Quality Rounds
Rehabbing Referral Rates
Cardiac rehabilitation reduces mortality among patients who’ve had a cardiovascular event. Why aren’t physicians referring more patients for services?
Interview by Scott D. Smith
Referral rates for cardiac rehabilitation for patients who’ve suffered a major cardiac event, have undergone cardiac surgery, or have certain heart conditions have remained dismally low for more than a decade, despite solid evidence that it saves lives and is included in many practice guidelines.
Randal Thomas, M.D., director of Mayo Clinic’s Cardiovascular Health Clinic, says given this poor track record, it’s time for physicians, clinics, and hospitals to be held accountable. Thomas chaired a group that has developed the nation’s first cardiac rehabilitation performance measures, which were released in October on behalf of the American Association of Cardiovascular and Pulmonary Rehabilitation, the American College of Cardiology, and the American Heart Association. A document on the measures was published in the October 2, 2007, issues of Circulation and the Journal of the American College of Cardiology and the September/October 2007 Journal of Cardiopulmonary Rehabilitation and Prevention.
Thomas shared his insights about cardiac rehabilitation, the new performance measures, and how physicians can make sure their cardiac patients get this life-saving care.
Why performance measures and why now?
Cardiac rehabilitation is an effective life-saving therapy that is underutilized, but previous attempts to increase its utilization have not worked very well.
If you look at the guidelines from the 1990s and also those from after 2000, they have consistently included recommendations for referring patients to cardiac rehabilitation. But the referral rate in 1990 was only about 25 percent for eligible patients. In 2007, it is nearly the same. So the guidelines and other methods to stimulate quality have not had much of an effect in this area.
What performance measures did the group recommend?
There are two sets of measures. The first largely targets physicians and other clinicians. It basically sets the expectation that each inpatient and outpatient who is eligible should be referred to a cardiac rehabilitation program. The second set is geared toward the programs themselves. They identify recommended structures, equipment, emergency precautions, personnel, and processes of care.
These are process measures. Why not track outcomes?
Our feeling was that an initial step would be to help identify the processes that should be followed. But this is just a first step, and future steps will include outcome measures.
What outcomes can patients expect from cardiac rehabilitation?
There is a 25 percent reduction in mortality for those who participate in a cardiac rehabilitation program compared with those who don’t. If we were to provide this to everybody who is eligible, then you’d see an overall improvement in mortality of about 20 percent for all of the people who’ve had a cardiac event. That’s a huge impact, considering that well over 1 million people a year have heart attacks, angioplasties, and bypass surgeries.
What should the referral rate be?
If you look at people who are eligible for a preventive program after a cardiac event, theoretically it would be 100 percent. There are some patients who can’t come to a center and need a home-based program, and you may have some patients with severe limitations—such as those with other life-threatening illnesses, and you could argue they aren’t as eligible. But really, all patients can benefit from secondary preventive services.
Who Should Be Referred?
All patients who have been hospitalized for one of the following cardiac events and outpatients who have experienced one or more of them in the last 12 months should be referred to an outpatient cardiac rehabilitation/
secondary prevention program:
• acute myocardial infarction
• chronic stable angina
• coronary artery bypass graft
surgery
• percutaneous coronary interventions
• valve repair or replacement
• cardiac transplantation
Source: AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services. |
How does Minnesota’s cardiac rehabilitation referral rate compare with the national rate?
It is better than the national average, which is about 17 percent of Medicare patients who are eligible for referral. In Minnesota, the rate is about 36 percent, and at Mayo Clinic, the referral rate generally runs between 50 and 60 percent.
What are the barriers to patients getting cardiac rehabilitation?
The No. 1 barrier is lack of physician referral.
Why don’t physicians refer?
The way the services are set up, the physician needs to fill out a referral form that explains why the patient is going to rehabilitation and basic information about the patient such as stress-testing results. To referring physicians, this process just seems like another half hour of paperwork.
What is the solution to overcoming the referral problem?
Centers that have made referral easier—they use standing orders or automatic orders—are where you see 50-, 60-, and 70-percent referral rates.
How can physicians improve their referral rates?
A first step is to track how many patients who are eligible are being referred. Most of us overestimate how well we are doing at this.
Then we need to implement a referral system that makes sense, is automatic, and is as easy as possible. The performance measures paper includes an example of a standing referral order. I’d recommend that every hospital have a standard, automatic cardiac rehabilitation referral order. I’d recommend a similar system for outpatient settings. A nurse or someone checking-in the patient could be authorized to identify those patients who are eligible for cardiac rehabilitation and then refer them to a program.
Finally, I would advise clinicians to contact their local cardiac rehabilitation programs to keep the dialogue open about decreasing any paperwork that might keep some physicians from referring patients.
What else might prevent patients from getting cardiac rehabilitation?
Lack of coverage, high co-pays, and misconceptions about rehabilitation. Also, some people don’t live close to a program. At Mayo, if a patient lives more than 20 minutes away, we offer to set them up with a home-based program.
What should doctors look for in a rehabilitation program?
The basic components are included in the performance measures: Education services, risk assessment, risk-reduction services that largely focus on recognizable, treatable factors such as tobacco use, cholesterol, blood pressure, diabetes, physical activity, and nutrition. In addition, programs should include screening for common and debilitating co-morbid conditions such as depression. People are at high risk for depression and other psychological problems after a cardiac event. The American Association of Cardiovascular and Pulmonary Rehabilitation also has a certification program, but only about one-third of programs are certified.
Is there a movement afoot to adopt the new performance measures?
They are brand new, so I don’t know yet. But at Mayo Clinic, we are in the process of implementing them.
Will the Centers for Medicare and Medicaid Services (CMS) adopt these measures?
We’ve had discussions with the people at CMS who actually helped start early discussions that led to the performance measures document. So I anticipate in the next year there will be more movement along those lines.
What result do you hope for?
As it stands right now, about 80 percent of our patients aren’t getting the benefits they need. So to even drop that number to 50 percent would be a great achievement. MM
Scott Smith is a staff writer for the Minnesota Medical Association.