David W. Schopfer

Predictive Value of Reactive Hyperemia for Cardiovascular Events in Patients With Peripheral Arterial Disease Undergoing Vascular Surgery

Objective— Reactive hyperemia is the compensatory increase in blood flow that occurs after a period of tissue ischemia, and this response is blunted in patients with cardiovascular risk factors. The predictive value of reactive hyperemia for cardiovascular events in patients with atherosclerosis and the relative importance of reactive hyperemia compared with other measures of vascular function have not been previously studied. Methods and Results— We prospectively measured reactive hyperemia and brachial artery flow-mediated dilation by ultrasound in 267 patients with peripheral arterial disease referred for vascular surgery (age 66±11 years, 26% female). Median follow-up was 309 days (range 1 to 730 days). Fifty patients (19%) had an event, including cardiac death (15), myocardial infarction (18), unstable angina (8), congestive heart failure (6), and nonhemorrhagic stroke (3). Patients with an event were older and had lower hyperemic flow velocity (75±39 versus 95±50 cm/s, P=0.009). Patients with an event also had lower flow-mediated dilation (4.5±3.0 versus 6.9±4.6%, P<0.001), and when these 2 measures of vascular function were included in the same Cox proportional hazards model, lower hyperemic flow (OR 2.7, 95% CI 1.2 to 5.9, P=0.018) and lower flow-mediated dilation (OR 4.2, 95% CI: 1.8 to 9.8, P=0.001) both predicted cardiovascular events while adjusting for other risk factors. Conclusions— Thus, lower reactive hyperemia is associated with increased cardiovascular risk in patients with peripheral arterial disease. Furthermore, flow-mediated dilation and reactive hyperemia incrementally relate to cardiovascular risk, although impaired flow-mediated dilation was the stronger predictor in this population. These findings further support the clinical relevance of vascular function measured in the microvasculature and conduit arteries in the upper extremity.

Cardiac Rehabilitation in Older Adults

The biology of aging and the pathophysiology of cardiovascular disease (CVD) overlap, with the effect that CVD is endemic in the growing population of older adults. Moreover, CVD in older adults is usually complicated by age-related complexities, including multimorbidity, polypharmacy, frailty, and other intricacies that add to the risks of ambiguous symptoms, deconditioning, iatrogenesis, falls, disability, and other challenges. Cardiac rehabilitation (CR) is a comprehensive lifestyle program that can have particular benefit for older patients with cardiovascular conditions. Although CR was originally designed primarily as an exercise training program for younger adults after a myocardial infarction or coronary artery bypass surgery, it has evolved as a comprehensive lifestyle program (promoting physical activity as well as education, diet, risk reduction, and adherence) for a broader range of CVD (coronary heart disease, heart failure, and valvular heart disease). It provides a valuable opportunity to address and moderate many of the challenges pertinent for the large and growing population of older adults with CVD. Cardiac rehabilitation promotes physical function (cardiorespiratory fitness as well as strength and balance) that helps overcome disease and deconditioning as well as related vulnerabilities such as disability, frailty, and falls. Similarly, CR facilitates education, monitoring, and guidance to reduce iatrogenesis and promote adherence. Furthermore, CR fosters cognition, socialization, and independence in older patients. Yet despite all its conceptual benefits, CR is significantly underused in older populations. This review discusses benefits and the paradoxical underuse of CR, as well as evolving models of care that may achieve greater application and efficacy.

Hospital compliance with performance measures and 30-day outcomes in patients with heart failure

BACKGROUND In 2005, the American College of Cardiology/American Heart Association published performance measures to provide a standard of care for hospitalized patients with heart failure (HF). Despite increasing compliance with these measures, hospital mortality and readmission rates remain stagnant. Whether compliance with HF performance measures improves patient outcomes at the hospital level is unclear. METHODS We evaluated compliance with HF performance measures at 3,655 US hospitals. Patients admitted with a diagnosis of HF in 2008 were identified using the US Department of Health and Human Services Hospital Compare database. Compliance with 4 specific performance measures was examined: evaluation of left ventricular systolic function, administration of angiotensin-converting enzyme inhibitor I or angiotensin-receptor blocker for left ventricular systolic dysfunction, offering smoking cessation advice and counseling, and providing discharge instructions. Thirty-day mortality and readmission rate were recorded. RESULTS Hospitals reporting greater compliance with the 4 performance measures had significantly lower 30-day mortality rates. However, these hospitals were also located in areas of higher socioeconomic status and treated higher volumes of patients with HF. After adjusting for socioeconomic and hospital factors, only evaluation of left ventricular systolic function was associated with lower 30-day mortality, and evaluation of left ventricular systolic function and smoking cessation counseling were associated with lower readmission rates. CONCLUSIONS We found that socioeconomic factors and hospital volume were stronger predictors of mortality than compliance with HF performance measures. After adjusting for socioeconomic factors and hospital volume, only 1 of the 4 performance measures was associated with lower 30-day mortality and 2 were associated with lower readmissions.

Transitional Care Challenges of Rehospitalized Veterans: Listening to Patients and Providers

Readmissions to the hospital are common and costly, often resulting from poor care coordination. Despite increased attention given to improving the quality and safety of care transitions, little is known about patient and provider perspectives of the transitional care needs of rehospitalized Veterans. As part of a larger quality improvement initiative to reduce hospital readmissions, the authors conducted semi-structured interviews with 25 patients and 14 of their interdisciplinary health care providers to better understand their perspectives of the transitional care needs and challenges faced by rehospitalized Veterans. Patients identified 3 common themes that led to rehospitalization: (1) knowledge gaps and deferred power; (2) difficulties navigating the health care system; and (3) complex psychiatric and social needs. Providers identified different themes that led to rehospitalization: (1) substance abuse and mental illness; (2) lack of social or financial support and homelessness; (3) premature discharge and poor communication; and (4) nonadherence with follow-up. Results underscore that rehospitalized Veterans have a complex overlapping profile of real and perceived physical, mental, and social needs. A paradigm of disempowerment and deferred responsibility appears to exist between patients and providers that contributes to ineffective care transitions, resulting in readmissions. These results highlight the cultural constraints on systems of care and suggest that process improvements should focus on increasing the sense of partnership between patients and providers, while simultaneously creating a culture of empowerment, ownership, and engagement, to achieve success in reducing hospital readmissions.

Cardiac Rehabilitation Use Among Veterans With Ischemic Heart Disease

Cardiac Rehabilitation Use Among Veterans With Ischemic Heart Disease Referral to exercise-based cardiac rehabilitation (CR) is 1 of 9 performance measures for secondary prevention after hospitalization for myocardial infarction (MI), p e r c u t a n e o u s c o r o n a r y intervention (PCI), and/or coronary artery bypass graft (CABG).1,2 Although CR programs significantly reduce morbidity and mortality in patients with ischemic heart disease (IHD),3 they are vastly underused among US Medicare beneficiaries.4 The use of CR programs in the Veterans Health Administration (VA) has not been described. Therefore, we sought to determine (1) the proportion of eligible veterans with IHD who participate in CR, (2) whether the presence of an on-site CR program is associated with greater participation, and (3) the characteristics of the CR participants.

Participation in Cardiac Rehabilitation Among Patients With Heart Failure

BACKGROUND Cardiac rehabilitation (CR) is linked to reduced mortality and morbidity, including improvements in cardiorespiratory fitness, psychosocial state, and quality of life in patients with heart failure (HF). However, little is known about CR utilization among patients with HF. OBJECTIVE We sought to determine (a) the proportion of patients with HF who participated in CR and (b) patient characteristics associated with participation. METHODS A retrospective study was conducted with the use of national data from the Centers for Medicare and Medicaid Services and the Veterans Health Administration. We used primary discharge ICD-9 codes to identify patients hospitalized for HF during 2007-2011 and identified CR participation with the use of current procedure terminology codes from claims data. Multivariate logistic regression was used to identify patient characteristics associated with CR participation. RESULTS There were 66,710 veterans and 243,208 Medicare beneficiaries hospitalized for HF and 1554 (2.3%) and 6280 (2.6%), respectively, who attended ≥1 sessions of outpatient CR. Among Medicare beneficiaries, men were more likely than women to participate in CR (3.7% vs 1.8%; P < .001), but there was no gender difference among veterans (2.3% vs 2.8%; P = .40). Characteristics associated with participation in CR in both groups included younger age, white race, and history of ischemic heart disease. CONCLUSIONS Very few HF patients participated in CR, with lower rates among older non-white women with a history of depression or other chronic medical conditions. Because Medicare has recently introduced coverage for CR in patients with systolic HF, we must increase efforts to improve CR participation, especially among these vulnerable groups.

Factors Associated With Utilization of Cardiac Rehabilitation Among Patients With Ischemic Heart Disease in the Veterans Health Administration: A QUALITATIVE STUDY.

BACKGROUND: Cardiac rehabilitation (CR) programs reduce morbidity and mortality in patients with ischemic heart disease but are vastly underutilized in the United States, including the Veterans Health Administration (VA) Healthcare System. Numerous barriers affecting utilization have been identified in other health care systems, but the specific factors affecting Veterans are unknown. We sought to identify barriers and facilitators associated with utilization of CR in VA facilities. METHODS: We performed a qualitative study of 56 VA patients, providers, and CR program managers at 30 VA facilities across the United States. We conducted semistructured interviews with key informants to explore their attitudes and knowledge toward CR. Interviews were conducted until thematic saturation occurred. Analyses using grounded theory to identify key themes were conducted using the qualitative data analysis package ATLAS.ti. RESULTS: We identified 6 themes as barriers and 5 as facilitators. The most common barriers to participation in CR were patient transportation issues (68%), lack of patient willingness to participate (41%), and no access to a nearby VA hospital with a CR program (30%). The most common facilitators were involvement of a dedicated provider or “clinical champion” (50%), provider knowledge of or experience with CR (48%), and patient desire for additional medical support (32%). CONCLUSIONS: Our findings suggest that addressing access issues and educating and activating providers on CR may increase utilization of CR programs. Targeting these specific factors may improve utilization of CR programs.

Growing Relevance of Cardiac Rehabilitation for an Older Population With Heart Failure

Cardiac rehabilitation (CR) is a comprehensive lifestyle program that can have particular benefit for older patients with heart failure (HF). Prevalence of HF is increasingly common among older adults. Mounting effects of cardiovascular risk factors in older age as well as the added effects of geriatric syndromes such as multimorbidity, frailty, and sedentariness contribute to the high incidence of HF as well as to management difficulty. CR can play a decisive role in improving function, quality of life, symptoms, morbidity, and mortality, and also address the idiosyncratic complexities of care that often arise in old age. Unfortunately, the current policies and practices regarding CR for patients with HF are limited to HF with reduced ejection fraction and do not extend to HF with preserved ejection fraction, which is likely undercutting its full potential to improve care for todays aging population. Despite the strong rationale for CR on important clinical outcomes, it remains underused, particularly among older patients with HF. In this review, we discuss both the potential and the limitations of contemporary CR for older adults with HF.

Association of Veterans Health Administration Home-Based Programs With Access to and Participation in Cardiac Rehabilitation

Author Contributions: Dr Petrillo 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: Petrillo, Lee. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Petrillo. Critical revision of the manuscript for important intellectual content: Gan, Jing, Lang-Brown, Boscardin, Lee. Statistical analysis: Petrillo, Gan, Jing, Boscardin, Lee. Obtained funding: Lee. Administrative, technical, or material support: Lang-Brown, Lee. Study supervision: Lee.

Geographic Variation in Cardiac Rehabilitation Participation in Medicare and Veterans Affairs Populations: Opportunity for Improvement

Background: Cardiac rehabilitation is strongly recommended after myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery, but it is historically underused. We sought to evaluate variation in cardiac rehabilitation participation across the United States. Methods: From administrative data from the Veterans Affairs (VA) healthcare system and a 5% Medicare sample, we used International Classification of Diseases, 9th Revision codes to identify patients hospitalized for myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery from 2007 to 2011. After excluding patients who died in ⩽30 days of hospitalization, we calculated the percentage of patients who participated in ≥1 outpatient visits for cardiac rehabilitation during the 12 months after hospitalization. We estimated adjusted and standardized rates of participation in cardiac rehabilitation by state using hierarchical logistic regression models. Results: Overall, participation in cardiac rehabilitation was 16.3% (23 403/143 756) in Medicare and 10.3% (9123/88 826) in VA. However, participation rates varied widely across states, ranging from 3.2% to 41.8% in Medicare and 1.2% to 47.6% in VA. Similar regional variation was observed in both populations. Patients in the West North Central region (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota) had the highest participation, whereas those in the Pacific region (Alaska, California, Hawaii, Oregon, and Washington) had the lowest participation in both Medicare (33.7% versus 10.6%) and VA (16.6% versus 5.1%) populations. Significant hospital-level variation was also present, with participation ranging from 3% to 75% in Medicare and 1% to 43% in VA. Conclusions: Cardiac rehabilitation participation remains low overall in both Medicare and VA populations. However, remarkably similar regional variation exists, with some regions and hospitals achieving high rates of participation in both populations. This provides an opportunity to identify best practices from higher performing hospitals and regions that could be used to improve cardiac rehabilitation participation in lower performing hospitals and regions.