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MVC, BMC2 Launch Michigan Cardiac Rehab Network & Toolkit

MVC, BMC2 Launch Michigan Cardiac Rehab Network & Toolkit

This year in the United States, cardiovascular disease will be responsible for one in every four deaths. Despite its prevalence, few cardiac patients eligible for cardiac rehabilitation utilize this life-changing program. In response, the Michigan Value Collaborative (MVC) and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) recently established the new Michigan Cardiac Rehab Network (MiCR) to collaborate on efforts that heighten awareness of these programs and support meaningful improvement in Michigan.

Cardiac rehabilitation (CR) is a comprehensive program encompassing supervised exercise, nutrition education, smoking cessation, mental health resources, skills training for heart-healthy lifestyles, and peer support from others who are experiencing a similar life event. It has a Class IA indication for recent cardiac-related events or procedures, meaning there is high-quality evidence that it is beneficial to patients. In fact, individuals who complete the full program of 36 sessions have a 47% lower risk of death and a 31% lower risk of heart attack than those who attend only one session. The evidence is clear that CR extends life and improves quality of life for patients with a recent cardiac-related event or procedure. Unfortunately, only one in three eligible Michiganders participates—a rate well below the Million Hearts nationwide goal of 70% participation.

Using claims data, MVC can assess both initiation and adherence – whether and when someone starts CR, and how long they keep going. There is wide variability in CR rates between MVC’s member hospitals (see Figure 1 for a sample plot from a recent blinded report). The site with the highest rate of cardiac rehab after coronary artery bypass graft surgery (CABG), for example, succeeds at sending 75% of their CABG patients to CR, while another only sends 28% of their CABG patients. This variation shows that it is possible to reach high CR rates, and hospitals can learn from each other to make improvements that save lives and reduce costs.

Figure 1. Collaborative-Wide CR Use Following CABG Discharge

MiCR was developed for this reason and will work to equitably increase CR participation for all eligible individuals in Michigan. Serving as Co-Directors of MiCR are Mike Thompson, Co-Director of MVC, and Dr. Devraj Sukul, Associate Director of BMC2 PCI. MiCR will distribute regular CR utilization summaries to relevant providers, convene regular meetings with its stakeholder and advisory groups, create resources that help hospitals and CR facilities optimize CR utilization, and continue to leverage the expertise of both CQIs.

In one of its first coordinated efforts, MiCR worked with CR providers and content experts to create a Cardiac Rehab Best Practices Toolkit, which was launched in April. It outlines initiation, maintenance, and innovation strategies for increasing the utilization of CR (see Figure 2 for a sample page). MVC encourages members to turn to this tool as they work to encourage the enrollment of more patients.

Figure 2. Sample Page from MiCR Best Practices Toolkit

The partner CQIs behind MiCR also released new statewide goals for improved CR utilization. Currently, 30% of patients utilize CR following transcatheter aortic valve replacement (TAVR), surgical aortic valve replacement (SAVR), coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), and acute myocardial infarction (AMI). The first goal is to reach 40% CR utilization for TAVR, SAVR, CABG, PCI, and AMI patients. In addition, only about 3% of congestive heart failure (CHF) patients currently utilize CR. The second statewide goal is a collaborative-wide utilization rate of 10% for CHF patients. Progress on these goals will be shared by MVC in its CR reports sent every six months.

The two CQIs will also continue with their respective activities in the CR space. MVC supports CR participation in two primary ways. One is providing opportunities for MVC members to collaborate, and the second is the preparation of reports using its unique multi-payer data sources. The MVC team supports collaboration through stakeholder meetings and workgroups, which allow sites and clinicians to share solutions for common challenges. The reports MVC prepares analyze member claims data with time-specific hospital-level information on CR enrollment and completed visits within one year of discharge. This allows hospitals to benchmark their performance against peers and identify areas for improvement. MVC will also share unblinded data on CR rates with members at its May semi-annual meeting in one week, which is meant to drive conversation and encourage best practice sharing across the collaborative. The MVC team hopes that its outreach and resources help members to save lives by providing strong endorsements for CR and addressing barriers that may limit patient participation.

For more information on MVC’s CR efforts, visit MVC’s Value Coalition Campaign webpage. For more information about CR, view this MVC video or visit the Million Hearts website. If you have questions about any of the above activities or resources, reach out to the Coordinating Center at michiganvaluecollaborative@gmail.com.

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MVC Draws Attention to Cardiac Rehab in Promotional Week

MVC Draws Attention to Cardiac Rehab in Promotional Week

Every February while the nation honors American Heart Month, a subset of heart health advocates spend one week paying tribute to the lifesaving value of cardiac rehabilitation. Last week the Michigan Value Collaborative (MVC) Coordinating Center joined in on Cardiac Rehabilitation Week by helping to increase awareness and promote MVC’s efforts to improve utilization. Over the course of the week, MVC distributed press releases, published a daily cadence of social media content on Twitter and LinkedIn, and launched a video about the importance of cardiac rehab – all in service of inspiring collaboration in this area.

Cardiac rehabilitation (CR) has a Class IA indication for recent cardiac-related events or procedures, meaning there is high-quality evidence that it is beneficial to patients. In fact, individuals who complete the full program of 36 sessions have a 25% lower risk of death and a 30% lower risk of heart attack than those who attend only one session. It also reduces hospital readmissions and saves thousands of dollars per patient per year of life saved. Nevertheless, CR is widely underutilized, with national utilization rates of only 25-50%. It is for this reason that MVC wishes to equitably increase CR participation for all eligible individuals in Michigan. Throughout CR week, therefore, MVC endeavored to define the value of CR, what it entails, and how the actions of MVC members impact CR participation.

MVC’s role in the CR space is two-fold. One is the preparation of reports using its unique multi-payer data sources, and the second is providing opportunities for MVC members to collaborate. The reports that MVC prepares for members analyze claims data with time-specific hospital-level information on CR enrollment and completed visits within one year of discharge. This allows hospitals to benchmark their performance against peers and identify areas for improvement. There’s a huge amount of variation in CR rates across many dimensions – hospitals, qualifying events, and payers. For example, the hospital with the highest rate of CR after coronary artery bypass graft surgery (CABG) succeeds at sending 75% of their CABG patients to CR, while another only sends 28% of their CABG patients. This variation shows that it is possible to reach high CR rates, and hospitals can learn from each other to make systemic improvements that get more patients into this life-changing (and cost-saving) program.

To support collaboration among its member base of 100 hospitals and 40 physician organizations, MVC hosted a special, one-time workgroup on CR last week as part of its newly launched “Health in Action” workgroup series. This series is meant to drive discussion and collaboration on special topics that rotate throughout the year. Last week’s session featured the expertise of two special voices in the world of CR: Steven Keteyian, Ph.D., Director of Cardiac Rehabilitation/Preventive Cardiology at Henry Ford Medical Group, and Greg Merritt, Ph.D., patient advocate and founder of Patient is Partner. The workgroup was well attended with over 100 guests, who benefitted from informative and inspiring presentations from both speakers.

Dr. Keteyian presented updates on the clinical effectiveness of CR as well as some of the key barriers facing the field. There is high-quality evidence that CR is beneficial to patients on a variety of physiological measures, including improved exercise tolerance, decreased risk of future hospitalization, and decreased cardiovascular mortality. He also reiterated the value of cardiac rehab relative to other recommended cardiac interventions, with CR demonstrating more lives saved per 1000 patients than ACE inhibitors, statins, and other common medications (see Figure 1).

Figure 1. Calculating the Value of Cardiac Rehab

The current quality measures for CR suggest a patient’s time to enrollment should occur within 21 days of discharge, and that the patient should attend at least 36 sessions to receive the greatest benefit. The current goal for CR participation set by the Million Hearts initiative is 70%. However, Dr. Keteyian found that of the CR-eligible beneficiaries, only 28.6% participated and only 27.6% of those participants completed all 36 sessions. This represents a significant utilization gap. While discussing related challenges, Dr. Keteyian suggested that hospitals implement EMR-driven automatic referrals, overt provider endorsements, and an inpatient liaison to bridge the gap between referral and enrollment. He also recommended the use of hybrid CR programs that leverage telehealth to offer remote options.

Dr. Merritt’s presentation included his own personal story of surviving a cardiac event and his ensuing participation in a CR program. Following his experience, he became a “patient questionologist” dedicated to finding opportunities for patient and provider collaboration. His story ultimately led to the founding of an organization called Patient is Partner, which is dedicated to the principles of patient-partnered care. Inspired by the writings of behavioral scientists as well as Why We Revolt by Victor Montori, Dr. Merritt outlined a vision for healthcare innovation that invites patients and their unique perspectives to help solve healthcare’s greatest challenges. He encouraged attendees to join the movement and invite more patient voices to contribute to their respective committees and teams.

At the conclusion of the week, the MVC team had helped its audiences connect to educational materials, data, specialists, former patients, and successful peers in this space. The Coordinating Center is eager to continue this momentum from CR Week in pursuit of a variety of goals for 2022 and beyond. If your hospital or physician organization is interested in improving CR utilization rates, you can learn more about how MVC supports members to increase CR enrollment or reach out directly at michiganvaluecollaborative@gmail.com. You can also view a recording of the full CR workgroup here.

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MVC Efforts to Improve Cardiac Rehab Enrollment in Michigan

MVC Efforts to Improve Cardiac Rehab Enrollment in Michigan

Cardiac rehabilitation (CR) is designed to improve cardiovascular function and mitigate risk factors for future cardiovascular events through monitored exercise, patient education, lifestyle modifications, smoking cessation, and social support (1). For over a decade, CR has been a Class I indication in clinical guidelines for patients who have had a heart attack, chronic stable angina, chronic heart failure, or have undergone a percutaneous coronary intervention (PCI), surgical (SAVR) or transcatheter aortic valve replacement (TAVR), or coronary artery bypass grafting (CABG). The evidence supporting CR as a high-value therapy for patients is clear: better long-term survival, fewer secondary cardiovascular events, fewer readmissions, improved quality of life, and lower healthcare utilization (2–6). 

Unfortunately, only a fraction of Michigan residents eligible for CR attend a single session following hospitalization for a qualifying condition, with rates as high as 59% for patients undergoing CABG and as low as 4% for patients with congestive heart failure (CHF) (see Figure 1). These data highlight that we as a state are well short of the national goal set by the Million Hearts Initiative of 70% enrollment for all eligible patients. Data from Michigan also suggests wide variation in CR enrollment across hospitals that are not fully explained by differences in patient case-mix (7).

Figure 1. Collaborative-wide CR enrollment rates for qualifying conditions (01/2017-12/2019)

Since 2019 the MVC Coordinating Center sought to equitably increase participation in CR for all eligible individuals in Michigan in partnership with the Blue Cross Blue Shield Cardiovascular Consortium (BMC2) and the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC). In an effort to drive improvement in this area across the collaborative’s membership, MVC developed a number of resources and strategies. For example, the MVC Coordinating Center built hospital-level reports that provide members with information on CR enrollment across eligible conditions benchmarked against all MVC hospitals. This week the newest iteration of this CR report was distributed to members. The previous version of the report was sent in March 2021 with a reporting period of 1/1/17 – 12/31/19. The latest version shifted that reporting period by six months (7/1/17 – 6/30/20), included Medicaid episodes for the first time, expanded the time horizon from 90 days to one year, and added information on CHF and acute myocardial infarction (AMI) episodes. 

With the addition of CHF and AMI (both “high-volume” MVC conditions), the number of hospitals eligible to receive a CR report doubled from 47 to 95, so many MVC hospitals received this report for the first time this month. The most significant methodological change compared to the previous report was the expansion of the episode window from 90 days to 365 days (one year). Previous reports undercounted the number of CR visits by using the standard MVC episode length of 90 days when a full CR program consists of 36 sessions, which are often not feasible to complete in 90 days. Therefore, it was important to expand the time horizon to achieve a fuller count. The report instead looked one full year beyond the index event (either PCI, TAVR, SAVR, CABG, CHF, or AMI) to calculate CR utilization rates and number of visits.

The MVC team also convened a multidisciplinary stakeholder group of CR practitioners, physicians, and CQI leaders to foster discussion around barriers and facilitators to CR enrollment. Many of the recent changes to the CR reports were a direct result of suggestions from this stakeholder group. Quarterly seminars have also provided opportunities for local facilities to share ongoing quality improvement activities and to learn from national leaders about innovations in the delivery and quality of CR.

More recently, the MVC team conducted virtual site visits with several CR facilities around the state to learn about their programs, the successes and challenges they have encountered, and ways to improve collaboration in Michigan around CR enrollment. Common themes emerged as barriers to CR enrollment, including lack of patient or physician engagement, geographical and/or technological gaps in care between the hospital and CR facility, and insurance coverage and reimbursement. Through collaborative learning and dissemination of best practices, the MVC Coordinating Center believes that its members can begin to address many of these challenges moving forward. 

These efforts are all the more important as CR facilities begin to recover from the effects of the COVID-19 pandemic. Many facilities had to reduce capacity and staff as a result of the pandemic, and the number of CR visits declined significantly compared to pre-pandemic months (see Figure 2). While many CR facilities are back to operating at full capacity, continued efforts will be needed to return CR enrollment to pre-pandemic levels. Some sites in Michigan have adopted virtual, home-based, or hybrid versions of CR to continue providing care to patients throughout the pandemic, and its place as a substitute for facility-based CR will require continued exploration that can be supported through collaborative efforts.

Figure 2. Changes in CR enrollment from 2019 to 2020 over time and by qualifying condition

While many challenges remain to achieve the national goal of 70% enrollment in CR for eligible individuals, the MVC Coordinating Center is optimistic that its current and planned efforts will provide opportunities for Michigan to lead the way. If you are interested in joining our efforts to equitably increase CR enrollment for eligible patients in Michigan, please reach out for more information at michiganvaluecollaborative@gmail.com.

References

  1. Rubin R. Although Cardiac Rehab Saves Lives, Few Eligible Patients Take Part. JAMA [Internet]. 2019 Jul 17; Available from: http://dx.doi.org/10.1001/jama.2019.8604 PMID: 31314061
  2. Heran BS, Chen JM, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD001800. PMCID: PMC4229995
  3. Taylor RS, Long L, Mordi IR, Madsen MT, Davies EJ, Dalal H, Rees K, Singh SJ, Gluud C, Zwisler A-D. Exercise-Based Rehabilitation for Heart Failure: Cochrane Systematic Review, Meta-Analysis, and Trial Sequential Analysis. JACC Heart Fail. 2019 Aug;7(8):691–705. PMID: 31302050
  4. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004 May 15;116(10):682–692. PMID: 15121495
  5. Anderson L, Thompson DR, Oldridge N, Zwisler A, Rees K, Martin N, Taylor RS. Exercise‐based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev [Internet]. John Wiley & Sons, Ltd; 2016 [cited 2021 Jan 25];(1). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001800.pub3/abstract
  6. Rejeski WJ, Foy CG, Brawley LR, Brubaker PH, Focht BC, Norris JL 3rd, Smith ML. Older adults in cardiac rehabilitation: a new strategy for enhancing physical function. Med Sci Sports Exerc. 2002 Nov;34(11):1705–1713. PMID: 12439072
  7. Thompson MP, Yaser JM, Hou H, Syrjamaki JD, DeLucia A 3rd, Likosky DS, Keteyian SJ, Prager RL, Gurm HS, Sukul D. Determinants of Hospital Variation in Cardiac Rehabilitation Enrollment During Coronary Artery Disease Episodes of Care. Circ Cardiovasc Qual Outcomes. American Heart Association; 2021 Feb;14(2):e007144. PMID: 33541107
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Cardiac Rehab Stakeholder Meeting Motivates Improvements in Care

Cardiac Rehab Stakeholder Meeting Motivates Improvements in Care

On Monday, March 22, 2021, a “stakeholder meeting” was hosted by the Michigan Value Collaborative (MVC) Coordinating Center with multiple key players in cardiac rehabilitation (CR) from around Michigan. As MVC has written about before, cardiac rehabilitation is a highly valuable but underutilized service and is the focus of one of MVC’s ongoing value coalition campaigns. The goal of the stakeholder meetings is to bring together key constituents to work towards solving the problem of underutilization. Attendees included managers of cardiac and pulmonary rehab facilities, quality improvement leaders and executives from  several MVC members, our payer partners from Blue Cross Blue Shield of Michigan, and representatives from the Michigan Society for Thoracic and Cardiovascular Surgeons (MSTCVS), the Michigan Society for Cardiovascular and Pulmonary Rehab (MSCVPR), and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2).

The stakeholder meeting occurred the week after MVC distributed new Master Cardiac Rehab reports, which detail several metrics on cardiac rehabilitation after percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), transcatheter aortic valve replacement (TAVR), and surgical aortic valve replacement (SAVR) procedures. The collaborative-wide average cardiac rehab utilization varied by procedure: 52.6% for SAVR, 30.1% for TAVR, 56.3% for CABG, and 32.3% for PCI (see Figure 1). The mean days to first cardiac rehab visit also varied by procedure: 46 days for SAVR patients, 43 days for TAVR patients, 45 days for CABG patients, and 34 days for PCI patients (see Figure 2).

Figure 1

Figure 2

The Master Cardiac Rehab reports were also distributed by our partners at MSTCVS and BMC2. The aim is to increase awareness of hospital-level CR utilization and encourage as many players as possible (cardiologists, cardiac surgeons, cardiac rehab staff, quality improvement staff, and executive leadership) to work together to increase CR utilization at every hospital. These reports were well-received at the March 22nd stakeholder meeting, with one attendee emphasizing that the information contained in the reports was “the envy of other states,” speaking to the utility of MVC data and the success of BCBSM Value Partnerships. Attendees also provided excellent suggestions for improvement which will be taken into account during the next report refresh later this year.

The data is distributed, and the stakeholder meeting is over, but the value coalition campaign is just getting started.  There’s still a lot of work to do in order to equitably increase cardiac rehabilitation use in our state, including studying barriers to entry, exploring the intricacies of benefit design, and making various operational changes hospital by hospital, health system by health system. Nevertheless, that Monday afternoon showed that sometimes, when you have the right people around the same (virtual) table, everyone can walk away connected, motivated, and ready to carry out their respective roles to improve health care.

The next cardiac rehab stakeholder meeting is scheduled for Monday, June 28, 2021 from 4:00-5:00pm. If you have an interest in joining this group, or if you have not received your Master Cardiac Rehab report, please email michiganvaluecollaborative@gmail.com.