By Carolyn Crist

(Reuters Health) – Just one in three patients enrolls in recommended cardiac rehabilitation after having a blocked heart artery cleared and a stent inserted, a Michigan study suggests.

Despite benefits from rehabilitation such as better quality of life and lower rates of rehospitalization, patients may not attend these sessions because of issues related to insurance, costs and access to a rehab facility, the study authors report in the Journal of the American College of Cardiology.

Efforts to get doctors to increase their referrals of patients for cardiac rehab have worked, the authors write, but more needs to be done to make sure patients attend the sessions.

“The use of cardiac rehabilitation after coronary stenting carries the strongest recommendation in our clinical practice guidelines,” said lead author Dr. Devraj Sukul of the University of Michigan in Ann Arbor.

“Unfortunately, the use of cardiac rehabilitation among eligible patients remains low,” he told Reuters Health by email.

Sukul and colleagues analyzed data on more than 42,000 Michigan patients who underwent percutaneous coronary intervention (PCI), a common procedure to clear a blocked heart artery that typically includes placement of a tiny tubular stent to keep the blood vessel open. Using two databases of medical and health insurance records, researchers tracked patients who received care at one of 47 Michigan hospitals between 2012 and 2016, noting who was referred to cardiac rehab, who attended and what factors may have influenced their participation.

The study team found that 30,075 patients were discharged alive to their homes with a referral for cardiac rehab, and 8,000 attended at least one session within 90 days after discharge. People were more likely to attend if they had an “acute” reason for getting PCI, such as certain types of heart attack. And those who had other health problems, such as diabetes and peripheral artery disease, were less likely than others to attend rehab.

In addition, patients covered by Medicare Fee-For-Service insurance were less likely to attend cardiac rehab than those covered by private Blue Cross Blue Shield of Michigan plans. Among all the patients with Medicare, those also covered by Medicaid, the state-run insurance plan for the poor, were less likely to attend a session.

Geography played an interesting role as well, the researchers note. The distance from the center of a patient’s home ZIP code to the nearest cardiac rehab session didn’t make a difference in who was likely to attend rehab. But if the cardiac rehab location was more than two miles from the site where the PCI procedure took place, a patient was less likely to attend cardiac rehab.

“We found it interesting that there were a diverse set of factors associated with patients ultimately attending cardiac rehabilitation,” Sukul said. “This suggests that multi-faceted strategies, such as insurance redesign, may need to be tested and implemented to improve cardiac rehabilitation use.”

“Ideally, cardiac rehab would be provided without cost to all patients who qualify regardless of financial ability,” said Dr. Ellen Keeley of University of Florida Health in Gainesville, who wasn’t involved in the study.

Keeley and colleagues run a clinic that evaluates heart attack patients after hospital discharge, which includes a conversation about cardiac rehab. Patients are more likely to enroll after hearing details about what it involves, such as exercise, nutrition counseling and smoking cessation, she noted.

“I think the one-on-one aspect – and the fact they have been out of the hospital for about one week – allows them to ask a lot of questions in a relaxed fashion, and then they see that this type of program has a lot to offer them,” Keeley said by email.

Making cardiac rehab more accessible through “pop-up” sites that use space in a community center, as well as mobile units and telemedicine, could help those who live far away, she added.

“Even if a patient cannot attend all the sessions due to finances or distance or both, I encourage them to at least attend one or two sessions,” she said. “They can learn a significant amount about diet and exercise and gain pointers on how to create their own program at home.”

SOURCE: Journal of the American College of Cardiology, online June 17, 2019.