Referral for cardiac rehabilitation low, utilization even lower among patients with HFrEF
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Key takeaways:
- One-quarter of clinically stable Medicare beneficiaries with HFrEF were referred for cardiac rehab after hospitalization.
- Less than 5% of patients would utilize the service.
Approximately one-quarter of patients with HF with reduced ejection fraction who are stable at 6 weeks after discharge are referred to an exercise program for cardiac rehabilitation, while less than 5% used it, researchers reported.
The analysis of participating centers in the American Heart Association Get with the Guidelines – Heart Failure (GWTG–HF) registry was published in Circulation: Heart Failure.
“The seminal HF-ACTION trial ... showed that among clinically stable outpatients with HFrEF, a supervised exercise program was significantly associated with improvements in quality of life, a modest but statistically significant improvement in peak exercise capacity, and a lower risk of all-cause death or hospitalization after prespecified adjustment,” Neil Keshvani, MD, chief resident in internal medicine at UT Southwestern Medical Center, and colleagues wrote. “Based on this evidence, [cardiac rehabilitation] is recommended for patients with Stage C HF in the 2022 American Heart Association (AHA)/American College of Cardiology (ACC)/ Heart Failure Society of America HF guidelines. Furthermore, CMS expanded coverage for [cardiac rehabilitation] in 2014 among patients with chronic, stable HFrEF who remain out of the hospital for 6 weeks.”
Keshvani and colleagues wrote that despite present evidence and guideline recommendations, rates of referral and utilization of cardiac rehabilitation remained low both before and early after expanded CMS coverage.
To better understand patterns of nonreferral and utilization, the researchers evaluated data from centers participating in the GWTG–HF registry recorded between January 2010 and July 2020.
Points of interest included patient and hospital-level predictors of cardiac rehabilitation referral; referral and proportional cardiac rehabilitation utilization within 1 year; and association between referral and the risk for 1-year death and rehospitalization.
Among 69,441 patients with HFrEF eligible for cardiac rehabilitation (median age, 67 years; 33% women; 30% Black), one-quarter were referred (24.6%).
Rates of cardiac rehabilitation referral increased from 8.1% in 2010 to 24.1% in 2020 (P for trend < .001), according to the study.
Among 8,310 Medicare beneficiaries who were clinically stable at 6 weeks after discharge, 25.8% were referred for cardiac rehabilitation; however, just 4.1% of those referred utilized cardiac rehabilitation, attending on average 6.7 sessions.
Patients not referred were more likely:
- to be older (OR per 10 year increase = 0.93; 95% CI, 0.91-0.95; P < .001);
- to be Black (HR = 0.9; 95% CI, 0.83-0.97; P = .032); and
- to have a higher comorbidity burden.
After adjustment, Keshvani and colleagues observed that patients with HFrEF eligible for referral for cardiac rehabilitation who were referred had lower risk for 1-year death compared with those not referred (HR = 0.84; 95% CI, 0.7-1; P = .049). The researchers reported no significant differences in 1-year rehospitalization.
“The present study highlights a substantial implementation gap in the referral and utilization of cardiac rehabilitation among patients with heart failure with reduced ejection fraction,” the researchers wrote. “Provider- and system-level interventions to improve patient referral and participation are needed to improve the quality of life and clinical outcomes.”
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