What you should know about cardiac rehabilitation

Podcast Transcript

Announcer: Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart and Vascular Institute at Cleveland Clinic.

In each podcast, we aim to provide relevant and helpful information for health care professionals involved in cardiac, vascular and thoracic specialties. Enjoy.

Dr. Betsy Stovsky: I'm here this morning with Dr. Erik Van Iterson from our Cleveland Clinic Cardiac Rehabilitation program. He's the director and he comes here with a lot of experience in cardiac rehab, and we're going to talk about cardiac rehabilitation.

Welcome.

Dr. Erik Van Iterson: Well, thank you, Betsy, for having me. And, I appreciate this opportunity.

Dr. Stovsky: So, tell me just about cardiac rehabilitation and what the proven benefits are.

Dr. Van Iterson: Well, currently, cardiac rehabilitation is a comprehensive plan for individuals that have unfortunately experienced major events. That includes heart failure, coronary arterial bypass graft surgery, valve surgery, acute cardio infraction, Percutaneous coronary intervention, and that it's important next step in their care plan in terms of providing the best opportunity to reduce risk for a recurring event as well as improving quality of life, functional capacity, healthy lifestyle, behavioral management and overall, improvement in decreased total mortality risk, as well as cardiovascular disease related risk.

Dr. Stovsky: Mm-hmm (affirmative). So, I think it's interesting you mentioned in the past that it's like medicine. And, people probably don't think of it that way. What do you mean when you say that?

Dr. Van Iterson: Complete body of evidence would clearly demonstrate that exercise centric cardiac rehabilitation is indeed a medicine in that it's now recognized as a level one recommendation for individuals who qualify for a medicare center procedures and major events, in that it's supported by robust body of evidence to clearly demonstrate that it has substantial or profound benefits. Both short and long term.

Dr. Stovsky: So, people do tend to think about maybe cardiac rehabilitation with bypass surgery or heart attack. But, you mention that there are a lot of other conditions that patients really would benefit. So, could you take a little bit more about those.

Dr. Van Iterson: Absolutely. For one, individuals with heart failure, where there's not enough blood that pumps out of their heart. They're qualifying in most cases for medicare covered cardiac rehab. But unfortunately, not a lot of individuals are aware that they're covered, and/or probably don't know that it's something that would still benefit them, even at older age.

I think that individuals who may be over the age of 65 also don't realize that they too may benefit from exercise at any point in time in their life, and that particularly, in heart failure, the older failure population is that there's a tremendous need to improve the referral rate as well as the actual utilization and enrollment of those individuals into the program.

Dr. Stovsky: Mm-hmm (affirmative). So, why do you think, with the body of knowledge that there is out there related to the benefits of cardiac rehab, why is there this gap with the utilization?

Dr. Van Iterson: There is a multitude of factors that contribute to the under-utilization of the actual enrollment itself, but also, once enrolled, the 100% adherence to the plan. That really does range across a spectra of your typical barriers, such as transportation, cost of co-payments, proximity to the center. But also, other, I think what we call modifiable barriers. That being improvement on the referral side of the primary care cardiologist or cardio thoracic surgeon, and that prior to the discharge, the referral should be made to the cardiac rehab center in that discussion between the provider to the patient should be very straightforward as to the benefit of cardiac rehab, and really emphasizing the importance of this immediate next step. Preferably, within the next 30 days after discharge.

Dr. Stovsky: Mm-hmm (affirmative). And then, how long would be a traditional cardiac rehab program?

Dr. Van Iterson: Yeah. So, traditionally, the United Stated model is 36 sessions to be carried out three times a week over 12 consecutive weeks. That model has demonstrated again very robust benefits in terms of reducing risk for re-hospitalizations, total mortality, as well as cardiovascular disease related mortality. We know that lesser adherence to the program results in a lesser benefit of cardiac rehabilitation, and that it's very important that once enrolled, that you strive your hardest to complete the program.

Dr. Stovsky: So, for health care providers, what would be some things that you could give them as far as guidelines or pointers of one they should actually prescribe cardiac rehab, and how did they keep in touch with the patient? How do you discuss that with the provider?

Dr. Van Iterson: And important step in terms of what we call the phase two cardiac rehab program is that, again, prior to the individual being discharged from the hospital, is that there should be a one to one conversation with both the patient, as well as the family members or loved ones, and to really emphasize that this is important. And, that referral should be made from the physician, the cardio thoracic surgeon, cardiologist, directly to a cardiac rehab center with an order placed, and therefore, the cardiac rehab center can then reach out to that individual to set up an initial entry visit.

I also think it's important, probably, for the provider to know who indeed is typically going to be covered under our current medicare services guidelines to ensure that they're not missing any individual, and that also, recognizing the potential barriers that may face an individual, may not be barriers at all. But, if you ask, then you don't know.

Dr. Stovsky: So, when we talk about utilization, just to give them an idea, what are the statistics and what are you hoping for as far as utilization?

Dr. Van Iterson: The current utilization rate has been demonstrated to be about 20 to 30% of all eligible patients for cardiac rehab, and unfortunately, that is a very low number that we hope to increase to roughly 70% by the year 2022. The forecast models estimate that if we can improve utilization from 20 to 30% up to 70% in that short period of time, that that can result in a massive improvement in mortality as well as a lesser chance for re-hospitalizations.

Again, it's not too much to ask, actually, to improve that number from 20 to 30% to 70%, because, in many instances, the infrastructure is in place and that it really just becomes a coordinated effort from the time that the individuals in the inpatient setting, and then, that immediate discharge period following the procedure.

Dr. Stovsky: Okay. So, cardiac rehab, just to also kind of talk about the breadth of cardiac rehab; it's not just exercise right? I mean, what else does it involve?

Dr. Van Iterson: We now know that the cardiac rehabilitation program has to be comprehensive. It needs to essentially be a disease management plan. It needs to involve secondary prevention strategies. That includes talking about nutrition. It talks about physical activity, making an emphasis that we need to decrease sedentary time, cessation of tobacco use, alcohol use, behavioral lifestyle management, and the ability to discuss barriers of how to potentially overcome barriers that occur in the real world practice, and so, we know that all those components together provide the patient the optimal chance for success with that, again, the key period following discharge from their major event.

Dr. Stovsky: Are you seeing any new trends in the way that cardiac rehabilitation is delivered?

Dr. Van Iterson: Oh, absolutely.

And so, fortunately, with the contemporary advancements in technology is that we have the ability now to potentially deploy cardiac rehab in a remote setting using our cell phone technology, laptop computers, as well as wearable technology. The real hope is, is that we can provide patients with all the opportunity in the world to engage in cardiac rehab, whether they live five miles from a center or 500 miles from a center. We would like to be able to couple the use of modern technology with the professionals on our end to communicate via any mode and that the deliver of cardiac rehab shouldn't be the barrier to participation.

Dr. Stovsky: That's great. Well, I think you've given us a really great, well-rounded view of cardiac rehab, this morning. And, I hope that, through your efforts, you can increase utilization with our patients.

Dr. Van Iterson: Absolutely. Well, thank you very much, again, for this opportunity. Thank you.

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