Cardiac rehabilitation and readmissions after heart transplantation

Abstract

Background: Exercise-based cardiac rehabilitation (CR) is under-utilized. CR is indicated after heart transplantation, but there are no data regarding CR participation in transplant recipients. We characterized current CR utilization among heart transplant recipients in the United States and the association of CR with 1-year readmissions using the 2013-2014 Medicare files.

Methods: The study population included Medicare beneficiaries enrolled due to disability (patients on the transplant list are eligible for disability benefits under Medicare regulations) or age ≥65 years. We identified heart transplant patients by diagnosis codes and cumulative CR sessions occurring within 1 year after the transplant hospitalization.

Results: There were 2,531 heart transplant patients in the USA in 2013, of whom 595 (24%) received Medicare coverage and were included in the study. CR utilization was low, with 326 patients (55%) participating in CR programs. The Midwest had the highest proportion of transplant recipients initiating CR (68%, p = 0.001). Patients initiating CR attended a mean of 26.7 (standard deviation 13.3) sessions, less than the generally prescribed program of 36 sessions. Transplant recipients age 35 to 49 years were less likely to initiate CR (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.23 to 0.66, p < 0.001) and attended 8.2 fewer sessions (95% CI 3.5 to 12.9, p < 0.001) than patients age ≥65 years. CR participation was associated with a 29% lower 1-year readmission risk (95% CI 13% to 42%, p = 0.001).

Conclusions: Only half of cardiac transplant recipients participate in CR, and those who do have a lower 1-year readmission risk. These data invite further study on barriers to CR in this population.

Keywords: cardiac rehabilitation; cardiac transplantation; health services research; heart transplantation; readmissions; rehabilitation.

Figure 1

Person-time approach (Mantel–Byar method) to defining cardiac rehabilitation (CR) participation status in modeling the association of CR with readmissions. In CR participants, the time between hospital discharge and CR initiation (immortal person-time) is classified as CR non-participation until CR initiation and CR participation thereafter.

Figure 2

Cumulative readmissions over time for Medicare beneficiaries receiving heart transplants in 2013, stratified by participation in cardiac rehabilitation. Cumulative readmissions were calculated using the Andersen–Gill model with a robust sandwich covariance estimator adjusted for age, gender, race, census region, comorbidities, discharge to an inpatient rehabilitation facility or skilled nursing facility, and previous ventricular assist device. Shaded areas represent 95% confidence intervals.