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Cardiac Rehabilitation
Improving the Quality of Care Following an Acute Cardiac Event—
The Role of Cardiac Rehabilitation in the Care Continuum
Marjorie L King, MD, FACC, FAACVPR
Director, Cardiac Services, Helen Hayes Hospital, West Haverstraw
Abstract
Cardiac rehabilitation programs are ideally situated to work with cardiologists and other healthcare providers to improve the quality of care for
patients who have suffered an acute cardiac event. Core components of cardiac rehabilitation include individualized treatment plans,
communication with other healthcare providers, working with patients to develop lifelong strategies for continued secondary prevention efforts,
and assessment of individual and program outcomes. Cardiac rehabilitation decreases disability and improves mortality, but unfortunately is
underutilized, especially in the elderly, women, and minorities. Barriers to participation are related to provider, patient, and health system
factors. Performance measures have been developed to promote referral and improve programming. Quality improvement strategies and
innovative delivery models are needed to remove barriers to participation in cardiac rehabilitation.
Keywords
Cardiac rehabilitation, care co-ordination, secondary prevention, exercise
Disclosure: The author has no conflicts of interest to declare.
Received: July 20, 2009 Accepted: September 10, 2009
Correspondence: Marjorie L King, MD, Helen Hayes Hospital, West Haverstraw, NY 10993. E: kingm@helenhayeshosp.org
In this era of healthcare financial reform, there is a growing consensus Mortality Benefit
that treatments should be cost-effective, decrease disability, and CR programs provide multidisciplinary and multidimensional lifestyle and
improve survival. There is also increasing recognition that healthcare medical therapies for patients who are recuperating from a cardiovascular
should be co-ordinated among clinicians and care settings, and that event. Recent evidence clearly shows that patients who participate in CR
patients should be involved in the decision-making process. Cardiac have reduced all-cause mortality. In a study of five-year mortality data in
rehabilitation (CR) programs are ideally situated to help physicians and 601,099 Medicare beneficiaries who had suffered a cardiac event, Suaya et
patients individualize and optimize secondary prevention, as well as al. demonstrated that those who attended CR had significantly decreased
decrease disability, across the care continuum. mortality compared with those who did not. This  ranged from a  34%
decrease using propensity-based matching to a 21% decrease including
Phases of Cardiac Rehabilitation instrumental variables. Patients who attended 25 or more sessions had a
CR is an integral component in the overall management of patients 19% lower likelihood of dying over five years relative to matched CR users
with cardiovascular disease and begins during the acute care who attended 24 or fewer sessions (p<0.001).
1
hospitalization. Typically, patients are referred to early outpatient CR
at discharge, which includes supervised, monitored exercise along Underutilization of Cardiac Rehabilitation
with education and counseling related to secondary prevention The biological, psychological, and clinical benefits of CR were reviewed
issues. Selected elderly patients may be referred for intensive in  US Cardiology in 2008 by Lavie and Milani.
2
Despite clear and
inpatient rehabilitation to improve mobility and function, typically in consistent evidence that CR improves health status, decreases disability,
an acute inpatient rehabilitation facility. and improves survival,
1,3,4
underutilization remains an issue, particularly
for minority, elderly, and female patients. Approximately 20–30% of
Upon ‘graduation’ from early outpatient CR, patients are encouraged to eligible patients participate in CR following a qualifying cardiovascular
continue lifelong regular physical activity and compliance with disease event, with significant geographical variation in CR participation
secondary prevention activities. Many CR programs offer maintenance across the US.
5,6
Professional associations including the American
courses for these patients—typically self-pay supervised exercise, Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR),
education, and support. Alternative delivery models have been American College of Cardiology (ACC), and American Heart Association
developed in research settings but are not widely used at this time, (AHA) have recognized this treatment gap. They have  published joint
often due to limited reimbursement (see Figure 1). performance measures related to CR referral and programming in order
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