Most people who have a minimally invasive heart valve replacement procedure do not undergo recommended cardiac rehabilitation, say US researchers, who used clinical registry and healthcare claims data from more than 3 300 patients to determine the rate of cardiac rehabilitation participation.
All of the patients had undergone transcatheter aortic valve replacement (TAVR), a minimally invasive procedure that replaces heart valves without open heart surgery, and which is safely used in older patients who are not good candidates for open heart surgery.
The Michigan Medicine-led study used data from 24 hospitals, from between 2016 and mid-2020, the results revealing that just 30.6% of patients who underwent TAVR participated in cardiac rehabilitation within 90 days of discharge.
Patients who were older, more frail, smoked or had a history of common heart rhythm issues, like atrial fibrillation, were less likely to enter cardiac rehab, the scientists found.
Whether a patient participated in the medically supervised exercise and educational programme varied substantially across the two dozen hospitals, ranging from 5% to 60%.
This variation across hospitals persisted despite accounting for differences in the characteristics of the patients treated, they wrote in their paper, which was published in JACC: Advances.
The participation rate for cardiac rehab after TAVR was significantly lower than that for patients who’d had open-heart surgeries.
Researchers say the difference may be explained by TAVR patients being more frail or medically complex than patients who undergo surgical repair.
Investigators also note that patients may not receive the appropriate education regarding the importance of cardiac rehabilitation after this minimally invasive procedure.
“Cardiac rehabilitation has been shown to improve the quality of life for so many patients after cardiovascular procedures,” said first author Devraj Sukul, MD, MSc, interventional cardiologist at the University of Michigan Health Frankel Cardiovascular Centre and clinical assistant professor of internal medicine-cardiology at University of Michigan Medical School.
“We found that the differences in participation between hospitals may be related to differences in the process each hospital takes after a patient undergoes TAVR. It is critical that we identify best practices to promote cardiac rehab participation to improve post-operative outcomes.”
Study details
Predictors and variation in cardiac rehabilitation participation after transcatheter aortic valve replacement
Devraj Sukul, Jeremy Albright, Michael Grossman, et al.
Published in JACC: Advances on 2 October 2023
Abstract
Background
Cardiac rehabilitation (CR) is strongly recommended for a spectrum of cardiovascular conditions and procedures including aortic valve replacement.
Objectives
The purpose of this study was to characterise patient and hospital factors associated with CR participation after transcatheter aortic valve replacement (TAVR) and determine which factors explain hospital-level variation in CR participation.
Methods
We linked clinical and administrative claims data from patients who underwent TAVR at 24 Michigan hospitals between January 1, 2016 and June 30, 2020 and obtained rates of CR enrolment within 90 days of discharge. Sequential mixed models were fit to evaluate hospital variation in 90-day post-TAVR CR participation.
Results
Among 3 372 patients, 30.6% participated in CR within 90-days after discharge. Several patient factors were negatively associated with CR participation after TAVR including older age, Medicaid insurance, atrial fibrillation/flutter, dialysis use, and slower baseline 5-m walk times. There was substantial hospital variation in CR participation after TAVR ranging from 5% to 60% across 24 hospitals. Patient case mix did not explain hospital variation in CR across hospitals with median OR numerically increasing from 2.11 (95% CI: 1.62-2.67) to 2.13 (95% CI: 1.61-2.68) after accounting for patient-level factors.
Conclusions
Less than one in three patients who underwent TAVR in Michigan participated in CR within 90-days of discharge. Although several patient factors are associated with CR participation, hospital-level variation in CR participation after TAVR is not explained by patient case mix. Identifying hospital processes of care that promote CR participation after TAVR will be critical to improving CR participation after TAVR.
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TAVR a durable remedy for those not eligible for open heart surgery
Longer life for elderly from TAVR
Brain microbleed common in older TAVR patients