utilization.
According to research presented at the American Heart Association Scientific Sessions, utilization of cardiac rehabilitation among patients with HFrEF remained low among women, those aged 85 years and older, and patients already on dual Medicare/Medicaid.
“Recent trials have shown that a supervised exercise training program like cardiac rehab can lead to modest reductions in all-cause mortality and hospitalization for patients with heart failure. Despite this robust evidence though, cardiac rehab remains minimally utilized, with less than 3% of patients with heart failure enrolled,” Vinay Guduguntla, MD, third-year internal medicine resident at the University of California, San Francisco, said during a presentation.
CMS expanded reimbursement for cardiac rehabilitation in 2014 to include patients with stable chronic HF, a cohort that was defined as patients with HFrEF, with NYHA class II through IV and already on optimal medical therapy. Patients also need to have no recent or planned CV hospitalization or procedures.
Guduguntla and colleagues sought to evaluate whether the expansion in reimbursement led to changes in utilization of cardiac rehabilitation among patients with HFrEF. The researchers compared a pre-policy period (2008 through 2013) with a post-policy period (2014 through 2017).
Among more than 16 million Medicare beneficiaries, more than 500,000 had HFrEF, of whom 30,853 enrolled in cardiac rehabilitation during the study period.
During the pre-policy period, cardiac rehabilitation utilization increased 0.15% per year compared with an increase of 0.31% per year during the post-policy period (difference, 0.16 percentage points; P < .001), according to the presentation.
“This amounts to an additional 50 patients per year that received cardiac rehab,” Guduguntla said. “We ran the analysis on a quarterly level, as well as a yearly level, and saw no change in our results.”
Individuals aged 65 to 74 years, men and those on Medicare only had the greatest levels of cardiac rehabilitation utilization at baseline, and the same subgroups experienced the greatest gain in utilization during the post-policy period.
Individuals aged 85 years and older and women had the least amount of change in cardiac rehabilitation utilization during the post-policy period compared with the pre-policy period, according to the presentation.
When the researchers assessed racial/ethnic subgroups, there was no significant change in utilization, according to the researchers.
“Overall, there’s a low absolute enrollment of patients in cardiac rehab. Even in 2017, 3 years after the ruling, only 5.5% of patients were enrolled,” Guduguntla said. “However, we did see a significant increase in utilization rates after coverage was expanded, amounting to a doubling of increase of rates.”
Guduguntla said it is important to target specific subgroups with low utilization and to also understand why there might be widening disparities over time.
“One large and important task is to increase awareness and referral of cardiac rehab for patients with heart failure,” Guduguntla said. “One possible intervention is to have an inpatient liaison that helps coordinate discharge referral. In addition, it will be relevant to broaden coverage criteria. Currently, patients have to wait at least 6 weeks after hospitalization to be able to be referred for cardiac rehab for heart failure. You can imagine this is a long period of time, and even patients who are post-acute MI can enroll in a shorter timeframe.”
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Guduguntla V, et al. Session QCOR.MDP.02 – QCOR at Sessions: QCOR Abstracts. Presented at: American Heart Association Scientific Sessions; Nov. 13-15, 2021 (virtual meeting).