Lichtman, Steven W.

Introduction: Cardiac rehabilitation (CR) is an effective but highly underutilized therapy for heart disease. Efforts are underway to increase CR referral and enrollment, but little is known about the potential capacity for growth in CR utilization in the United States. To address this concern, we estimated the current national capacity of CR programs across the United States and assessed obstacles to potential growth. Methods: We surveyed all CR Program Directors listed in the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) database in November of 2012. Respondents reported current enrollment levels, current program capacity, program capacity given reasonable expansion, and obstacles to growth. Results: Of 812 Program Directors in the AACVPR database, 290 (36%) completed the full survey. Respondents represented somewhat larger programs compared to non-respondents (4.0 vs. 4.6 full time employees, p = 0.01), but were otherwise similar. Current enrollment levels demonstrated a median [IQ range] of 140 [75,232] patients per year and a current estimated capacity of 192 [100,300] patient per year. Respondents estimated that programs could expand services by 25% to 240 [141,380] patients annually, assuming a significant increase in patient demand and a feasible increase in resources. We estimate that if programs filled to their current capacity, national CR utilization rates would increase from 34.7% to 46.4% (95% CI, 43.9 to 48.9) of eligible US patients each year. Given feasible program expansion, utilization could increase to a maximum of 58.4% (95% CI, 55.2 to 61.6) of qualifying patients. Capacity projections based upon absolute patient numbers and national statistics revealed concordant results. The most commonly cited obstacles to increasing patient participation are shown in the figure. As seen, the majority (88%) are controllable system-related factors unrelated to patient behavior. Conclusions: Even with substantial expansion of all existing CR programs, there is currently insufficient capacity in current CR programs to meet national service needs. Solutions to this problem will likely include the creation of new CR programs, and new policies that improve reimbursement for CR and also embrace new models of CR delivery.

Background: Cardiac Rehabilitation (CR) is an effective but highly underutilized treatment for heart disease. Prior studies have demonstrated that the use of strategies such as systematic referral (as part of an order set that does not depend on physician initiative or memory, usually with an opt-out option), liaison facilitated referral (a specific staff member who discusses the program, encourages attendance, and facilitates referral), an early appointment (< 2 weeks), and telephone appointment reminder calls can all improved enrollment rates. However, it is unclear how frequently these strategies are utilized across the United States, how often CR programs monitor their participation rates, and how often quality improvement (QI) projects designed to improve participation rates are performed. Methods: We surveyed all CR program directors in the American Association of Cardiovascular and Pulmonary Rehabilitation’s (AACVPR) database. We assessed basic program features, use of systematic referral, liaison facilitated referral, early appointments, and telephone reminder calls and QI projects. We also assessed self-reported referral, enrollment, and completion rates. Results: Response rate was 36% (290/812). Non-response bias analysis showed reasonable survey representativeness. Over the past 5 years, 49% of programs measured hospital referral, 21% office/clinic referral, 71% program enrollment, and 74% program completion rates. Self-reported rates (interquartile range) were 68 [32 to 90]% for hospital referral, 35 [15 to 60]% for office/clinic referral, 70[46 to 80]% for program enrollment, and 75[62 to 82]% for program completion. Programs reported utilizing a hospital-based systematic referral, liaison facilitated referral, or inpatient CR program 64%, 68%, and 60% of the time, respectively. Early appointments (< 2 weeks) were utilized by 35% and consistent phone call appointment reminders were utilized by 50%. Over the past 5 years, the percent or programs performing QI projects were 62% for hospital referral, 42% for clinic referral, 60% for program enrollment, and 57% for program completion. Measurement of participation rates was highly correlated with performing QI projects (p < 0.0001.) Conclusions: Although programs are aware of participation rate gaps, the monitoring of participation rates is suboptimal, quality improvement initiatives are infrequent, and proven strategies for increasing patient participation are inconsistently utilized. Awareness in outpatient clinical settings is particularly low. These issues likely contribute to the national CR participation gap and may prove to be useful targets for national QI initiatives.