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Cardiopulmonary Rehabilitation

Jacob Comstock, Kelsey Hagerdon,

Adam Cook, Brandon Bergquist

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Objectives

• Examine benefits of Cardiopulmonary Rehab

• Comparison of Hospital, Outpatient, and home

health care for cardiopulmonary Rehab

• Referral strategies for cardiopulmonary

rehabilitation

• Clinical guidelines for exercise when working

with a cardiopulmonary patient

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What is

Cardiopulmonary

Rehabilitation?

• Medically supervised multifaceted program

aimed to reverse limitations in patients who

have suffered a cardiac event or required

surgery or medical care.

• Program consists of:

• Exercise training/Physical activity

• Education on heart healthy living, tobacco

cessation, prescription management

• Stress management/psychosocial effects

• Integration into functional status in family and

society

• Limit risk of re-infarction or sudden death

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Indication for

Cardiopulmonary

Rehab

• Recent MI

• Percutaneous coronary intervention

• CABG

• Chronic stable angina

• Congestive heart failure

• Cardiac transplantation

• Valvular heart disease

*Medicare provides reimbursement for all

except congestive heart failure.

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Phases of

Cardiopulmonary

Rehabilitation

I. In hospital patient period

• Pt. and family education

• Identify CV risk factors

• Lifestyle modification plan

• Discharge planning and activity program

II. Post discharge period

• Reinforce cardiac risk factor modification

• Continued education

• Gradual activity and low level exercise regime 4-6 weeks post MI.

III. Cardiac Rehabilitation and Prevention

• Structured exercise training

• 6 week duration

• Exercise class including warm up, and cool down.

IV. Maintenance

• Support groups/family involvement

• Telephone follow up

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Statistics of

cardiopulmonary

rehabilitation

• Of the 935,000 Americans having a coronary event, more

than 30% will have a second, potentially fatal one.

• Fewer than 20% of those eligible for a CR program,

participate in one.

• Utilization rate for Medicare patients is only 12%.

• 14-35% of eligible heart attack survivors participate in

cardiopulmonary rehab

• 31% of CABG patients participate in cardiopulmonary

rehab

• Participation can reduce likelihood of hospital readmissions

by 25%

• 25% reduction in all-cause mortality rates

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STUDY:

Outpatient vs home-based pulmonary

rehabilitation in COPD: a randomized control

trial

• Comparison of outpatient

pulmonary rehab to home-based

pulmonary rehab (Also included a

control)

• 117 patients with COPD (after

exclusions: 42 home-based, 46

outpatient, 29 control

• Comparisons were made using

6MWT and BODE scale

• Outpatient and home-based rehab

had similar results

• Both were superior to the control

BODE index variation before and after rehabilitation program

Intra-group results of distance walked on six-minute walk test

before and after rehabilitation program

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STUDY:

Home-based versus centre-

based cardiac rehabilitation

• The purpose of this study was to look at the efficacy of

cardiac-centered home health programs versus the efficacy

of a cardiac rehabilitation center.

• Methods:

• The authors included randomized controlled trials,

systematic reviews, and meta-analyses

• Populations included adults who have, or had, an MI,

angina, revascularization, heart failure, or invites to take

part in cardiac rehabilitation

• Outcome measures used included mortality, morbidity,

exercise capacity, modifiable coronary risk factors, health

service utilization, or adherence to intervention.

• Conclusions:

• Both settings appear to be equally effective towards

improving clinical and health-related quality of life

outcomes in acute MI and revascularization patients.

• This review found no difference in healthcare

costs between the 2 settings.

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Effect of Rehabilitation Referral Strategies on

Utilization Rates: A Prospective, Controlled

Study

• 4 referral systems:– automatic referral using electronic patient records or

standard discharge orders as a systematic prompt before

hospital discharge

– liaison referral(referral is facilitated through a personal

discussion with a health care professional)

– a combination of both

– “usual” referral at the discretion of health care providers

• Compares 4 referral strategies for

referring patients with acute

coronary syndrome to Cardiac

Rehabilitaion(CR)

• 1809 participants completed a

mailed survey that assessed CR

utilization.

• Combined automatic and liaison

referral was found to result in the

largest degree of CR referral and

enrollment, followed by automatic

only, and liaison only.

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CR Utilization Continued

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Outpatient interventions

for patients with cardiac

diseases

http://journals.sagepub.com/doi/pdf/10.1177/2047487316657669

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Clinical practice guidelines for pulmonary rehab from American

College of Chest Physicians (ACCP) and the American Association of

Cardiovascular and Pulmonary Rehabilitation. (AACVPR)

• Exercise training of the muscles of ambulation is a mandatory component of pulmonary rehabilitation for patients with COPD. (1A recommendation)

• Both low- and high-intensity exercise training produce clinical benefits for patients with COPD. (1A recommendation)

• Unsupported endurance training of the upper extremities is beneficial in patients with COPD. (1A recommendation)

• Six to 12 weeks of pulmonary rehabilitation produces benefits in several outcomes. (1A recommendation)

• Addition of a strength training component increases muscle strength and mass. (1A recommendation)

• High-intensity exercise of the lower extremities produces greater physiologic benefits than low-intensity training in patients with COPD. (1B recommendation)

• Education should include information on collaborative self-management, prevention, and treatment of exacerbations. (1B recommendation)

Grading

Grade 1: strong

recommendations with

certainty that the benefits do

or do not outweigh risk.

grade 2: indicates weaker

recommendations with less

certainty .

A: High-quality RCT

B: RCT's with limitations or

inconsistent results

C: Non RCT studies

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Local cardiopulmonary

rehabilitation facilities

• Norton Health Care

• Baptist Health Louisville

• Kentucky One Health

• Jewish Hospital

• Frazier Rehab Institute

• Robley Rex VA Medical Center

• Sts. Mary & Elizabeth Hospital

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Conclusion

• Cardiopulmonary Rehab is heavily underutilized but provides

many physiological benefits.

• Outpatient and Home based pulmonary rehabilitation are viable

options for patients.

• Home based and center-based cardiac rehab programs are

equally effective towards improving clinical and health-

related quality of life outcomes in acute MI

and revascularization patients

– No difference in healthcare cost was found between the 2 settings

• Combined automatic and physician referral results in largest

enrollment to cardiopulmonary rehabilitation.

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References

1. American Heart Association. Cardiac Rehab Fact Sheet 2013 Final. 2013.

https://www.heart.org/idc/groups/heart-

public/@wcm/@adv/documents/downloadable/ucm_449722.pdf

2. Anderson L, Sharp G, Taylor R, et al. Home-based versus centre-based cardiac rehabilitation. The Cochrane

Database Of Systematic Reviews [serial online]. June 30, 2017;6:CD007130. Available from: MEDLINE,

Ipswich, MA. Accessed November 13, 2017.

3. Grace SL, Russell KL, Reid RD, et al. Effect of cardiac rehabilitation referral strategies on utilization

rates: A prospective, controlled study. Archives of Internal Medicine. 2011;171(3):235-241.

4. Lowe R. Cardiac Rehabilitation. Physiopedia. http://www.physio-pedia.com/Cardiac_Rehabilitation.

Accessed November 7, 2017.

5. Mendes de Oliveira JC, Studart Leitão Filho FS, Malosa Sampaio LM, et al. Outpatient vs. home-based

pulmonary rehabilitation in COPD: a randomized controlled trial. Multidisciplinary Respiratory Medicine.

2010;5(6):401-408. doi:10.1186/2049-6958-5-6-401.

6. Price KJ, Gordon BA, Bird SR, Benson AC. A review of guidelines for cardiac rehabilitation exercise

programmes: Is there an international consensus? European Journal of Preventive Cardiology.

2016;23(16):1715-1733.

7. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-

Based Clinical Practice Guidelines. Chest. 2007;131(5, Supplement):4S-42S.