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SPECIAL ARTICLE

Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative

Philip A. Ades, MD; Steven J. Keteyian, PhD; Janet S. Wright, MD; Larry F. Hamm, PhD; Karen Lui, RN, MS; Kimberly Newlin, ANP; Donald S. Shepard, PhD; and Randal J. Thomas, MD, MS

Abstract

The primary aim of the Million Hearts initiative is to prevent 1 million cardiovascular events over 5 years. Concordant with the Million Hearts’ focus on achieving more than 70% performance in the “ABCS” of aspirin for those at risk, blood pressure control, cholesterol management, and smoking cessation, we outline the cardiovascular events that would be prevented and a road map to achieve more than 70% participation in cardiac rehabilitation (CR)/secondary prevention programs by the year 2022. Cardiac rehabilitation is a class Ia recommendation of the American Heart Association and the American College of Cardiology after myocardial infarction or coronary revascularization, promotes the ABCS along with lifestyle counseling and exercise, and is associated with decreased total mortality, cardiac mortality, and rehospitalizations. However, current participation rates for CR in the United States generally range from only 20% to 30%. This road map focuses on interventions, such as electronic medical recordebased prompts and staffing liaisons that increase referrals of appropriate patients to CR, increase enrollment of appropriate individuals into CR, and increase adherence to longer-term CR. We also calculate that increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitali- zations annually in the United States.

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From the Cardiac Reha- bilitation and Prevention Program, University of Vermont College of Med- icine, Burlington, VT (P.A.A.); Preventive Cardiology, Henry Ford Hospital, Detroit, MI (S.J.K.); Million Hearts, Centers for Disease Control and Prevention, Atlanta, GA (J.S.W.); Clinical Exercise Physi- ology Program, Depart- ment of Exercise and Nutrition Sciences, George Washington University, Washington, DC (L.F.H.); GRQ, LLC, Vienna, VA (K.L.); Cardiac

Affiliations continued at the end of this article.

M illion Hearts is a national initiative co-led by the Centers for Disease Control and Prevention and the

Centers for Medicare and Medicaid Services launched in 2012 and renewed in 2017 that brings together health care professionals and systems, federal and private sector organiza- tions, communities, and individuals to prevent 1 million cardiovascular events over 5 years.1,2

Million Hearts is designed to drive the imple- mentation of evidence-based interventions across communities and health care settings. A major component is focused on achieving at least 70% performance in the “ABCS”daspirin for those at risk, blood pres- sure control, cholesterol management, and smoking cessation.3 In recognition of the impact that cardiac rehabilitation (CR) has on outcomes for those who have cardiovascular

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disease, Million Hearts convened representa- tives from over 30 organizations and agencies as well as CR graduates and family members in November 2015 to address the barriers to and facilitators of participation. Represented organizations included the American Associa- tion of Cardiovascular and Pulmonary Rehabil- itation, American Heart Association (AHA), American College of Cardiology (ACC), American Association of Nurse Practitioners, American College of Physicians, American Hospital Association, Heart Failure Society of America, Preventive Cardiovascular Nurses Association, Blue Cross Blue Shield Associa- tion, and others. Summit participants formed the Million Hearts Cardiac Rehabilitation Collaborative, developed a 2016 action plan, and have set an aim to boost participation in CR from 20% to 70% by 2022 through

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individual and collective action. Representing the Cardiac Rehabilitation Collaborative, we describe the potential benefits of CR and pro- vide a road map to attain a similar rate of partic- ipation in CR of at least 70%. Although others have previously outlined the importance of CR and described several broad strategies to improve referrals,4 no prior work has systemat- ically compiled and applied strategies to target the combination of increasing referrals to CR and, as or more importantly, increasing pro- gram enrollment and adherence. This effort is supported by a concurrent initiative at the Centers for Medicare and Medicaid Services designed to encourage the use of CR services for Medicare beneficiaries after a myocardial infarction (MI) or coronary artery bypass surgery.5

Participation in CR is a class Ia recommen- dation of the AHA/ACC for individuals with an acute MI or coronary revascularization.6

Additionally, for patients with stable chronic systolic heart failure, exercise training is a class I recommendation, whereas CR is a class IIa recommendation.7 Despite these high levels of recommendation of CR by the AHA and ACC, participation in CR remains low, and effective strategies to increase referral and enrollment are needed. In that adherence with CR is related to the magnitude of the clinical benefit, we also address strategies to sustain participation in CR.8

BACKGROUND Benefits of CR participation are broad and compelling and include a 13% to 24% reduc- tion in total mortality over 1 to 3 years, a 31% decrease in rehospitalizations over 1 year, and an increase in physical function and quality of life.9-13 Much of the clinical benefit of CR has been ascribed to increases in fitness from a structured exercise program14,15 and the asso- ciated favorable physiologic effects on coro- nary endothelial function, insulin resistance, blood pressure, inflammatory markers, and fibrinolytic state.15-17 However, CR programs have also evolved to become disease manage- ment and secondary prevention centers that assist with medication adherence to the ABCS and the management of behavioral weight loss, smoking cessation, hypertension, diabetes, depression, and mental stress.13,17,18

In this way, CR programs and the peer

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networks therein help patients develop essen- tial skills in healthy living as well as medica- tion management.

Despite the fact that CR services are covered by Medicare and by private payers and are cost- effective,19 CR participation rates are very low, ranging from 19% to 34% in national ana- lyses20,21 with strong state-by-state geographic variations and differences by cardiac diag- nosis.20 States also vary in the availability of center-based CR programs.20 The highest participation rates are in the Midwestern states, with lowest participation rates in the South.20

Participation rates are higher after coronary bypass surgery than after MI.20,22 Whether CR disproportionately benefits patients with one cardiac diagnosis vs another is unclear, although a survival benefit of CR has been documented for patients after MI, percuta- neous coronary intervention (PCI), coronary artery bypass graft (CABG), systolic heart fail- ure, and heart transplant, whereas no such benefit has yet been reported after heart valve replacement.23-25 High-performing CR pro- grams and entire states have attained CR participation rates in the range of 60% for eligible patients.20,22,26 Therefore, it is chal- lenging, but not unreasonable, to target 70% utilization as a national goal concordant with the Million Hearts ABCS 70% targets for risk factor management.

POTENTIAL IMPACT What would be the impact of increasing CR participation from 20% to 70% in terms of cardiovascular events prevented as a compo- nent of Million Hearts? We performed this calculation with a simple model using pub- lished literature. We first summed the annual number of CR-qualifying events: acute MI (735,000), CABG surgery (395,000), PCI (454,000), and new cases of systolic heart failure discharged from the hospital (504,000).27-30 We then obtained contempo- rary 1-year mortality rates and rehospitaliza- tion rates by these indications from the medical literature.31-33 To estimate the num- ber of unduplicated individuals, correcting for overlap, we divided the totals by 1.94 based on rates of CABG, PCI, or congestive heart failure at or within 1 year of referral to CR in a cohort study.34 We derived the asso- ciated benefits of CR based on a systematic

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review of randomized trials, which found that CR reduced all-cause mortality by 13% and subsequent all-cause hospitalizations by 31%.9 Thus, an initial calculation reveals that in the first year after CR, 12,000 lives could be saved and 87,000 hospitalizations averted. Furthermore, an observational study of 70,040 matched pairs of Medicare benefi- ciaries found that the benefits of CR extended throughout the 5-year study.35 The 5-year mortality reductions were 2.08 times those observed in the first year after CR (ie, about 18 months after the index hospitalization). Assuming that a comparable factor applies to hospitalizations, an estimated 25,000 lives could be saved and 180,000 hospitalizations prevented annually over the long term by increasing CR participation from 20% to 70%. These rough estimates do not include other important benefits of CR, such as fewer emergency department visits,34 increased exer- cise tolerance, reduced symptoms, and improved quality of life.13

To increase CR participation so substan- tially, from the current rate of 20% to 30% to the goal rate of 70%, improvements in 2 critical steps are necessary. First, the systematic referral of eligible patients to a CR program needs to be increased, and second, the successful enroll- ment of referred patients into a CR program needs to be optimized. Cardiac rehabilitation referral is defined by the combination of an order in the medical record, a discussion be- tween a clinician and patient regarding CR participation, and receipt of the order by a CR program. Enrollment in CR is defined by partic- ipation in at least one CR session (Medicare and most commercial insurers cover up to 36 sessions). Although improvements in these 2 areas are needed for all patient groups, they are particularly important in subgroups of the population in which CR participation rates are the lowest, including older patients, women, individuals with multiple comorbid- ities, people from underserved racial/ethnic groups, and those of lower socioeconomic status.34-36 Because the benefits of CR are dose related,8,34,35 CR adherence is also impor- tant and is addressed subsequently.

It is important to note that there would not be an instant ability of CR programs to in- crease capacity to accommodate both an enrollment rate of 70% and improved patient

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adherence. Given current CR capacity in the United States, expanding capabilities to accommodate a large increase in participation and adherence would need to be gradual and require both improvement in program operations and broadening of the current facility-based model. This process should include the use of a hybrid model with on- site coordination of home programs and mobile monitoring technologies.37 Further- more, the methods of increasing CR referral and participation may vary based on the local environment, with each program and hospital having unique patient populations and bar- riers to improving the quality of and access to care. Nonetheless, widespread adoption of a few specific strategies to improve referral and enrollment, along with programmatic ad- aptations to efficiently and effectively deliver care to more patients, will have a profound impact on morbidity and mortality in those at high risk for future events.

IMPROVING CR REFERRAL Cardiac rehabilitation referral rates can be almost tripled by using the systematic approach to referral developed by Grace et al,38 which includes an automatic electronic medical recordebased CR referral system. This “default” or “opt-out” order for patients with qualifying diagnoses results in efficient, systematic referral to outpatient CR during the hospital discharge process. Additionally, a staff member or “liaison” meets with each pa- tient to introduce CR and help coordinate the referral process38 (Table 1).4,38-43 In the study by Grace et al,38 an automatic referral com- bined with a liaison attained referral rates of 86% compared with 32% in controls who received neither intervention. Automatic referral alone increased the referral rate to 70%. If all hospitals in the United States were able to adopt such a combined strategy, CR referral rates in the United States could be almost tripled from the current level of approximately 20% to 30%, to an estimated level of 54% to 81% (Figure).

The use of CR referral as a “quality of care indicator” also appears to be a promising tool to improve CR referral.44 Performance mea- sures for CR referral have been developed, endorsed, and implemented to promote im- provements in CR referral. One study by

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TABLE 1. Strategies That Influence Referral and Enrollment to Cardiac Rehabilitation

Strategy Brief description Outcome Reference

Automatic in-patient CR referral system CR referral is carried out as an automatic EMR order for all eligible patients

CR referral was 70% (compared with 32% for usual care); enrollment was 61% (compared with 29% for usual care)

38

Inpatient “liaison” to help educate and refer patients to out-patient CR

A liaison or “coach” meets with inpatients who are eligible for CR, educating and guiding them in the CR enrollment process

CR referral was 59% (compared with 32% for usual care); enrollment was 51% (compared with 29% for usual care)

38

Combination of automatic CR referral system and “liaison”

Combination of the 2 strategies listed above

CR referral was 85% (compared with 32% for usual care); enrollment was 74% (compared with 29% for usual care)

38

Limit or eliminate out-of-pocket expenses to patients for CR services

Negotiate with insurance companies to limit or eliminate co-payments and other out-of-pocket expenses for patients enrolled in CR

Studies of preventive medication adherence suggest that reducing or eliminating co-payments improves utilization and adherence

39,40

Inclusion of home-based CR option for patients who are not able to attend a center-based CR program

Protocol-driven, nurse-managed home- based approaches to CR delivery provide CR services to patients at home for low- to moderate-risk patients

Outcomes are similar and participation rates may be higher in home-based CR programs compared with center-based CR programs

41

Flexible hours of operation Increased flexibility of CR center hours to include early morning, noontime, after work, and weekend hours

10% Improvement in enrollment and participation; will require creative staff scheduling to avoid increasing costs of program delivery

4

Early outpatient appointment established before hospital discharge

Inpatient staff members work and EMR set up an outpatient CR enrollment appointment for each eligible patient within 12 days of hospital discharge

20%-25% Improvement in CR enrollment 42

Use of CR referral performance measures in a quality improvement system

CR referral is assessed, reported, and acted upon in a systematic quality improvement program

CR referral rates improved by 12.5% over 5 years in centers participating in a quality improvement program

43

CR ¼ cardiac rehabilitation; EMR ¼ electronic medical record.

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Beatty et al43 using the ACC’s National Cardio- vascular Data Registry documented a signifi- cant 8% absolute improvement in CR referral rate to over 80% in hospitals participating in the quality improvement activities.

IMPROVING CR ENROLLMENT The transition from CR referral to CR enroll- ment is a crucial step in the overall CR partic- ipation process. Systematic approaches to CR enrollment substantially increase CR participa- tion rates (Table 1). First, the systematic CR referral strategy of Grace et al38 was also asso- ciated with a higher overall CR enrollment rate, 74% in centers that used a computerized automatic referral system with liaisons to help patients navigate the enrollment process vs 29% in centers using “usual care” proced- ures.38 This increase exceeds the 70% national

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goal outlined previously. Other approaches and their estimated impact on CR enrollment rates include (1) inclusion of a home-based CR option for patients (estimated 20% relative improvement),41 (2) flexible hours of opera- tion for CR centers (estimated 10% relative improvement),4 and (3) scheduling the first CR appointment before patient discharge from the hospital at 10 to 12 days after hospi- tal discharge (18% improvement in enroll- ment over standard care, from 59% to 77% participation).42 Whether these effects are ad- ditive or overlapping is unknown. It is also important to note that for every 1-day delay in starting CR, there is an approximate 1% less likelihood of the patient enrolling.42,45

Although use of a performance measure for CR enrollment has not yet been implemented or tested, it likely represents an additional

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FIGURE. Conceptual framework for increasing cardiac rehabilitation (CR) participation from 20% to 70%. EMR ¼ electronic medical record.

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promising tool in helping to improve CR enrollment for eligible patients.

Participation rates also depend somewhat on cardiac diagnosis because patients who have undergone surgical revascularization have higher participation rates than patients who have MI or undergo percutaneous revas- cularization.20,22 Cardiac rehabilitation partic- ipation rates for individuals with chronic systolic heart failure have yet to be deter- mined, although given that many of these patients are of advanced age and present with multiple comorbidities, the present enrollment rates are most likely lower than for patients in other diagnostic categories.

INCREASING ADHERENCE TO CR Another challenge and opportunity for CR programs is ensuring that all patients receive the largest “dose” possible of program partici- pation. Specifically, several studies suggest that the magnitude of clinical benefit derived from participation in CR is related to the num- ber of sessions completed by patients.8,34,35

Cardiac rehabilitation participants face a vari- ety of barriers in attending and completing the program. Among these barriers are the need to return to work, the cost burden, inconvenient hours, transportation issues, and cultural barriers. Cardiac rehabilitation programs can substantially boost adherence and help patients receive an ideal dose of CR by incorporating specific strategies that opti- mize adherence.

Table 241,46-55 summarizes adherence stra- tegies that have been studied to maximize adherence, such as an expectation that patients complete all 36 sessions of the CR protocol and small motivational rewards or incentives for completing blocks of sessions.46,47

Contemporary CR programs are encouraged to incrementally adopt and apply many of these strategies, eventually incorporating them as routine elements of daily operations. Other strategies to consider include record keeping by participants (eg, diaries, logs, step counts), matching program hours of operation to patient rather than to staff needs, and offer- ing program content that is culturally and linguistically appropriate and considerate of age, sex, comorbidities, and coexisting disabil- ities. Although not all patients have co- payments for CR sessions, insurers can reduce

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or eliminate these co-payments or cost share to encourage more and longer participation, which leads to better outcomes for users.39,40

INSTITUTING SYSTEM-BASED APPROACHES The widespread use of system-based ap- proaches for both CR referral and enrollment would improve CR participation rates substan- tially. If all hospitals adopted the systematic CR referral approach with liaisons, CR referral rates could approach 90%.38 If all hospitals and CR programs adopted the CR enrollment strategies outlined previously, then overall enrollment rates could exceed 70%, assuming the geographic availability of a CR program. Even if only half of US hospitals and CR pro- grams adopted such strategies, CR referral and enrollment rates would still improve substan- tially, approaching rates of 60% and 50%, respectively.

Cardiac rehabilitation is a class Ia AHA/ ACC recommendation for patients after an acute MI or coronary revascularization,6 and exercise training is similarly a class I indication for individuals with chronic systolic heart failure.7 Yet, unlike medications taken for secondary prevention (eg, statins, aspirin) and despite its proven benefits, CR

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TABLE 2. Strategies That Influence Adherence in Patients Enrolled in Cardiac Rehabilitation

Strategy/factor Brief description Outcome Reference

Incorporate motivational and financial incentives. Introductory video

Rewards (shirts with program logo or similar items) based on session attendance. Video to describe CR program and impact on health outcomes. Video shown before hospital discharge or at beginning of outpatient CR

Improved program completion rates 46,47

Change program procedures to recommend 36 visits for all patients

Provide 36 visits using a 2-visit vs 3-visit per week schedule

Observed increase in number of attended visits per patient

46-48

Modify program structure to accommodate more total patients and more patients per day. Align frequency of visits to clinical status and patient preferences

Incorporate group orientations; develop hybrid model of home-based and facility-based program that includes key components of CR; shift from class structure to open-gym model; minimize (de-emphasize) frequency/ use of ECG telemetry monitoring

Improved cost efficiency of delivery 41,49,50

Gender-tailored delivery of CR Women-only CR ¼ traditional CR þ structured behavioral learning strategies on decision balance, self- efficacy, and processes of change

Attendance to women-only classes was 90%, compared with 77% in women undergoing traditional CR only

51

Text messaging Use TM for appointment reminders and to augment classroom education; participation in TM should be voluntary; limit to 3-5 texts per week

Program completion rates were higher with SMS messaging; number of sessions attended was 20% greater with use of TM

52

Establish philanthropic fund to partly underwrite CR costs for patients with high co-payments or without insurance

Annual appeal letter to CR “graduates” (and past fund contributors) asking for contributions; emphasize the purpose to help others with limited resources

Return rates (with contributions) to direct mail solicitation as high as 7%

53

Altering program structure and design Programs in the Wisconsin CR registry were surveyed and analyzed for factors that improve adherence

Factors that influenced adherence included adequate space and equipment, medical director on site >15 min/wk, assessment of patient satisfaction, individual/group diet counseling, relaxation training, group education, and group psychological counseling

54

Use of motivational letter Intervention letter based on theory of planned behavior; targeted attitude toward best recovery, assistance with control and choices, and importance of following recommendations

Attendance rates for the intervention group were substantially higher than those for the control group

55

CR ¼ cardiac rehabilitation; ECG ¼ electrocardiographic; SMS ¼ short message service; TM ¼ text messaging.

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participation among those eligible and known to benefit is presently in the range of only 20% to 30%. Indeed, many consider exercise “like a pill that should be taken daily.”56,57 Achieving a 70% enrollment rate in CR, concordant with targets set for the Million Hearts ABCS, is possible through individual and collective action to implement the evidence-based strate- gies described previously. Doing so will save

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lives, reduce avoidable hospitalizations, and improve the quality of life for hundreds of thousands of individuals each year in the United States.

IMPLEMENTATION AND PRACTICAL CONSIDERATIONS Implementation of this road map should begin with CR programs and their affiliated hospitals

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instituting process improvements designed to accommodate more patients in an efficient manner, as well as working with their informa- tion systems department and electronic medical record personnel to develop an automated CR referral during the hospital discharge process. Patients with appropriate diagnoses should leave the hospital with a written CR referral and a scheduled individual or group visit at the CR program within 1 week of discharge. This referral should be discussed with a CR liaison while the patient is still in the hospital, and communication should be maintained until the patient’s case manager assumes CR care. Cardiac rehabilitation programs and their affili- ated hospitals and clinics can work together to identify local gaps in CR delivery and work to continuously reduce those gaps by implement- ing the additional interventions to increase CR referral and participation listed in Table 1 and the strategies for adherence in Table 2. Practical aspects of systematizing CR referral and enroll- ment in the Canadian system of care have been well described.58 Taken together, these efforts should increase CR referral rates to over 90%, with CR participation rates that approach or exceed 70%.

CONCLUSION The benefits of CR are broad and compelling, ranging from decreased mortality and decreased hospitalizations to improvements in functional capacity, insulin sensitivity, depres- sion, and quality of life. Secondary prevention practices in CR support and align with the ABCS of Million Hearts. Improving CR partici- pation from 20% to 70% in 5 years or less is achievable through individual and collective action to implement evidence-based strategies that increase CR referral, enrollment, and adherence. A concordant effort from hospitals and CR programs to increase capacity will also be needed. Doing so will save lives, reduce avoidable hospitalizations, and improve the quality of life for hundreds of thousands of individuals in the United States.

ACKNOWLEDGMENTS The authors thank David Whellan, MD, for his helpful suggestions after reviewing the submit- ted manuscript. We also express gratitude for

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the commitment, expertise, and actions of members of the Million Hearts Cardiac Reha- bilitation Collaborative, an outgrowth of the Million Hearts Cardiac Rehabilitation Leader- ship Summit held in November 2015 in Washington, DC, with representatives from over 30 organizations and agencies as well as CR graduates and their families. Represented organizations include the American Associa- tion of Cardiovascular and Pulmonary Reha- bilitation, AHA, ACC, American Association of Nurse Practitioners, American College of Physicians, American Hospital Association, Heart Failure Society of America, Preventive Cardiovascular Nurses Association, Blue Cross Blue Shield Association, National Medical As- sociation, Patient-Centered Outcomes Research Institute, America’s Essential Hospi- tals, Mended Hearts, WomenHeart, and Med- Star Health. More about the Million Hearts initiative can be found on the Million Hearts website.2

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Abbreviations and Acronyms: ABCS = aspirin for those at risk, blood pressure control, cholesterol management, and smoking cessation; ACC = American College of Cardiology; AHA = American Heart Association; CABG = coronary artery bypass graft; CR = cardiac rehabilitation; MI = myocardial infarction; PCI = percutaneous coronary intervention

Affiliations (Continued from the first page of this article.): and Pulmonary Rehabilitation, Sutter Roseville Medical Center, Roseville, CA (K.N.); Heller School for So- cial Policy and Management, Brandeis University, Waltham, MA (D.S.S.); and Cardiac Rehabilitation Program, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (R.J.T.).

Grant Support: This work was supported in part by Na- tional Institutes of Health Center of Biomedical Research Excellence award P20GM103644 from the National Insti- tute of General Medical Sciences (P.A.A., D.S.S.).

Potential Competing Interests: Dr Keteyian reports per- sonal fees from NimbleHeart, Inc, unrelated to the submit- ted work. Ms Lui reports that GRQ, LLC, represents the American Association of Cardiovascular and Pulmonary Rehabilitation regarding regulatory and legislative issues that affect cardiac rehabilitation.

Correspondence: Address to Philip A. Ades, MD, Univer- sity of Vermont Medical Center, 62 Tilley Dr, South Burling- ton, VT 05403 (Philip.ades@uvmhealth.org).

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