WomenHeart recommends that all eligible women who have had a heart attack or certain types of heart disease be referred, enrolled, and complete a cardiac rehabilitation program. Successful completion of a cardiac rehabilitation program has been shown to reduce all-cause mortality rates, reduce symptoms, and reduce cardiac readmission rates.1 Despite these positive outcomes, referral and enrollment rates among women are lower than men, and not where they need to be to save lives.1,2 All barriers must be removed so that 100% of eligible women have the opportunity to enroll in a program of cardiac rehabilitation.
Since 1984, more cardiovascular deaths continue to occur annually among women than men; coronary deaths in women exceed deaths in women from all forms of cancer combined.4 For women who have had heart attacks and other heart conditions, enrollment and completion in cardiac rehabilitation programs is both a life-saving and life enhancing opportunity. Cardiac rehabilitation is a comprehensive exercise, education and behavioral modification program for patients with medical conditions such as myocardial infarction, coronary bypass surgery, and heart failure.5 Sessions are usually scheduled three times a week for a three month period. Patients perform physical exercise under supervision with the goal of being able to return to work and perform daily life activities. The program also helps the patient with exercise training, education on nutrition, smoking cessation and counseling to reduce stress levels.5,6 Cardiac rehabilitation programs are individualized to allow patients to perform at their own pace.
Benefits of Cardiac Rehabilitation:
Cardiac rehabilitation has been found to reduce rates of mortality, morbidity, and functional disability.1,7,8 Data suggests that cardiac rehabilitation could protect two thirds of heart attack victims from experiencing a second attack.8 Participation in cardiac rehabilitation reduces all-cause mortality by 25%, lowers blood pressure, and reduces low-density lipoproteins serum levels, which are known to cause atherosclerosis.8,9 In addition, participation in a cardiac rehabilitation program can reduce the likelihood of hospital readmissions and reduce cardiovascular symptoms such angina, dyspnea, and fatigue.10,11,12
A study presented at the Canadian Cardiovascular Congress found that cardiac rehabilitation resulted in a 31% reduction in hospital readmissions – reducing costs associated with hospital admissions from heart attack by $8.5 million a year, for a 7% return on investment.13 The authors projected that if physician costs were included, the benefits would have been 15%-20% greater.13 A recent study conducted in Minnesota found that cardiac rehabilitation participation was associated with a 25% reduction in long-term readmission risk.2 Another study in Vermont found that hospitalization costs over the follow-up period for cardiac admissions were roughly $900 less for patients who completed a cardiac rehabilitation program.14 Based on the above, increased exercise performance and better health outcomes translate into reduced hospitalizations and use of medical resources.10
Statement of the Problem:
Despite the evidence of long-term health benefits, fewer than 20% of all eligible patients ever participate in a cardiac rehabilitation program.15,16 The percentages of heart attack survivors who utilize this program is 13.9% and only 31% of patients recovering from coronary bypass surgery use cardiac rehabilitation programs.6,17 Among Medicare beneficiaries the utilization rate for eligible beneficiaries is 12%.
Although CR is recommended for all patients with CAD and chronic angina, participation rate is low especially in women.18 Of specific concern to WomenHeart are recent studies completed by the American College of Cardiology that have shown disparities in the referral and attendance rates for cardiac rehabilitation among men and women.
For example, only 31% of eligible women are referred for cardiac rehabilitation compared to 42% of men, and once referred, attendance rates for women are 50.1%, compared to 60.4% of men.2,3 Furthermore, women are twice as likely not to complete a rehabilitation program compared to men, often related to depressive symptoms.18 Since currently 23% of women die within one year after their first heart attack, utilizing cardiac rehabilitation programs could ultimately save lives.1
For many women, cardiac rehabilitation is the first time they encounter other women living with heart disease. This can be a big step on their road to recovery and gives them an opportunity for social support. Women can also be connected to organizations such as WomenHeart, which provide an array of educational options and social networks.
WomenHeart strongly supports referral, enrollment, and completion of cardiac rehabilitation by all women and men who qualify. Improvements must be made throughout the process from diagnosis of medical conditions eligible for cardiac rehabilitation to discharge instructions that ensure all eligible patients have the necessary information and access to an affordable cardiac rehabilitation programs. Automatic hospital referrals after discharge and individualized, gender-specific sessions have been effective in increasing the rates of enrollment for women, which we endorse.19, 20 To ensure that cardiac rehabilitation programs for eligible women are as accessible as possible, we offer the following recommendations:
- Pass S. 488 and HR 3355 to allow physician assistants, nurse practitioners, and clinical nurse specialists to supervise patients in cardiac and pulmonary rehabilitation programs.
- Work with Medicare Advantage programs and private payers to remove cost and access barriers and make coverage for cardiac rehabilitation available and affordable.
- Educate physicians and other health care providers about the value of cardiac rehabilitation in improving patient outcomes, reducing hospital readmission rates, and lowering health care costs to increase referrals and ensure enrollment.
- Create incentives within new models of care to increase completion rates for cardiac rehabilitation and develop mechanisms for primary care providers and cardiologists to confirm enrollment.
- Add cardiac syndrome X and microvascular angina to the list of conditions for which cardiac rehabilitation is covered by Medicare.21
- Support alternatives to traditional cardiac rehabilitation programs that address logistical barriers associated with non-participation.
- Include meaningful coverage for cardiac rehabilitation in state essential health benefit packages.
- Increase awareness among women of the value of cardiac rehabilitation programs and the need to seek appropriate referrals on their own, if necessary.
- Encourage the development of gender sensitive programs to address the specific needs of women living with heart disease, including flexible days and hours of operation.
- Reduce the cost of copays and other out of pocket expenses so that participation in cardiac rehabilitation is affordable.
1Department of Health and Human Services, Agency for Health Care Policy and Research (AHCPR). Cardiac Rehabilitation, Clinical Guidelines. Rockville, MD: AHCPR, 1995.
2Dunlay, SM et al. Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction. The American Journal of medicine.2014. 127.6: 538-546.
3Mozaffarian, D., et al. Heart disease and stroke statistics-2015 update: a report from the American Heart Association. Circulation. 2015. 131(4): e29-e322.
4Wenger, NK Women and Coronary Heart Disease: A Century After Herrick. American Heart Association. Circulation2012; 126: 604-611.
5Balady GJ, Williams Ma, Ades PA, Bittner V, Comoss P, Foody JM, Franklin B, Sanderson B, Southard D. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councilson Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007; 115: 2675-2682.
6Balady GJ, Fletcher BJ, Froelicher ES, Hartley LH, Krauss RM, Oberman A, Pollock MK,Taylor CB. Cardiac rehabilitation programs: A statement for health care professionals from the American Heart Association. Circulation 1994; 90:1602.
7Goel K, Lennon RJ, Tilbury RT, Squires RW, Thomas RJ. Impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary intervention in the community. Circulation. 2011; 123: 2344-2352.
8Smith Jr SC, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerosis vascular disease: 2011 update a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011; 124: 2458-73.
9L. Anderson, C.D. Adams, E.M. Antman et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol, 50 (2007), pp. e1–e157.
10Suaya, JA., et al. Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol.2009. 54(1): 25-33.
11Benz S, et al. Effect of Patient Navigation on Enrollment in Cardiac Rehabilitation. JAMA Intern Med. 2013; 173 (3):244-246. doi:10.1001/2013.jamainternmed.1042.
12Plüss, Cet al. Long-term effects of an expanded cardiac rehabilitation programme after myocardial infarction or coronary artery bypass surgery: a five-year follow-up of a randomized controlled study. Clinical rehabilitation.2011.25.1: 79-87.
13Humen D, et al. A Cost Analysis of Event Reduction Provided by a Comprehensive Cardiac Rehabilitation Program. Canadian Journal of Cardiology. 2014; 29.10: S156.
14Ades PA, et al.Cardiac rehabilitation participation predicts lower rehospitalization costs. American heart journal. 1992; 123.4: 916-921.
15Hammill, BG.Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries.Circulation.2009. 121(1): 63-70.
16Suaya, JA., et al. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation.2007.116.15: 1653-1662.
17Jolliffe JA, et al., Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2001; (1):CD001800.
18 Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013 Oct;34 (38):2949–3003.
19Beckie TM, Beckstead JW, Schocken DD, et al. The effects of a tailored cardiac rehabilitation program on depressive symptoms in women: A randomized clinical trial. Int J Nurs Stud48:3-12. This study is the first RCT to examine the effects of a gender specific cardiac rehabilitation program for women on depressive symptoms.
20Beckie TM, Mendonca MA, Fletcher GF, et al. Examining the challenges of recruiting women into a cardiac rehabilitation clinical trial J Cardiopulmonary Rehabilitation Prev. 2009;29:13-21.
21 Laksanakorn W, Laprattanagul T, Wei J, Shufelt C, Minissian M, Mehta PK, Merz CNB. Cardiac rehabilitation for cardiac syndrome X and microvascular angina: A case report. Int J Case Rep Images 2015;6 (4):239–244.