Cardiac rehab participation after TAVR remains poor; researchers seek answers
Key takeaways:
- Despite recommendations, cardiac rehabilitation after transcatheter aortic valve replacement is highly underused.
- There is substantial hospital variation in rates of cardiac rehab use after TAVR.
Fewer than one in three adults who underwent transcatheter aortic valve replacement in Michigan participated in cardiac rehab within 90 days of discharge, but hospital-level variations were not explained by patient case mix, data show.
“TAVR represents an enlarging cohort of patients where little is understood about their utilization of cardiac rehab, even though it is recommended and covered by insurers and Medicare,” Devraj Sukul, MD, MSc, an interventional cardiologist and health services researcher at University of Michigan Health and a co-director of the Michigan Cardiac Rehab Collaborative, told Healio. “We know more about the dramatic underuse of cardiac rehab across cardiac care and procedures, but there has been a relative paucity of understanding its use after TAVR. Frankly, there is not a lot of robust data around the clear observed benefits of cardiac rebab after TAVR, but it is obvious that patients benefit from the educational and exercise components of cardiac rehab.”
The findings were published in JACC: Advances.
Claims data analysis
Sukul and colleagues linked clinical and administrative claims data from 3,372 patients who underwent TAVR at 24 Michigan hospitals from 2016 to June 2020, using data from the Michigan Structural Heart Consortium clinical TAVR registry and the Michigan Value Collaborative, a validated claims-based registry with 90-day episodes of care from Medicare fee-for-service and commercial and Medicare Advantage claims from Blue Cross Blue Shield of Michigan. The researchers also obtained rates of cardiac rehab enrollment within 90 days of discharge and evaluated hospital variation in cardiac rehab participation at 90 days after TAVR.
Researchers found that 30.6% of patients participated in at least one cardiac rehab session within 90 days after discharge, increasing from 27% in 2016 to 33% in 2019 before dropping to 20% through the first two quarters of 2020, coinciding with the onset of the COVID-19 pandemic.
Sukul said several patient factors were negatively associated with cardiac rehab participation after TAVR including older age, Medicaid insurance, atrial fibrillation/flutter, dialysis use and slower baseline 5-minute walk times. However, the Distressed Communities Index scores, a measure of ZIP code-level socioeconomic distress, were not associated with downstream cardiac rehab use, nor were post-procedure, in-hospital complications such as stroke, pacemaker implantation and vascular complications.
There was also substantial hospital variation in cardiac rehab participation after TAVR, ranging from 5% to 60% across 24 hospitals. Patient case mix did not explain this variation, with median ORs increasing from 2.11 (95% CI, 1.62-2.67) to 2.13 (95% CI, 1.61-2.68) after accounting for patient-level factors.
“Interestingly, the rates of cardiac rehab after TAVR are similar to the rates of cardiac rehab usage after PCI and not after CABG,” Sukul said during an interview. “It makes me wonder about several things. Several patient factors are related [to usage], but not dramatically so. Generally speaking, the frailer the patient, the less likely they are to attend cardiac rehab. But after we adjusted for multiple clinical and socioeconomic factors, there was no difference at a site level in terms of variation. It signaled to me that this is more related to system processes that are in place. That is a challenge across the board in delivering cardiac rehab care appropriately.”
Referrals are not enough
Sukul said referrals to cardiac rehab programs are critical but “not enough,” adding TAVR registries that are now collecting cardiac rehab referral data may help increase attendance. Research is also needed about the factors that impede cardiac rehab attendance and novel ways to align cardiac rehab sites with hospitals to ensure patients receive care.
“Cardiac rehab is one of the few therapies that has no real side effects and dramatic benefits,” Sukul said. “Yet, as an interventional cardiologist, I hammer home that you have to take your aspirin and [clopidogrel] after a PCI. More recently, I have hammered home how important cardiac rehab is, but I’m not so sure that is the message patients are taking away after these procedures.”
For more information:
Devraj Sukul, MD, MSc, can be reached at dsukul@umich.edu.
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