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Improving Cardiac Rehab Enrollment for Veterans after Percutaneous Coronary Intervention – A Quality Improvement Study

Danny Mohama, MD

Primary Mentors: Dr. Viorel Florea, Dr. Susan Lou

VA Medical Center: Minneapolis

Academic Affiliate: University of Minnesota

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INTRODUCTION

Cardiac Rehab (CR) definition, perks, and best practices

Supervised, structured exercise training, nutrition and psychosocial counseling
Aerobic endurance training, resistance training, flexibility training
CR ↓mortality, ↓hospitalization, ↑QOL
Class IA AHA/ACC recommendation after percutaneous coronary intervention (PCI)

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Taylor, R. S., Dalal, H. M., & McDonagh, S. T. (2022). The role of cardiac rehabilitation in improving cardiovascular outcomes. Nature Reviews Cardiology, 19(3), 180-194.

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INTRODUCTION

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INTRODUCTION

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6.9% average participation

33% lower mortality for participants

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INTRODUCTION

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The Minneapolis VA has enrolled 23% of veterans post-PCI in cardiac rehab between October 2017 and August 2023
The Minneapolis VA has referred 32% of patients

Problem statement: The Minneapolis VA under-utilizes cardiac rehabilitation for veterans who have undergone PCI

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BASELINE DATA FOR MINNEAPOLIS VA

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BASELINE DATA FOR MINNEAPOLIS VA

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FISHBONE DIAGRAM

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Low rate of cardiac rehab enrollment for veterans post-PCI

Management

People

Equipment/Technology

Materials/Supplies

Environment

Provider lack of knowledge about benefits 🡪 no order

Patient refusal due to “orthopedic” or “neuropathy” issues

Lack of equipment and space to accommodate all post-PCI patients on site

Lack of staff to perform health coaching, initial intake to accommodate larger initial referrals

Processes/Methods

Referral order too cumbersome 🡪 delayed or missed orders

Not part of post-PCI order set, “opt-in” system missed referrals

First interventional clinic visit delayed after PCI, further delays in CR referral at that visit decreases likelihood of attendance

Environment of cath lab and high turnover not conducive to immediately placing CR referral order

Driving distance a limiting factor for many veterans

Underdeveloped at-home cardiac rehab option

Veteran scheduling missed due to inadequate contacting efforts by phone or mail

Cardiac rehab department does not have their own scheduler

CR gets deprioritized for scheduling

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FISHBONE DIAGRAM

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Low rate of cardiac rehab enrollment for veterans post-PCI

Management

People

Equipment/Technology

Materials/Supplies

Environment

Provider lack of knowledge about benefits 🡪 no order

Patient refusal due to “orthopedic” or “neuropathy” issues

Lack of equipment and space to accommodate all post-PCI patients on site

Lack of staff to perform health coaching, initial intake to accommodate larger initial referrals

Processes/Methods

Referral order too cumbersome 🡪 delayed or missed orders by blue team or interventional clinic

Not part of post-PCI order set, “opt-in” system missed referrals

First interventional clinic visit delayed after PCI, further delays in CR referral at that visit decreases likelihood of attendance

CR gets deprioritized for scheduling

Cardiac rehab department does not have their own scheduler

Environment of cath lab and high turnover not conducive to immediately placing CR referral order

Driving distance a limiting factor for many veterans

Underdeveloped at-home cardiac rehab option

Veteran scheduling missed due to inadequate contacting efforts by phone or mail

Prior interventional outpatient NP spread thin with tasks, post PCI patients deprioritized. New NP hired May 2020

I want to highlight people, processes, and management, as these are the areas of focus I chose to look at. The broad themes here are that cardiac rehab is forgotten because referrals are not automated, and the process by which cardiac rehab orders are placed rely on too many variables at first glance – mainly the providers responsible for ordering them. Number one, The residents often don’t know that a rehab order needs to be placed or simply forget. Further delays remove the urgency that veterans feel for starting cardiac rehab and thus many simply refuse if placed too late within interventional clinic. More than this, there was a large change in the system that occurred in May of 2020. Since referrals get pushed to interventional clinic this is historically where much of the orders were placed. Unfortunately pre 2020 the prior NP was overburdened with job responsibilities, and thus post PCI patients were deprioritized. These were the overarching themes I hoped to address in my QI initiative, which focuses on highlighting both retrospective changes and using education to inform a prospective intervention. Before I highlight interventions however, let’s see how cardiac rehab referrals are ordered at the Minneapolis VA to better understand the system.

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MVAHCS PROCESS MAP

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MVAHCS PROCESS MAP

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MVAHCS PROCESS MAP

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TWO CRITICAL ACTION STEPS FOR CR REFERRAL

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Discharging Inpatient Medical Residents

Outpatient Interventional Clinic Provider

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AIM

Our aim: improve cardiac rehab enrollment to 40% and cardiac rehab referral to 50% of patients post-PCI at the Minneapolis VA by May 2024
Overall strategy: maximize strong provider endorsement
Interventions:

Workflow intervention: May 2020 interventional clinic staffing change
Educational intervention: Late February 2024 inpatient resident education

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METHODS

VA CART database used to obtain data on all patients who underwent PCI at Minneapolis VA Oct 2017 – August 2023

Excluded: patients who died within 30 days of their procedure, any repeat PCIs done for the same patient within 1 year

VA administrative data used to gather primary outcome and process measures: cardiac rehab referral and first CR visit presentation (enrollment)
Biweekly data on primary process and outcome measures from September 2023 – May 2024

Statistical process control p-charts created with fixed limits applied May 2020 (staffing intervention) on retrospective data
P-charts created with fixed limits applied late Feb 2024 (educational intervention)
Two sample t-test used to compare monthly and biweekly referral and enrollment rates before and after each intervention
This study met local criteria as a quality improvement project and did not need IRB review

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METHODS

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Type of Metric	Conceptual Definition	Operational Definition
Process measure(s)	Monthly/biweekly %patients undergoing PCI who were referred to CR after PCI	%veterans during a particular month or 2-week period who had undergone PCI at the Minneapolis VA who subsequently had a cardiac rehab referral ordered within 90 days of their procedure
Outcome measure(s)	Monthly/biweekly %patients undergoing PCI who enrolled in CR	%veterans during a particular month or 2-week period who had undergone PCI at the Minneapolis VA and subsequently enrolled in CR within 1 year of their index procedure
Balancing measure	Capacity overwhelm of physical therapy department	Qualitative measure of physical therapy department overwhelm through periodic interviews

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RESULTS

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RESULTS

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RESULTS

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Monthly Average CR Rehab Referral and Enrollment Rate Before and After Interventional Clinic Nurse Practitioner Staffing Change in May 2020
	Before Staffing Change (%)	After Staffing Change (%)	P-value
CR Referral Rate	23.9 ± 11.9	36.9 ± 12.9	<0.001
CR Enrollment Rate	14.4 ± 10.2	28.0 ± 11.7	<0.001

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RESULTS

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RESULTS

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INTERVENTION 2

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RESULTS

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Biweekly Average CR Rehab Referral Rate Before and After Educational Intervention in February 2024
	Before Intervention (%)	After Intervention (%)	P-value
CR Referral Rate	37.0 ± 9.2	56.3 ± 22.2	0.09

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DISCUSSION

A staffing intervention through dedicated nurse practitioner role for post-PCI patients successfully increased cardiac rehab referral rates from 24 to 37%, and enrollment rates from 14% to 28%
A follow up educational intervention targeting the primary process measure further increased referral rates to 53%, though did not reach statistical significance
Biweekly enrollment rates not measured as many veterans had not yet scheduled their first appointment, ongoing data collection

Enrollment known to be more likely when patients educated about CR during hospitalization or immediately after hospital discharge (Vanzella)
Earlier appointments post discharge retains more patients (Pack)

Why did what we do work?

Targeted interventions based on facility process map
Strong provider endorsement works, thus educating patients AND providers matters (Sukul, Beatty, Beckie)

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Outpatient Interventional Nurse Practitioner

Discharging Inpatient Medical Residents

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FUTURE DIRECTIONS

Limitations: lack of prospective data points to show meaningful change, wide variability in PCI volumes from month to month
Future directions: automation in electronic health record, maximize human factors design principles
Sustainability plan

Three internal medicine residents to take over project with local VA champion (Dr. Viorel Florea, Director of Cardiac Rehab)
Data source within Power BI accessible to future project leaders

Goal >70% average referral rate in 2024

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REFERENCES

Taylor, R. S., Dalal, H. M., & McDonagh, S. T. (2022). The role of cardiac rehabilitation in improving cardiovascular outcomes. Nature Reviews Cardiology, 19(3), 180-194. https://doi.org/10.1038/s41569-021-00611-7
Suaya, J. A., Stason, W. B., Ades, P. A., Normand, S. L. T., & Shepard, D. S. (2009). Cardiac rehabilitation and survival in older coronary patients. Journal of the American college of Cardiology, 54(1), 25-33. https://doi.org/10.1016/j.jacc.2009.01.078
Shields, G. E., Wells, A., Doherty, P., Heagerty, A., Buck, D., & Davies, L. M. (2018). Cost-effectiveness of cardiac rehabilitation: a systematic review. Heart, 104(17), 1403-1410.
Beatty, A. L., Doll, J. A., Schopfer, D. W., Maynard, C., Plomondon, M. E., Shen, H., & Whooley, M. A. (2018). Cardiac rehabilitation participation and mortality after percutaneous coronary intervention: insights from the veterans affairs clinical assessment, reporting, and tracking program. Journal of the American Heart Association, 7(19), e010010. https://doi.org/10.1161/jaha.118.010010
Ritchey, M. D., Maresh, S., McNeely, J., Shaffer, T., Jackson, S. L., Keteyian, S. J., ... & Wright, J. (2020). Tracking cardiac rehabilitation participation and completion among Medicare beneficiaries to inform the efforts of a national initiative. Circulation: Cardiovascular Quality and Outcomes, 13(1), e005902.
Forman, D. E., McDannold, S., Schopfer, D. W., & Whooley, M. A. (2016, July). Decisive bearing of organizational dynamics on the application and success of hospital-based cardiac rehabilitation. In Mayo Clinic Proceedings (Vol. 91, No. 7, p. 975). Elsevier Limited. https://doi.org/10.1016/j.mayocp.2016.04.019
Sukul, D., Seth, M., Barnes, G. D., Dupree, J. M., Syrjamaki, J. D., Dixon, S. R., ... & Gurm, H. S. (2019). Cardiac rehabilitation use after percutaneous coronary intervention. Journal of the American College of Cardiology, 73(24), 3148-3152.
Writing Committee Members, Lawton, J. S., Tamis-Holland, J. E., Bangalore, S., Bates, E. R., Beckie, T. M., ... & Zwischenberger, B. A. (2022). 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology, 79(2), e21-e129.
Beatty, A. L., Beckie, T. M., Dodson, J., Goldstein, C. M., Hughes, J. W., Kraus, W. E., ... & Franklin, B. A. (2023). A new era in cardiac rehabilitation delivery: research gaps, questions, strategies, and priorities. Circulation, 147(3), 254-266.
Price, K. J., Gordon, B. A., Bird, S. R., & Benson, A. C. (2016). A review of guidelines for cardiac rehabilitation exercise programmes: is there an international consensus?. European journal of preventive cardiology, 23(16), 1715-1733.
Adusumalli, S., Jolly, E., Chokshi, N. P., Gitelman, Y., Rareshide, C. A., Kolansky, D. M., & Patel, M. S. (2021). Referral rates for cardiac rehabilitation among eligible inpatients after implementation of a default opt-out decision pathway in the electronic medical record. JAMA network open, 4(1), e2033472-e2033472.
https://academic.oup.com/eurheartj/article/31/16/1967/433769?login=true – talks about exercise testing thresholds and early timing being safe
Duscha, B. D., Ross, L. M., Hoselton, A. L., Piner, L. W., Pieper, C. F., & Kraus, W. E. (2024). A Detailed Analysis of Cardiac Rehabilitation on 180-Day All-Cause Hospital Readmission and Mortality. Journal of Cardiopulmonary Rehabilitation and Prevention, 44(2), 99-106.
Vanzella, L. M., Konidis, R., Pakosh, M., Aultman, C., & de Melo Ghisi, G. L. (2024). A Systematic Review of Interventions With an Educational Component Aimed at Increasing Enrollment and Participation in Cardiac Rehabilitation. Journal of Cardiopulmonary Rehabilitation and Prevention, 44(2), 83-90.
Russell, K. L., Holloway, T. M., Brum, M., Caruso, V., Chessex, C., & Grace, S. L. (2011). Cardiac rehabilitation wait times: effect on enrollment. Journal of Cardiopulmonary Rehabilitation and Prevention, 31(6), 373-377.
Pack, Q. R., Mansour, M., Barboza, J. S., Hibner, B. A., Mahan, M. G., Ehrman, J. K., ... & Keteyian, S. J. (2013). An early appointment to outpatient cardiac rehabilitation at hospital discharge improves attendance at orientation: a randomized, single-blind, controlled trial. Circulation, 127(3), 349-355.
American Society for Quality. Data collection and analysis tools: Control chart. 2009 [cited 2009 June 26]; Available from: http://www.asq.org/learn-about-quality/data-collection-analysis-tools/overview/control-chart.html.

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