American College of Cardiology

American College of Cardiology

March 16, 2019
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Type 2 MI: Cardiac rehab referrals, attendance low

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Jason Wasfy
Jason Wasfy

NEW ORLEANS — Patients with type 2 MI are not only rarely referred to cardiac rehabilitation, but they are even less likely to attend.

“Not much is known about how to best help patients with type 2 MI,” Jason Wasfy, MD, MPhil, director of quality and analytics at Massachusetts General Hospital Heart Center, medical director of the Massachusetts General Physicians Organization and assistant professor of medicine at Harvard Medical School, wrote in an email to Cardiology Today. “Research on this topic is becoming much easier, in part because of the introduction of a separate billing code for type 2 MI. Because of this billing code, it is now easier to identify these patients and study their clinical outcomes.”

In a study, which was simultaneously published in the Journal of the American College of Cardiology, Wasfy and colleagues used the new ICD-10 billing code to identify patients with type 2 MI at Massachusetts General Hospital from October 2017 to May 2018. They gathered data on cardiac rehab referral, scheduling and attendance through physician chart review.

“We were particularly interested in whether these patients are referred and attend cardiac rehab. Low rates of referral and attendance at cardiac rehab are a major gap in the quality of care for patients with coronary disease nationally,” said Wasfy, a Cardiology Today Editorial Board Member.

Lack of referrals, attendance

During the study period, 359 patients were characterized as having type 2 MI. Of the 321 patients who were alive at discharge, however, only 21 were referred to cardiac rehab.

“Since rates of referral and attendance at cardiac rehab are known to be low, we were not surprised that patients with type 2 MI had low referral and attendance rates. What surprised us — really shocked us — is how low these rates were. Only 6.5% of patients with type 2 MI were referred to cardiac rehab. Out of 359 patients, literally no one actually attended,” Wasfy told Cardiology Today.

The researchers found that patients had a high prevalence of CV and non-CV morbidities, but they noted no differences between those who were referred to cardiac rehab and those who were not in terms of baseline characteristics, diagnostic testing or treatment strategies.

Among the patients who were not scheduled for cardiac rehab, 29% did not meet insurance criteria, with most having Medicare; 14% of patients declined; 19% were deemed not appropriate for cardiac rehab at the time; 14% were referred to but did not attend cardiac rehab at another facility; and 10% could not be contacted. There was no identifiable reason for not scheduling cardiac rehab in 14% of patients.

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Benefits of cardiac rehab

These low rates are discouraging, the researchers noted, as cardiac rehab has several benefits, such as the favorable effects of exercise in patients with MI and the potential for lifestyle and medication adjustments to address the common coexisting comorbidities in this patient population.

“Our findings suggest a real gap in the quality of care for patients with type 2 MI. It is possible that patients with type 2 MI either benefit less or more from cardiac rehab than other patients with MI, and prospective trials are sorely needed,” Wasfy said. “However, until those trials are available, there are both conceptual, pathophysiological reasons why these patients would benefit from cardiac rehabilitation, and it is recommended as a mortality-reducing intervention for all patients with MI.”

In addition to exploring optimal treatment strategies for patients with type 2 MI, he said there is another area that researchers should explore.

“We need validation of pragmatic reforms in care delivery, such as registries, that could improve referral, access and adherence to cardiac rehabilitation,” Wasfy told Cardiology Today. – by Melissa Foster

References:

McCarthy CP. Abstract 1231-387. Presented at: American College of Cardiology Scientific Session; March 16-18, 2019; New Orleans.

McCarthy CP, et al. J Am Coll Cardiol. 2019;doi:10.1016/j.jacc.2019.01.032.

Disclosures: Wasfy reports he has received grants from the American Heart Association, Harvard Catalyst and NIH, and he has received a minor speaking fee from the American Association of Cardiovascular and Pulmonary Rehabilitation. Please see the study for all other authors’ relevant financial disclosures.