Cardiac Rehabilitation (CRE)

The percentage of persons 18 years and older who attended cardiac rehabilitation following a qualifying cardiac event, including myocardial infarction (MI), percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), heart and heart/lung transplantation or heart valve repair/replacement. Four rates are reported: 

  • Initiation. The percentage of persons who attended 2 or more sessions of cardiac rehabilitation within 30 days after a qualifying event. 
  • Engagement 1. The percentage of persons who attended 12 or more sessions of cardiac rehabilitation within 90 days after a qualifying event. 
  • Engagement 2. The percentage of persons who attended 24 or more sessions of cardiac rehabilitation within 180 days after a qualifying event. 
  • Achievement. The percentage of persons who attended 36 or more sessions of cardiac rehabilitation within 180 days after a qualifying event. 

Why it Matters

Cardiac rehabilitation (CR) is a medical program that aims to help patients regain cardiovascular health and heart function after a cardiac-related event. Most commonly delivered in outpatient settings, CR programs provide exercise training, healthy lifestyle education and stress counseling (1). The comprehensive components of CR promote physical and psychological recovery, reduce cardiovascular risk and mortality and prevent secondary cardiac events (2,3). Additional improvements such as exercise tolerance, medical regimen compliance and smoking cessation have also been associated with participation (4). 

Following a qualifying cardiac event, time to initiation is an important factor of adherence, completion and outcomes. Referral for CR can be provided as early as pre-discharge or at the first follow-up visit (5). Depending on the patient’s condition and previous functional status, physical activity can begin immediately after discharge with daily walking; aerobic training can begin within 1–2 weeks and resistance training can begin within 2–4 weeks (6). All factors considered, the ACC defines CR initiation as one or more CR sessions within 21 days of the qualifying cardiac event (7). 

There is a strong dose-response relationship for CR: Attending more sessions is linked with improved outcomes. A national study of Medicare beneficiaries found that mortality rates at 5 years after discharge for a qualifying cardiac event or condition were 8% lower for patients who attended CR than for patients who did not. When comparing CR attendees, patients who attended 25 or more sessions were 3% less likely to die than patients who attended 24 or fewer sessions (8). An additional study of a sample of Medicare beneficiaries found that patients who attended 36 sessions of CR had a lower risk of death than patients who attended 1, 12 and 24 sessions by 47%–58%, 22%–29% and 14%–18%, respectively (9). The recommended doses of 36 sessions and 25 sessions have shown to be meaningful. Both thresholds are associated with improved survival rates and decreased cardiac risk factors (10). 

The American College of Cardiology and American Heart Association (ACC/AHA) recommend CR for patients who have experienced MI, CABG, PCI, coronary revascularization or coronary artery and other atherosclerotic vascular disease. Participation in CR can decrease recurrent cardiac-related events, reduce mortality by more than 12%, reduce hospitalizations by 20%–30% and improve quality of life (11). 

CR is associated with decreased hospitalizations and health system costs. Compared with usual care, CR cost-effectiveness ratios range from $1,065 to $71,755 per quality-adjusted life year (12). Per person, cardiac rehabilitation saves approximately $4,950–$9,200 per year of life saved (13). 

Despite the Class IA recommendation and stated benefits, CR is historically underused, with participation ranging from 19%–34% nationally, with geographic variances (13). 

Historical Results – National Averages

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References

  1. American Heart Association (AHA). 2020. What Is Cardiac Rehabilitation? https://www.heart.org/-/media/Files/Health-Topics/Answers-by-Heart/What-Is-Cardiac-Rehabilitation.pdf
  2. Ades, P.A., S.J. Keteyian, J.S. Wright, L.F. Hamm, K. Lui, K. Newlin, D.S. Shepard, and R.J. Thomas. 2017. “Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative.” Mayo Clinic Proceedings 92 (2): 234–42. https://www.nejm.org/doi/pdf/10.1056/NEJMoa2026141
  3. Bracewell, N.J., J. Plasschaert, C.R. Conti, E.C. Keeley, and J.B. Conti. September 2, 2022. “Cardiac Rehabilitation: Effective yet Underutilized in Patients with Cardiovascular Disease.” Clinical Cardiology 45, no. 11: 1128–34. https://doi.org/10.1002/clc.23911
  4. O’Gara, P.T., F.G. Kushner, D.E. Casey Jr, J.A. de Lemos, J.C. Fang, B.A. Franklin, H.M. Krumholz, et al. 2013. “2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.” Circulation 127 (4): e362–425. https://doi.org/10.1161/CIR.0b013e31823ba622
  5. Smith, S.C., E.J. Benjamin, R.O. Bonow, L.T. Braun, M.A. Creager, B.A. Franklin, R.J. Gibbons, et al. 2011. “AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update.” Circulation 124 (22): 2458–73. https://doi.org/10.1161/CIR.0b013e318235eb4d
  6. Amsterdam, E.A., N.K. Wenger, R.G. Brindis, D.E. Casey, T.G. Ganiats, D.R. Holmes, A.S. Jaffe, et al. 2014. “2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.” Circulation 130 (25): e344–426. https://doi.org/10.1161/CIR.0000000000000134
  7. Ritchey, M., S. Maresh, S. Keteyian, C. Brawner, A. Beatty, M. Whooley, J. McNeely, et al. 2019. “Cardiac Rehabilitation Use Among Eligible Medicare Fee-for-Service Beneficiaries, 2016-2017.” Journal of the American College of Cardiology 73 (9 Supplement 1): 1688. https://doi.org/10.1016/S0735-1097(19)32294-6
  8. Suaya, J.A., W.B. Stason, P.A. Ades, S.T. Normand, and D.S. Shepard. 2009. “Cardiac Rehabilitation and Survival in Older Coronary Patients.” Journal of the American College of Cardiology 54 (1): 25–33. https://doi.org/10.1016/j.jacc.2009.01.078
  9. Hammill, B.G., L.H. Curtis, K.A. Schulman, and D.J. Whellan. 2010. “Relationship Between Cardiac Rehabilitation and Long-Term Risks of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries.” Circulation 121 (1): 63–70. https://doi.org/10.1161/CIRCULATIONAHA.109.876383
  10. CDC. 2018. Cardiac Rehabilitation Change Package. US Dept of Health and Human Services. https://millionhearts.hhs.gov/tools-protocols/action-guides/cardiac-change-package/index.html
  11. Thomas, R.J., G. Balady, G. Banka, T.M. Beckie, J. Chiu, S. Gokak, P.M. Ho, et al. 2018. “2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.” Circulation 11 (4): 1–29. https://doi.org/10.1161/HCQ.0000000000000037
  12. Shields, G.E., A. Wells, P. Doherty, A. Heagerty, D. Buck, and L.M. Davies. 2018. “Cost-Effectiveness of Cardiac Rehabilitation: A Systematic Review.” Heart 104 (17): 1403–10. https://doi.org/10.1136/heartjnl-2017-312809
  13. Edwards, K., N. Jones, J. Newton, C. Foster, A. Judge, K. Jackson, N.K. Arden, and R. Pinedo-Villanueva. 2017. “The Cost-Effectiveness of Exercise-Based Cardiac Rehabilitation: A Systematic Review of the Characteristics and Methodological Quality of Published Literature.” Health Economics Review 7 (October). https://doi.org/10.1186/s13561-017-0173-3

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