Despite all the attention to COVID-19, heart disease remains one of the greatest threats to health. Indeed, many people did not take care of their heart health during the pandemic and experience a reduced quality of life as a result. If you are reading this from the couch with a bag of potato chips, this may include you.
Cardiac rehabilitation alleviates this, but only 10 to 25% of heart patients have access to it. It helps if patients and their loved ones are aware of cardiac rehabilitation and ask their doctor for a recommendation, but there are established strategies to ensure that patients have access to these programs, which we desperately need to implement.
As a cardiac rehabilitation researcher, I have been working with the Cardiac Preventive Community for the past 20 years to provide more patients with access to these life-saving programs.
What is cardiac rehabilitation
Heart disease is chronic and untreatable, so it often leads to further cardiac events, such as re-admission to the hospital or the need for a stent – a small tube placed in a vessel in the heart muscle to keep it open so the blood , rich in oxygen and nutrients, can flow to it. But the chances of this can be drastically reduced with a cheap, holistic approach to cardiac rehabilitation.
Cardiac rehabilitation includes exercise, diet, lifestyle and psychosocial counseling. (pixels)
Cardiac rehabilitation is an outpatient chronic disease management program that offers patients one-hour sessions about twice a week for several months. The programs offer structured exercises, patient education, and lifestyle (such as diet, tobacco use, adherence to medications) and psychosocial (things like depression, anxiety, sleep, stress, sex, if applicable) counseling. Think of it as a one-stop shop for all proven heart disease risk reduction recommendations, delivered in a coordinated manner with your emergency physicians and primary care provider over time. We are the middle link in the chain that keeps patients thriving.
Cardiac rehabilitation is “not just broccoli and sneakers,” as our medical director likes to say; participation reduces mortality and hospitalization by more than 20 percent, and also improves well-being and helps return to desired life roles. Still, few heart patients receive it, while other heart care recommendations as medications are applied more than 80 percent of the time.
As a cardiac rehabilitation community, we did research to see what this could fix. These include innovative health system payment models, automated e-referral, clinician training courses and technology-based cardiac rehabilitation. Unfortunately, things have not changed and patients are not receiving the necessary support.
Payment for cardiac rehabilitation
In Canada and other countries, health care providers cannot directly charge government health systems for cardiac rehabilitation, as they can for a stent or visit a cardiologist, despite all clinical recommendations for patients to receive rehabilitation. We advocate for this cost recovery or other innovative payment models to make the rehabilitation of cardiac rehabilitation more financially viable and to provide enough cardiac rehabilitation facilities for all patients who need it.
Automatic tagging of patients with a stent for referral to cardiac rehabilitation can help improve access speed. (Shutterstock)
For example, if a patient receives a stent or cardiac bypass, the hospital may be paid a “package” fee, which includes money not only for the procedure but also for the rehabilitation that follows. Package payments, which include rehabilitation, have now been introduced to replace the hip and knee in Ontario, for example, but we are still waiting for cardiac procedures, as promised.
As a proponent of cardiac rehabilitation, I have heard the argument that heart risks are related to lifestyle and government-funded health systems should not be concerned with changing individual health behaviors. This is despite evidence that cardiac rehabilitation is cost-effective, leading to an earlier return to work, as well as a reduction in deaths and repeat hospital visits (which are very costly to the healthcare system).
Moreover, the same unhealthy behavior that underlies heart disease is also linked to cancer, but we do not blame cancer patients for their condition.
Probably the lack of public policy – to guarantee citizens access to safe green areas for exercise, sources of healthy food and fresh air in all neighborhoods, regardless of socio-economic status, as well as better control of smoking – leads to heart disease ; so governments obviously have an important role to play in changing lifestyles.
Participation in cardiac rehabilitation reduces mortality and hospitalization by more than 20 percent, improves well-being and helps return to desired life roles. (Pixabay)
People need support to learn how to manage their condition and change many health behaviors, as well as to cope with the high rate of psychosocial problems that not only hinder their ability to manage their condition, but also lead to worse health results.
Other solutions include the use of electronic health records, so that, for example, when a heart patient receives a stent or bypass, their file is automatically marked for cardiac rehabilitation because of its obvious benefits in those patients. Systematic referrals such as these increase the use of rehabilitation eightfold, and this is further increased by training hospital clinicians to inform and encourage patients to sign up for cardiac rehabilitation by the bed.
Reaching the most needy patients
Finally, we can also provide cardiac rehabilitation widely, using technology to reach all patients in need. The rehabilitation utilization rate of 10 to 25 percent is average. Use is even lower in certain populations, such as women, rural and racial people, and low-income people in Canada and around the world. And this is particularly embarrassing, because in lower-income countries, heart disease is epidemic.
Many middle-income countries are now developing cardiology programs as the severity of the disease shifts from contagious to non-infectious. It is embarrassing that these advanced centers place high-frequency stents, but often neglect cardiac rehabilitation, which is less expensive and in many cases of similar or better benefit. In addition, doctors prefer to specialize in interventional rather than preventive cardiology, as it is more lucrative, so there are few clinicians to provide cardiac rehabilitation.
Efforts are being made to increase the training of health professionals in cardiac rehabilitation worldwide. We hope that their cardiology systems will not look like those in high-income settings, with most of the focus and resources on emergency care to ignore prevention and chronic care.
When we bring all these strategies together, the cardiac rehabilitation community can reach out and care for the patients who need us most. If you or a loved one has heart disease, ask your doctor for a referral for cardiac rehabilitation – this could save your life.
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