The Implications of Underutilizing Cardiac Rehabilitation in Patients Undergoing Coronary Artery Bypass Grafting and/or Valvular Heart Surgery: A Quality Improvement Project

From the 2018 HVPAA National Conference

ABDELRAHMAN AHMED (Wayne State University/Detroit Medical Center), Ahmad Abu-heija (Wayne State University/Detroit Medical Center), Mohan Palla (Wayne State University/Detroit Medical Center), Preeti Ramappa (Wayne State University/Detroit Medical Center/John D.Dingell VA Medical Center)

Background

Cardiac rehabilitation(CR) is a recognized component of modern cardiac care in  secondary prevention of specific cardiovascular conditions. Participation in CR for patients following coronary artery bypass grafting(CABG) or valve replacements improves five-year mortality by 25-46%.Less than 30% of eligible patients participate in a CR program following a cardiovascular event.

Objectives

This study aims to assess the utilization of CR services for patients undergoing CABG and/or valve heart surgery in our institution, John D Dingell VA Medical Center (VAMC),Detroit.In addition, it highlights the negative impact of CR underutilization on hospital readmissions.

Methods

We retrospectively reviewed data on patients who were referred from Detroit VAMC to the referring facility, Ann Arbor VAMC, to undergo CABG and/or valvular repair/replacement surgeries in 2015.All Detroit VA patients who underwent valve heart surgery or CABG surgery at Ann Arbor VAMC during that time period were included in this study.The total number of patients was 54. The  data was used to evaluate adherence to secondary prevention guidelines in referring patients to CR in an appropriate and timely manner which was defined as 3 months post-surgery. Descriptive and bivariate statistics were performed using statistical software SAS University edition.

Results

The total number of patients was 54.Of them, only 12 (22%) were referred for CR within 3 months of cardiac surgery. All patients who were referred to CR attended all of their sessions. There was a significant difference in hospital readmission rates at 3 months between patients who were referred and attended CR(0%) and patients who did not attend due to lack of referral (33%) [p < 0.02].  Readmission rates without CR referral was 13.7% for CABG group; 28.6% for valvular surgery group and 27.2% for the group with CABG and valvular surgery.

Conclusion

Data from this study show that referral to CR remains underutilized in our institution and this underutilization is closely associated with higher 3-month readmission rates. We recognize that this low rate is partially due to the obstacles we encounter, that are specific to our facility. All Detroit VAMC patients are referred to another VA facility (Ann Arbor) to undergo cardiac surgery.In addition, we do not have an in-house CR program to help initiate early post-op rehab.  Patients will therefore have to be referred out to community hospitals.The interventions implemented after this study will be assessed in a 3-monthly PDSA cycle. Results of the interventions applied should be included when this poster/oral presentation is to be presented.

Implications for the Patient

Results from this study triggered a root cause analysis and we implemented several interventions starting February 2018. Our interventions included sending remidners to PCP and cardiolgoy clinics to refer patients after surgery, EMR alerts and EMR changes to the referral order.