Quinn R. Pack

Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction

BACKGROUND Participation in cardiac rehabilitation has been shown to decrease mortality after acute myocardial infarction, but its impact on readmissions requires examination. METHODS We conducted a population-based surveillance study of residents discharged from the hospital after their first-ever myocardial infarction in Olmsted County, Minnesota, from January 1, 1987, to September 30, 2010. Patients were followed up through December 31, 2010. Participation in cardiac rehabilitation after myocardial infarction was determined using billing data. We used a landmark analysis approach (cardiac rehabilitation participant vs not determined by attendance in at least 1 session of cardiac rehabilitation at 90 days post-myocardial infarction discharge) to compare readmission and mortality risk between cardiac rehabilitation participants and nonparticipants accounting for propensity to participate using inverse probability treatment weighting. RESULTS Of 2991 patients with incident myocardial infarction, 1569 (52.5%) participated in cardiac rehabilitation after hospital discharge. The cardiac rehabilitation participation rate did not change during the study period, but increased in the elderly and decreased in men and younger patients. After adjustment, cardiac rehabilitation participants had lower all-cause readmission (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.65-0.87; P < .001), cardiovascular readmission (HR, 0.80; 95% CI, 0.65-0.99; P = .037), noncardiovascular readmission (HR, 0.72; 95% CI, 0.61-0.85; P < .001), and mortality (HR, 0.58; 95% CI, 0.49-0.68; P < .001) risk. CONCLUSIONS Cardiac rehabilitation participation is associated with a markedly reduced risk of readmission and death after incident myocardial infarction. Improving cardiac rehabilitation participation rates may have a large impact on post-myocardial infarction healthcare resource use and outcomes.

Participation in Cardiac Rehabilitation and Survival After Coronary Artery Bypass Graft Surgery A Community-Based Study

Background— Cardiac rehabilitation (CR) is recommended for all patients after coronary artery bypass surgery, yet little is known about the long-term mortality effects of CR in this population. Methods and Results— We performed a community-based analysis on residents of Olmsted County, Minnesota, who underwent coronary artery bypass surgery between 1996 and 2007. We assessed the association between subsequent outpatient CR attendance and long-term survival. Propensity analysis was performed. Cox proportional hazards regression was then used to assess the association between CR attendance and all-cause mortality adjusted for the propensity to attend CR. We identified 846 eligible patients (age 66±11 years, 76% men, and 96% non-Hispanic whites) who survived at least 6 months after surgery, of whom 582 (69%) attended CR. During a mean (±SD) follow-up of 9.0±3.7 years, the 10-year all-cause Kaplan-Meier mortality rate was 28% (193 deaths). Adjusted for the propensity to attend CR, participation in CR was associated with a 10-year relative risk reduction in all-cause mortality of 46% (hazard ratio, 0.54; 95% confidence interval, 0.40–0.74; P<0.001) and a 10-year absolute risk reduction of 12.7% (number needed to treat=8). There was no evidence of a differential effect of CR on mortality with respect to age (≥65 versus <65 years), sex, diabetes, or prior myocardial infarction. Conclusions— CR attendance is associated with a significant reduction in 10-year all-cause mortality after coronary artery bypass surgery. Our results strongly support national standards that recommend CR for this patient group.

An Early Appointment to Outpatient Cardiac Rehabilitation at Hospital Discharge Improves Attendance at Orientation A Randomized, Single-Blind, Controlled Trial

Background— Outpatient cardiac rehabilitation (CR) decreases mortality rates but is underutilized. Current median time from hospital discharge to enrollment is 35 days. We hypothesized that an appointment within 10 days would improve attendance at CR orientation. Methods and Results— At hospital discharge, 148 patients with a nonsurgical qualifying diagnosis for CR were randomized to receive a CR orientation appointment either within 10 days (early) or at 35 days (standard). The primary end point was attendance at CR orientation. Secondary outcome measures were attendance at ≥1 exercise session, the total number of exercise sessions attended, completion of CR, and change in exercise training workload while in CR. Average age was 60±12 years; 56% of participants were male and 49% were black, with balanced baseline characteristics between groups. Median time (95% confidence interval) to orientation was 8.5 (7–13) versus 42 (35 to NA [not applicable]) days for the early and standard appointment groups, respectively (P<0.001). Attendance rates at the orientation session were 77% (57/74) versus 59% (44/74) in the early and standard appointment groups, respectively, which demonstrates a significant 18% absolute and 56% relative improvement (relative risk, 1.56; 95% confidence interval, 1.03–2.37; P=0.022). The number needed to treat was 5.7. There was no difference (P>0.05) in any of the secondary outcome measures, but statistical power for these end points was low. Safety analysis demonstrated no difference between groups in CR-related adverse events. Conclusions— Early appointments for CR significantly improve attendance at orientation. This simple technique could potentially increase initial CR participation nationwide. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01596036.

Cardiac rehabilitation is associated with reduced long-term mortality in patients undergoing combined heart valve and CABG surgery.

Background No reports have been published to date on the impact of cardiac rehabilitation (CR) on mortality in patients undergoing combined heart valve and coronary artery bypass graft (CABG) surgery (V + CABG), a procedure that has increased significantly in frequency in recent years. Methods We identified consecutive patients who underwent V + CABG surgery in the Olmsted County from 1996 to 2007. Propensity scores were developed using more than 40 clinical, operative, and post-operative characteristics. The impact of CR on long-term mortality was assessed via landmark analysis and using propensity score regression adjustment and stratification techniques. Results A total of 201 patients were included in our study, in whom 86 deaths occurred over a mean follow up of 6.8 years. Forty-seven per cent of patients participated in CR, with a significant trend towards increased participation in recent years (p = 0.04). Conditional on 6-month survival and controlling for propensity factors as well as mortality risk factors, CR participation was associated with a significant reduction in mortality (propensity score adjustment: HR 0.48, p = 0.009; propensity score stratification: HR 0.48, p = 0.016). The absolute risk reduction over 10 years was 14.5% (number needed to treat = 7). Results did not differ significantly based on age, gender, emergent status, or history of heart failure or arrhythmias, but CR participation was more beneficial for patients who underwent a mitral valve procedure (HR 0.24, 95% CI 0.08–0.77). Conclusions This is the first study reporting a significant survival benefit with CR participation in patients who have undergone combined V + CABG surgery. These findings provide evidence in support of recommendations for CR participation after V + CABG surgery.

The current and potential capacity for cardiac rehabilitation utilization in the United States.

PURPOSE:Prior studies suggest that program capacity restraints may be an important reason for outpatient cardiac rehabilitation (CR) underutilization. We sought to measure current CR capacity and growth potential. METHODS:We surveyed all CR program directors listed in the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) database in November 2012. Respondents reported current enrollment levels, program capacity, expansion potential, and obstacles to growth. RESULTS:Of the 812 program directors in the AACVPR database, 290 (36%) completed the full survey. Respondents represented somewhat larger programs than nonrespondents but were otherwise representative of all registered AACVPR programs. Current enrollment, estimated capacity, and estimated expansion capacity were reported at a median (interquartile range) of 140 (75, 232), 192 (100, 300), and 240 (141, 380) patients annually, respectively. Using these data, we estimated that, in the year 2012, national CR utilization was 28% (min, max: 20, 38) of eligible patients. Even with modest expansion of all existing programs operating at capacity, a maximum of 47% (min, max: 32, 67) of qualifying patients in the United States could be serviced by existing CR programs. Obstacles to increasing patient participation were primarily controllable system-related problems such as facility restraints and staffing needs. CONCLUSIONS:Even with substantial expansion of all existing CR programs, there is currently insufficient capacity to meet national service needs. This limit probably contributes to CR underutilization and has important policy implications. Solutions to this problem will likely include the creation of new CR programs, improved CR reimbursement strategies, and new models of CR delivery.

Improving cardiac rehabilitation attendance and completion through quality improvement activities and a motivational program.

PURPOSE: Recent studies have demonstrated that patients who attend more cardiac rehabilitation (CR) sessions have lower subsequent mortality rates than those who attend fewer sessions. METHODS: We analyzed the impact of several phased-in policy and process changes implemented to increase patient participation in CR. In March 2010, our CR program changed from a policy of individualizing the recommended number of CR sessions per patient to a policy that recommended all 36 CR sessions. In October 2010, we introduced a 7-minute video describing the benefits of CR. In August 2011, we introduced a motivational program that rewarded patients after every sixth CR session. The number of CR sessions attended was determined through review of billing records. Enrollment and completion were defined as attending ≥1 session and ≥30 sessions, respectively. RESULTS: We identified 1103 patients sequentially enrolled in CR between May 2009 and January 2012. Overall, the median number of sessions per patient improved from 12 to 20 (P < .001). Completion rate improved from 14% to 39% (P < .001). The motivational program increased attendance by a median of 3 sessions per patient (P = .04), but this effect was limited to local CR participants. Financial analysis suggested that for every

Safety of Early Enrollment into Outpatient Cardiac Rehabilitation After Open Heart Surgery

100 spent on motivational rewards, patients attended an additional 6.6 (95% CI, −1 to 14) sessions of CR. CONCLUSIONS: Quality improvement activities significantly increased CR participation. Wide implementation of such programs may favorably impact patient participation in CR and potentially decrease the rate of subsequent cardiac events.

Trends and Predictors of Smoking Cessation After Percutaneous Coronary Intervention (from Olmsted County, Minnesota, 1999 to 2010)

The safety of early enrollment (<2 weeks after hospital discharge) into cardiac rehabilitation (CR) after recent coronary artery bypass graft (CABG) surgery or heart valve surgery (HVS) has not previously been assessed and has important policy implications. Consequently, we performed a detailed review of all clinical adverse events within 6 months of hospital discharge. We compared early and late attendees for patients undergoing CABG surgery or HVS and included patients with myocardial infarction (MI) as an additional control group. We analyzed 112 patients undergoing CABG surgery, 69 patients undergoing HVS, and 59 patients with MI. Median time (interquartile range) from hospital discharge to CR enrollment was 10.5 (8 to 15), 12 (8.5 to 21), and 9 days (7 to 14), respectively. There was no difference in major event rates between early and late enrollees (17% vs 17%, respectively, log-rank p = 0.98) or by diagnosis (15%, 16%, and 22% for CABG surgery, HVS, and MI, respectively; log-rank p = 0.50). Sternal instability and wound infection rates were similar. CR-related adverse events trended toward increased event rates in surgical and early enrollees, but of 44 events, only 3 were exercise related, none resulted in permanent harm, and 41 (93%) were managed in CR without need for emergency services. In conclusion, it appears that a policy of encouraging early enrollment into CR in patients with a recent open heart surgery seems unlikely to harm patients when careful individualized assessment and exercise prescription take place within the bounds of an established CR program.

Validation and Comparison of Seven Mortality Prediction Models for Hospitalized Patients With Acute Decompensated Heart Failure

Smoke-free ordinance implementation and advances in smoking cessation (SC) treatment have occurred in the past decade; however, little is known about their impact on SC in patients with coronary artery disease. We conducted a retrospective cohort study of 2,306 consecutive patients from Olmsted County, Minnesota, who underwent their first percutaneous coronary intervention (PCI) from 1999 to 2009, and assessed the trends and predictors of SC after PCI. Smoking status was ascertained by structured telephone survey 6 and 12 months after PCI (ending in 2010). The prevalence of smoking in patients who underwent PCI increased nonsignificantly from 20% in 1999 to 2001 to 24% in 2007 to 2009 (p = 0.14), whereas SC at 6 months after PCI decreased nonsignificantly from 50% (1999 to 2001) to 49% (2007 to 2009), p = 0.82. The 12-month quit rate did not change significantly (48% in 1999 to 2001 vs 56% in 2007 to 2009, p = 0.38), even during the time periods after the enactment of smoke-free policies. The strongest predictor of SC at 6 months after PCI was participation in cardiac rehabilitation (odds ratio [OR] 3.17, 95% confidence interval [CI] 2.05 to 4.91, p <0.001), older age (OR 1.42 per decade, 95% CI 1.16 to 1.73, p <0.001), and concurrent myocardial infarction at the time of PCI (OR 1.77, 95% CI 1.18 to 2.65, p = 0.006). One-year mortality was lower in the group of smokers compared with never smokers (3% vs 7%, p <0.001). In conclusion, SC rates have not improved after PCI over the past decade in our cohort, despite the presence of smoke-free ordinances and improved treatment strategies. Improvements in delivery of systematic services aimed at promoting SC (such as cardiac rehabilitation) should be part of future efforts to improve SC rates after PCI.

Participation Rates, Process Monitoring, and Quality Improvement Among Cardiac Rehabilitation Programs in the United States: A NATIONAL SURVEY.

Background—Heart failure (HF) inpatient mortality prediction models can help clinicians make treatment decisions and researchers conduct observational studies; however, published models have not been validated in external populations. Methods and Results—We compared the performance of 7 models that predict inpatient mortality in patients hospitalized with acute decompensated heart failure: 4 HF-specific mortality prediction models developed from 3 clinical databases (ADHERE [Acute Decompensated Heart Failure National Registry], EFFECT study [Enhanced Feedback for Effective Cardiac Treatment], and GWTG-HF registry [Get With the Guidelines-Heart Failure]); 2 administrative HF mortality prediction models (Premier, Premier+); and a model that uses clinical data but is not specific for HF (Laboratory-Based Acute Physiology Score [LAPS2]). Using a multihospital, electronic health record–derived data set (HealthFacts [Cerner Corp], 2010–2012), we identified patients ≥18 years admitted with HF. Of 13 163 eligible patients, median age was 74 years; half were women; and 27% were black. In-hospital mortality was 4.3%. Model-predicted mortality ranges varied: Premier+ (0.8%–23.1%), LAPS2 (0.7%–19.0%), ADHERE (1.2%–17.4%), EFFECT (1.0%–12.8%), GWTG-Eapen (1.2%–13.8%), and GWTG-Peterson (1.1%–12.8%). The LAPS2 and Premier models outperformed the clinical models (C statistics: LAPS2 0.80 [95% confidence interval 0.78–0.82], Premier models 0.81 [95% confidence interval 0.79–0.83] and 0.76 [95% confidence interval 0.74–0.78], and clinical models 0.68 to 0.70). Conclusions—Four clinically derived, inpatient, HF mortality models exhibited similar performance, with C statistics near 0.70. Three other models, 1 developed in electronic health record data and 2 developed in administrative data, also were predictive, with C statistics from 0.76 to 0.80. Because every model performed acceptably, the decision to use a given model should depend on practical concerns and intended use.