Cardiac Rehab Effective but Under-Utilized

Bill Brady is a 4:28 marathoner, father of four, CEO of a biofuels company, and a recent heart attack survivor.

The 48-year-old Wellesley resident, who is neither overweight nor a smoker, has one other key moniker: new cardiac rehabilitation patient. Brady, who ran the 2009 Boston Marathon in April, then had a heart attack in June, started rehab in October - even though he was skeptical an exercise and education program could help him. And besides, he was busy.

But Brady stuck with it - something most people don’t do.

“This program helps you look back objectively,’’ he said, “And when I look back, there were a number of factors, some family history [of heart disease], the pace of my life . . . and I had this mentality that was completely wrong, that I could eat whatever I want ’cause I am going to run it off tomorrow.’’

If an ounce of prevention is worth a pound of cure, then cardiac rehabilitation can boast some serious curative tonnage. Study after study has shown that patients who attend even a few sessions can significantly increase their chances of survival. The problem is, most people who have had a heart attack or bypass surgery - and are therefore at risk of a repeat - don’t go to rehab, and many of those who do go don’t stick with it.

Some cardiologists say the programs often aren’t promoted to patients because they aren’t the money-makers for hospitals that other cardiac treatments are, such as bypass surgery or angioplasty. And given the prestige and heroics associated with those higher-tech, immediate interventions, the self-discipline and perseverance needed for successful rehab tend to relegate it to the lower echelon for resources and respect in the medical community, said cardiologist Philip Ades, a professor of medicine at the University of Vermont and director of cardiac rehab and preventive cardiology at Fletcher Allen Health Care in Burlington.

“To this day, the majority of hospitals in the US don’t recruit patients as actively in their rehab program because they are worried about the medical politics,’’ Ades said.

Ades coauthored a 2007 study, published in the American Heart Association journal Circulation, that tracked Medicare claims and found that, nationwide, cardiac rehab was provided to just 13.9 percent of patients hospitalized for heart attacks and 31 percent who had undergone bypass surgery.

The study concluded that patients would be more likely to attend rehab if hospitals more aggressively referred them, using automatic enrollment after hospitalization and creating Web-based referral options. It also said that boosting insurance reimbursement rates to hospitals for rehab could provide an incentive to recommend the therapy to more patients. It noted that some physicians who run rehab programs say the relatively low payment for such services is a “deterrent’’ to rehab use.

And yet, studies have shown that cardiac rehab works. The most recent research, published in December in Circulation, tracked more than 30,000 Medicare patients over age 65 for four years and, after taking into account age and other differences among cardiac patients, found that those who completed all 36 sessions of rehab had a 47 percent reduction in the risk of death from any cause, and 31 percent risk reduction for a heart attack in the subsequent four years compared with those who attended just one session.

But only 18 percent of the patients went to all 36 sessions, even though Medicare was paying the tab, a drop-out rate similar to what was found in other cardiac rehab studies.

The researchers didn’t delve into the reasons for the poor showing, but cardiac specialists who are all too familiar with the no-show phenomenon say the short-shrift starts with patients’ fast-paced, too-busy, pop-a-pill-to-cure-my-ailment mentality.

“It’s a big effort to get to a place, to drive there or be driven, and for many older people who can’t drive, it puts a big burden on the rest of the family,’’ said cardiologist Daniel Forman, director of cardiac rehab at Brigham and Women’s Hospital.

Of course, rehab efforts vary from hospital to hospital. The Brigham, for example, used to have a small rehab program, with a nurse assigned to recruit cardiac patients before discharge, said Forman. The hospital closed that program six or seven years ago and merged its rehab with a program at the Brigham-affiliated Faulkner Hospital, in Jamaica Plain. But in February, the Brigham is slated to open a rehab program in Foxborough, in a space donated by Robert Kraft at Patriot Place, said Forman, who will head that program. And once again, a nurse, armed with an educational video explaining the benefits of rehab, will be assigned to recruit cardiac patients before discharge.

Cardiac rehab - which includes lifestyle counseling, nutritional advice, weight management, exercise, and even cooking classes - typically runs for 30 weeks. The program Brady, the Wellesley marathoner, attends at Newton-Wellesley Hospital meets twice a week for two hours, also typical for such programs. Patients exercise - usually on a treadmill or elliptical trainer - for the first hour, then attend educational sessions on nutrition and stress management the second hour. Every other session substitutes yoga for the second hour.

“After you have a heart attack, you are scared to death to run,’’ Brady said. Rehab “gave me confidence that I could get my heart rate up and nothing bad would happen to me.’’ It also taught him how to take a few minutes off during his work day and do some breathing exercises to bring down his stress level and heart rate.

In several respects, Brady is typical of the patients who do make it to cardiac rehab: He has a college education, lives in an affluent community, and has few other complicating illnesses such as diabetes or orthopedic problems. Donald Shepard, a health economist and professor at Brandeis University’s Heller School, pinpointed these common traits in a study published in 2007.

Then last year, Shepard completed an analysis for Medicare on the cost-effectiveness of cardiac rehab. He concluded that patients who use cardiac rehab are more costly to Medicare in the first year after they are discharged from the hospital, but go on to save Medicare, on average, $2,830, per patient in the subsequent four years because of fewer hospitalizations and home health services. He also concluded that it saved lives.

“The reduction in mortality translates to approximately one additional year in life,’’ Shepard said. “These people, on average, were 73 years old and all had heart disease, and even with these people, this relatively simple and inexpensive treatment would add a year to their life.’’

-From “The beat goes on; Studies show that cardiac rehab helps heart attack survivors avoid future trouble. So why do so few take advantage of it?” By Kay Lazar, The Boston Globe,  January 11, 2010, http://www.boston.com/news/health/articles/2010/01/11/why_do_so_few_heart_attack_survivors_take_advantage_of_cardiac_rehab_programs/ retrieved 1-11-10.

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