Dr. Randal J. Thomas
Appearances
Health Chatter
Cardiac Rehab
Yeah, so another good question. Medicare, as it's reviewed all of the data, And the data is in all fields of medicine. It's not complete, of course. We can always have more. But based on Medicare's review, they determined that for seven conditions, 36 sessions would be covered. So the 12-week, 36 sessions, they would cover it. So it's the same coverage for all the conditions.
Health Chatter
Cardiac Rehab
So it's, as you would imagine, heart attack, stenting, bypass surgery, bowel surgery, transplant, heart failure, and angina, stable angina. They also cover it for peripheral disease, the PAD, the disease in the legs. But anyway, they cover the same program. Each program is individualized. So say a bypass surgery patient comes in for the first six weeks.
Health Chatter
Cardiac Rehab
They're doing things a little differently than someone who's had a heart attack and had a stent put in. And someone with surgery who had their chest opened as part of the procedure, their sternum is going to be healing over several weeks. So we make sure we help them through their recovery in a different way than, say, a heart attack patient would be doing.
Health Chatter
Cardiac Rehab
But the timing and the coverage is really similar. The implementation of the program is individualized according to the patient's own needs.
Health Chatter
Cardiac Rehab
Yeah. And this is one of the great things about cardiac rehabilitation too. It's a team. And so the physicians are there to help, uh, assess patients, make sure they're stable, assess any problems they're having along the way, make sure the program is safe. Um, There are nurses that help with those assessments and implementation of the program, checking patients as they come in.
Health Chatter
Cardiac Rehab
And we have exercise physiologists, clinical exercise physiologists who are trained to do exercise therapy in patients with heart disease. We have dieticians. We have social workers and psychiatrists who help us in the psychological aspect of recovery. We have physical therapists who help us because a large percentage of our patients have hip pain and knee pain and other limitations.
Health Chatter
Cardiac Rehab
We connect with sleep specialists and diabetes specialists and hypertension specialists. So we're connecting all throughout. But the people who deliver the care actually are mainly the exercise physiologists and the nurses. at least here in the United States. In other countries, it varies somewhat. In many countries around the world, physicians have more of a hands-on role and nurses.
Health Chatter
Cardiac Rehab
And in some countries, more physical therapists take over and help with this. But here in the United States, it's primarily exercise physiologists and nurses who help.
Health Chatter
Cardiac Rehab
Yeah, usually the nurse will be the one to meet the patient. I mean, we have a desk person, of course, to check people in.
Health Chatter
Cardiac Rehab
The person who helps with the evaluation initially, usually the nurse, and the exercise physiologist work together with the nurses. The nurse does a medical evaluation, and in many centers, a physician does part of that. or all of that. And then there's a team approach or some assessments done initially to see where they are, what their needs are, and a baseline functioning and needs and so forth.
Health Chatter
Cardiac Rehab
And then those are tracked over time and repeated so they can measure progress. And those repeated measurements are done by the same people too. But the team members are introduced along the way as needed. Dietitian, our patients all see a dietitian at least once. And for those who need a lot of help, I'll see them more than that.
Health Chatter
Cardiac Rehab
And for those who, and we do some initial evaluation for depression, which is a very common thing after a heart attack. For those who have depression, we make sure they get plugged in for evaluation and management for those needs. Same thing for sleep apnea, diabetes, et cetera. So depending on their needs, after that initial assessment, we'll design a treatment plan for them
Health Chatter
Cardiac Rehab
And I'll just point out one thing, one of the great things about the team approach and the multidisciplinary approach. Several studies have shown that people who participate in cardiac rehabilitation are less likely to be hospitalized during the year after a heart attack. That's an important quality measure.
Health Chatter
Cardiac Rehab
It not only tells us that the patients are doing better, but also that the care that's been given is assuming a higher quality, right? Yeah. So what's interesting, though, is for those who go to cardiac rehabilitation, they're less likely to be hospitalized for cardiac reasons as well as non-cardiac reasons. And it only makes sense because it's a multidisciplinary approach.
Health Chatter
Cardiac Rehab
So we help to identify lung issues or diabetes issues or other things that might land them back in the hospital, but with the help of our team can often pick that up and reduce the chance of that happening.
Health Chatter
Cardiac Rehab
Yes. Yes, definitely. You know, these principles, reduce the risk of future heart problems. And they're applied to people with known heart disease, mainly because that's the targeted audience and clientele. And the service is covered through insurance carriers and so forth. But in reality, those principles apply to everybody.
Health Chatter
Cardiac Rehab
you know, exercise, health eating, et cetera, that's going to help us all to do better. If you look at, there's a concept of number needed to treat that you may have talked about in this show before. So how many people do you need to treat with a given therapy to save one life, right?
Health Chatter
Cardiac Rehab
And for cardiac rehabilitation, it'll vary somewhat, but it's anywhere from about 15 to 50 people needing to be treated to save a life. And for many, that's in the secondary prevention realm. So we're trying to avoid those second events. For the primary prevention, we're trying to avoid the first events. It's going to be about 150 to 300 people treated to save one life.
Health Chatter
Cardiac Rehab
So that's because people generally you know, are lower risk than those who've had an event already. So you need to treat more people to have the, you know, to save that one life. But it's still beneficial and still very important. There are many programs, many cardiac rehabilitation programs that offer primary prevention options to people.
Health Chatter
Cardiac Rehab
So they're like people with diabetes. There's diabetes prevention programs and diabetes management programs. And when we talk about the future opportunities for rehabilitation, that's right square in the middle. And we sometimes call that prehabilitation, where you take care of it before the event.
Health Chatter
Cardiac Rehab
And actually, it's even been shown for people who need heart surgery, if you rehabilitate them before surgery, they're going to do better after surgery.
Health Chatter
Cardiac Rehab
yeah so so there's a lot of opportunity along those lines and uh we need to find and this is true for secondary prevention too we need to find more effective cheaper ways to do things for everybody and because we can all benefit so you said um if somebody has an event typically um
Health Chatter
Cardiac Rehab
Fair. Now, it's a really good place to start. It may seem pretty logical to us today that rehabilitation after a cardiac event just makes sense because it does. It hasn't always made sense. And in fact, looking back into the like in the early 1900s, even into the mid 1900s, it was thought that activity in people with heart conditions was harmful.
Health Chatter
Cardiac Rehab
More forward-thinking third-party payers that are covering primary prevention rehabilitation, particularly for people with diabetes. So that's happening. And there are some demonstration projects through Medicare, too, that have looked at this. But a lot of the private insurers are doing this more and more.
Health Chatter
Cardiac Rehab
Yeah, absolutely. So when patients graduate from our program, at that three month mark, you know, we remind them that their rehabilitation doesn't stop. In fact, I like to remind people at that point, they're graduating, And now you're going to graduate school. You're going to be working on your PhD and getting a healthy heart.
Health Chatter
Cardiac Rehab
And so connecting to silver sneakers, connecting to other groups in the community are a key part to that. There are churches that help with this too. The Princess Brewer, who I think you know from our group, has helped to do that too, and many of the churches in the area. And that's a great connection too. So we look for those connections. Some programs actually do provide a longer-term option.
Health Chatter
Cardiac Rehab
It's called a maintenance program where people pay out of their pocket to come in. They don't get quite the same level of attention as they did during the earlier part. but they're there to exercise and ask questions and check their blood pressure and so forth. So that does exist in some centers too.
Health Chatter
Cardiac Rehab
So that's a great question. That gives a nice segue into the question of, you know, what are the challenges and the barriers to rehabilitation? I've already mentioned, if you look at any outcomes, if you look at things like recurrent heart attacks, cholesterol control, blood pressure control, smoking rates, medication adherence, re-hospitalization, death rates, all better.
Health Chatter
Cardiac Rehab
You know, depression scores, all better. So why then don't we have 100% participation, right? It seems like it'd be a slam dunk. It's actually not too surprising, though, that we don't. If you look at almost any therapy, Almost anything we do in medicine, it's not perfect.
Health Chatter
Cardiac Rehab
In fact, if you look at cholesterol control, something like 25% to 30% of people who need to have their cholesterol controlled have their cholesterol controlled at the appropriate level. So it's not unusual that we have gaps. It's unfortunate, though. So in cardiac rehabilitation, it's been studied a lot.
Health Chatter
Cardiac Rehab
the percentage of people, this is in the Medicare population, the percentage who participate in cardiac rehabilitation of those who are eligible, about 25%. That's among all comers. And if you look among women, it's about half that. Among social and racial minority groups, about 7 to 10%.
Health Chatter
Cardiac Rehab
And this has been, this has been pointed out and this has been worked on for many, many years and been part of many groups who've been working on this.
Health Chatter
Cardiac Rehab
So we do see, so for example, I mentioned the buy-in in recent years, the major organizations, the CDC and Medicare have formed something called Million Hearts, which is an organization that is aimed to save a million lives per year from heart problems. And cardiac rehabilitation is a major focus of that group.
Health Chatter
Cardiac Rehab
And he was, in fact, advised against in most cases. A good example of a turning point occurred when Dwight Eisenhower was serving as president of the United States and he had a heart attack. And all of his specialists gathered around him and said, okay, you need to get bed rest for six months. You need to curl back on your work in the White House. There's no way you can run for reelection.
Health Chatter
Cardiac Rehab
So they've helped to gather business leaders and educational leaders, researchers, patient groups, and really making some good headway. And for the first time, as we looked at changes over time, we're seeing some improvements. So after heart attack and stenting, and after heart attack and bypass surgery, those combinations
Health Chatter
Cardiac Rehab
from about 1990 till about 2020, we've seen a near doubling of participation rates. It's still way below where we need to be, but it's much, much better. There are some groups where it's still not going up. For example, if you have a heart attack and no procedure, it's not looking good still. It looks like procedures were more tuned in on plugging people into these protocols. But on the other end,
Health Chatter
Cardiac Rehab
And how do we expand the reach to get to more people? Because if I have to go into a cardiac rehabilitation center, particularly if, say, I live in New York City or I live in a major metropolitan city, it's going to take me an hour to get to the center and exercise and an hour to get home. I'm not going to do that. Right. Or if a program, the closest program to me, I live in the rural areas,
Health Chatter
Cardiac Rehab
is say the closest program is an hour away. I'm not going to do that either. So over the years, home-based rehabilitation has been studied and has been shown to be effective. In fact, in my fellowship back in 1990, a long time ago, when I was at Stanford, I was part of a group that did a project looking at home-based rehabilitation and found it to be very effective.
Health Chatter
Cardiac Rehab
And that model has been implemented through the Kaiser Permanente system in California very effectively. It's not effectively covered elsewhere, unfortunately, yet. During the pandemic, when we all shifted to home-based care, home-based rehabilitation was covered temporarily by Medicare. Now it's not, or it's going away. So we're trying to get that covered again.
Health Chatter
Cardiac Rehab
So we can have home-based options. It's not the only thing that we need.
Health Chatter
Cardiac Rehab
Yeah. In fact, there's some studies showing it may be more effective. There's a study out of Australia, for example, a few years ago that showed that people are actually more likely to complete cardiac rehabilitation at home. And it makes sense.
Health Chatter
Cardiac Rehab
And, you know, you just need to kind of take it easy for the rest of your life. So he called in a specialist from Boston, Paul Dudley White, who was one of the grandfathers of preventive cardiology. And Paul Dudley White said, No, actually, exercise is gonna be good for you. You need to quit smoking. And you need to be active.
Health Chatter
Cardiac Rehab
That's exactly where it needs to go, definitely. And that's, I think, where we're getting out with the Million Hearts work. Yeah, yeah.
Health Chatter
Cardiac Rehab
And the CDC is really, really, really committed to this. I know you mentioned here in Minnesota that you worked with the CDC on some of this before, too. But the CDC is very invested in this, which has been a great thing to see. And there's some real champions at the CDC and Medicare and really in the government.
Health Chatter
Cardiac Rehab
And so making coverage of rehabilitation a higher priority is one way that can come into being, of course. And then especially looking at alternative methods of delivery being covered. And that's also being pursued very aggressively, you know, through national coverage policies. And then allowing other health professionals to be part of the equation.
Health Chatter
Cardiac Rehab
nurse practitioners, and others who can serve as medical supervisors of a rehabilitation program, particularly for the critical access hospitals that may not have doctors around. So all those things, those are all parts of things that are happening to try to expand in the reach of cardiac rehabilitation.
Health Chatter
Cardiac Rehab
I'll mention a couple of others very briefly because there's some internal things that we can do. and definitely some external things. Internally, so for example, if you provide incentives to people, they would be more likely to come to rehabilitation and participate.
Health Chatter
Cardiac Rehab
Yeah, so some simple, I'll give you a simple one and a more complex one. Simple one, we published on this a few years ago. So we did some very simple things. So at key time points, at session 10, at session 20, That's section 36. So a patient gets a T-shirt, they get a water bottle, you know, they get a book on nutrition. That's a complete rehabilitation. And they get encouragement along the way.
Health Chatter
Cardiac Rehab
And we found a significant improvement in completion rates and participation rates. That's a simple thing. And a more complex way to do it was studied in Vermont, actually. You're talking about Medicaid patients before, too, and this was done in Medicaid patients in Vermont, Phil Ades and his group.
Health Chatter
Cardiac Rehab
And we're going to control your blood pressure with the medications that they had at the time. And he got him back, you know, more and more active and He certainly had some problems with his heart after that, but he was able to recover. And it was kind of a turning point for preventive cardiology in a way where people started to look at this opportunity.
Health Chatter
Cardiac Rehab
What they did was they took a group of patients who are Medicaid recipients who needed cardiac rehabilitation. That's among the lowest of the low participation rates of all the groups I've mentioned. And they built into the program and the incentive group. So the intervention group received incentives. They were financial incentives. So they received about $25 per session.
Health Chatter
Cardiac Rehab
And then once they graduated, it was like $150, you know, some incentives. And they found that the participation rates went out the roof for those who are in the incentive group. And they found not only that, I think they were getting ready to publish these data, they found that the overall cost to the healthcare system was less in the people receiving the incentives.
Health Chatter
Cardiac Rehab
Because they were doing better staying out of the hospital, staying healthier. So those are some examples of some internal things that we can do potentially.
Health Chatter
Cardiac Rehab
We've also looked at some things like report cards, performance measures, and we helped to put together some performance measures so that hospitals and medical groups are graded based on how well they do at getting people into cardiac rehabilitation. And that helped a little bit. That's helped a little bit. At least the referral to patients to cardiac rehabilitation has helped.
Health Chatter
Cardiac Rehab
Yeah. And this is kind of getting into the future rehabilitation and really the present as well. So, Yes, there are options. In fact, there's a growing number of companies who are getting into this arena. There are apps, there are online options.
Health Chatter
Cardiac Rehab
and there's there's some things that help with center-based care and there's some things that help with home-based care and there's some that do both it's more of a hybrid approach which i think is going to be the way to go in the future where you get some benefits of group interaction in person but the convenience of home and still some interactions and so forth but there are there are different applications and and programs are available
Health Chatter
Cardiac Rehab
And there were studies at that time that started to look at some simple things like instead of having people at bed rest for six weeks in the hospital after a heart attack, let's have them sit up in a chair. And they found that people did better. And then they said, well, why don't we walk them up and down the hallway and And they did some studies along those lines.
Health Chatter
Cardiac Rehab
to use for patients. Now, in 1990, when we did the project, it was called the MultiFit Study. The device we used at that time, the nurses that carried out the program, they used a phone, a telephone. That was the device we used. And that works. Simple telephone connection with patients can work. There are devices such as a smart watch
Health Chatter
Cardiac Rehab
So you can pre-program a smartwatch and make it so that everything is there. You give the patient the watch. They go home with it, and the watch communicates with them every day, helps them to kind of go through their rehabilitation, et cetera. And it can help in many different ways very simply. The problem with some of the electronics and the apps that are available –
Health Chatter
Cardiac Rehab
And so trying to find a simple way to do that is going to be key and a cheap way to do it too. So you don't have to buy fancy equipment or pay for a new phone line or anything. But it's happening, definitely happening.
Health Chatter
Cardiac Rehab
And Dr. Brewer is a good one to, that she works with us down here pretty closely and, and some new innovative ways to deliver rehabilitation to us.
Health Chatter
Cardiac Rehab
And sure enough, people did better. It felt better, recovered quicker, got back to work quicker and so forth. And then they started to be even more bold and said, why don't we take it to the outpatient setting? And the doctors at the time that were pursuing this were really, they faced a lot of opposition. People thought it was too dangerous. These are people with heart conditions.
Health Chatter
Cardiac Rehab
Yeah. The, um, I guess what I would just say is that it's been very encouraging to see the progress over time of rehabilitation and its acceptance and identification of it as a critically important therapy that has been underutilized. It's probably the largest gap in delivery in cardiovascular care today. I mean,
Health Chatter
Cardiac Rehab
apart from the disparities that we've already talked about from social and racial reasons. But my cardiac rehabilitation is one of the biggest gaps in care that we have today. So it deserves our attention.
Health Chatter
Cardiac Rehab
Absolutely. I would just say we need to have the same courage that our colleagues did back in the 1950s when they said, the status quo doesn't seem right. We shouldn't be keeping people in bed rest for six weeks. Let's try something new. And so we need to have the same courage to look outside the status quo and just keep finding better ways to do things.
Health Chatter
Cardiac Rehab
And fortunately, there's a lot of people in the arena in this area who are trying to do that. And I look, as I mentioned, our trainees and our patients and professionals in the field. This is the best time to be in the field of cardiac rehabilitation as a professional and as a patient. Never been better. This is a great time. We have a lot of work to do still, but never been better.
Health Chatter
Cardiac Rehab
Their hearts are going to burst. There's all kinds of concerns. And sure enough, as they implemented the program in the outpatient setting, they showed that it could be done safely and effectively. So that's kind of taking you up to about 1980. From 1980 on, what started to become clear was that it was more than exercise. It was more than like the physical rehabilitation side of things.
Health Chatter
Cardiac Rehab
It's interesting that physical therapy, developed after the polio pandemic and after World War I and World War II, when there were so many people with debilitating conditions, they needed help to recuperate. So cardiac rehabilitation kind of came in the shadows of that. But then in the 1980s, it was clear there was more to it than just getting people to be more active.
Health Chatter
Cardiac Rehab
That's when cholesterol and blood pressure and smoking and other risk factors became more clear and treatment for them became more available. And so from that point on, from the 1980s on, cardiac rehabilitation became more of a multidimensional program to implement a prevention program in individuals with heart disease.
Health Chatter
Cardiac Rehab
And that's why it's continued until today that cardiac rehabilitation is really looked at as a center of secondary prevention, so to speak, or recovery after an event for individuals with heart disease?
Health Chatter
Cardiac Rehab
So cardiac rehabilitation, as I mentioned, currently is a program to implement therapies of known benefit that help people recover after a cardiac event and do better, live longer, feel better, et cetera. And so the goals are really to help individuals with heart conditions to attain optimal levels of treatment, and recovery and health. So that's in a nutshell, those are the goals.
Health Chatter
Cardiac Rehab
So cholesterol control, blood pressure control, diabetes control, smoking cessation, exercising, eating healthy foods, keeping trim, all those things that we know can be a benefit. So it's a systematic approach to implement those strategies in individuals with heart conditions.
Health Chatter
Cardiac Rehab
Well, that is a great question, and it's not for lack of trying. But it's probably just a matter of the old adage for marketing, seven times, seven different ways. I think we need to just keep at it and be more effective in what we're doing.
Health Chatter
Cardiac Rehab
To tell you the truth, so when I started my career in training, when my interest in cardiac rehabilitation really caught fire, it was back in the 1980s with John Kentwell down in Atlanta. At that time, it was not even on anybody's radar, really. It was essentially unknown except for by a few people who had an interest in that area.
Health Chatter
Cardiac Rehab
And then you fast forward to today, and now the American College of Cardiology, American Heart Association, and other national organizations and international organizations are all in. I mean, they see the importance, see the benefits. They're pushing for it. We're working with congressional leaders to improve
Health Chatter
Cardiac Rehab
coverage and and the reach of cardiac rehabilitation but the marketing and the messaging still is not as effective as it could be generally people will hear about it after they've had an event or after a family member's had an event and somebody visits them in the hospital and says hey you should go to cardiac rehabilitation you'll do better you'll feel better you'll live longer and that's what people usually hear about it there are there are messaging campaigns that are going on
Health Chatter
Cardiac Rehab
for the organizations that I mentioned, but we can always do better in getting the reach further into all of our communities. And we'll come back and we'll talk a little bit about utilization of rehabilitation, particularly in certain population, because that's a extremely important topic. Okay.
Health Chatter
Cardiac Rehab
Yeah, absolutely. And so as part of the requirements of critical rehabilitation programs, they are to not only make assessments periodically during the patient's program, they do that at least every 30 days. It's a three-month program. But they also communicate that information to the referring provider or providers. In addition, as things come up, you know, intolerance to medications,
Health Chatter
Cardiac Rehab
new symptoms, those are communicated directly back to the provider. So the cardiac rehabilitation professionals really are disease managers, and they're care coordinators in many ways, a really key part to what they do. One of the benefits of cardiac rehabilitation, one of many,
Health Chatter
Cardiac Rehab
In fact, if you look at any outcome you can look at, you can find research to show benefits of cardiac rehabilitation in those outcomes. But one of them is adherence to medication. We did a study here a few years ago, and we looked at adherence to important medications after a heart attack, like beta blockers and aspirin and cholesterol medication and so forth. things that help you to do better.
Health Chatter
Cardiac Rehab
And we found, and this was among a group of patients that had insurance, they had a good coverage, they had good care and 34% continued to take all of their medications at three years, 34%. Um, The only thing that predicted better adherence was if they participated in cardiac rehabilitation. And a few studies have found this now. And it just, it makes sense.
Health Chatter
Cardiac Rehab
You know, for those of us who work in the field, you know, you see patients, they're coming in, they don't have the right medications. So you help them get on them. Or they're on medications and they're having side effects. And instead of them stopping them, you help them get on the right doses as you communicate with the providers, the primary providers.
Health Chatter
Cardiac Rehab
So there's definitely a lot of communication going back and forth. And one of the key things, I think, to cardiac rehabilitation is a communication link.
Health Chatter
Cardiac Rehab
Typically it's 36 sessions. It's three per week for 12 weeks generally. But some programs is a little bit less than that. And some do a little bit more.
Health Chatter
Cardiac Rehab
That's a good question. And that's a whole topic in and of itself, too. We'll talk about that. So home-based rehabilitation is an option. And so it's basically a three-month program is one way to look at it. So if you're coming into the center-based program, you come in three times a week for 12 weeks.
Health Chatter
Cardiac Rehab
a home-based program, you would do home-based rehabilitation with some connections, either by phone or video, sometimes in person. And you do that also for about a 12-week period.