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

2. 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

3. 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

4. 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

5. 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.

6. 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”.

7. 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, ; P=0.035)

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

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

11. 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 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

12. 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 (

13. 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

14. 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).

15. Rebranding the term “Rehabilitation”
Cardiac Rejuvenation ?
Suggestions?

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

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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, ; medium/low: relative risk, 1.04; 95% CI, ; between subgroup difference P=.03). This reduction was also significant in meta- regression (high vs medium/low: -0.73; SE, 0.20; P<.001).

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

24. 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

25. 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.

27. Questions?