Target Audience (click to view)
This activity is designed to meet the needs of physicians.
Learning Objectives(click to view)
Upon completion of the educational activity, participants should be able to:
- Discuss the findings of a study conducted to assess the use, trends, and hospital factors associated with cardiac rehabilitation referral at hospital discharge among patients admitted with decompensated heart failure.
Method of Participation(click to view)
Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation. A statement of credit will be available upon completion of an online evaluation/claimed credit form at http://akhcme.com/akhcme/lessons/6. You must participate in the entire activity to receive credit. If you have questions about this CME/CE activity, please contact AKH Inc. at firstname.lastname@example.org.
Credit Available(click to view)
CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.
AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Commercial Support(click to view)
There is no commercial support for this activity.
Disclosures(click to view)
It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.
Disclosure of Unlabeled Use & Investigational Product(click to view)
This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer(click to view)
This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.
Faculty & Credentials(click to view)
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH planners and reviewers have no relevant financial relationships to disclose.
Complete the Post Test(click to view)
According to recent estimates, heart failure (HF) affects an estimated 6 million Americans, and 870,000 people in the United States are newly diagnosed with HF each year. The disease accounts for more than 1 million hospitalizations and over $30 billion in direct costs annually. Several clinical trials have shown that HF patients who undergo a rigorous 36-week cardiac rehabilitation (CR) program that focuses on aerobic exercise training are more capable of controlling shortness of breath symptoms and are better able to perform daily activities, such as walking and climbing stairs.
In 2007, a landmark study called the Heart Failure and A Controlled Trial Investigating Outcomes of Exercise Training (HF–ACTION) revealed that patients who underwent exercise training after being hospitalized for HF improved their ability to perform normal daily living tasks, were less likely to be rehospitalized, and had a lower mortality rate. “After data from HF–ACTION were released, the American College of Cardiology and American Heart Association (ACC/AHA) issued guidelines recommending CR for medically stable HF patients,” explains Gregg C. Fonarow, MD. “Recently, CMS approved CR for eligible patients with HF with reduced ejection fraction, making it available to a broader group of Medicare patients.”
Assessing CR Trends
Current guidelines recommend CR in medically stable outpatients with HF, but few studies have examined temporal trends and factors associated with CR referral among these patients in real-world practices. To explore this issue further, Dr. Fonarow and colleagues conducted a study to assess the use, trends, and hospital factors associated with CR referral at discharge among patients admitted with decompensated HF. The study, published in the Journal of the American College of Cardiology, is among the first since the ACC/AHA guidelines were issued to assess how often physicians refer patients to CR programs upon hospital discharge and the factors associated with these referrals.
Using data from a national Get With The Guidelines–Heart Failure registry, Dr. Fonarow and colleagues assessed temporal trends in CR referral among eligible patients with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). Data were drawn from a national database of more than 105,000 people with HF who were discharged from hospitals between 2005 and 2014 and were eligible for CR programs.
Few Patients Receive Referrals
According to the study results, just 10.4% of eligible patients were referred to a CR program when they were discharged. Of these patients, CR referral rates were 12.2% for those with HFrEF and 8.8% for those with HFpEF. The research team noted that a significant increase in CR referral rates was observed among both HFpEF and HFrEF patients over the study period; Dr. Fonarow notes that that these rates were still low overall.
“It was alarming to see that only one in 10 eligible HF patients received CR referrals at discharge after being hospitalized with HF,” says Dr. Fonarow. “Physicians who were more likely to incorporate state-of-the-art therapies in the management of HF were also more likely to refer patients to CR programs. This suggests that raising awareness about the benefits of these programs may be an effective strategy for increasing referrals.”
When compared with patients who were discharged with CR referrals, those who were not referred to these programs tended to be older, were predominantly women, and were less likely to receive evidence-based, guideline-recommended HF therapies at discharge. In a multivariable analysis, the authors found that younger age, fewer comorbid conditions, and in-hospital procedures—such as CABG, PCI, and cardiac valve surgery—were most strongly associated with CR referral (Figure).
More Efforts Needed
Dr. Fonarow says that clinicians need to develop strategies to improve physician and patient awareness about the benefits of CR to increase referrals to these programs when managing patients with HF. “These trends occurred despite strong evidence that CR improves quality of life and reduces the likelihood of future hospitalizations and mortality,” he says. “We need better strategies to increase physician and patient awareness on the individual and public health benefits of CR programs. This is especially important considering the escalating healthcare expenditures that have been associated with HF hospitalizations.”
It is equally important to increase insurance coverage and reduce copayments for CR programs, according to the study. The investigators also recommend increasing access to community-based CR. “These efforts are paramount to reducing the burden of HF to society and improving patient outcomes,” Dr. Fonarow says.
Readings & Resources (click to view)
Golwala H, Pandey A, Ju C, et al. Temporal trends and factors associated with cardiac rehabilitation referral among patients hospitalized with heart failure: findings from Get With The Guidelines–Heart Failure Registry. J Am Coll Cardiol. 2015;66:917-926. Available at: http://content.onlinejacc.org/article.aspx?articleid=2429015&resultClick=3.
Creaser JW, DePasquale EC, Vandenbogaart E, Rourke D, Chaker T, Fonarow GC. Team-based care for outpatients with heart failure. Heart Fail Clin. 2015;11:379-405.
Cheng RK, Cox M, Neely ML, et al. Outcomes in patients with heart failure with preserved, borderline, and reduced ejection fraction in the Medicare population. Am Heart J. 2014;168:721-730.
Taylor RS, Sagar VA, Davies EJ, et al. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev. 2014;4:CD003331.
O’Connor CM, Whellan DJ, Lee KL, et al; HF-ACTION Investigators. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301:1439-1450.