Selected Podcast
Cardiac Rehabilitation
Ken Bodine MD describes components of a well-rounded cardiac rehabilitation program. He shares when patients should be referred to the program and the ways to increase adherence rates for better outcomes for patients with cardiac conditions.
Featuring:
Learn more about Ken Bodine, MD
Ken Bodine, MD
Ken Bodine, MD specialties include Cardiology, Heart and Vascular.Learn more about Ken Bodine, MD
Transcription:
Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and joining me today is Dr. Ken Bodine. He's a Cardiologist with the Carle Foundation Hospital, and he's here to highlight cardiac rehabilitation at the Carle Foundation Hospital.
Dr. Bodine, it's a pleasure to have you join us today. Can you tell us a little bit about cardiac rehabilitation in general and some of the program components?
Ken Bodine, MD (Guest): Yeah, and thanks a lot for inviting me today. I'm glad to be able to speak on this topic. Basically cardiac rehabilitation programs, they're comprehensive physician supervised programs that provide exercise training in conjunction with other secondary prevention measures. So the basis is an exercise prescription for the patients that participate.
But in addition, they receive extensive education about diet, exercise, what heart disease is, what procedures they may have undergone. What medicines they're on, why they need to be compliant with those. We review the risk factors and target goals for each patient. So things like their blood pressure, cholesterol, weight, physical activity, et cetera. We also are able to offer smoking cessation services for patients that might require it. And then, an important component is just the psychosocial support. A lot of patients after they've had a cardiac event, have issues with anxiety and depression and they do need professional help for that. And then finally, just the occupational issues. A lot of our patients are younger. They were in the workforce before their cardiac event and they really want to get back and cardiac rehabilitation can help them achieve that goal.
Host: So you mentioned that many patients are younger and back in the day, of course, it was mostly older men and they stayed still after an event and not a lot happened, but now everything is different. Plus we're seeing more women as women entered the work force and became stressed out and all of these things. So I'd like you to speak about referral to a cardiac rehabilitation program. Who can benefit from it? Is it someone only that has to have an event happen to them? Tell us a little bit about referral.
Dr. Bodine: CMS has six major indications for cardiac rehabilitation. And the most common are patients that have had some sort of acute coronary syndrome or myocardial infarction within the last 12 months. Patients that have undergone coronary stenting or angioplasty or bypass surgery are good candidates. Patients that have had valve repair or replacement, or cardiac transplantation, also patients that have chronic stable angina, and then more recently two newer indications, patients with heart failure with reduced ejection fraction. Those are patients that have ejection fractions less than 35%. And then patients with peripheral vascular disease. There's good data that all of those patients will benefit from referral to a cardiac rehabilitation program.
Host: What can those patients expect Dr. Bodine when they start a program, because we know, first of all, you mentioned the psychosocial and behavioral and smoking cessation and lifestyle modification lessons, that sort of thing. Tell us a little bit about what they can expect at a program.
Dr. Bodine: The way these programs work, there's actually three phases to them. The phase one program actually starts when they're in the hospital. Years ago, like you mentioned, when patients were more sedentary that was probably the crux of cardiac rehabilitation, but nowadays patients are in and out of the hospital in just a couple of days.
So when they are in the hospital, we have a system set up where we have a liaison for phase one, and we receive a referral. The exercise physiologists will go up and visit with the patient, educate them about the program. Try to do maybe one or two exercise sessions and then make sure that they have a referral for the phase two cardiac rehabilitation.
Phase two is really the primary part of cardiac rehabilitation now, and that's the outpatient program. Insurance will cover 12 weeks. It's usually three sessions per week. So a total of 36 sessions and it's during those classes, these patients are monitored with telemetry monitoring. And during this, they undergo exercise training.
And then in addition the education and other things that I mentioned. The final phase is phase three. And that's just sort of long-term maintenance is basically like attending a community gym, but a lot of patients because of the friendships and bonding that they've made with the cardiac rehabilitation staff and other members; they want to come to the cardiac rehabilitation program. And so they will come and exercise a couple of times a week. They aren't monitored during that. And the idea is just to make them a lifelong exerciser and heart healthy habits.
Host: Well, you mentioned that comradery and that is so important. I remember when I was doing it and people are meeting at a time when they're coming back from an event. So, it's not a depressing time. It's more of an uplifting time, but speak a little bit about the adherence rates, Dr. Bodine. Why is emotional health so important during cardiac rehab and the compliance rates? Are your patients pretty good? What have you seen as far as outcomes?
Dr. Bodine: So, that's a great question because that's where some of the disappointment comes. It's sort of been seen nationwide that of all the patients that are eligible for cardiac rehabilitation probably only about 30% or so are actually referred to a cardiac rehabilitation program. And then amongst that group, there's a smaller percentage that actually enrolls in or completes it. We do have a lot of patients that will come and initiate the cardiac rehabilitation program, but to actually complete all 36 sessions, it's probably around 25% or less. Like you mentioned, the comradery is great. A lot of patients will come in. They're sort of scared they had a cardiac event. They find that a lot of other patients have gone through the same sort of event and recovery. And so that's very good, but unfortunately the compliance does fall off and there are certainly a number of different reasons for that.
Host: What are some of those reasons?
Dr. Bodine: Well, that's sort of where we can talk a bit and talk about ways we can improve it. One of the things is we talked about younger patients and working; a lot of them do need to get back to work. Sometimes the hours of these programs aren't good as far as the work schedule is concerned, so they may start out and then they realize they have to get back to work. Also, cost is an issue. Insurance does cover cardiac rehabilitation, but a lot of it also has a co-pay involved. Some of these patients can't afford that copay, so they will go a few sessions and then stop.
The availability of the program is also an issue. I mentioned that these programs are physician supervised currently. So that means that a lot of these programs are at major hospitals or major medical centers. And a lot of patients don't live close and so transportation can be an issue. Currently cost of fuel is a problem. We have a lot of rural population here at Carle and patients don't want to drive 20, 30 miles both ways, three times a week to attend these programs.
Host: What did COVID do to that? Because I know in my own practice, I started using an iPad to help people with their exercises, and even now, still doing that. What happened during COVID and has any of that affected what you're doing now?
Dr. Bodine: When COVID hit two years ago, all of these programs had to shut down for a number of months. And so we started looking into virtual options, just like you mentioned, and home-based cardiac rehabilitation. And we learned a lot of lessons. There were a number of patients were able to do this. And, it seemed to work reasonably well, and as we sort of move into the future with cardiac rehabilitation, there's a lot of talk about going to more of a virtual option or maybe a hybrid model where patients come to the center for a couple of weeks and then transition to a home program. So it really showed that this is possible and it may improve the adherence rates.
Host: Well, I think it would. And I think it definitely takes a comprehensive approach and a few home visits to see what they have set up. And, along those lines, following that, tell us about your team because we're really looking for ways to increase referral to the program at Carle. And so tell us about your team and who's involved.
Dr. Bodine: These programs, like I mentioned, for CMS rules right now, they have to be a physician supervised, but the bulk of the work is done by our exercise physiologists and exercise therapists. They're working with these patients, day in and day out, and then also registered dieticians and psychologists are part of the team, as needed. And then as I mentioned, we also have a smoking cessation programs that are available through the Carle system.
Host: It's such a great program and it helps so many people. Wrap it up for us, Dr. Bodine, what you'd like referring physicians to know about the cardiac rehabilitation program at the Carle Foundation Hospital.
Dr. Bodine: I think in general, people need to realize that the cardiac rehabilitation is a significant part of the overall treatment plan for our cardiac patients. The benefits that you can get from cardiac rehabilitation, randomized clinical trials have shown that the benefit is just as good as some of the medications and procedures that we do with these patients.
So it really adds to the whole comprehensive care of these patients. And it's important for them to realize which patients are eligible for it and which patients would benefit for it so that we can get the referrals. We do have systems set up here for our inpatients that, if they qualify, we do automatically, give them a phase one and phase two order, while they're here in the hospital. But some of these patients will be seen by primary care physicians and adult medicine doctors, and they certainly can refer these patients also.
Host: Thank you for such great information, Dr. Bodine for joining us and for more information, or to get connected with one of our providers, you can always visit carle.org. Or for a listing of Carle providers and to view Carle's sponsored educational activities, please visit our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole.
Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and joining me today is Dr. Ken Bodine. He's a Cardiologist with the Carle Foundation Hospital, and he's here to highlight cardiac rehabilitation at the Carle Foundation Hospital.
Dr. Bodine, it's a pleasure to have you join us today. Can you tell us a little bit about cardiac rehabilitation in general and some of the program components?
Ken Bodine, MD (Guest): Yeah, and thanks a lot for inviting me today. I'm glad to be able to speak on this topic. Basically cardiac rehabilitation programs, they're comprehensive physician supervised programs that provide exercise training in conjunction with other secondary prevention measures. So the basis is an exercise prescription for the patients that participate.
But in addition, they receive extensive education about diet, exercise, what heart disease is, what procedures they may have undergone. What medicines they're on, why they need to be compliant with those. We review the risk factors and target goals for each patient. So things like their blood pressure, cholesterol, weight, physical activity, et cetera. We also are able to offer smoking cessation services for patients that might require it. And then, an important component is just the psychosocial support. A lot of patients after they've had a cardiac event, have issues with anxiety and depression and they do need professional help for that. And then finally, just the occupational issues. A lot of our patients are younger. They were in the workforce before their cardiac event and they really want to get back and cardiac rehabilitation can help them achieve that goal.
Host: So you mentioned that many patients are younger and back in the day, of course, it was mostly older men and they stayed still after an event and not a lot happened, but now everything is different. Plus we're seeing more women as women entered the work force and became stressed out and all of these things. So I'd like you to speak about referral to a cardiac rehabilitation program. Who can benefit from it? Is it someone only that has to have an event happen to them? Tell us a little bit about referral.
Dr. Bodine: CMS has six major indications for cardiac rehabilitation. And the most common are patients that have had some sort of acute coronary syndrome or myocardial infarction within the last 12 months. Patients that have undergone coronary stenting or angioplasty or bypass surgery are good candidates. Patients that have had valve repair or replacement, or cardiac transplantation, also patients that have chronic stable angina, and then more recently two newer indications, patients with heart failure with reduced ejection fraction. Those are patients that have ejection fractions less than 35%. And then patients with peripheral vascular disease. There's good data that all of those patients will benefit from referral to a cardiac rehabilitation program.
Host: What can those patients expect Dr. Bodine when they start a program, because we know, first of all, you mentioned the psychosocial and behavioral and smoking cessation and lifestyle modification lessons, that sort of thing. Tell us a little bit about what they can expect at a program.
Dr. Bodine: The way these programs work, there's actually three phases to them. The phase one program actually starts when they're in the hospital. Years ago, like you mentioned, when patients were more sedentary that was probably the crux of cardiac rehabilitation, but nowadays patients are in and out of the hospital in just a couple of days.
So when they are in the hospital, we have a system set up where we have a liaison for phase one, and we receive a referral. The exercise physiologists will go up and visit with the patient, educate them about the program. Try to do maybe one or two exercise sessions and then make sure that they have a referral for the phase two cardiac rehabilitation.
Phase two is really the primary part of cardiac rehabilitation now, and that's the outpatient program. Insurance will cover 12 weeks. It's usually three sessions per week. So a total of 36 sessions and it's during those classes, these patients are monitored with telemetry monitoring. And during this, they undergo exercise training.
And then in addition the education and other things that I mentioned. The final phase is phase three. And that's just sort of long-term maintenance is basically like attending a community gym, but a lot of patients because of the friendships and bonding that they've made with the cardiac rehabilitation staff and other members; they want to come to the cardiac rehabilitation program. And so they will come and exercise a couple of times a week. They aren't monitored during that. And the idea is just to make them a lifelong exerciser and heart healthy habits.
Host: Well, you mentioned that comradery and that is so important. I remember when I was doing it and people are meeting at a time when they're coming back from an event. So, it's not a depressing time. It's more of an uplifting time, but speak a little bit about the adherence rates, Dr. Bodine. Why is emotional health so important during cardiac rehab and the compliance rates? Are your patients pretty good? What have you seen as far as outcomes?
Dr. Bodine: So, that's a great question because that's where some of the disappointment comes. It's sort of been seen nationwide that of all the patients that are eligible for cardiac rehabilitation probably only about 30% or so are actually referred to a cardiac rehabilitation program. And then amongst that group, there's a smaller percentage that actually enrolls in or completes it. We do have a lot of patients that will come and initiate the cardiac rehabilitation program, but to actually complete all 36 sessions, it's probably around 25% or less. Like you mentioned, the comradery is great. A lot of patients will come in. They're sort of scared they had a cardiac event. They find that a lot of other patients have gone through the same sort of event and recovery. And so that's very good, but unfortunately the compliance does fall off and there are certainly a number of different reasons for that.
Host: What are some of those reasons?
Dr. Bodine: Well, that's sort of where we can talk a bit and talk about ways we can improve it. One of the things is we talked about younger patients and working; a lot of them do need to get back to work. Sometimes the hours of these programs aren't good as far as the work schedule is concerned, so they may start out and then they realize they have to get back to work. Also, cost is an issue. Insurance does cover cardiac rehabilitation, but a lot of it also has a co-pay involved. Some of these patients can't afford that copay, so they will go a few sessions and then stop.
The availability of the program is also an issue. I mentioned that these programs are physician supervised currently. So that means that a lot of these programs are at major hospitals or major medical centers. And a lot of patients don't live close and so transportation can be an issue. Currently cost of fuel is a problem. We have a lot of rural population here at Carle and patients don't want to drive 20, 30 miles both ways, three times a week to attend these programs.
Host: What did COVID do to that? Because I know in my own practice, I started using an iPad to help people with their exercises, and even now, still doing that. What happened during COVID and has any of that affected what you're doing now?
Dr. Bodine: When COVID hit two years ago, all of these programs had to shut down for a number of months. And so we started looking into virtual options, just like you mentioned, and home-based cardiac rehabilitation. And we learned a lot of lessons. There were a number of patients were able to do this. And, it seemed to work reasonably well, and as we sort of move into the future with cardiac rehabilitation, there's a lot of talk about going to more of a virtual option or maybe a hybrid model where patients come to the center for a couple of weeks and then transition to a home program. So it really showed that this is possible and it may improve the adherence rates.
Host: Well, I think it would. And I think it definitely takes a comprehensive approach and a few home visits to see what they have set up. And, along those lines, following that, tell us about your team because we're really looking for ways to increase referral to the program at Carle. And so tell us about your team and who's involved.
Dr. Bodine: These programs, like I mentioned, for CMS rules right now, they have to be a physician supervised, but the bulk of the work is done by our exercise physiologists and exercise therapists. They're working with these patients, day in and day out, and then also registered dieticians and psychologists are part of the team, as needed. And then as I mentioned, we also have a smoking cessation programs that are available through the Carle system.
Host: It's such a great program and it helps so many people. Wrap it up for us, Dr. Bodine, what you'd like referring physicians to know about the cardiac rehabilitation program at the Carle Foundation Hospital.
Dr. Bodine: I think in general, people need to realize that the cardiac rehabilitation is a significant part of the overall treatment plan for our cardiac patients. The benefits that you can get from cardiac rehabilitation, randomized clinical trials have shown that the benefit is just as good as some of the medications and procedures that we do with these patients.
So it really adds to the whole comprehensive care of these patients. And it's important for them to realize which patients are eligible for it and which patients would benefit for it so that we can get the referrals. We do have systems set up here for our inpatients that, if they qualify, we do automatically, give them a phase one and phase two order, while they're here in the hospital. But some of these patients will be seen by primary care physicians and adult medicine doctors, and they certainly can refer these patients also.
Host: Thank you for such great information, Dr. Bodine for joining us and for more information, or to get connected with one of our providers, you can always visit carle.org. Or for a listing of Carle providers and to view Carle's sponsored educational activities, please visit our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole.