Relatively low utilization seen in population for whom it is covered
Patients fresh out of cardiac valve surgery are no exception to the general underutilization of cardiac rehabilitation in the U.S., according to an observational cohort study.
Enrolling in a comprehensive program of supervised exercise, cardiac risk factor modification, and psychosocial support was associated with reduced risks of re-hospitalization (adjusted HR 0.66, 95% CI 0.63-0.69) and mortality (adjusted HR 0.39, 95% CI 0.35-0.44) within 1 year of discharge after valve surgery.
Yet only 43.2% of the 41,369 fee-for-service Medicare beneficiaries who had such a procedure in 2014 enrolled in cardiac rehabilitation (CR), attending a median of 32 sessions, Justin Bachmann, MD, MPH, of Vanderbilt University Medical Center in Nashville, Tennessee, and colleagues reported in JAMA Cardiology.
"Although CR enrollment after CVS [cardiac valve surgery] is still low, this analysis demonstrates that this population has some of the highest CR enrollment rates seen to date, with the exception of patients who had had heart transplants," the group said.
Approximately half of patients attend cardiac rehab after heart transplant, while enrollment rates are in the 35-40% range after coronary artery bypass grafting (CABG), Bachmann's team noted.
In their study, particularly poor odds of entering such a program after valve surgery despite coverage by Medicare, were seen in minorities:
- White patients: 45.0% enrollment
- Black patients 23.7% (OR 0.60, 95% CI 0.54-0.67)
- Asian patients: 19.9% (OR 0.36, 95% CI 0.28-0.47)
- Hispanic patients: 17.9% (OR 0.36, 95% CI 0.28-0.46)
"This work demonstrates that racial/ethnic disparities in CR enrollment among Medicare patients undergoing CVS are at least as large as in ischemic heart disease," Bachmann and colleagues noted.
On the other hand, people in the Midwest region were more than twice as likely as others to enroll, presenting an "opportunity," they said. "By studying best practices in high-performing centers, perhaps CR enrollment can be optimized at other institutions."
Higher cardiac rehab utilization was also observed of men (45.5% vs 39.9% for women; OR 1.17, 95% CI 1.12-1.23) and people who got concomitant CABG (45.7% vs 44.7% for any aortic surgery; OR 1.26, 95% CI 1.20-1.31).
The patients included in the study most commonly received an aortic valve procedure (68.3%), followed by mitral valve replacement, mitral valve repair, and tricuspid valve surgery.
Median age was 73 years. Women comprised 40.9% of the cohort.
The findings from the current study were "remarkable and novel for several reasons," wrote Randal Thomas, MD, and LaPrincess Brewer, MD, MPH, both of the Mayo Clinic in Rochester, Minnesota, in an invited commentary.
"To our knowledge, this study is the first national, large-scale study to assess aspects of posthospital care (e.g., CR) on patient outcomes after heart valve surgery," they said.
And in contrast to early single-center studies of cardiac rehabilitation after heart valve surgery, here there was no difference in outcomes for patients undergoing aortic versus mitral or tricuspid valve surgery, according to Thomas and Brewer.
"Although it is not possible to account for all potential confounding factors, sensitivity analyses adjusting for observed confounding and unobserved confounding demonstrated similar results," the authors noted.
The observational study may nevertheless have limited generalizability to younger patients, Bachmann's team acknowledged.
Another limitation was the lack of details from the Medicare dataset regarding cardiac rehab referral and interventions, according to Thomas and Brewer.
"Nonetheless, the study adds vital and solid evidence to increase understanding of the significant and meaningful benefits associated with CR for patients recovering from heart valve surgery," the editorialists said.
"As CR delivery methods, quality improvement practices, and coverage policies continue to evolve, health care practitioners and policy makers must implement more effective and innovative strategies to improve delivery of CR services to all eligible patients, including those patients undergoing heart valve surgery," they concluded.
The study was funded by grants from the NIH and the Agency for Healthcare Research and Quality.
Bachmann, Thomas, and Brewer listed no disclosures.
One study co-author reported ties to Roche Diagnostics, Edwards Lifesciences, and Medtronic.
Source Reference: Patel DK, et al "Association of cardiac rehabilitation with decreased hospitalization and mortality risk after cardiac valve surgery" JAMA Cardiol 2019; DOI: 10.1001/jamacardio.2019.4032.
Source Reference: Thomas RJ, Brewer LC "Strengthening the evidence for cardiac rehabilitation benefits" JAMA Cardiol 2019; DOI: 10.1001/jamacardio.2019.4077.
Read the original article on Medpage Today: After Cardiac Valve Surgery, Too Few Go to Rehab