Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Dec;16(12):e010131.
doi: 10.1161/CIRCOUTCOMES.123.010131. Epub 2023 Dec 1.

Intensive Versus Traditional Cardiac Rehabilitation: Mortality and Cardiovascular Outcomes in a 2016-2020 Retrospective Medicare Cohort

Mustafa Husaini  1 , Elena Deych  1 , R J Waken  1 , Blake Sells  1 , Andrew Lai  1 , Susan B Racette  2 , Michael W Rich  1 , Karen E Joynt Maddox  1 , Linda R Peterson  1
Affiliations

Intensive Versus Traditional Cardiac Rehabilitation: Mortality and Cardiovascular Outcomes in a 2016-2020 Retrospective Medicare Cohort

Mustafa Husaini et al. Circ Cardiovasc Qual Outcomes. 2023 Dec.

Abstract

Background: Traditional cardiac rehabilitation (CR) improves cardiovascular outcomes and reduces mortality, but less is known about the relative benefit of intensive CR (ICR) which incorporates greater lifestyle education through 72 sessions (versus 36 in CR). Our objective was to determine whether ICR is associated with a mortality and cardiovascular benefit compared with CR.

Methods: Retrospective cohort study of Medicare Fee-For-Service beneficiaries in a 100% sample, claims data set. Qualifying events were captured from May 1, 2016 to December 31, 2019 and ICR/CR utilization captured from May 1, 2016 to December 31, 2020. Among patients attending at least 1 day of either CR or ICR, Cox proportional hazards models using a 1 to 5 propensity score match were used to compare utilization and the association of ICR versus CR participation with (1) all-cause mortality and (2) cardiovascular-related hospitalizations or nonfatal cardiac events. Dose-response was assessed by the number of days attended.

Results: From 2016 to 2019, 1 277 358 unique patients met at least one qualifying indication for ICR/CR from 2016 to 2019. Of these, 262 579 (20.6%) and 4452 (0.4%) attended at least one session of CR or ICR, respectively (mean [SD] age, 73.2 [7.8] years; 32.3% female). In the matched sample, including 26 659 total patients (median, 2.4-year follow-up), ICR was associated with 12% lower all-cause mortality (multivariable adjusted hazard ratio, 0.88 [95% CI, 0.78-0.99]; P=0.036) compared with CR but no significant difference for cardiovascular-related hospitalization or nonfatal cardiac events. The mortality benefit was seen for both ICR and CR per day strata, with each modality demonstrating a clear dose-response benefit.

Conclusions: ICR is associated with lower mortality than traditional CR among Medicare beneficiaries but no difference in cardiovascular-related hospitalization or nonfatal cardiac events. Moreover, ICR and CR demonstrate a dose-response relationship for mortality. Additional studies are needed to confirm these observations and to better understand the mechanisms by which ICR may lead to a reduction in mortality.

Keywords: coronary artery bypass; exercise; hospitalization; lifestyle; myocardial infarction; secondary prevention.

PubMed Disclaimer

Conflict of interest statement

Disclosures Dr Husaini received research support from Pritikin intensive cardiac rehabilitation (ICR), LLC through the Foundation for Barnes-Jewish Hospital and has received honoraria from Bristol Meyers Squibb. Dr Racette receives research support from the National Institutes of Health (NIH; R01 AG070717, R01 AG060499, R61 HL155858, R34 HL158947, R33 AG070455, R25 HL105400), and the Foundation for Barnes-Jewish Hospital. Dr Rich receives support from the NIH (R01 AG060499, R01 AG078153, R01 HL147862, R01 HL151431). Dr Joynt Maddox receives research support from the National Heart, Lung, and Blood Institute (R01HL143421 and R01HL164561), National Institute of Nursing research (U01NR020555), and National Institute on Aging (R01AG060935, R01AG063759, and R21AG065526), and from Humana. She also serves on the Health Policy Advisory Council for the Centene Corporation (St Louis, MO). Dr Peterson has stock holdings in Medtronic, Johnson and Johnson and receives research support from the NIH (R61/R33 HL155858, R01 AG060499-01, R01 HL 165238), the American Heart Association (No. 23SCISA1145192), the Children’s Discovery Institute, the Clinical and Translational Research Funding Program (CTRFP), and the Foundation for Barnes-Jewish Hospital in Saint Louis, MO. The other authors report no conflicts.

Figures

Figure 1.
Figure 1.. Adjusted Survival and Non-Fatal major adverse cardiac event (MACE) Analysis, Medicare Beneficiaries Participating in ICR versus CR, 2016–2020
5-to-1 matched survival analysis (A) and non-fatal MACE analysis (B). There was a significant survival advantage of ICR vs. CR in terms of survival (p < 0.036), but not in non-fatal MACE (p = 0.41). Abbreviations: CR = cardiac rehabilitation, ICR = intensive cardiac rehabilitation
Figure 2.
Figure 2.. Association of ICR with Mortality in Selected Subgroups
Adjusted subgroup analysis from 2016 to 2019 (A) and frailty subgroup analysis from 2017 to 2020 (B). None of the interaction p-values were significant, sex (p = 0.85), age (p = 0.37), diabetes (p = 0.38), qualifying event (p = 0.27), and frailty (p = 0.08). Abbreviations: CR = cardiac rehabilitation, ICR = intensive cardiac rehabilitation
Figure 3.
Figure 3.. Adjusted Dose-Response Relationship of ICR and CR with Mortality
Adjusted analysis with 1–9 days as the baseline comparator. Patients included if alive 1 year after first ICR/CR claim. ICR adjusted for age, sex, race, and comorbidities. CR adjusted for age, sex, race, qualifying indication, Medicaid enrollment, geography, and comorbidities. For both ICR (A) and CR (B) there was a stepwise reduction in mortality for 10–18 days, 19–35 days and 36 days of participation (p<0.0001 for all), compared to 1–9 days of participation.
See this image and copyright information in PMC

References

    1. Suaya JA, Stason WB, Ades PA, Normand SL, Shepard DS. Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol. Jun 2009;54(1):25–33. doi:10.1016/j.jacc.2009.01.078 - DOI - PubMed
    1. Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation. Jan 5 2010;121(1):63–70. doi:10.1161/circulationaha.109.876383 - DOI - PMC - PubMed
    1. Pack QR, Squires RW, Lopez-Jimenez F, et al. Participation Rates, Process Monitoring, and Quality Improvement Among Cardiac Rehabilitation Programs in the United States: A NATIONAL SURVEY. J Cardiopulm Rehabil Prev. May-Jun 2015;35(3):173–80. doi:10.1097/hcr.0000000000000108 - DOI - PMC - PubMed
    1. Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. Oct 2007;116(15):1653–62. doi:10.1161/CIRCULATIONAHA.107.701466 - DOI - PubMed
    1. Ritchey MD, Maresh S, McNeely J, et al. Tracking Cardiac Rehabilitation Participation and Completion Among Medicare Beneficiaries to Inform the Efforts of a National Initiative. Circ Cardiovasc Qual Outcomes. 01 2020;13(1):e005902. doi:10.1161/CIRCOUTCOMES.119.005902 - DOI - PMC - PubMed

Publication types