Advertisement
Mayo Clinic Proceedings Home

Decisive Bearing of Organizational Dynamics on the Application and Success of Hospital-Based Cardiac Rehabilitation

      To the Editor:
      Analyses and reviews regarding cardiac rehabilitation (CR) are frequently featured in top-tier journals.
      • Sandesara P.B.
      • Lambert C.T.
      • Gordon N.F.
      • et al.
      Cardiac rehabilitation and risk reduction: time to “rebrand and reinvigorate.”.
      • Forman D.E.
      Cardiac rehabilitation: the mandate grows.
      Cardiac rehabilitation is a comprehensive secondary prevention program involving exercise training as well as medical evaluation, cardiac risk factor modification, education, and counseling.
      • Sandesara P.B.
      • Lambert C.T.
      • Gordon N.F.
      • et al.
      Cardiac rehabilitation and risk reduction: time to “rebrand and reinvigorate.”.
      It been established as one of 9 performance measures for patients with ischemic heart disease by the American College of Cardiology Foundation and other preeminent medical organizations,
      • Drozda Jr., J.
      • Messer J.V.
      • Spertus J.
      • et al.
      ACCF/AHA/AMA–PCPI 2011 performance measures for adults with coronary artery disease and hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association–Physician Consortium for Performance Improvement.
      and it has growing relevance amid present-day surges of obesity, sedentariness, multimorbidity, aging, and other complexities of care for a growing spectrum of patients.
      • Sandesara P.B.
      • Lambert C.T.
      • Gordon N.F.
      • et al.
      Cardiac rehabilitation and risk reduction: time to “rebrand and reinvigorate.”.
      • Balady G.J.
      • Ades P.A.
      • Bittner V.A.
      • et al.
      Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association.
      Yet, CR underutilization remains entrenched. Logistic (eg, excessive distance and/or lack of transportation) and cost (eg, unaffordable copayments) impediments are often cited as key deterrents.
      • Balady G.J.
      • Ades P.A.
      • Bittner V.A.
      • et al.
      Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association.
      Many suggest that new models of care (particularly home-based CR) are essential to overcome imbedded obstacles.
      • Balady G.J.
      • Ades P.A.
      • Bittner V.A.
      • et al.
      Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association.
      • Taylor R.S.
      • Dalal H.
      • Jolly K.
      • et al.
      Home-based versus centre-based cardiac rehabilitation.
      Although most CR analyses have focused on patient-specific factors affecting CR utilization, we investigated facility and organizational differences under the premise that there may still be unidentified modifiable organizational, local institutional, and personnel structures that influence enrollment and participation. By examining these relationships, we aimed to identify features conducive to utilization.

      Methods

      The Veterans Health Administration has 35 hospital-based CR programs among its 124 hospital facilities with inpatient cardiovascular services.
      • Schopfer D.W.
      • Takemoto S.
      • Allsup K.
      • et al.
      Cardiac rehabilitation use among veterans with ischemic heart disease.
      Severe underuse (only 8.4%) of hospital-based CR by veterans eligible for CR has been described previously.
      • Schopfer D.W.
      • Takemoto S.
      • Allsup K.
      • et al.
      Cardiac rehabilitation use among veterans with ischemic heart disease.
      Using administrative data, we found wide variations in utilization of CR across the different Veterans Health Administration facilities with CR programs. We identified 3 high-enrolling and 3 low-enrolling sites with similar complexity characteristics. Using a qualitative study design, we conducted semistructured interviews with a diverse range of patients and health care professionals (up to 4 of each) from each site to characterize features of high and low utilization. In each of the 6 programs, we spoke with patients who did and did not enroll, hospital cardiology staff (cardiologists, hospitalists, nurses), and CR staff (cardiologists, nurses, physical therapists, and exercise specialists) to clarify organizational and contextual barriers to and facilitators of CR utilization.

      Results

      Our results revealed important differences distinguishing high-enrolling vs low-enrolling sites. Patients from high-enrolling sites uniformly described participating because of strong health care professional endorsement. In contrast, patients from low-enrolling sites who did not enroll could not recall being informed about the program; most did not know the program even existed. Even if these patients were told and forgot, their statements suggest there was something ineffective about the messages they received. Health care professionals from high-enrolling sites uniformly described distinctive organizational climates in relation to CR, ie, there were coherent and uniform messages regarding the value and importance of CR as part of standard care and/or there were organizational processes in place to systematize CR referrals. They also described close working relationships between the cardiology and CR programs. In facilities with low enrollment, cardiology services and CR services were relatively less programmatically aligned. Cardiology staff described limited and sometimes even tense interactions with the CR service, particularly when CR was not managed by cardiology staff.
      Although several patients at high-enrolling sites described distance as being a potential barrier to CR, these logistic impediments were generally offset by perceptions that CR had great value, that a spouse or family member could help with driving, and that CR programs could bend to accommodate their schedules and needs.

      Discussion

      The literature continues to promulgate the benefits of CR at a time when many hospital-based CR programs are closing amid dwindling enrollments. Our study results suggest that organization and personnel dynamics are an important aspect of CR program success. Logistics seemed relatively less determinant of utilization in programs with optimal organizational dynamics.
      At a time when many aspects of medical care are being curtailed, especially if their value is deemed marginal, we assert that hospital-based CR is more impactful and feasible than many may appreciate. However, for patients to take advantage of CR, organizations must implement or reinforce good working relationships between cardiology and CR services and organizational processes that systematize CR referrals. Therefore, rather than dismissing hospital-based CR as impractical, we identified an opportunity to initiate changes that foster an organizational climate favorable to this vital secondary prevention program.

      References

        • Sandesara P.B.
        • Lambert C.T.
        • Gordon N.F.
        • et al.
        Cardiac rehabilitation and risk reduction: time to “rebrand and reinvigorate.”.
        J Am Coll Cardiol. 2015; 65: 389-395
        • Forman D.E.
        Cardiac rehabilitation: the mandate grows.
        Mayo Clin Proc. 2016; 91 ([editorial]): 125-128
        • Drozda Jr., J.
        • Messer J.V.
        • Spertus J.
        • et al.
        ACCF/AHA/AMA–PCPI 2011 performance measures for adults with coronary artery disease and hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association–Physician Consortium for Performance Improvement.
        J Am Coll Cardiol. 2011; 58: 316-336
        • Balady G.J.
        • Ades P.A.
        • Bittner V.A.
        • et al.
        Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association.
        Circulation. 2011; 124: 2951-2960
        • Taylor R.S.
        • Dalal H.
        • Jolly K.
        • et al.
        Home-based versus centre-based cardiac rehabilitation.
        Cochrane Database Syst Rev. 2015; 8: CD007130
        • Schopfer D.W.
        • Takemoto S.
        • Allsup K.
        • et al.
        Cardiac rehabilitation use among veterans with ischemic heart disease.
        JAMA Intern Med. 2014; 174: 1687-1689