Availability and Utilization of Cardiac Rehab in the VA: 

Current Challenges and Opportunities

Daniel E. Forman, MD

Director, Cardiac Rehabilitation, 

Section of Cardiology;

Physician Scientist, Geriatric Research 

Education and Clinical Center, 

VA Boston Healthcare System

Director, Cardiac Rehabilitation and 

The Exercise Testing Laboratory

Division of Cardiovascular Medicine, 

Brigham and Women’s Hospital

Associate Professor of Medicine, 

Harvard Medical School

Mary Whooley, MD, FACP, FAHA, FACC

Director, Cardiac Rehabilitation, 

San Francisco VA Medical Center

Professor of Medicine and Epidemiology

University of California, San Francisco

April 29, 2013
Poll Question #1

• What is your primary role in VA? 

– student, trainee, or fellow

– clinician

– researcher 

– manager or policy-maker 

– Other 
Poll Question #2

• What percent of eligible patients receive cardiac 

rehab in the VA?

– Less than 10%

– 10 to 25%

– 26 to 50%

– 51 to 75%

– Greater than 75%
Poll Question #3

• Which statement best describes your personal 

experience with cardiac rehab?

– I am not familiar with cardiac rehab 

– I am familiar with cardiac rehab but have not used it

– I have referred patients for cardiac rehab

– I am a cardiac rehab provider

– I conduct research about cardiac rehab
Cardiac Rehabilitation in VHA

• History of Cardiac Rehabilitation (Forman)

• Current Status (Whooley)

• Challenges for Implementation (Forman)

• Opportunities and Future Directions (Whooley)

5 
History of Cardiac Rehabilitation

Underuse of Cardiac Rehabilitation 

Post-MI once regarded as a period in which physical 

movement was highly destabilizing and harmful.

• Bernard Lown (Re. AMI therapy in the 1950s):

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. During 

the first week, they were fed. Moving their bowels and 

urinating required a bedpan. 
Getting AMI Patients Out of Bed:

Controversial Care

• Predictions that patients would 

experience fatal arrhythmias, heart 

rupture, or congestive heart failure 

from an overstressed heart muscle 

Levin S, Lown B. NEJM. 1952;148:1365-9 
Dwight Eisenhower

Heart attack in office in 1955

Paul Dudley White prescribed graded 

levels of exercise (swimming, walking, 

and golf).

Viewed by many physicians as reckless 

and inappropriate, but results 

remarkably positive
Historical orientation overshadows broader 

relevance of Cardiac Rehabilitation in 2013

Multifactorial Program:

• Exercise/physical activity

 Prescription and Surveillance: Advance activity amidst 

clinical instability

• Education

• Risk factor management

• Nutrition (weight management) 

• Psychosocial support

Team Approach

• Cardiologist; Nurse; Exercise physiologist; Nutritionist; 

Psychologist
Paradigm of Cardiac Rehabilitation 

(1970’s-1980’s) 

• Oriented to

– Completed MI

– Ischemic cardiomyopathy 

• Pro-ischemic; Pro-arrhythmic

• Hemodynamically unstable

• Cardiac rehabilitation as a means

to initiate and advance exercise for a population presumed 

unstable.

• Conceptualized as a means to get a “man back to work”
Insurance Eligible 

• CAD: Revascularized (CABG), stable angina, recent MI 

– Added to recent ACS guidelines

• Recently Expanded Eligibility: 

– MI within the preceding 12 months 

– Percutaneous coronary intervention 

– Heart valve repair/replacement 

– Heart or heart-lung transplant

– Heart Failure

– PAD

– 1° Prevention for women

• Heart failure, PAD, and Primary Prevention not currently covered for 

CR by most insurers
3 Phases of Cardiac Rehabilitation 

• Phase I: inpatient phase (1960s), early graded 

mobilization to the level of activity required to perform 

simple household tasks. 

• Phase II: hospital-based outpatient program (1970s on) 

monitored exercise and risk factor reduction.

• Phase III: maintenance phase. Hospital- or medicallybased; goal of continuing the risk factor modification 

and maintaining exercise intensity.
• Exercise Prescription 

– Intensity

– Mode 

– Frequency 

– Content and duration 

Exercise Training

• Class B: 

Clinically stable; Low risk of CV 

complications

• Class C: 

 Moderate–High risk of CV 

complications (Hx low EF, 

cardiac arrest, NYHA class III or 

IV, low Ex capacity, or residual 

ischemia
J Suaya et al. Circulation. 2007;116:1653-62 

Utilization of cardiac 

rehabilitation by state
♀♂ Therapeutic Goals 2013

• Physical Activity (Surveillance, education)

• Risk Factor Modification (Rx, Education) 

– Tobacco, Diabetes, Blood Pressure, 

Cholesterol, Weight, Inflammation

– Stabilize Coronary Plaque, endothelial 

 responsiveness, distensibility, remodeling 

• Modify Stress, Anxiety, Depression

• Diet (salt, cholesterol, cooking, restaurants, weight loss)

• Return to work, key family roles, QOL, independence, 

rehospitalization 
Cardiac Rehabilitation and Survival 

Suaya JA, et al. JACC. 2009; 54:25-33 

• 21-34% Mortality 

Reduction

• Advanced ages

• Socioeconomic range

• ACS: Revasc, HF

• Severity of dz

• Extent of Comorbidity

Cumulative Mortality Rate

Months from Discharge

N=601,099

Medicare Population 
Cardiac Rehabilitation in VHA

• History of Cardiac Rehabilitation (Forman)

• Current Status (Whooley)

• Challenges for Implementation (Forman)

• Opportunities and Future Directions (Whooley)

17
Cardiac Rehabilitation in VHA

• History of Cardiac Rehabilitation (Forman)

• Current Status (Whooley)

• Challenges for Implementation (Forman)

• Opportunities and Future Directions (Whooley)

18
19
26% reduction in mortality among patients with CHD

20
Decreased CV mortality or HF hospitalization, JAMA 2009;301:1439-50

Improved quality of life, JAMA 2009;301:1451-1459

Lower depressive symptoms, JAMA 2012;308:465-474

21
Performance Measures for Referral to Cardiac Rehab

22
Patients Who Should be Referred from an Inpatient Setting 

(AACVPR/AACF/AHA Performance Measures):

All patients with a primary diagnosis of: 

• Myocardial infarction

• Chronic stable angina

• Heart failure 

• Peripheral artery disease

All patients status post one of these procedures:

• Coronary artery bypass grafting 

• Percutaneous coronary intervention 

• Cardiac valve surgery

• Cardiac transplantation

Circulation. 2011;124:2458-2473 23
All patients who within the past 12 months have experienced:

• Acute myocardial infarction

• Chronic stable angina

• Coronary artery bypass grafting

• Cardiac valve surgery

• Cardiac transplantation

• Percutaneous coronary intervention

Patients Who Should be Referred from an Outpatient Setting 

(AACVPR/AACF/AHA Performance Measures):

Circulation. 2011;124:2458-2473 24
Drozda et al. Circulation. 2011;124:248-270

Performance Measures for Secondary Prevention
Performance Measures for Secondary Prevention

1) Blood pressure control

2) Lipid control

3) Smoking cessation

4) Anti-platelet therapy

5) Beta-blocker therapy

6) ACE/ARB therapy

7) Physical activity assessment

8) Symptom management

9) Cardiac rehabilitation

Drozda et al, Circulation. 2011;124:248-270
Performance Measures for Secondary Prevention

1) Blood pressure control

2) Lipid control

3) Smoking cessation

4) Anti-platelet therapy

5) Beta-blocker therapy

6) ACE/ARB therapy

7) Physical activity assessment

8) Symptom management

9) Cardiac rehabilitation

“All patients evaluated in an 

outpatient setting who within the 

previous 12 months have experienced 

acute MI, CABG, PCI or who have 

chronic stable angina and have not 

already participated in a cardiac rehab 

or secondary prevention program for 

the qualifying event/diagnosis must 

be referred to such a program.”

Drozda et al, Circulation. 2011;124:248-270
Suaya et al. Circulation. 2007;116:1653-62

28
2011 Survey of VA Cardiovasc

(Healthcare Analysis &

VA Medica

(n=1

Inpatien

provi

(

CR program

n=1

program

(n=35, 28%)

CR program

(n=35, 28%)

Schopfer D, pre

cular Specialty Care 

& Information Group

al Centers

149)

nt care

ided

123)

No CR progra

(n=88, 72%

No CR progra

esented at AHA Scientific Se
35 VA Facilities with Onsite Cardiac Rehab (by VISN)

1 Boston HCS-West Roxbury

2 Syracuse, NY

2 Western New York HCS

3 New Jersey HCS-East Orange

3 New York Harbor HCS-Brooklyn

3 New York Harbor HCS-New York

3 Northport, NY

4 Wilkes-Barre, PA

5 Washington, DC

6 Richmond, VA

7 Augusta, GA

8 Bay Pines HCS

8 Caribbean HCS-San Juan

8 Miami HCS

8 Tampa, FL

8 West Palm Beach, FL

9 Louisville, KY

10 Cleveland, OH-Wade Park

10 Dayton, OH

11 Ann Arbor HCS

12 Hines, IL

12 Madison, WI

12 Milwaukee, WI

15 Columbia, MO

16 Houston, TX

16 Oklahoma City, OK

17 North Texas HCS

18 Phoenix, AZ

19 Montana HCS

19 Salt Lake City HCS

20 Puget Sound HCS-Seattle

22 Greater Los Angeles HCS

22 Long Beach HCS

23 Black Hills HCS-Fort Meade

23 Black Hills HCS-Hot Springs
31

VA HSR&D QuERI Rapid Response Proposal 12-232 

• Number of Veterans hospitalized 2008-2011: 

• 20,837 myocardial infarction

• 25,214 percutaneous coronary intervention

• 10,989 coronary artery bypass grafting 

• Proportion who participated in CR (VA or non-VA):

• 8.9% at VA facilities with onsite CR program

• 5.1% at VA facilities without onsite CR program
Common Barriers

 Patient-level factors:

• Distance from center

• Lack of transportation

• Financial constraints

• Time off from work

• Limited motivation

Schopfer D, presented at AHA Scientific Sessions, Nov 2012 
Common Barriers

 Patient-level factors:

• Distance from center

• Lack of transportation

• Financial constraints

• Time off from work

• Limited motivation

 Provider-level factors

• Awareness of guidelines

• Unsure how to refer 

Schopfer D, presented at AHA Scientific Sessions, Nov 2012 
Common Barriers

 Patient-level factors:

• Distance from center

• Lack of transportation

• Financial constraints

• Time off from work

• Limited motivation

 Provider-level factors

• Awareness of guidelines

• Unsure how to refer 

System-level factors:

• Poor reimbursement

• Variability /complexity of 

programs 

Schopfer D, presented at AHA Scientific Sessions, Nov 2012 
Circulation. 2011;124:2951-2960
Cardiac Rehabilitation in VHA

• History of Cardiac Rehabilitation (Forman)

• Current Status (Whooley)

• Challenges for Implementation (Forman)

• Opportunities and Future Directions (Whooley)

36
Cardiac Rehabilitation in VHA

• History of Cardiac Rehabilitation (Forman)

• Current Status (Whooley)

• Challenges for Implementation (Forman)

• Opportunities and Future Directions (Whooley)

37
There is a need...

There is proven 

efficacy...

How to modify process 

of care to better suit 

the patients?

Secondary Prevention: Recognizing the need 
Challenges of Secondary Prevention 

• Risk factor modification often complicated, especially 

amidst multimorbidity and polypharmacy

• Exercise neither intuitive or easily adapted. 

• Behavior changes are hard to sustain 

• Meaningful education hard to achieve 

• How to achieve personalized care more comprehensively 

and with greater efficiency?
Secondary Prevention: harder than it seems...

Physical Activity, 

diet, tobacco, 

medical compliance
Personalized Care

• Relatively more patients are stable from a CV 

perspective, but more are vulnerable from a 

composite health perspective
Complexity of most patients

• Age, multimorbidity, polypharmacy

• Life stressors—divorce, finances, job 

• Education, socioeconomics, family dynamics, pain, 

depression, nutrition

• Frailty

– Physical limitations

– Cognition
Cardiac Rehabilitation is useful

• Redefining the process of care to better capitalize on its 

benefits

– Access; Relevance for patients 

• Are there key elements or CR that may be similarly or 

better achieved at home or in a community setting?

• Technology may help facilitate

exercise, education, and

risk factor modification 
Technology-augmented care 

modifying the paradigm

• Technology facilitates

– Virtual provider in your home

• Reinforce links to exercise physiologist, nutritionist, nurse, 

physician

– Virtual community 

• Reinforce links to members of the group 

• Out of the hospital can be better medicine
Linking the patient to the provider and 

the hospital structure 

Physical monitoring is one component

– Means to facilitate guidance and proactive care.

• Relative safety with contemporary care (revascularization 

and medical therapy), but...

—Ischemia, hemodynamics, arrhythmia, balance

—Age and complexity of patients (Comorbidity, Medications, 

Mood)

—Sensory, cognitive, and physical limits 
Technology-augmented 

education and risk factor modification 

Day-to-day prompts: links to pertinent education with 

different levels of sophistication

• Immediate feedback 

– Medical questions

– Dietary questions 

– Symptoms and signs 

Potential to share information: to reinforce/refine care

– Medical staff, designated family members

– Reduce risk, increase compliance
Caroline R. Richardson 

Generating Data 
Data that are linked to a programmatic CR design

Daily Guidance:

Personalized prompts 

for daily activity, therapy 

(compliance), and daily 

education 

Objective Tracking:

Accelerometer data to 

track day-to-day activity 

 

Potential Links:

Links to CR staff, as 

well as to designated 

family members, and/or 

to others in CR
For Clinicians:

 Efficiencies...and enhancement of care

 
Pt exercising with an avatar

Next generation:

Visual feedback... Watching a trainer, watching your own body movements (position, breathing)

• Multiple patients monitored by providers

• Patients can be watching other patients

Strength training, balance training, broader groups of patients 

Expand the concept 

of video-conferencing 
Efficiency

 and Personalized-care 

• Linking providers to more patients with greater 

efficiency, but also higher quality

• Tailored-care that responses to each patient’s 

circumstances 
Cardiac Rehabilitation Hybrid Model 

• Technological links can be initiated as part of 

acute care

– Options for better hospital-based outpatient program

– Options for better home care

– Options for better community care

• Overriding goals to establish therapeutic models 

that increase efficiency and quality of care. 
Cardiac Rehabilitation in VHA

• History of Cardiac Rehabilitation (Forman)

• Current Status (Whooley)

• Challenges for Implementation (Forman)

• Opportunities and Future Directions (Whooley)

53
Cardiac Rehabilitation in VHA

• History of Cardiac Rehabilitation (Forman)

• Current Status (Whooley)

• Challenges for Implementation (Forman)

• Opportunities and Future Directions (Whooley)

54
35 Cardiac Rehab Centers in VHA 

55

Of the 9.3 million Veterans currently enrolled in VHA, 

6.9 million (74%) live more than 60 minutes from a VA CR center. 
56
57
No significant difference in mortality 

(home vs. center-based)

58
No significant difference in mortality 

(home vs. center-based)

“Home- and center-based CR programs appear to be equally effective in 

improving the clinical and health-related quality of life outcomes in acute MI 

and revascularization patients. This finding, together with an absence of 

difference in healthcare costs between the two approaches, would support 

the extension of home-based programs. “ 59
Similar efficacy x greater participation 

may lead to greater effectiveness

Referral to Cardiac Rehabilitation

Home-based 

Efficacy

X 

Participation

Effectiveness

Center-based 

Yes No Yes No
“A home-based CR program can be substituted for a 

supervised, center-based program for low-risk patients.”

(Class I Recommendation; Level of Evidence A) 

61
5060 exercise studies in 4250 high risk patients, including:

• N= 1289 Congestive Heart Failure

• N= 598 Hypertrophic Cardiomyopathy

• N= 194 Pulmonary Hypertension

• N= 212 Aortic Stenosis

• N= 686 Age 75 or Older

• N= 1748 Women 

• N= 1192 Peak V02 < 14 ml/kg/min

Skalski et al, Circulation 2012;126:2465-2472 62
No adverse events

in 5,052 studies

(99.84%)

Skalski et a

Adverseevent in

8 di

V

T

8 studies

(0.16%)

1 

1 

l, Circulation 2012;126
No adverse events

in 5,052 studies 

(99.84%)

64

Adverse 

event in

8 studies 

(0.16%)

6 (0.12%) 

Sustained 

Ventricular 

Tachycardia

1 (0.02%) MI 

1 (0.02%) Other 

0 Deaths 

Skalski et al, Circulation 2012;126:2465-2472
65

Piccini et al. J Am Coll Cardiol HF 2013;1:142-148
 No evidence of increased ICD shocks associated with exercise training 

(n=546) vs. usual care (n=507) in patients with HF and reduced LVEF.

Piccini et al. J Am Coll Cardiol HF 2013;1:142-148

66
67

Kaiser Permanente Multifit Program

http://www.permanente.net/homepage/kaiser/pdf/6377.pdf
American Heart Association (AHA), January 2013

“An Active Partnership For the Health of Your Heart”

https://www.kramesstore.com/OA_HTML/ActivePartnership.html 68
69 http://www.ruralhealth.va.gov/resource-centers/central/cardiac-rehab.asp

Remote Cardiac Rehab Program, Iowa City VA

Veteran’s Rural Health Resource Center-Central Region 
70

Exercise Peddler ($25)

Pedometer ($27)

TheraBand
Conclusions

• Cardiac rehabilitation improves cardiac outcomes

• Vastly underutilized both inside and outside VA

• Geographic distance a major barrier 

• Home cardiac rehab and new technologies may 

improve utilization

71
Contact Information

• Dr. Dan Forman: deforman@partners.org

• Dr. Mary Whooley: mary.whooley@ucsf.edu

72