Read the original article from the Blue Cross Blue Shield of Michigan Value Partnerships June 2022 Newsletter

A new joint venture to equitably increase participation in cardiac rehabilitation for all eligible patients in Michigan

As many as one in three women and one in four men will be diagnosed with heart disease this year in the US, and over one million families will watch their loved one struggle through the toll of a coronary event or cardiac procedure. Despite the prominence of cardiovascular disease, too few patients and loved ones are familiar with cardiac rehabilitation, a life-changing program available to cardiac patients. To make a meaningful impact on cardiac rehabilitation utilization in across the state, a new Michigan Cardiac Rehab Network, or MiCR, was established by collaborative team of physicians, researchers, data analysts, and engagement specialists from two Collaborative Quality Initiatives:  Michigan Value Collaborative, or MVC, and Blue Cross Blue Shield of Michigan Cardiovascular Consortium, or BMC2. MVC co-directors are Mike Thompson, Ph.D. and assistant professor in the Department of Cardiac Surgery at Michigan Medicine, and Devraj Sukul, M.D., M.S., interventional cardiologist and BMC2 associate director.

Cardiac rehab benefits

Cardiac rehabilitation, or CR, has a Class IA indication for recent cardiac-related events or procedures. This means high-quality evidence shows CR 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. 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%. “The evidence is clear,” said Thompson. “Cardiac rehab extends life and improves the quality of life for patients with a recent cardiac-related event or procedure. Unfortunately, two of every three Michiganders eligible for CR never participate.”

Making a change

MiCR was created to equitably increase CR participation for all eligible individuals in across the state. BMC2 is a collaborative consortium of health care providers dedicated to improving the quality of care and outcomes for cardiovascular patients across Michigan. MVC is a collaborative that helps 100 Michigan hospitals and 40 physician organizations to improve the health of Michigan through sustainable, high-value health care. MVC helps its members better understand their performance using robust multi-payer data, customized analytics and collaborative learning opportunities that enable providers to learn from one another in a cooperative, non-competitive space.

MiCR will distribute regular CR utilization summaries to providers, convene meetings with stakeholder and advisory groups, create resources to help hospitals and CR facilities optimize utilization, and continue to leverage expertise of both CQIs. MiCR has completed cardiac rehab site visits with hospitals and launched a Cardiac Rehab Best Practices Toolkit. The toolkit was a group effort of dedicated CR providers and content experts to identify best practices for CR facilities, hospitals and health systems. The contributors encourage local quality improvement teams to tailor interventions to their own sites.

“We are really excited to combine the strengths of BMC2 and MVC with the tremendous passion for cardiac rehabilitation demonstrated by health care providers and personnel across the state in an effort to improve the care of thousands of patients every year,” said Sukul.

Goals

MiCR also just announced new statewide goals for improved CR utilization. Currently, only 30% of patients utilize CR following transcatheter aortic valve replacement or TAVR, surgical aortic valve replacement, or SAVR, coronary artery bypass graft surgery, or CAB, percutaneous coronary intervention, or PCI, and acute myocardial infarction, or AMI. The first goal is to reach 40% CR utilization for all these patients. MVC will identify patients hospitalized at member hospitals for these conditions and count how many attended at least one outpatient CR visit within 90 days of discharge. Since only 3% of congestive heart failure, or CHF, patients currently utilize CR, the second goal is a collaborative-wide utilization rate of 10% for CHF patients and would count those with at least one outpatient CR visit within 365 days of discharge. Site progress will be shared by MVC in its CR reports sent every six months.

In support of the major initiatives implemented cooperatively by MiCR, the two CQIs will also continue with their respective activities in the CR space. MVC supports CR participation in two ways: 1) providing opportunities for MVC members to collaborate, and 2) preparation of reports using 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. MVC’s reports 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 be sharing unblinded data on CR rates with members at its May semi-annual meeting to drive conversation and encourage best practice sharing across the CQI.

Feasibility

“In claims data, we can assess both initiation and adherence – whether and when someone starts cardiac rehab and how long they keep going,” said MVC Analyst Jessica Yaser. “There’s a huge amount of variation in CR rates across many dimensions – across hospitals, qualifying events and payers. The hospital with the highest rate of cardiac rehab after CAB sends 75% of their patients to CR, while another only sends 28% of their CAB patients. This demonstrates the feasibility of achieving high rates. Hospitals can learn from each other to make systemic improvements to get more patients to life-changing (and cost-saving) cardiac rehab programs.”

BMC2 began tracking CR referral as a BMC2-PCI performance metric in 2010. At that time, the consortium average referral rate was 64%. By 2018, they exceeded the target referral rate of 90%. In 2020, BMC2 identified key stakeholders including CR personnel from BMC2 sites to identify and share best practices to improve CR utilization. They created a metric to track physician endorsement of CR. Webinars were held on how to evolve their CR efforts during the pandemic and after Medicare’s approval of virtual CR. Efforts have translated to over 18,000 patients referred to CR in 2021.

Conclusion

The MiCR team anticipates these concerted efforts and turnkey tools will help hospitals across the state make an impact on removing barriers to patient participation, and on having family members and physicians help patients commit to full engagement in rehabilitation. Doing so would save thousands of lives.