Cardiac Rehabilitation Is Associated With Decreased Hospitalization and Mortality After Cardiac Valve Surgery

Mandana Chitsazan, M.D.
By Mandana Chitsazan, M.D. on

Cardiac rehabilitation after cardiac valve surgery is associated with lower hospitalizations and mortality at one year. A recent cohort study of Medicare beneficiaries, published in JAMA Cardiology, revealed. 

Medicare covers cardiac rehabilitation after myocardial infarction, heart transplant, coronary artery bypass grafting (CABG), and cardiac valve surgery. Approximately 40% of eligible patients undergoing CABG enroll in cardiac rehabilitation. That is true for nearly half of eligible patients after a heart transplant. However, there is limited data regarding cardiac rehabilitation enrollment after cardiac valve surgery.

This observational study done by investigators from Vanderbilt University aimed to evaluate the current use of cardiac rehabilitation among Medicare beneficiaries after cardiac valve surgery in the United States. The association of cardiac rehabilitation enrollment with 1- year cumulative hospitalizations and mortality was also investigated. Medicare beneficiaries (65 years or older or with qualifying disabilities) undergoing cardiac valve surgery in 2014 were included in the study. Enrollment in cardiac rehabilitation programs (as a dichotomous variable) was the primary exposure. The secondary exposure was cardiac rehabilitation as a continuous variable (number of sessions attended). Secondary outcomes included hospitalizations within one year of discharge after valve surgery and all-cause mortality within one year of discharge after valve surgery. Sensitivity analyses to address observed and unobserved confounding factors were also done. Further analyses were conducted to measure the sensitivity of the association of cardiac rehabilitation with mortality to residual confounding from frailty and other unmeasured variables. These analyses make statistical inferences about the true association of cardiac rehabilitation with mortality.

After excluding patients who attended cardiac rehabilitation programs prior to the surgery, patients with interrupted Medicare coverage, non-US residents, and patients who died in the hospital or within 30 days of discharge, a total of 41 369 Medicare beneficiaries undergoing valve surgery in 2014 were included in the final analysis. The median age of the patients was 73 [interquartile range (IQR), 68-79] years and 16 939 patients (40.9%) were female. Aortic valve procedures were the most common valve surgery (28 238 [68.3%]), followed by mitral valve replacement (5068 [12.3%]), mitral valve repair (3799 [9.2%]), and tricuspid valve surgery (484 [1.2%]). One-year mortality was 2726 (6.6%). Nearly 41% of the patients (16 964) were hospitalized at least once within one year after discharge.

A total of 17 855 Medicare beneficiaries (43.2%) enrolled in cardiac rehabilitation programs after cardiac valve surgery. The median number of sessions attended was 32 (IQR, 18-36). After multivariate adjustments, patients who underwent a concomitant CABG surgery were more likely to enroll in a cardiac rehabilitation program (odds ratio [OR], 1.26 [95%CI, 1.20- 1.31]). Of note, there were substantial differences in the use of cardiac rehabilitation by racial/ethnical groups. Asian patients (OR, 0.36 [95%CI, 0.28- 0.47]), black patients (OR, 0.60 [95% CI, 0.54-0.67]), and Hispanic patients (OR, 0.36 [95% CI, 0.28-0.46]) were much less likely to enroll in cardiac rehabilitation compared with white patients. Residents of the Midwest census region were more than twice as likely as patients residing in the South census region (reference) to attend cardiac rehabilitation programs (OR, 2.40 [95% CI, 2.28-2.54]). There was no significant difference in regard to the median (IQR) number of cardiac rehabilitation sessions among types of valve surgery. The median time between discharge and the first CR session was 44 (IQR, 29- 66) days.

Cardiac rehabilitation was associated with a lower 1-year hospitalization risk (hazard ratio [HR], 0.66 [95% CI, 0.63-0.69] after multivariable adjustment. Enrollment in cardiac rehabilitation was also associated with a 4.2% absolute decrease in 1-year mortality risk CVS (HR, 0.39 [95%CI, 0.35-0.44] after multivariable adjustment. After stratifying the models by aortic valve surgery, mitral valve repair, mitral valve replacement, and multiple valve replacement, the association between cardiac rehabilitation use and cumulative 1-year hospitalization risk remained similar. Sensitivity analyses adjusting for observed and unobserved confounding factors, particularly frailty, demonstrated similar results.

We identified major racial/ethnic disparities and geographic variation in cardiac rehabilitation enrollment in this population.These results invite further study on barriers to cardiac rehabilitation enrollment in patients who have had CVS, as well as efforts to expand cardiac rehabilitation access to groups of patients who have had cardiac valve surgery and have particularly low enrollment rates”.- Dr. Patel, et al.

This study has implications at both the clinical and policy levels. The racial/ethnic disparities and geographic variations in cardiac rehabilitation use warrants further evaluation for barriers in underserved areas and low-performing institutions. This study is relevant to the value-based health care delivery model. Cardiac rehabilitation will likely play a crucial role in bundled services, including those associated with cardiac valve surgery.

The study had some limitations that should be considered when interpreting the results. As an observational study, it was prone to unmeasured confounding bias. Medicare beneficiaries included patients 65 years or older or with disabilities. Therefore, the generalizability of the study results to younger patients is questionable.

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