Participation in Cardiac Rehabilitation Programs Among Older Patients After Acute Myocardial Infarction

A recent clinical practice guideline strongly supports cardiac rehabilitation for patients after acute myocardial infarction (AMI).¹ Cardiac rehabilitation programs are multifaceted outpatient interventions that include individualized exercise regimens, health education, and structured support focused on cardiovascular risk reduction and medication adherence.² Patients typically attend 2 to 3 sessions weekly for up to 36 sessions. Cardiac rehabilitation improves survival after AMI³ and is associated with improvements in lifestyle, functional capacity, and quality of life for older adults.^4,5 Despite these benefits, rates of referral and participation have traditionally been low, especially among older adults.^6,7

Using a national quality improvement registry, we assessed rates of enrollment in cardiac rehabilitation, as well as completeness of participation (number of sessions attended), among older adults and compared characteristics between patients who did and did not participate after referral.

We linked clinical data from the National Cardiovascular Data Registry Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines to Medicare claims for patients 65 years or older presenting with AMIs from January 2007 through December 2010 (n = 74 798). This registry was either approved by an institutional review board, or considered quality assurance data and not subject to institutional review board approval based on individual site determinations. We excluded patients unlikely to be eligible for cardiac rehabilitation, including those who died during the index hospitalization, were transferred to another hospital, discharged to hospice or comfort care, left against medical advice, or were discharged on no post-AMI secondary prevention medications (eg, aspirin, β-blocker, statin, P2Y₁₂ receptor inhibitor, or angiotensin converting enzyme inhibitor and/or angiotensin receptor blocker). Cardiac rehabilitation referral was captured as part of the registry data collection form. Program attendance was identified using Current Procedural Terminology codes (93797 and 93798) and Healthcare Common Procedure Coding System codes (G0422 and G0423) in Medicare claims. Baseline characteristics and treatment variables were compared using χ² tests for categorical variables and Wilcoxon rank sum tests for continuous variables.

From 2007 to 2010, we identified 58 269 older patients eligible for cardiac rehabilitation after AMI and who met our inclusion criteria. Of these, 36 376 (62.4%) were referred to cardiac rehabilitation at the time of hospital discharge. Of those referred, 11 862 (32.6%) attended at least 1 session within the next year. Among those not initially referred, 1795 (8.2%) attended at least 1 session. Among participants, the median number of sessions attended was 26 (interquartile range, 14-35), with 3305 (24.2%) of participants attending at least 36 sessions and 1188 (8.7%) attending fewer than 5 sessions (Figure). In total, 13 657 of 58 269 (23.4%) AMI patients attended 1 or more cardiac rehabilitation sessions; 3175 (5.4%) completed 36 sessions or more.

Compared with those who did not participate, patients who participated in at least 1 session of cardiac rehabilitation were younger and more likely to be male, white, nonsmokers, and to have fewer baseline comorbidities (Table). Presentation with ST-segment elevation myocardial infarction was more common among participants. Participation was more common for patients treated with coronary artery bypass graft (2085/4271 [48.8%]) than those treated with percutaneous coronary interventions (8296/23 040 [36.0%]) or medical management (1469/9000 [16.3%]).

The rate of participation in cardiac rehabilitation is low in the United States, even among patients with AMI who are referred. Our analysis identifies opportunities to improve the use of cardiac rehabilitation by older adults. We found that 37.6% of patients were not referred when they were discharged from the hospital, and approximately two-thirds of the patients who were referred did not attend an initial session. About three-quarters of participants dropped out prior to completing the 36 sessions that are typically covered by health insurance. Quality improvement efforts should focus not only on increasing referral rates but also on addressing barriers to attending rehabilitation sessions, such as travel distance, copayments, and lack of coordination between inpatient and outpatient clinicians. Alternative methods of providing cardiac rehabilitation, such as home-based programs, may be needed to improve participation rates.

Corresponding Author: Jacob A. Doll, MD, 2400 Pratt St, Durham, NC 27705 (jacob.doll@duke.edu).

Published Online: August 3, 2015. doi:10.1001/jamainternmed.2015.3819.

Author Contributions: Dr Doll had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Doll,Wang.

Acquisition, analysis, or interpretation of data: Doll, Hellkamp, Ho, Kontos, Whooley, Peterson, Wang.

Drafting of the manuscript: Doll.

Critical revision of the manuscript for important intellectual content: Doll, Hellkamp, Ho, Kontos, Whooley, Peterson, Wang.

Statistical analysis: Hellkamp, Peterson, Wang.

Obtained funding: Wang.

Study supervision: Doll, Wang.

Additional Contributions: We acknowledge Laine Thomas, PhD (Duke Clinical Research Institute, Durham, North Carolina), for statistical support and Thomas Boyden, MD, MS (Spectrum Health, Grand Rapids, Michigan), for critical revision of the manuscript. Neither individual received financial compensation for their role.

Conflict of Interest Disclosures: Dr Kontos has received consulting honoraria from Astellas, Ikaria, Provencio, AstraZenica, and Wellpoint. Dr Wang has received research grants to the Duke Clinical Research Institute from AstraZeneca, Boston Scientific, Bristol Myers Squibb, Daiichi Sankyo, Eli Lilly, Gilead Science, GlaxoSmith Kline, and Regeneron as well as consulting honoraria from AstraZeneca and Eli Lilly. No other conflicts are reported.

Funding/Support: This project was supported by grant number U19HS021092 from the Agency for Healthcare Research and Quality (AHRQ).

Role of the Funder/Sponsor: The AHRQ had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.