Patient care after stent placement plays a critical role, both in their recovery and in preventing further issues.
However, recent studies have found that many patients aren’t getting the care that they need post-placement. Just one in three patients enroll in recommended cardiac rehabilitation after their stent placement, according to a Michigan study reported in the Journal of the American College of Cardiology.
And yet, accessing aftercare may be one of the best things a patient can do to improve their health:
“For reducing deaths and increasing quality of life, cardiac rehab exceeds any pill, any procedure,” says Dr. Daniel Forman, Director of Exercise Testing Lab at Brigham and Women’s Hospital and an Assistant Professor at Harvard Medical School. “Whether it’s getting a patient through a heart attack, placing a stent, or repairing a heart valve, what helped people get through their cardiac event will only be meaningful if we maintain that benefit. Cardiac rehab is an opportunity to do just that.” (Source)
With around 965,000 cardiac stents placed each year, lack of aftercare can represent a significant risk to patients and to the practices that care for them. Overall health of patients is a concern, as are readmission rates for healthcare facilities.
Why patients don’t get post-stent care
There are a number of key reasons why patients don’t get post-stent care:
Cost: This is identified as the number one barrier in most cases where patients don’t seek aftercare. In the Michigan study, patients covered by Medicare fee-for-service or by Medicaid were less likely to take up rehabilitation. In other cases, insurance co-pays are too much for them to manage, or they may be uninsured. (Uninsured rates across all age groups have risen). Most rehab programs encourage attendance two or three days per week for at least twelve weeks – those costs soon add up.
No “acute” reason for attendance: Patients in the Michigan study were more likely to attend if they had an acute condition that led to the stent, whereas patients with conditions such as diabetes or peripheral artery disease were less likely to attend.
Accessibility: In many cities, cardiac rehabilitation centers are few and far between. Insurance reimbursement for the professionals in the clinics is often low, which can be a contributing factor to how much is on offer.
Patients may have to travel great distances, or they may have trouble getting to a rehabilitation center that is outside of their regular route. Interestingly, the Michigan study found that geography played a role, but it wasn’t about distance from their home to the rehabilitation center. Patients were more likely to attend rehabilitation if it was within two miles of the site where their PCI procedure took place.
Program Availability: There aren’t enough rehab programs for qualifying patients. An NPR story revealed: “A recent study in the Journal of Cardiopulmonary Rehabilitation and Prevention surveyed 812 existing cardiac rehab programs across the nation and found that even if they were expanded modestly and operated at capacity, the existing programs could serve only 47 percent of qualifying patients.”
Misperceptions about cardiac rehabilitation: Patients might assume that cardiac rehabilitation means working out in a gym. If they have a prior aversion to the gym, or a disability that makes working out difficult, they may not attend. This comes back to patient education and ensuring they understand all facets of cardiac rehabilitation.
Consequences of missed rehabilitation
Mortality is the most significant consequence of skipping rehabilitation after the placement of a cardiac stent. Studies have shown that cardiac rehabilitation patients see a 45 to 47 percent decrease in mortality rates compared to those who don’t participate. There is a 25 percent reduction in all-cause mortality and decreased mortality five years past participation.
Patients also miss out on better quality of life that participation in cardiac rehabilitation can bring. Improved fitness, wellness, and overall health are known benefits of rehabilitation, often prolonging life or the time between stent placement and the need for bypass surgery.
For both patients and healthcare facilities, a major consequence is the increased number of readmissions that are associated with missing rehabilitation. Participating in cardiac rehabilitation reduces readmissions by up to 25 percent, also saving millions of dollars in fees.
Under the Affordable Care Act, hospitals face financial penalties if too many cardiac patients are readmitted soon after discharge. The incentive is definitely there for both patients and healthcare organizations to seek rehabilitation for better outcomes.
Getting more patients into rehabilitation
What can be done about the vast numbers who don’t attend post-care after stent placement? One thing we already know from the Michigan study is that simply getting physicians on board with recommending rehabilitation works. Previously, some studies have shown that physician referrals to cardiac rehabilitation were as low as twenty percent.
Ensuring patients have all the information they need and the support to be comfortable with rehabilitation is another important strategy. A welcoming environment and trained staff to ease their fears helps.
A recent joint scientific statement from the ACC, the American Heart Association, and the American Association of Cardiovascular and Pulmonary Rehabilitation published May 13, 2019 in the Journal of the American College of Cardiology stated that home-based cardiac rehabilitation may be a reasonable option for some patients.
The overall lack of accessibility and cost barriers for many patients highlight the importance of finding alternatives to attending clinics and presenting new ways of delivering care. The statement authors found that:
“…although the science behind home-based cardiac rehab is relatively new and less developed, its findings are generally consistent with those reported for center-based cardiac rehab.”
While they acknowledge that lack of reimbursements may be a barrier, they state that as technology improves to allow home-based cardiac rehabilitation, more needs to be done to work with policymakers and ensure home-based is a covered option.
Cardiac rehabilitation post-stent placement is critical for most patients, yet it is grossly under-attended. There are several barriers at play, including accessibility, cost, education and referrals.
Lack of participation in rehabilitation leads to poorer health outcomes and higher incidences of readmissions. This is bad news for physicians and their patients, with the physician perspective including penalties for readmissions.
While studies point to an overall shortage of cardiac rehabilitation being available across the country, home-based care may be a viable alternative. This is a space to watch – we need alternative options that get more patients the post-care that they need.