Patient-provider communication is a hallmark of rehabilitation and recovery. Cardiac rehabilitation (CR) programs have been beneficial in reducing morbidity and mortality for patients following a cardiac event. As early as 1993, the World Health Organization (WHO) emphasized that cardiac rehabilitation programs offered patients the greatest "physical, mental and social conditions" for restoring optimal cardiovascular health. Decades later, countless studies have documented not only the benefits but also the necessity of CR; yet, referrals and participation rates remain low.

Whether or not a patient participates in a cardiac rehabilitation program is dependent upon a health care provider (HCP) referral, patient incentive and nursing support. Of these three variables, HCP referral and nursing support are probably two variables that are easier to manipulate than patient incentive! Qualitative studies have the potential to offer powerful insight into patients' beliefs and perceptions about health, illness and recovery. Employing a qualitative research design, Mitoff, Wesolowski, Abramson and Grace were first to study the cardiac rehabilitation referral communication dynamics between patients and their health care providers. The authors concluded that although CR significantly improves health in this patient population, the programs are underutilized. Their recommendations were for referrals facilitated by nurses (usually more effective than provider recommendation), easier referral and enrollment processes, systematic referral for eligible patients and consistent follow-up communication.

I am fortunate to have had the "lived experience" in the evolution of cardiac rehabilitation. From bedside nursing in cardiac care units in the seventies when patients were on bedrest for weeks post myocardial infarction (MI), to decades as an inpatient cardiac rehabilitation coordinator and cardiovascular case manager, the transition of CR as a concept of care to the reality of evidence based care was transformative.

Early CR program formats included Phases I (inpatient), II (36 outpatient monitored sessions) and III (self-pay maintenance). The inpatient programs were one-on-one communication with patients post-event that included activity progression and counseling about disease process, recovery and risk factor modification. All inpatients were automatically referred to CR programs based on diagnoses of angina, MI, percutaneous coronary intervention (PTCA), coronary artery bypass graft (CABG), heart failure and heart surgeries. A major role of the inpatient nurse coordinator was initiating the cardiac rehabilitation process and continued with patient interaction though discharge; thereby, establishing a relationship with patients and families. The natural recovery progression was to move from Phase I inpatient CR to outpatient Phases II and III. A majority of the patients referred to the outpatient program completed 36 sessions. Cardiac rehabilitation was not just a mentioned topic, but a therapeutic treatment strategy as important as medication, diet and follow up HCP visits. Sadly, as Phase I programs were eliminated due to reimbursement issues, outpatient CR referrals and patient interest decreased.

The patient-provider communication referral problems identified by Mitoff and colleagues 15 years ago still exist today. Cardiac rehabilitation program referrals and participation rates for persons recovering from cardiac events remain low in spite of 1A-B recommendations of the American College of Cardiology and the American Heart Association (AHA). A recent proposed measurement tool to address care gaps related to underutilization of CR programs was developed and tested by the National Committee for Quality Assurance (NCQA, 2020). Initial results found that only 19% of Medicare and 29% of commercial members completed 2 of 36 CR sessions, 14% Medicare and 9% commercial members completed at least 12 of 36 sessions and 5% Medicare and 2% commercial members achieved the recommended 36 session goal. These numbers are not only devastating for dedicated cardiac rehabilitation professionals but also and more importantly, a disservice to patients recovering from cardiac events. The Proposed New Measure for HEDIS MY 2020 Cardiac Rehabilitation will be included in the Healthcare Effectiveness Data and Information Set (HEDIS) for 2020, collecting data from health plans and health care organizations. This focus is certainly a step in the right direction because there is a mountain of supporting evidence as to the importance and benefits of cardiac rehabilitation. Data collection is just the beginning to understanding the depth of the problem, but patient communication, as described by Mitoff and colleagues in 2005, is still key in 2020.

How do we as rehabilitation nurses reverse this growing underutilization trend? First of all, do not underestimate the potential to influence patient incentive to hear and respond to advice when facing recovery from a cardiac event or procedure. It is well known that a health crisis often drives behavior change. Second, the recommendations by Mitoff et al. are applicable today especially nursing's "integral role in the recruitment and referral of patients to CR." Nurse leaders, nurse practitioners, clinical nurse specialists and bedside nurses can promote CR. Nurses and HCPs who are willing to step up and champion this essential secondary prevention program should consider a plan of care to include: an inpatient cardiac rehabilitation coordinator, routine CR referrals for all eligible patients, visits from outpatient CR professionals, follow up phone calls for questions and easy to understand directions to the CR facility.

According to the AHA, heart disease is still the leading cause of death in the United States. Participation in CR decreases recurrent cardiac events, reduces mortality and hospitalization and improves quality of life. Nothing to lose and everything to gain! Rehabilitation nurses must be the voice that communicates this message to our patients. Underutilized CR is hurting our patients[horizontal ellipsis]our patients deserve better.

Cheryl E. Gies, DNP, APRN, CNP

Professor Emerita, University of Toledo

College of Nursing

Toledo, OH, USA

Member, Rehabilitation Nursing Editorial Board

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