Failure to refer: why are doctors ignoring cardiac rehab?

by Carolyn Thomas   ♥  @HeartSisters

Anne-Marie felt nervous after she was discharged from hospital following triple bypass surgery. She had only her immediate family to help her at home. And as she described:

“I felt like I fell through the cracks. When I left the hospital, my husband was given a sick woman in a wheelchair and a big bag of pills. I had heard about cardiac rehabilitation, so I followed up to see if I could join a program as I thought this could help me get back on my feet.

“But I was told they would get back to me. When they finally did – 15 weeks after my operation – I was already back at work, so couldn’t attend. I wasn’t offered any other alternative.”

When the British Heart Foundation’s National Audit of Cardiac Rehabilitation report was published, a blunt analysis by their auditors concluded that “cardiac rehabilitation remains a Cinderella service.” 

But the grim reality is hardly less Cinderella-ish on this side of the pond. And the reason so many freshly-diagnosed heart patients like Anne-Marie are falling through the cracks lies squarely with the doctors who are failing to refer their patients to cardiac rehab.

Research on the known life-saving benefits of cardiac rehabilitation is overwhelmingly positive. As I’ve written previously (here and here), the benefits of supervised rehab after a cardiac event include:

• reduced mortality (an impressive 26-40% reduction in cardiac mortality over the following five years – and that by the way, is a better outcome than that promised by taking statins)
• symptom relief
• reduction in smoking
• improved exercise tolerance
• cardiac risk factor modification
• overall psychosocial well-being.

In fact, for most heart patients, cardiac rehabilitation is one of the most cost-effective heart treatments available. In current practice guidelines of all cardiovascular societies worldwide, cardiac rehabilitation for heart patients (following heart attack or heart failure, bypass surgery, angioplasty to treat blocked coronary arteries, or heart valve replacement) is a Class I recommendation (which means that a procedure/treatment should be performed/administered).

So it might surprise you to learn that doctors themselves are a significant obstacle to cardiac rehabilitation participation, as described in this 2012 American Heart Association report published in the journal Circulation(1):

“Given the well-documented benefits of participation in cardiac rehabilitation, it is surprising how few eligible patients are referred to rehab. A number of recent surveys have reported referral rates in the order of 20%.^{(2, 3)} The under-utilization of cardiac rehab is particularly apparent:

• in women
• in those with low socioeconomic status
• in African-Americans
• in the elderly

Each of these groups represents those who are significantly more likely to die within five years following a first heart attack.^(4)”

So, let me get this straight.

Heart patients who are most likely to die within five years after their first heart attacks are the very ones who are least likely to be referred by their doctors to the cardiac rehabilitation programs that are most likely to reduce their mortality risk?

A Canadian study on cardiac rehabilitation referrals published in the European Journal of Preventive Cardiology confirmed this reality – particularly among female heart patients(6) :

“Overall, significantly more men than women are referred.”

Study author Dr. Sherry Grace of Toronto’s York University describes women’s referral reality (quite charitably, I thought) as simply “suboptimal”.

In fact, the failure of physicians to refer women patients to rehab is particularly dangerous, according to The American College of Cardiology  – and thanks to my heart sister Jodi Jackson who reminded me of this fact! ♥

“Women with coronary artery disease who completed a 12-week cardiac rehabilitation program were two-thirds less likely to die compared to those who were not referred to the program. In addition, the mortality benefit derived from this evidence-based program appears to be much more striking in women than men with the same condition, yet referrals and attendance among women fall short.” 

The trouble here is that supervised cardiac rehab programs are not simply drop-in exercise sessions. 

Recuperating heart patients need a physician’s referral to register – which is why that puny 20% doctor referral rate mentioned in the 2012 report is so appalling.

A referral is not just a piece of paper or a tickbox to be checked off on a hospital discharge form, however. It requires strong endorsement of the program’s benefits by the heart patient’s doctor. Physician endorsement is in fact one of the strongest predictors of full participation in cardiac rehabilitation.

After my own heart attack, I was, like Anne-Marie, on my own when it came to cardiac rehab. 

Not one doctor, nurse, resident, med student or janitor in the hospital’s Coronary Care Unit said one word about it to me before discharge.  I knew nothing about this program, but after I was sent back home, I did find a little brochure about cardiac rehabilitation in the big pile of paperwork I’d been given before leaving the CCU.

I was curious, so I phoned the number on the brochure for more info. I was told the basic details (it turns out that rehab is widely available at several regional sites throughout my city), but was also told that I would first need a signed doctor’s referral letter, which I had to ask for during my next doctor’s appointment. Again, this entire process was left completely up to me – NOT as a result of any health care provider telling me at any time how critically important it was for me to sign up. 

So although I was technically among those patients “referred” by a physician, my referral happened only after I did the sleuthing required to get one. And we already know what happens to the vast majority of heart patients who don’t or can’t do their own sleuthing.

No referral. 

No cardiac rehabilitation.

Oregon cardiologist Dr. James Beckerman is the author of the highly-recommended book called Heart To Start, in which he slams his colleagues who fail to refer their heart patients to cardiac rehab:

“It is bad medicine to withhold life-saving treatments, and many physicians are selling their patients short.  Cardiac rehabilitation is the best medication that you will never find in a television commercial, and its only side effect is a better quality of life.”

And cardiologist Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic in Rochester, Minnesota, has this important advice for all heart patients:

 “If your doctor recommends cardiac rehabilitation, go. 

“If you’re not referred, ask.”

. . . and then she adds this gem on Twitter (@SharonneHayes)

Some experts have been so alarmed by inexcusably poor doctor referral stats despite overwhelming evidence of benefit that in 2007, the American College of Cardiology, the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation actually included cardiac rehabilitation referrals from inpatient settings as a performance measure for acute myocardial infarction (heart attack).  Performance measures are a way that the quality of the health care provided to us is evaluated based on structures, processes and (arguably the most important) our treatment outcomes.

Seven years later, a 2014 follow-up study(5) published in the Journal of the American College of Cardiology found that cardiac rehabilitation referrals had improved since those new performance measures were introduced, but for some inexplicable reason they still remained highest in white males (once again confirming the 2012 stats in that Circulation report citing inadequate referrals among both women and non-white heart patients).

And worse, study authors also noted that, compared to all other acute heart attack discharge performance measures, cardiac rehabilitation referral still has the “lowest adherence among physicians”.

Why are so many doctors non-adherent when it comes to recommending a Class 1 guideline protocol to eligible patients? Why are so many of them just not getting it?

We’re not talking about isolated rural areas or small towns in which out-patient cardiac rehab programs may simply not be available at all.  Here’s what we’re talking about:

• rehab programs that are already in place
• physicians who seem unaware of the importance of referring their heart patients to rehab
• unacceptably low physician referrals to those programs
• even among those lucky enough to be referred, significantly higher numbers of men referred compared to their female counterparts.

The puzzling explanation for this epic failure on the part of the very profession that heart patients are trusting to look out for them is this whopper, according to the 2012 AHA report:

“First, the benefits of cardiac rehabilitation are greatly under-appreciated in the medical community.

“Greater efforts are needed to educate healthcare providers and the public regarding the benefits of cardiac rehab.”

I had to go have a wee lie-down after I read that part of the study’s conclusions.

Does this sound to you as if researchers are actually suggesting that the brainiacs in the medical community are somehow ignorant about those well-documented benefits? If I were a physician, I might be feeling embarrassed right about now at this insinuation.

How is it even possible that physicians are failing to routinely refer patients to cardiac rehabilitation because they’re uneducated about rehab benefits – and whose job is it to educate them?

I have yet to hear of any physician who fails to routinely prescribe statins or beta blockers or other heart drugs to their freshly-diagnosed heart patients. Most docs seem extremely well-educated about the benefits of pharmaceuticals in cardiac care.

The Circulation study even attempts to absolve these non-referring physicians entirely by suggesting that, since docs don’t seem to be adequately “educated” about the importance of cardiac rehabilitation, maybe we should simply look to nurses to do this for them:

“Referral for cardiac rehabilitation has frequently been the responsibility of the physician, who, largely due to time constraints and lack of awareness of its value, has generally not been a strong advocate for rehab.”

Researchers note that perhaps nurses – both in acute-care hospital and home-visit settings – can help to impact these two important predictors(5) of successful participation in a cardiac rehabilitation program:

• the heart patient should be referred while still in hospital before being discharged back home
  
• the patient must understand the importance of participating in a cardiac rehab program

But personally, I’d like to now take this suggestion several steps further.

If you’re a nurse working with hospitalized heart patients, doing home visits post-discharge, or seeing them in out-patient clinics, please pro-actively preach the vital longterm importance of participating in a cardiac rehabilitation program to your patients.

If you’re a physician who up until now has been unaware of all the longterm benefits of cardiac rehab, please do some homework about local programs in your area, and don’t let another new heart patient leave your office before you enthusiastically promote the benefits of rehab to each one.

If you’re a recently diagnosed heart patient, please do not be content to sit around like Anne-Marie did, patiently waiting for a healthcare professional who may or may not be educated enough to refer you to cardiac rehabilitation. Be loud and clear in arranging a rehab referral from your physician, and don’t stop asking until you get satisfactory answers.

If somebody you care about has recently been diagnosed with heart disease, do whatever you can to support them to register for cardiac rehabilitation. And if you’re in Canada, find the closest program here – and then educate your own physician about it.

What if you live in an area that doesn’t offer cardiac rehab? Even if heart patients are not able to get out to a supervised group cardiac rehab program in person, home-based rehab shows promising results as well.  A study published in the journal Applied Physiology, Nutrition and Metabolism, for example, found that heart patients even in home-based settings who stuck to their prescribed rehab plan achieved similar gains in cardiovascular fitness and overall cardioprotective benefits compared to heart patients attending non-home-based programs(8). Learn more from HealthLink BC about starting a modified walking/stationary bike program at home for heart patients.

Now let’s hope that physicians will not ignore this option as well.

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(1) Arena, R et al. Increasing referral and participation rates to outpatient cardiac rehabilitation: the valuable role of healthcare professionals in the inpatient and home health settings. A Science Advisory From the American Heart Association. Circulation. January 30, 2012

(2) Suaya JA, Shepard DS, Normand SL, et al. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation 2007;116:1653-1662

(3) Boyden T et al. Can increasing referral to cardiac rehabilitation improve participation? Prev Cardiol 2010;13:198-202

(4) Roger VL, et al., on behalf of the American Heart Association Statistics Committee and Stroke Statistics Committee. Heart disease and stroke statistics – 2011 update. a report from the American Heart Association. Circulation 2011;123:e18-e209

(5) Beatty A et al. Trends in Referral to Cardiac Rehabilitation After Myocardial Infarction: Data From the National Cardiovascular Data Registry 2007 to 2012. J Am Coll Cardiol. 2014;63(23):2582-2583

(6) Grace S et al. Effect of referral strategies on access to cardiac rehabilitation among women. European Journal of Preventive Cardiology August 2014 vol. 21 no. 8 1018-1025

(7) Dunlay SM et al. Barriers to participation in cardiac rehabilitation. Am Heart J 2009;158(5):852-859

(8) Kerseri Scane et al. Adherence to a cardiac rehabilitation home program model of care: a comparison to a well-established traditional on-site supervised program. Applied Physiology, Nutrition, and Metabolism, 2012, 37(2): 206-213, 10.1139/h11-151

Q: Did your physician strongly recommend cardiac rehab to you?

♥

NOTE FROM CAROLYN:  I wrote more about the importance of cardiac rehabilitation for women diagnosed with heart disease in my new book, “A Woman’s Guide to Living with Heart Disease”  (Johns Hopkins University Press, November 2017). 

See also:

• Returning to Exercise (and Training) After Heart Surgery (THE best and most comprehensive overview on this topic I’ve seen yet, written by cardiologist and triathlete Dr. Larry Creswell; especially useful for heart patients who have been regular exercisers before their cardiac event and are wondering how to safely resume their routine)
• Do we need to change the name of cardiac rehab?
• The surprising reasons heart patients don’t go to cardiac rehab
• Why aren’t women heart attack survivors showing up for cardiac rehab?
• ‘Women-only’ cardiac rehabilitation curbs depression for heart attack survivors
• How gender bias threatens women’s health
• Were you “born to walk”?
• Heart disease is a sitting disease
• Physical exercise vs. the ‘plumber’s pipe’ theory of heart disease treatment

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