**Transcript of Cyberseminar**

**QUERI Implementation Practice Seminar Series**

**Availability and Utilization of Cardiac Rehab in the VA: Current Challenges and Opportunities**

**Presenters:  Daniel E. Forman, MD; Mary Whooley, MD, FACP, FAHA, FACC**

**April 29, 2013**

**Availability and Utilization of Cardiac Rehab in the VA: Current Challenges and Opportunities**

**April 29, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact:**Daniel.Forman@va.gov**or**Mary.Whooley@va.gov*

Moderator:Without further ado I want to introduce our speakers today. Today’s presentation is part of the QUERI Implementation Practice Seminar Series. And today’s topic is “Availability and Utilization of Cardiac Rehab in the VA: Current Challenges and Opportunities.” Speaking first, we have Dr. Daniel Forman. He is the director of Cardiac Rehabilitation in the Section of Cardiology, and a Physician Scientist, at Geriatric Research Education and Clinical Centers, The VA Boston Healthcare System, also the director of Cardiac Rehabilitation in the Exercise Testing Laboratory in the division of Cardiovascular Medicine at Brigham and Women’s Hospital, and an Associate Professor of Medicine at Harvard Medical School. 

Joining him and presenting second will be Dr. Mary Whooley. She is a primary care physician at San Francisco VA Medical Center, Director of Cardiac Rehabilitation in San Francisco VA Medical Center and Professor of Medicine in Epidemiology at University of California San Francisco. And I do apologize if I butchered your last name there Mary. Without further ado, I would like to turn it over to Dr. Forman at this time. 

Dr. Daniel Forman:Thank you very much. So, I am going to be speaking about the history of cardiac rehabilitation that will lead to a broader discussion with Dr. Whooley and myself going back and forth. When I talk about the history of cardiac rehabilitation, I really do it to point towards the – what I would consider the underuse of cardiac rehabilitation. The orientation historically, is one that heart attacks in the 1950s and 60s which are increasingly oriented towards hospital management were a time that was regarded as very precarious for the patient. If they were lucky, they got to the hospital and endured the event, but they were left highly unstable in spite of the various medications and interventions at the time. 

The problem is there really were not a lot of options, medically. Patients had completed infarcts, no revascularization, no beta blockers; no aspirin. So, the notion of mobilizing patients who were lying in bed at that point with their highly unstable cardiac disease was one that was associated with a great deal of trepidation. This quote from Dr. Bernard Lown who really rose to stardom, clinically, during this time really characterizes the precarious nature of patients and the way they were treated. Dr. Lown writes this in his blog. It’s available if you google his name very easily. “Patients were confined to strict bedrest for four to six weeks. Sitting in a chair was prohibited. They were not allowed to turn from side to side without assistance, and during the first week, they were fed, moving their bowels and urinating required a bed pan.” 

So, Dr. Lown along with Sam Levin, two prominent doctors had the novel idea of getting a patient out of bed. They thought that despite any intrinsic cardiac disease that the benefits of mobilizing patients would reduce pulmonary emboli, reduce depression and do a whole lot of good for their patients who had been doing quite poorly in their bedridden state. Despite what may, in hindsight, seem very logical, there was enormous concern about this type of management. There were predictions that patients would experience fatal arrhythmias, heart rupture, congestive heart failure form the overstressed heart muscle. 

Well, I’ll spare you the data; because it is self-evident at this point that mobilizing the patients did a whole lot of good. Patients did better. They left the hospital earlier, and they were much more satisfied with their care, and management began to change. That was published in *The New England Journal*in 1952, but it still remained controversial for quite a number of years. And actually what happened in the same time period, which really reinforced the impact on the clinical milieu was the fact that the President at the time Dwight Eisenhower suffered a heart attack during his first term in office, so in 1955 he suffers a heart attack, and he is someone who loved athletics in his life. And given the controversial nature of management, he opted to have a doctor flown in regularly from Boston, Dr. Paul Dudley White flying back and forth from Boston to manage the President’s care. 

Certainly that was a very colorful state of medical management. And Dr. White recommended exercise for his presidential president. And that again, playing out in the front page of every paper, magazine of the time was one in which many physicians regarded Dr. White as reckless and inappropriate, but ultimately his results proved to be very positive. The President went on for recovery as well as served a second term and full recovery as far as his cardiac conditions were concerned, very colorful at the time. 

So, we talk about the management of patients with cardiac rehabilitation, I really think that orientation to the very sick debilitated patient still reverberates in the minds of many clinicians. Most people say that they refer their patients for exercise surveillance as if that is the critical component of care. But if you look at cardiac rehabilitation in 2013, and for the last number of years, it has really broadened. It’s a multifactorial program which still includes exercise and physical activity, but now en-broadened to include education as a key component, risk factor management on a much broader scale, with both education as well as pharmacological manipulations, nutrition with weight management as a priority as well salt and cholesterol guidance, and psychosocial support. 

So, the orientation to the patient who is moribund, I would argue somewhat of a dinosaur. There is a lot of energy being spent on something that goes beyond the dinosaur, and yet the dinosaur is kind of always there in the mindsets of how we take care of our patients. We have this fantastic team of cardiologists and nurses, and exercise physiologist or physical therapist, nutritionists, psychologists, managing our patients in ways that really go well beyond a single patient type to a much broader spectrum of patients. 

So, again, I say the cardiac rehabilitation model, really which developed and became more standardized in the 70s and 80s is oriented towards one type of patient, the very sick patient with the completed MI, proischemic, proarrhythmic, hemodynamically unstable, which is not the typical patient anymore. Most patients, as I have mentioned, they are revascularized. They are on beta blockers, aspirin and a host of other medication modalities which makes this a very different type of patient than we once had for cardiac rehabilitation. 

Again, when you ask physicians why, or nurses why would they refer their patient? It is a means to initiate and advance exercise for a population that is presumed to be unstable. It actually was even characterized in the earliest literature, and it still reverberates. It is getting a man back to work, again, with the president in mind, a man at the peak of his career, suddenly stricken with this terrible disease. Let’s get him back to work. This just misses the boat for older patients, for women patients, for minority patients, and many other patients that are not referred. 

We look at who is eligible for insurance for cardiac rehabilitation. It is still the dinosaur. It’s still the old patient, recent MI, but also extended CABG patients, earliest CABG patients were also moribund for some time. Patients that were no amenable to being revascularized with surgery. It broadened somewhat for patients with MI within the last twelve months, percutaneous interventions, heart valve repair/replacements or heart transplants. But again, thinking of very sick patients, when we look at guidelines, who is recommended to have cardiac rehabilitation? Heart failure, PAD, primary prevention, but they are not eligible for cardiac rehabilitation in terms of insurance. 

So, we have this disconnect between what we think is reasonable and what is actually used in mainstream medicine. And I think this reverberates in the VA and every other caregiving situation. Even the language of cardiac rehabilitation, which has not been updated since 2004, although it will be in August this year, still talks about things which are dinosaurs, phase-one rehabilitation for the moraban [PH] patient who is in the hospital for weeks, who is otherwise sitting in bed. Well here is cardiac rehabilitation. They get him or her up out of bed and walking around the hospital, but most patients are not there that long for phase one to exist. It has been phased out. 

And what we think about with cardiac rehabilitation is usually phase two, this hospital phase program with monitored exercise and risk factor reduction. Even that is beginning to fade rapidly from many hospitals including the VA. And phase three is pretty much all but gone already. This is the maintenance phase for patients that might have gone through phase two, but still are considered too sick, because they have had this big MI, this big infirmity that they don’t feel that they are stable enough to go to a gym, to the Y or any other health providing exercise program. 

So, we have you know a dinosaur type program that really may not respond to our patients. Lastly, this notion of exercise training which was the main component of cardiac rehabilitation in the 70s and 80s and earlier was that patients were too unstable and that we had to kind of moderate their instability. So, we had this notion of class D, class C, distinguishing lesser and more degrees of instability. And this very detailed sense of prescription intensity, mode, and frequency of exercise. But this is not pertinent to many patients that have a different orientation to exercise, many of whom are quickly frustrated with a nurse or a physical therapist hovering over them, and really want a different substrate. 

The patients that may benefit, ironically enough, are the elderly patients or the frail patients, but they are terribly under referred to cardiac rehabilitation. So on both levels, patients that are too fit or under-fit; we just seem to miss the boat. This is Dr. Whooley’s slide. I am going to just present it just to allude to it. This is a slide originally made by Jose Suaya, and she will discuss it in a moment. But it just, in terms of the lighter color which refers to the massive under referral of cardiac rehabilitation, less than about 13% of eligible patients are referred to cardiac rehabilitation across the country. It does not mean that every doctor is bad or every nurse is bad. It means that there is a disconnect between what people believe is appropriate about cardiac rehabilitation and what it can actually do. 

This is what it can do, Therapeutic Goals in 2013, again, activity modification with surveillance and education as mainstays, but also risk factor modification with both therapy and education again. Providing a platform of education, a platform of working with other patients in developing a sense of community, addressing risk factors that we know are not just fluff, they are elemental in stabilizing coronary plaque in endothelium, and vascular distensibility and even heart remodeling. These are elemental parts of recovery. Cardiac rehabilitation is more important than just about anything else we can do. Modifying stress and anxiety and depression, modifying diet in terms of salt and cholesterol, but also how to cook, how to go to restaurants, how to achieve weight loss, very complicated. And then not just returning to work, perhaps, but key family roles for women and men, quality of life and independence, and avoiding rehospitalization; all very key goals. 

I am going to end with this slide, again, another slide by Jose Suaya, and work at Brandeis, and it is a propensity analysis working with an older population, the Medicare population. And it shows in a spectrum of patients including those with very advanced stages, including those with different socioeconomics, including a wide range of myocardial infarction, details with revascularization, some without, with heart failure, some without. It covers the spectrum of disease, one, two, or three vessels, the extent of comorbidities. 

With all those details incorporated, there is a 21 to 34% reduction of mortality in those that go to cardiac rehabilitation, superseding any other things that we do for our patients. To me this would be the most important medication you could bring forward and yet, we have this massive disconnect between what I think many people perceive as the dinosaur in what the need is of our patients. Thank you very much. 

Moderator:Thank you very much, and Mary would you like to get into our poll questions now?

Dr. Mary Whooley:That would be perfect. 

Moderator:Excellent. So, for our audience members, we’re going to ask you just a few poll questions, so that we can get an idea of who is in our audience and a little bit of your role in cardiac rehabilitation. So, the first poll question is up on your screen now. What is your primary role in VA? The options as you can see are: student training or fellow, clinician, researcher, manager or other policy maker, and other. And it looks like two thirds of our audience has voted. So, we will give people just a few more seconds to get their responses in. We appreciate your feedback. This does help our presenters gear the talk specifically to our group. Okay, and it looks like 80% have voted and the answers have stopped coming in. I am going to share those results real quick, looks like we have about 3% student training fellow, 43% clinicians, 23% researchers, 20% manager and policy makers, and 10% other. So, thank you. Mary, do you want to go ahead, should we do the other two now?

Dr. Mary Whooley:Yes please. 

Moderator:Alright, so the next question is up on your screen. What percent of eligible patients receive cardiac rehab in the VA? Please go ahead and make your best guess at this time. Answer option number one, less than 10%, 10% - 25%, 26% to 50%, 51% to 75%, or greater than 75%. And it looks like we’ve also had about 80% response rate. So, I am going to go ahead and close this down. And I will share the results. We have 47% saying less than 10%. We have 30% guessing 10% to 25%. About 13% saying 26% to 50%, and 7% say more than half, up to three quarters, and 3% saying greater than 75. Thank you again, for those responses. And we have one more quick poll for you and then we will get back to the presentation. So, this question for the audience, which statement best describes your personal experience with cardiac rehab? Option number one, I am not familiar with cardiac rehab. Number two, I am familiar with cardiac rehab; have not used it. Number three, I have referred patients for cardiac rehab. Number four; I am a cardiac rehab provider. And number five; I conduct research about cardiac rehab. And it looks like about three fourths of our audience has already answered. And the options have stopped coming in. So, I will go ahead and share those results. Mary can you see those on your screen?

Dr. Mary Whooley:Yes. 

Moderator:Great. Do you want to talk through those real quick, or just get started on the slides?

Dr. Mary Whooley:So, hello everyone. I’m Mary Whooley from San Francisco. Thank you so much for joining us today on the webinar, and thanks to Dan for his great introduction. It looks here like we have 3% who are not familiar with cardiac rehab, 28% who are familiar but have not used it, 17% who have referred patients for cardiac rehab, 31% cardiac rehab providers, and 21% researchers, a nice broad distribution. Okay, so then I will open up my slides. I’m trying to click on, show my screen, it’ll take a moment. And I will be – can everyone see this now Molly?

Moderator:Not, yet, lets’ try that one more time. Okay, let me see if I can turn it back over to you. Okay, you should see the button, show my screen now. Go ahead and just click that. Perfect! There was go. 

Dr. Mary Whooley:Excellent! Okay, so, I’m going to talk about what is going on at the VA these days, and what some of our goals are for implementing cardiac rehab and thinking about ways to improve our delivery of cardiac rehab. 

Moderator:You can just click anywhere on the slide; it will advance. 

Dr. Mary Whooley:This was a metaanalysis that was published by the Cochrane Collaboration in 2009, and they reviewed about twelve randomized controlled trials of exercise-based rehab for coronary heart disease versus usual care. And as you can see, there were a wide range of results, but at the bottom, you can see that there was a 26% reduction in mortality among patients with coronary heart disease when all twelve trials were combined. 

In addition to coronary heart disease, exercise rehab is valuable for patients with heart failure, and these are three publications from the Heart Failure Action Control Trial. One publication evaluated the efficacy and safety of exercise training in a Knot [PH] publication; they showed decreased cardiovascular mortality or heart failure or hospitalization. Another evaluated the effects of exercise training on health status, and found that it was associated with improved quality of life. And a third evaluated the effects of exercise training on depressive symptoms, and found that it was associated with lower depressive symptoms. 

So, this has resulted in a big push for improving delivery of cardiac rehab, not only in the US, but in the UK and Europe as well. And these performance measures for cardiac rehab were published in 2010. They say that the patients who should be referred from an inpatient setting are all patients with a primary diagnosis of acute myocardial infarction, chronic stable angina, heart failure or peripheral artery disease. And all patients who have had one of these procedures should also be referred, coronary bypass grafting, percutaneous coronary intervention, cardiac valve surgery or cardiac transplantation. As far as patients who should be referred from an outpatient setting is anyone who has not been referred, if they, within the past twelve months experienced an acute MI, angina, CABG, valve surgery, transplantation, or PCI. 

Now, the performance measures that we just reviewed were performance measures for cardiac rehab. This is a separate set of performance measures published in 2011 for secondary prevention, in adults with coronary artery disease. In this publication, the usual suspects appeared blood pressure control, lipids, smoking, antiplatelet therapy, beta blockers, ACE and ARBS, physical activity assessment and management of symptoms. But a new, this is a new added performance measure in 2011 was cardiac rehab. And what they specifically said was all patients evaluated in an outpatient setting who within the previous twelve months have experienced acute MI, CABG, PCI, or chronic stable angina and have not already participated in a rehab or secondary prevention program must be referred to such a program. 

So, as Dan showed you earlier, the uptake of cardiac rehab has been far from optimal. And we tried to figure out in the VA what was happening in cardiac rehab, and fortunately John Remfield [PH] in the cardiovascular group in Patient Care Services had conducted a survey of VA cardiovascular Specialty Care Services. And they asked the question, do you have cardiac rehab? And there were programs that said yes, and programs that said no. And we called all the programs that said yes to verify that they actually had cardiac rehab, and all but three of them did. And the ones that we verified were 35 VAs that actually offered cardiac rehab programs or 28% and 88 VAs that did not offer cardiac rehab. At those VAs patients of course have the option of getting cardiac rehab through non-VA care or used to be called C-Basis, but no rehab programs were available onsite. 

I’m sure everybody is interested in which VA facilities they were, and so those are listed in the slides, and you can download them from the website. We also looked at the number of Veterans hospitalized between, 2008 to 2011, and we were trying to figure out what proportions of Veterans are actually receiving this guideline recommended therapy. And there were, as expected, loots of MIs, PCI, and CABG. And we were really surprised to find that the proportion of participants who – the proportion of eligible patients who participated in cardiac rehab through the VA, through non-VA care, through Medicare, or any other insurance were only 8.9% at VA facilities that had an onsite program and 5% at VA facilities without an onsite program. So, all of you that guessed less than 10% were exactly right. And although this is of course, a difference, the onsite CR programs have better participation than the ones without onsite CR programs, obvious we are nowhere close to where we want to be. And these kinds of numbers are really suggesting that we need to have some kind of change in the delivery paradigm, because what we are currently doing is just not working. 

We then evaluated common barriers that were associated with utilization of cardiac rehab, and we spoke with patients and providers and administrators, and really the biggest thing that came up was distance from the medical center. They can’t get there. They don’t have the money to travel. They can’t take the time off from work, limited motivation. A lot of providers are not aware of the guidelines. They have only recently been published, and they don’t really know how to refer. Then the system has very poor reimbursement on the outside for cardiac rehab. The places that offer cardiac rehab really do it out of the love of their heart, because they definitely do not make much money doing it. And I think the complexity of programs with so many different components makes it a little bit confusing for people to know, oh wait a minute, I’m kind of doing most of the cardiac rehab stuff myself, in terms of lipids, beta blockers, aspirin, ACE inhibitors. Telling people to stop smoking, and exercise. So, kind of what else is needed? 

So, with all of the data that had accumulated in 2012, the AHA Presidential Advisory released a statement that said the remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehab and clinical implementation of rehab programs is unacceptable. And with that challenge, I will turn it back over to my esteemed colleague. 

Moderator:Alright, Dr. Forman you should see that pop-up now. 

Dr. Daniel Forman:Thank you. Thanks. Thank you, Mary. So, I am going to continue this theme just alluding to the article by Dr. Yancey who is the President of the American Heart Association at the time, along with Gary Balady who has been one of the champions of cardiac rehab throughout his career. So, there is a need that secondary prevention can be done a whole lot better, certainly for coronary disease, but for all aspects of cardiovascular disease management. The similar efficacies we’ve heard indications for heart failure in PAD which is not even reimbursed by traditional insurers, and yet here is proven efficacy and a mandate to use it. 

So, my question is how can we modify the program to provide better care for the patients? And as Mary was saying, it’s an issue of patients, and it’s also an issue of providers compelling on multiple levels, compelling to hospitals who I think see cardiac rehabilitation as expensive and burdensome to organize. Secondary prevention, I would argue is much easier said than done. I’ve heard many clinicians, many colleagues who say; oh we could just do this if you are organized well in your clinic. You can get this into your ten minute office visit for patients that may have multiple issues that are kind of relevant simultaneously. 

So, how do you achieve risk factor modification, especially amidst multiple morbidity and poly pharmacy? My background is strongly oriented towards aging which is highly relevant as our cardiovascular patients are getting older. But even younger patients are inherently more complex with obesity and alcoholism, just to mention some of the many dynamics that complicate this notion of secondary prevention. Exercise is neither intuitive, not easily adapted, behavior changes are hard to initiate, hard to sustain. Meaningful education is hard to achieve especially with cognitive changes of aging. 

Then we talk about personalized care, so there is somehow we can tailor our care and hit our patients right on and be compelling on multiple levels, but how do we really do this for our patients? What is the language? What are the metrics? And how do we do it efficiently? I would argue cardiac rehabilitation is really an inherent answer which we have managed not to use. It’s astonishing really when you think about how complicated each of these issues are, behavior, diet, tobacco, medication compliance amidst the current pressures on our patients to do other things and to live other ways. And how do we really overcome these barriers? And I would argue it is not done well in the VA, and it’s not done well outside the VA. 

Personalized care, I rivet on this notion, because it is used so frequently, and somehow it’s just we are missing the boat. We are not good providers. Ironically, patients are more stable from a cardiovascular perspective. I mean, cardiology has a lot to pat itself on the back about in terms of revascularization and medications. And yet, ironically, patients are more vulnerable from other perspectives, from their back pain, from their pills, for multiple conditions, not only their heart conditions, because it’s not just usually coronary disease. It is coronary disease with heart failure, with atrial fibrillation; with you know other things as well, plus non-cardiac disease. They all occur simultaneously in most patients as they get older. 

So, it is very rate that a physician can really address these issues and their complexity at one time. And most patients are on 15 plus medicines by the time they are 70. So, there again, you have inherent polypharmacies adding to the complexity. So, age, multi morbidity, polypharmacy, these are almost certain complexities of our patients. You add to that life stressors like divorce or finances or job, and how do you think about secondary prevention? How do you get that in there, especially when you are dealing with differences of education and socioeconomics, family dynamics, pain, depression, nutrition? 

This is just you know, like a list that – but it is relevant for every patient you see. And add to that frailty which is suddenly a very popular term, but it really reflects a very insidious issue with our aging population. They are physically limited. They are cognitively limited, and it has been shown to be inherently associated with cardiovascular disease arising from the same inflammation states that are a part of cardiovascular disease. And inherently predisposing to cardiovascular disease, and inherently predisposing to bad outcomes. 

So, I would argue without any question, that cardiac rehabilitation is incredibly important, and the fact that it is underused seems really hard to believe. So, the question is, how do you redefine the process of care? Because I started with this notion that I live with that I think that cardiac rehabilitation is, in many of my colleague’s eyes, in many of my patient’s eyes, is a dinosaur. They don’t think it’s worth the money, the time. You know, Mary alluded to some of these logistic issues. If patients really thought this was the most important thing in their lives, that their physician was telling them that, their nurse, their hospital, I believe they would use it. They don’t get that message. So, it’s access, but its access in a context. Is it relevant for our patients, relevant for their families to say this is important for mom or dad? Is it relevant for providers to say you should do this to their patients? Do they want to like deal with the turmult that is going to occur by saying this in important? And are there ways that we can make it more accessible? Are there key elements in cardiac rehabilitation that can be achieved at home or in a community setting? 

I rivet on the notion of community setting, but for some patients home setting may be the best, especially if you are dealing with logistics, away from the medical center. And I would argue that technology is a very important consideration to help facilitate exercise, education, and risk factor modification. Easy technology, people that love their cell phone might really like a program that is built into their cell phone, people that like their Xbox maybe like a program that is built into their Xbox. 

So, technology, in my opinion, can facilitate a whole new dimension of care, having a virtual provider in your home or in your community center. And it’s not just something that is instead of the hospital, it is something which is, I would argue, done well, is better medicine. It’s not instead of, it is part of the hospital experience, and it is tying the hospital into a home or community setting. Reinforcing the links to the physiologist and the nutritionist, the nurse, the physician, the whole team can suddenly be accessible, because this communication that can go back and forth. And likewise, patients, even if they are isolated in an environmental circumstance in a rural health area, can tie to other patients if the technology facilitates it.

So, physical monitoring is one component. Because of accelerometers, with pedometers, there is a way of seeing what patients are doing and to track it. And I will talk a little bit more about that, but the more important dynamic that I want to emphasize is you can guide management. You can see what someone did yesterday. You can see what they complained about, and you can really modify the regimen on a day to day basis, even on an hour to hour basis, depending on the feedback you get. And this really fills in the gap that you get even in cardiac rehabilitation where you see patients two or three days a week, what happens on the other days? You can start to see these things. It is complimentary to cardiac rehabilitation. It is not necessarily in leu of it. But it also goes beyond it, because it can facilitate a similar program for people who may not be able to get to the hospital in the first place. 

And I will argue that patients are inherently safer nowadays than they were in the past. They are not the time bombs that they were in the 1950s when Dr. Lown wrote about the patients. But there are still patients that have inherent ischemia, and even those that have non-ischemic heart failure have hemodynamic issues, arrhythmia issues, balance issues, especially when you put age and polypharmacy into it. So, patients are more complex and in many cases sensory, hearing and visual changes, cognitive changes which really make these things even more difficult. 

So, if a physician says to his or her patient, go exercise. I would argue that’s crazy. In most cases the patient has no idea what you are doing, and they have no idea how to do it in the first place. So, you need another layer of sophistication to make that feasible. So, again, I would argue that technology provides a way of augmenting and monitoring exercise, and likewise it can be for education and risk factor modification. Day to day prompts, did you take your meds? If there is confusion about the meds, they can link a patient to resources, and you can make these resources sensitive to their cognition, to their font size for their vision, to auditory stimuli if they can’t read. 

There are all kinds of variations that can be used to address the patient’s needs and achieve personalized care. It becomes real, because technology facilitates it. And there is potential to share information. So, even as a doctor or nurse says to go exercise, now they can track it on a day to day basis and know if patients are really doing what they say and really have a way of providing feedback information to themselves, feedback to the patient, and linking designated family members into the loop to reinforce compliance, all kinds of levels of improvement. 

I do want to talk about the rapid evolution of technology, because there is a whole literature now that is just kind of just catching up to the publication about pedometers and accelerometers that is already, in a sense, obsolete. If you think about those devices they provide feedback to the patient and it presumes the patient is able to read it, to incorporate it, to respond to it, to communicate it to his or her doctor or nurse. But now it is going forward, because now there is a whole set of technology that tie to cell phones or iPads that you can still track data with accelerometers that built into it, but it feeds back to the nurse of the hospital. It ties the hospital right to the patient, and tracks it in a way that brings in the physiologist or the exercise therapist, the physiologist or the physical therapist. And it brings in other people that are relative to the care, and it links the hospital to the patient. It links the provider to other people in the family, and it provides different levels that were otherwise possible. 

I also want to emphasize the notion of efficiency, because one of my peeves in terms of what are the guidelines for cardiac rehabilitation, as wonderful as it is to have the doctor, the nurse, and all these other people involved in patient care. It is a tight ratio for patients that have been in many cases are relatively stable. And it is cost inefficient, and this is one of the reasons why hospitals tend to abandon it, the VA and other hospitals. It becomes unyielding. And ironically its underuse makes it insult to injury, but here you have a system which ties a provider to multiple patients. You can have dozens of patients being followed on a moment to moment basis over a period of time with much greater efficiency, using telecommunication than they would be on an onsite campus. So, it really changes the whole formula the whole strategy, the whole efficacy of care provision. 

And for patients that cannot use cell phones or the equivalent then this in my opinion is the next generation, the Xbox derivatives. So you can actually film patients and monitor sensory stimuli, follow their heart rate, their breathing; that is the other physiological component, and really see how they are doing. They can see it themselves; you can see it. They can see a model that shows them what they are doing. It can describe the differences. This, in my opinion is critical for notions of strength training, for balance training, for things that you don’t, otherwise, do with a pedometer or an accelerometer. This is another whole layer of sophistication which is really at our finger tips, through the technologies that are available to us. 

This is the future. So, efficiency and personalized care, linking providers to patients with greater efficacy, but also higher quality really surpassing the status quo of current in-hospital programs or hospital-based programs, and really finally achieving tailored care that responds to each patient’s circumstances over time, in their own environment, and really bringing things to a different dimension of care. I really don’t see it as one versus the other. I see it as a continuum between the two, or a hybrid model. I believe that technology really can and should be initiated as part of the incident event that brings someone into the thought processes as a cardiovascular patient, initiating it as part of heart failure, initiating as part of CAD management, in-hospital. And some patients can go right home and continue to use it. 

I think the vast majority of patients need to get acclimated. They might need a transition period of several visits where they use this device and become familiar, and they begin to know the nurse involved, the doctor involved their team. They can connect to their team visually, but then go home, or then go to a community program where they can have a different level of experience that ties them to the hospital, even if they live 40 miles away. One of the things that Mary mentioned was that patients, sometimes, are too far away. In our experience in Boston, patients can live down the block and they come. I mean, it is not necessarily distance. It is a mental attitude that compounds the distance.

 So, I would argue for many reasons, these types of technologies are very important. And with the overriding, the responsive details, which is the right style, which strategy, which device? But I think as a general principal, there is the potential to establish new models of therapeutic efficacy that really enhance the caregiving quality and the quality of therapeutics the patient experiences. So, thank you very much. 

Moderator:Thank you, and now we will turn it back over to Mary. There you are. 

Dr. Mary Whooley:Can you see my screen now?

Moderator:Yes, we can. 

Dr. Mary Whooley:Excellent! Thank you so much, Dan, for that great overview of the challenges and ideas for improving implementation of cardiac rehab. I am going to talk through some opportunities and future directions that we have taken in our research, and some people have already taken it clinically that I think may be the way of the future for VA cardiac rehab. This is a map of cardiac rehab centers in the Department of Veteran Affairs, and in the upper right corner, there is a chart that has travel time, and the number of Veterans within each travel time. So, 396,000 Veterans live within 15 minutes to the VA, 844,000 live within 30 minutes, 1.2 million, 60 minutes, and then 6.9 million over 60 minutes. So, of the 9.3 million Veterans that are currently enrolled in the VA, 6.9 million or 74% live more than an hour from a VA cardiac rehab center. 

So, no matter how much we motivate them or how many programs are offered, there is just no way that we are ever going to reach all those people with center-based programs. And this, by the way, is not unique to the VA. Medicare also has very poor utilization rates for cardiac rehab, and the UK has been struggling with the same challenges. So, this center – this is a typical center-based cardiac rehab program, and it is really just not going to be the way of the future. I think there are patients who will benefit from this, and they should certainly still be offered. But we need to move beyond this and start thinking about home-based cardiac rehab. 

This was a metaanalysis that was published in the Cochrane Collaboration Group, of home based versus center based cardiac rehab. And they reviewed four randomized trials of studies that randomly assigned patients to either center based on home based cardiac rehab. And as you can see here, the difference between home and center based cardiac rehab were not significant. So, home and center based rehab had very similar mortality. The risk ratio for home versus center was 1.31 with a wide confidence interval. And so, although this is very few studies, this was reassuring that home is a viable option. 

Moreover, we need to remember that anyone who enters a trial of home versus center based cardiac rehab has to be willing to be randomly assigned to the center based arm. So, this kind of a study would exclude 75% of Veterans who would not be able to be randomly assigned to a center based arm. So, what we are really talking about ... here is the conclusion of the Cochrane Collaboration metaanalysis. So, what we are really talking about is a difference in participation. If we have patients referred to home based or center based therapy, and they have similar efficacy, but we have way more participation in home-based therapy. Then, we're going to have much more effectiveness in home-based programs than we will in center-based programs, and it doesn't mean center-based programs should go away. 

It just means that we need to broaden our deliver system to meet the needs of our patients. The secondary prevention and risk reduction guidelines for patients with coronary disease specifically state a home-based cardia rehab program can be substituted for a supervised center-based program for low risk patients, and this is a class-one recommendation level of evidence A which is as high as you can get. You notice that it says for low-risk patients which makes you think, hmm? That doesn’t sound like any Veteran I know, and it's true that our Veteran are not low risk. They are very sick. They've got lots of comorbid conditions, and so, one wonders whether home-cardiac rehab will be safe in these patients. 

Well, this study, recently published evaluated the safety of cardiopulmonary exercise testing in a population of patients with high-risk cardiovascular disease. They evaluated over 5,000 exercise studies in 4,250 high-risk patients including 1,289 patient with CHS, 598 with hypertrophic cardiomyopathy, 194 with pulmonary hypertension, 212 with aortic stenosis, 686 who were older than 75, 1,748 women, and 1,192 with a peak CO2 of less than 14 which is poor functional status. 

Amazingly, they have found in 505 two studies which was 99.84% of the studies there were no adverse events. In the over 5,000 studies they evaluated there were only eight that had adverse events and those eight studies are represented by that black line. 

So all of the blue are the studies that had no adverse events and that tiny black line is a depiction of studies that have adverse events, and you might think, okay. Well, if I had eight deaths, that is not okay. I wouldn't even want to take that risk. Well, it was six patients who sustained ventricular tachycardia. That was not fatal, one patient who developed an MI and one patient who was admitted to a hospital for another reason. It was actually shortness of breath, dyspnea. There were no deaths, and so these findings were really reassuring that it actually is safe for patients with comorbid conditions to go home, and do exercise at home. And we don't need to be as concerned as perhaps we have in the past about supervising and monitoring every moment of their exercise. 

This was another trial that was just recently published in *Jack Heart Failure*, again from The Heart Failure Action Group on exercise training and implantable cardioverter defibrillator shock in patients with heart failure. So, they randomly assign patients to exercise training, or not, and looked at how many defibrillator shocks were delivered, and they found no evidence of increased ICD shocks associated with exercise training in 546 patients who underwent exercise training versus 507 patient who were in usual care, and these were all patients with heart failure, and reduce LVEF, so again, very reassuring. 

The big issue with home-based rehab is that it’s not reimbursed by Medicare, so how can any person in The U.S. offer a home-based rehab program if it's not going to be reimbursed? And I think that that's going to be our key question and barrier moving forward, but in The VA, we are an integrated healthcare system where perhaps we can cover things that Medicare may not, and we very similarly to Kaiser may benefit from these kinds of preventive care programs. Indeed, Kaiser does have a home-care management program. It's called the multi-fit program, and they have nurses contact the patients immediately after discharge, and essentially provide close case management with rehab for up to a year following their cardiac events, and they have more information about it on the internet. 

The American Heart Association has published a book it's called *An Active Partnership for the Health of your Heart*, and it comes with a DVD, and the book and DVD are a 12-week program that goes through 12 different topics like nutrition, smoking, weight control, physical activity, exercise, and this *Active Partnership for the Health of your Heart*, is coordinated with the Kaiser Permanente multi-fit program. They were both developed from the same materials, and in our very own VA, we have a group in the Iowa City VA who have, in fact, adopted this program into a remote cardiac rehab program that they have started to deliver with funding from The Office of Rural Health. And they have done a pilot study in about 45 patients who underwent this home rehab, and found that it was as safe as the usual care, and that it actually resulted in better patient compliance which is really what we are looking for, and it's very cheap. 

You can get a pedometer for $27, an exercise peddler for $25 a Thera-Band for a few cents, and we can send the patients home with these things, and go through each week of the manual. So, in conclusion we are very aware that cardiac rehab improves cardiac outcomes. Cardiac rehab is vastly underutilized both inside, and outside The VA. And I think geographic distance is, by far, the largest barrier, and so our conclusion is that home-cardiac rehab and new technologies may help to improve utilization among these high-risk patients. Thanks so much. 

Moderator: Thank you both, very much. For our attendees who joined us after the top of the hour, to submit a question or comment for the presenters, simply use that control panel on the right-hand side of the screen, and there's a box where you can ask a question for the staff. Go ahead, and type it into there, and press send, and we'll get to them in the order that they were received. We do have one question pending at this time. It came in fairly early. Sorry, go ahead. 

Dr. Daniel Forman: This is Dave Foreman. I just wanted to make a comment in regard to both of our talks, and to highlight the fact that the whole concept of cardiac rehabilitation may vary with each reference throughout our talk together. If you look at AACDPR guidelines, currently, this is the parent organization that monitors and regulates cardiac rehabilitation, and they determine a ratio of staff to patient. They determine what components are critical for cardiac rehabilitation to be reimbursed to be credited, and I'm sure many of the people on the phone know these details very well, and they do a great deal of work to achieve the metrics that are required. 

When one talks about home care, or even technically-based care, those metrics really need, are implicitly modified, and I think one of the challenges which really I think, personally I think The VA could really be at the forefront is perhaps challenging the status quo. Not to disregard it, perhaps, but really try to propel it forward. The status quo really, was built in the context of what I call the dinosaur a different type of patient, and it's been very hard to really overcome that with different metrics responding to different types of patients that Mary and I both talked about, but again, we have a set of criteria that defines cardiac rehab. I think, the word itself is used in many different ways at this point. 

Moderator: Excellent! Thank you. Mary did you want to add anything before we get to questions? 

Dr. Mary Whooley: No. I agree. That was really well said. 

Moderator: Thanks so much. The first question that came in, it's regarding the therapeutic goals of 2013 slide. Who framed those goals?

Dr. Mary Whooley: I think that was Dan's slide.

Dr. Daniel Forman: Right, I think, those are the goals that are really defined in various in the statements that were part of Mary's and my talks in terms of things that are a part of the achievements that one hopes for their patients as part cardiac rehabilitation experience. So that slide itself is just an overview of things that I pulled from clinical experience, but I know that the roots for me are just in the guidelines themselves from 2004. And as I mentioned they're going to be revised, August this year, they're going to be published in an updated form, so those goals may be slightly modified, but the notion of exercise, education, diet, and the other components are really, I think, the standard metrics of what cardiac rehabilitation is supposed to achieve. 

Moderator: Thank you for that response. The next question we have. I am struck by the higher utilization of cardiac rehab in The Northern Midwest than in other areas. Is cardiac rehab more available in these locations?

Dr. Daniel Forman: I guess I could...

Dr. Mary Whooley: Go ahead. Yes. 

Dr. Daniel Forman: Well, this is one part of the answer which I do know, because Jose Souya and I are friends, and we've talked about that a great deal, and he's the one that published, this, and they found in those sites that there was it was the surgeons that really drove it. There was a much greater organization between the surgeons, and the referral to cardiac rehabilitation than other providers in those systems. And so the dark blue in that slide really is a testament, it reflects the surgical standardization of cardiac rehabilitation as part of surgical care. 

Dr. Mary Whooley: I agree.

Moderator: Mary would you like to add to that?

Dr. Mary Whooley: I agree. 

Moderator: Well thank you for the... great, thank you. Let's see. We do have a couple of people wanting to thank you for an informative session, and a couple of people are looking for the slides. You can find the slides, the link to it, in the reminder email that you received a couple hours ago. Just scroll down, and there's a hyperlink to them, or you can write in, and I'll send you a copy. The next question, of the 35 VA facilities that have CR, do we know how many disciplines are involved? How many are just exercise? How many are, psychology, nutrition etc.? 

Dr. Mary Whooley: That's a great question. As far as the 35 facilities that offer cardiac rehab it's really quite a variety of departments that organize it. Some are organized by physical therapy. Some are organized by cardiology. Others are organized by cardiothoracic surgery. And most of them are, as far as I can tell not tremendously comprehensive. I think that psychology is probably not considered a key discipline. For most programs, they are very much focused on exercise training, and getting patients to become more active. 

Moderator:Thank you for that reply. The next question we have, can you please speak to behavior change/lifestyle management programs such as Ornish, Medicare Demonstration Project and CR?

Dr. Mary Whooley:I would be happy to discuss that. Dean Ornish managed to get his lifestyle program covered by Medicare, his lifestyle change program. He runs a very intense lifestyle change program that people can read about on the internet, but it involves very severe nutrition and physical activity changes. And there are a very small minority of patients who can comply with those kinds of changes. I don’t think that we have many Veterans who would be able to do that. I certainly can’t think of any in my clinic, because it is pretty intense, and it does require that the patients go to a center that offers this program. And the way that it’s working is that centers can become Medicare certified for delivering the Dean Ornish program. 

Then if they are Medicare certified, then they are allowed to bill for administering the Ornish Program. If they are not Medicare certified, they are not able to bill for administering the Ornish Program. And I am hoping that home cardiac rehab might follow suite, because if we could have some way of certifying like Dan was saying, a specific list of criteria for home rehab, and make sure that people are actually fulfilling those criteria, then perhaps it would be something that could be covered. 

Dr. Daniel Forman:One of my concerns which overlaps with what Mary was just saying is that I am not – I mean, the Ornish System has many followers and there is some data which are very compelling about the utility of this very intense lifestyle modification that it implies. But I do think it skews the perception of what cardiac rehab means to many other people, and unfortunately it carries an enormous amount of public attention. I think many people associate this with cardiac rehab and it adds to the list. I mean, Mary emphasized logistics several times about distance. But also my own belief is that, again, I am just drawing this on my own clinical experience that patient that live down the block, they are just as reluctant in many cases to go to cardiac rehab. 

You say well why is that? I think some of their preconceptions that are colored by Ornish that are colored by what their own sense of what exercise entails are really part of the problem. I wish there was some way of really standardizing programs that were really in the eyes of most eligible patients, things that they could do that they derive benefit from. I think everyone on the phone is probably aware that any exercise is better than no exercise. But when a patient thinks that exercise means pole vaulting or the equivalent then they are not going to do it, and they miss the chance, and likewise with diet modification and socialization and many other components that are part of a cardiac rehab experience. So, if we could figure out how to get an easier way to access that rudimentary care, I think so many would benefit. 

Moderator:Thank you for that, a followup to it, what about bringing to VA a modified form of this, more compliant for Veterans, possibly aligning this to using health coaches?

Dr. Mary Whooley:Well that is a great, a fantastic idea and the Iowa City VA has already implemented a home rehab program that involves weekly coaching, and weekly exercise monitoring, and nutrition monitoring and training. And so, their model is very much in line with that suggestion. We are trying to implement that same program here at the San Francisco VA with funding from the Office of Rural Health. And there are a handful of other VAs that are also trying to implement it at their centers that the contact person is Dr. Bonnie Wakefield who is at the Iowa City VA. 

Moderator:Thank you very much. Are there fee-basis challenges for reimbursement for home based rehab or the expenses that will need to be covered? 

Dr. Mary Whooley:That’s a great question also. I think the fee basis rules seem to vary by site, because I know some sites where you just enter a fee basis or now called non-VA care consult and it gets approved. And the patient can go and pick out whatever cardiac rehab center they want to attend close to their house, and the VA will reimburse for that therapy. But there are other VAs where the Chief of Cardiology has to be consulted for approval every single time a fee basis consult or a non-VA care consult for cardiac rehab is entered. There are still other facilities that don’t provide it at all. So, it is quite variable, but technically we should all be able to enter a non-VA care consult that says, please provide cardiac rehab for my patient, and the patient can then find a cardiac rehab center close to their house and the VA will reimburse the cardiac rehab center for that therapy. 

Dr. Daniel Forman:I am just going to resonate with a related point, acknowledging Mary’s expertise, particularly with home care, but just saying we have had similar experiences in Boston as part of my work with cardiac rehab for congenital heart disease, cardiac rehab for heart failure. So in each case, it became a petition to the local hospital or the VA and it was decided on a case by case basis. And I think that’s part of the challenge that I think we as providers on the phone and you know Mary and myself have in the future is to really achieve this in a way that is more standardized, where it does not have to take so much energy and time in the case of each patient. 

I think home care is a superior model to no care at all. It has some limitations which may be overcome by technology, perhaps, but even in a simple form does so much more good than someone just being sedentary on their couch. So, I feel like this is a huge need for our patients who are prone to rehospitalization and progressive morbidity, and we have mandate after mandate coming from medical literature saying this is a top priority. And yet, we don’t have a mechanism to achieve it that is realistic for our patients, but we are getting there with the types of things we have talked about today. So, I think its incumbent on us to work together. I think it is going to take many efforts that are organized together to overcome the inertia and change policy. 

Moderator:Thank you both for those replies. We do have two more pending questions. Do you have time to stay on for those real quick?

Dr. Mary Whooley:No problem. 

Dr. Daniel Forman:Yeah. 

Moderator:Thank you. The first one, what kinds of adaptations are made for older frail Veterans? Are there any collaborative models that have physical therapists work with, exercise physiologists? 

Dr. Daniel Forman:I think that is a great question, but I am not aware of those types of programs. Mary, are you? 

Dr. Mary Whooley:I am not aware of them either. 

Dr. Daniel Forman:I’m not saying there aren’t, and actually it’s a really wonderful question to me. I am part of the GREC [PH] and I really feel like I should have a good answer to that, and yet I don’t. So I think if the person who asked it sends me an email, I will make it my priority to come up with a better answer that can be disseminated. 

Moderator:Thank you for making yourself available offline. I will be sure to pass that name along to you. And the final one is a question and a comment. Our facility requires all patients requesting non-VA care CR to come to an office visit to find out what they should be looking for. Most agree to attend the program here once they see how comprehensive it is. So, I guess there is no question, but they would like your comments on that. 

Dr. Mary Whooley:Yes, every VA has a different procedure for authorizing fee basis and I can see how the VA wherever you are might use that as a way to kind of filter out patients who really are motivated and to identify patients who are really going to utilize the services that are paid for by the VA. 

Moderator:Thank you. Well that is the final comment from our audience members. Would either of you like to make any concluding comments?

Dr. Daniel Forman:Mary?

Dr. Mary Whooley:I wanted to mention one thing. The person who asked about lifestyle coaching, there is a new lifestyle coaching program. It is really excellent. It has been rolled out by the Move Program. And it has some similar elements to cardiac rehab in terms of helping patients exercise and watch their weight and eat better. But one key difference, I think is that it is really a huge opportunity to get people to change after they have had a major event like this, after they have had cardiac surgery or a big heart attack or stents, they are really motivated to change and it is a really unique opportunity for us to jump in and try to do that. The lifestyle coaching is wonderful, but it does not come with as much motivation as post cardiac events. 

Moderator:Thank you, and Dan would you like to give any concluding comments?

Dr. Daniel Forman:I think patients get mixed messages after events. As much as I think – I totally agree with what Mary just said that the life – the medical event is an opportunity for change, but I do think that cardiology has created an illusion that they do procedures that save people. And I think it confuses many people that want to feel like they are better, and they don’t need to exercise. I think the science has really changed in the last five years or ten years where we know that it is inflammatory, that inflammatory processes underlie whenever mechanical interventions are performed, and the patients really are still sick. So, that it is important that we recreate the message in a sense and not to take away any of the luster of the cardiologists who have done a spectacular job, but to say that it is really only the first step and the follow through is critical. 

And I somehow think that message can be done even better than it is now. I think – I always tell my patients that the real battle is not what happens in the hospital, it is whether they go to the refrigerator the third time in the afternoon. And that – it has to heavily have that sense of urgency every time they feel the inclination to do something which they know is inherently unhealthy. So, I think that message can be done better with cardiac rehab as part of the solution. 

Moderator:Thank you, words from the wise that we all take away from that, well I want to thank all of our attendees for joining us today, and please as you exit the session, do fill out the feedback survey that pops up on your screen. It is your opinions that help guide our program. I also want to extend a huge thanks to Dan and Mary for presenting for us today. Your insights for the field are invaluable. So, thank you both. And please do join us for future HS R&D Cyber Seminars. You can look for those on our Cyber Seminar Catalog online. Thank you all, and have a great day. 

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