It's a big accomplishment to survive a heart attack, heart failure or heart surgery. But it’s one thing to survive a brush with death, and it’s another to thrive.
That’s where cardiac rehabilitation programs come in. They’re medically supervised programs designed to improve cardiovascular health through exercise, education and counseling. Research shows these programs are effective, reducing heart-related mortality rates by about 35%, and usually covered by insurance plans, including Medicaid and Medicare.
Although cardiac rehabilitation is highly recommended for patients after a heart event, it is very underused among racial and ethnic minority groups, as well as dual-eligible individuals enrolled in both Medicaid and Medicare. The latter group is primarily low-income individuals with high health care needs. Researchers from the College of Health want to discover why this program is underutilized, and recently published a study in the Journal of the American Heart Association that drilled down to program usage at a county level.
“If you’re a Medicare beneficiary or dually enrolled in both Medicare and Medicaid, you are qualified to receive cardiac rehabilitation,” Lin-Na Chou, PhD, assistant professor in the Department of Physical Therapy and Athletic Training, said. “We wanted to understand why patients aren’t receiving these services.”
Using metrics from the Centers for Disease Control and Prevention Atlas of Heart Disease and Stroke database, Chou and her fellow researchers, including mentor Amit Kumar, PhD, conducted a cross-sectional study across 2,382 counties nationwide. They examined the percentage of eligible Medicare beneficiaries receiving at least one cardiac rehabilitation session within 365 days of a heart event.
The numbers were telling. The COH team found significant geographic variation in cardiac rehabilitation usage in counties with higher percentages of racial and ethnic minoritized groups, dual-eligible patients, and non-urban residents. In counties that had high numbers of both minorities and dual-eligible patients, the gap in participation was even higher.
“We know that these patients have higher risks of rehospitalization and worse health outcomes,” Chou said. “We should be delivering more cardiac rehabilitation services in these underserved geographical areas, but that is not happening.”
One reason could be that there are less providers in these counties, as well as less awareness about the preventive rehabilitation programs in general. Chou said that it’s also important to keep in mind that individuals in these counties could have other conditions that require additional preventive and rehabilitation services.
Nationally there are some efforts to encourage the use of cardiac rehabilitation, but the research team believes that areas with lower participation should be prioritized. Because insurance is likely to cover the program, it’s very cost-effective, and Kumar said it can also be done as a home-based program.
Delaying cardiac rehabilitation poses significant health risks, leading to adverse outcomes and potential medical complications. This not only jeopardizes patient well-being but also escalates medical expenses for both individuals and the Medicare insurance program.
“We want to create more awareness among these populations about the benefits of this program,” Kumar said. “From a policy point of view, let’s increase the number of outpatient cardiac rehabilitation centers in rural areas so they can get more access to this rehabilitation.”
Kumar brought his expertise in health equity to the study, and the COH’s Haley Bento, PhD, and Alex Terrill, PhD, also served as co-authors. Shweta Gore, PhD, DPT, another coauthor from the MGH Institute of Health Professions brought her expertise in cardiovascular and pulmonary rehabilitation.
Chou recently completed her PhD clinical science-health service research and joined the department as a new faculty member at the end of 2023. Despite her short stint as a faculty member, she’s already well-published and brings extensive experience in biostatistics for clinical trials and outcome research.
“For me this is a new collaboration, and I’ve enjoyed it,” she said. “I hope we can continue to collaborate on future projects, and I can build up my skill as a researcher.”
The team wants to include Medicare Advantage patients in future research, who use plans provided by private insurance instead of the federal government. These plans can be cheaper and provide extra preventive care benefits but can limit the choice of providers and require preauthorization. Medicare Advantage patients make up more than half of the total Medicare population and are more likely to be racial minorities.
In the meantime, data has clearly identified where patients aren’t receiving enough services.
“Our research shows an intersectionality of race, ethnicity and socioeconomic status—if you’re a minority or have a lower income, you’re less likely to use this program, and that’s compounded if you live in a rural or poor neighborhood,” Kumar said. “It’s a significant milestone in health equity research.”