Participation in cardiac rehabilitation after AVR varies greatly across hospitals
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Participation in cardiac rehabilitation following surgical or transcatheter aortic valve replacement varies greatly from hospital to hospital, although researchers observed a correlation between participation and treatment strategy.
In a presentation at the American Heart Association Quality of Care and Outcomes Research Scientific Sessions, researchers showed that participation in cardiac rehabilitation following surgical AVR and TAVR may be affected by hospital-specific practice patterns. However, participation also varied by patient age, sex and insurance status.
The findings were simultaneously published in Circulation: Cardiovascular Quality and Outcomes.
“Increasing CR utilization after valve replacement requires a better understanding of the underlying determinants of participation. Prior studies have focused on national-level CR participation for aortic valve replacement (AVR) patients or on hospital-level CR variation for other conditions, such as coronary artery disease,” Vinay Guduguntla, MD, internal medicine resident at the University of California, San Francisco, and colleagues wrote in the simultaneous publication. “However, little is known about the extent to which differences in CR participation for AVR patients is a product of patient, treatment or hospital-specific factors, as clinical registries do not often capture all of this information.”
Researchers utilized a statewide, multi-payer administrative claims registry in Michigan to identify 10,124 surgical AVR and TAVR episodes of care from 32 hospitals and to assess factors associated with variations in cardiac rehabilitation participation.
Enrollment in cardiac rehabilitation was defined a single professional or facility claim within 90 days of discharge for TAVR or surgical AVR.
A total of 39.8% of episodes of care had any participation in cardiac rehabilitation within 90 days of discharge, with participation of 50.9% among those who underwent surgical AVR and 28.9% in those who underwent TAVR (P < .001).
Over a 6-year period, cardiac rehabilitation increased from 47.4% to 54.1% after surgical AVR and from 18.9% to 33.2% after TAVR (P for all < .001).
Predictors of participation
Researchers reported that patients with commercial insurance had greater participation in cardiac rehabilitation compared with beneficiaries of Medicare Advantage and Medicare fee-for-service for both surgical AVR and TAVR procedures (P for all < .01).
In addition, participation was lower among women compared with men after surgical AVR (adjusted OR = 0.78; 95% CI, 0.69-0.88; P < .001) but did not differ by sex following TAVR (aOR = 0.88; 95% CI, .78-1.01; P = .068).
Participation in cardiac rehabilitation following surgical AVR increased as patients’ age increased (aOR = 1.01; 95% CI, 1-1.02; P = .015) while, in contrast, participation post-TAVR increased as patients age decreased (aOR = 0.98; 95% CI, 0.97-0.99; P < .01).
Researchers reported that patients with comorbidities were less likely to enroll in cardiac rehabilitation, regardless of the procedure.
Hospital variation
After researchers adjusted for patient factors, rates of participation in cardiac rehabilitation varied by hospital from 4.8% to 68.7% for all AVR episodes of care; from 8.7% to 78.6% after surgical AVR; and from 3.8% to 58.6% after TAVR.
Moreover, researchers observed a moderate correlation in rehabilitation participation by treatment strategy (Pearson r = .56; P < .01).
“There are no large, randomized clinical trials (RCTs) that demonstrate reductions in morbidity or mortality for CR in AVR patients,” the researchers wrote. “For this reason, meta-analyses have been uncertain about the impact of CR in patients receiving valve surgery. Instead, current literature is comprised of small RCTs and observational studies that are limited by lack of patient participation, diversity and data on important primary outcomes, such as morbidity and mortality.
“Results from this study should represent a call to action for more robust evidence on the utility of CR post-AVR, focusing specifically on TAVR,” the researchers wrote. “These patients are often the most multimorbid and medically complex, will have different needs than patients with CAD or CHF, and would benefit most from a tailored CR approach. It is important to note, however, that there is considerable evidence for CR in other cardiac conditions, such as CAD, but rates remain suboptimal.”
Reference:
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Guduguntla V, et al. Early Career Investigator Award Finalists. Presented at: American Heart Association Quality of Care and Outcomes Research Scientific Sessions; May 13-14, 2022; Reston, Va. (hybrid meeting).
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