Cardiac Rehab Riya Pulicharam, MD National Medical Director, Population Health & Clinical Outcomes ©2018 HealthCare Partners All Rights Reserved. Confidential and proprietary.

Agenda Background Cost of Care Million Hearts Initiative Focus Group Discussion Benefits of Participation Barriers that Patients Face Technology in Cardiac Rehab HCP Pilot for Cardiac Rehab Conclusion

Cardiac Rehab: Under-Utilized! Patients who Register for Cardiac Rehab Program Patients who Complete a Cardiac Rehab Program Only 33% of Heart Attack Survivors Register for a Cardiac Rehabilitation Program

Increase Risk of Second Event Increase Risk of Death 30% heart attack survivors will have 2nd heart event Increase of Costly Treatments The American Heart Association estimates 30% of the more than 915,000 Americans who experience a heart attack annually will have a second event

Healthcare Cost: Cardiovascular Disease About $1 out of every $6 spent on healthcare in the U.S., is spent on cardiovascular disease Equates to $320 million a year in direct medical costs and lost productivity In the first 90 days following a heart attack costs an average of more than $38,000 Medicare spends about $14,000 per patient on hospital bills over the course of year following an attack. Both Medicare and private health insurers amounts rise about 4% a year.

Million Hearts Initiative The aim of the Million Hearts Initiative is to prevent 1 million CV events over 5 years. The focus of the initiative is to achieve more than 70% performance in the ABCs (aspirin for those at risk, BP reduction, cholesterol lowering and tobacco cessation) Increasing cardiac rehabilitation participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the US. Findings according to Mayo Clinic Proceeding article published in 2017, titled “Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative”.

Cardiac Rehab: ABCs and More Aspirin (medication) Graded physical Activity Blood Pressure reduction Cholesterol and diabetes control Tobacco Cessation Counseling (nutrition) Screening (depression) Immunizations Stress management Cardiac rehab is a class 1a recommendation from both the American Heart Association and the American College of Cardiology Participants in the Cardiac Rehab + Stress Management Therapy group exhibited lower rates of clinical events compared with those in the Cardiac Rehab-alone group (18% versus 33%; hazard ratio=0.49; 95% confidence interval, 0.25-0.95; P=0.035)

"So ,then do you have any artery softeners?"

Focus Group Discussions & Perspective Patient PCP Cardiologist Organization Rehab Facility onsite vs. stand alone Physiotherapist

Missed Opportunities to Impact Evidence-Based Intervention Patient Survival Quality Of Life Functional Status Cardio Risk Profile Reduce Risk of 2nd Heart Attack Improve Mental Well-being A study published this week by the Centers for Disease Control and Prevention examined cardiac rehabilitation enrollment among patients across 20 states in 2013. It found that only 34% of patients with heart failure used rehab that year. A 2015 analysis of heart attack survivors in four states found 36% were enrolled in such programs. "These estimates highlight missed opportunities to access an evidenced-based intervention that has been documented to improve patient survival, quality of life, functional status, and cardiovascular risk profile following a significant health event, as well as reduce risk for a recurrent heart attack and psychological disorders," the authors wrote

Benefits of Cardiac Rehab Program 26% Decline in Mortality Decline in Mortality Can Decrease hospital admissions by 31% compared to patients who don’t enroll Decrease Hospital Admissions 25% reduction in risk of long-term admission Decrease in Risk of Long-Term Admission Hospital Savings of $900 Per Patient Cost Savings cardiac rehab programs result in a 26% decline in mortality, and can decrease hospital admissions by 31% compared to cardiac patients who don't enroll in a rehab program. Cardiac rehab has been associated with a 25% reduction in the risk of long-term readmission and hospital savings of $900 per patient. Exercise pic Plate with healthy food The right meds (

Myths Keeping Patients from Pursuing Rehab Not sure if Rehab is safe for them Doesn’t have the time to work out Not sure if they can afford rehabilitation Feels like they know everything about their health

Factors that Impact Participation Cost Illness Transportation Difficulties Distance Work Embarrassment Motivation Interest Time Other cited barriers to patients’ participation are: illness, transportation difficulties, distance, work, sickness, embarrassment about group activities and the lack of understanding, motivation, interest and time (89).

Rebranding the term “Rehabilitation” Cardiac Rejuvenation ? Suggestions?

Ways to Increase Participation Rate Home-Based Cardiac Rehab Primary Care Physician Involvement Use of Modern Technology

Home-Based versus Hospital-Based Alternative to hospital-based cardiac rehabilitation as method to improve participation rate A meta-analysis showed the effect of home-based cardiac rehabilitation is similar to hospital-based cardiac rehabilitation. The (BRUM) Study found no difference in risk factor control, self-reported physical activity and the distance walked on the incremental shuttle walk test when home-based compared to hospital-based Home-based cardiac rehabilitation programs as an alternative to hospital-based cardiac rehabilitation have also been recommended as another method to improve participation rate. A recent meta-analysis showed that the effect of home-based cardiac rehabilitation is similar to hospital-based cardiac rehabilitation. The Birmingham Rehabilitation Uptake Maximization (BRUM) Study involving 525 participants following MI or coronary revascularization compared home-based cardiac rehabilitation with center-based cardiac rehabilitation from four hospitals and found no difference in risk factor control, self-reported physical activity and the distance walked on the incremental shuttle walk test (88). A

PCP Involvement Although cardiac rehabilitation programs are mostly run by cardiologists, primary care physicians’ involvement is thought to improve access and retention in the long term.

Use of Technology in Rehabilitation Can help increase enrollment Reduce risk factors Improve benefit-cost ratio The use of modern technologies offers interesting prospects for the delivery and expansion of cardiac rehabilitation programs beyond the setting of supervised, structured, and group-based rehabilitation

CHF Post-Discharge Program Congestive Heart Failure Biotelemetry Pilot The study aims to evaluate the effect of biotelemetry equipment with a centralized monitoring program on hospital admissions and HRQOL over one year. Structured clinical CHF-specific information on symptoms, functional status, and medication adherence are collected on a tablet. Objectives Reduce hospital readmissions Quality of life? Functional status? Med adherence? Patient satisfaction? Piloting in… Post discharge from hospital High risk CHF patients Study Group 400 Patients Bluetooth-equipped blood pressure cuffs and scales transmit vital signs to a tablet with 2Net Mobile Technology Patients California

CHF Pilot Results 30% reduction in the hospitalization rate among the intervention group, compared to the control group (p=0.03), which was statistically significant Readmissions within 90 days were 57% lower in the intervention group, compared to the control group (p=0.03), which was statistically significant

Patient Journey to Cardiac Rehab Appropriate referral Timely enrollment Maintain adherence Appropriate intensity Dose = duration x frequency/week High dose (> 36 sessions) Significantly reduced all-cause mortality Significantly fewer percutaneous coronary interventions Medium dose (12 – 35 sessions) Low dose (< 12 sessions) According to an article published in the Mayo Clinic Proceedings in 2017, that found that greater dose was significantly related to lower all-cause mortality (high: -0.77; SE, 0.22; P<.001; medium: -0.80; SE, 0.21; P<.001) when compared with low dose. With regard to morbidity, it revealed that dose was significantly associated with fewer percutaneous coronary interventions (high: relative risk, 0.65; 95% CI, 0.50-0.84; medium/low: relative risk, 1.04; 95% CI, 0.74-1.48; between subgroup difference P=.03). This reduction was also significant in meta- regression (high vs medium/low: -0.73; SE, 0.20; P<.001).

Cardiac Rehab Pilot: Preliminary 30-Day Readmission Rates 55% Decrease 30-Day Readmission Rates (N=50)

HCP Pilot - 12 week Timeline 30-Day Program Timeline HCP Pilot - 12 week Timeline In-Home Assessment Medication reconciliation & optimization Baseline assessment Environmental assessment Establish patient goals (e.g., smoking cessation, exercise, etc.) Education on condition, therapy, equipment (devices for heart rate, exercise tracking, pulse ox, pill box sensors for med adherence) Video Appointment Reinforce compliance Continuing education Address health issues Additional as necessary Interdisciplinary Team Weekly meetings to address problems. review patient progress and identify potential issues DAY 0 Discharge Coordination Graduation Goal assessment Post Program Survey Week 12 Rehab Program Graduation DAY 1-2 In-Home Assessment with Cardiac Health Coach DAY 8 PCP Appt Week 6 Video Appt Week 2 Video Appt Week 5 Video Appt Week 10 Video Appt Week 3 Video Appt Week 4 Video Appt Week 7 Video Appt Week 8 Video Appt Week 9 Video Appt Week 11 In Office Appt with Cardiologist Immediately communicated to care team: medication recommendations, changes in health status, clinical escalations, treatment plan issues DAY 0 Patient Referral SUMMARY REPORT Provided to clinical care team

Conclusion Cardiac Rehab is Under-Used Can Improve Quality of Life Can Reduce Morbidity and Mortality Improve Referral Process Use of Technology to Enhance Program Cardiac rehabilitation has been proven to be safe and effective in improving cardiovascular patients' life quality and reducing morbidity and mortality. Despite the evidence of its benefits, cardiac rehabilitation remains underused. More patients would benefit from this cost-effective tool by improving referral and participation to cardiac rehabilitation programs and individualizing services taking into account the patients' profile. New research areas include exploring new ways of cardiac rehabilitation delivery to improve referral and participation rates as well as developing new exercise regimens that are more effective and versatile and that incorporates new technologies in cardiac rehabilitation to maximize its benefits.  

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