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Older Adults Use of Postacute and Cardiac Rehabilitation Services After Hospitalization for a Cardiac Event (CE)
The purpose of this study was to describe older patients’ use of postacute care (PAC) and outpatient cardiac rehabilitation (CR) services after a cardiac event and to describe the differences between older adults who use these services and those who do not. Under a longitudinal descriptive design, data were collected during hospitalization for a cardiac event, 3 and 6 weeks later, and 4 and 6 months later. Of the 60 older adults in the sample, 73% used PAC after discharge. Older adults discharged home without PAC services had fewer complications and were less depressed than those who used PAC. Older adults discharged to a skilled nursing facility had poorer physical function both before the cardiac event and during hospitalization. Twenty-five percent participated in outpatient CR. Older adults who went to CR were male, had better physical function, and did not live alone. Understanding the use of PAC and CR services will help with discharge planning and customizing PAC and CR services for older adults to optimize cardiac recovery. The integration of CR principles into PAC may be an opportunity to enhance recovery for older adults, especially because only a small percentage of older adults attend CR.
Demographics of people with cardiac disease have changed, and older and sicker adults are surviving cardiac events (Pashkow, 1993). In fact, more than half of patients who have had a myocardial infarction (MI) and coronary artery bypass surgery are over the age of 65 (American Heart Association, 2006). To assist with recovery after hospitalization for a cardiac event, two types of services are available: traditional and specialized. Traditional services begin after discharge and consist of postacute care (PAC) services, which include home health care (HHC), skilled nursing facility (SNF) care, inpatient rehabilitation facility (IRF) care, and long-term care in hospitals (MEDPAC, 2006). Specialized care consists of outpatient cardiac rehabilitation (CR), which begins 4–6 weeks after discharge.
In the 1990s, 17%–37% of older adults used traditional PAC services after a cardiac event (Bohmer, Newell, & Torchiana, 2002; Bronskill, Normand, & McNeil, 2002), and 17%–22% used CR (Ades, Waldmann, Polk, & Coflesky, 1992; Thomas et al., 1996). The rate of current use of PAC and CR for older adults is not known. Factors associated with low CR attendance rates have not included the potentially difficult recovery experienced by older adults and the timing of CR. In fact, at 6 weeks after discharge, when outpatient CR begins, the majority of older adults are not back to pre-event physical function (Dolansky & Moore, 2007).
The current use of PAC and CR services and the characteristics of older adults who use these services must be elucidated to optimize timing of rehabilitation services and cardiac recovery for older adults. The purpose of this article is to determine the proportion of older adults who use PAC (HHC, SNF, or IRF) and CR services and compare older adults who use PAC and CR services after a cardiac event with those who do not.
PAC and CR Services
Although all older adults hospitalized for a cardiac event are at risk for compromised physical function (Kamper, Stott, Hyland, Murray, & Ford, 2005; Mendes de Leon et al., 2005), only some need PAC. Older adults who do not need additional rehabilitation or nursing care go home and follow up with their physicians. Older adults who are able to return home but need rehabilitation or care from a registered nurse receive HHC. HHC consists of one to three visits per week from a registered nurse who assists with wound management, monitoring of vital signs, and education on medications, activity, and diet. Physical and occupational therapy can also be delivered during home care. Older adults who are unable to return home because they need more extensive nursing care or therapy are discharged to an SNF or IRF. The goal of SNF and IRF care is to improve independence in activities of daily living (ADL) and return the patient home. IRFs provide more intensive therapy; patients must be able to tolerate 3 hours of intensive daily therapy. PAC services begin right after discharge and promote recovery by assisting with the transition from dependence on healthcare professionals to independent functioning. No reimbursed CR services are provided during PAC.
Specialized cardiac services are provided during outpatient CR. Outpatient CR is reimbursed by Medicare and consists of a 12-week program that begins 4–6 weeks after discharge. Participants attend 1-hour sessions three times per week. Each session consists of supervised exercise and education on survival management and lifestyle modification. The goals of CR are to improve functional capacity, alleviate activity-related symptoms, reduce disability, enhance self-management, and modify coronary risk factors in an attempt to reduce subsequent morbidity and mortality (Balady et al., 2000). The benefits of participation in an outpatient CR program are well documented and include improved quality of life, physical function, cognitive status, and lower extremity function and lower mortality (Ades & Grunvald, 1990; Ades, Maloney, Savage, & Carhart, 1999; Ades, Waldmann, & Gillespie, 1995; Ades et al., 1993; Dolansky & Moore, 2000; Jolliffe et al., 2001; Marchionni et al., 1994; Wenger, Froelicher, & Smith, 1995). Notably, older adults with compromised physical function benefit the most from CR (Ades et al., 1999).
Characteristics of Older Adults Using PAC and CR Services
Two previous studies examined the characteristics of older adults after a cardiac event and the use of PAC. Both studies used large administrative databases and therefore were limited in the factors that predicted PAC use. According to the Centers for Medicare and Medicaid Services 1995–1996 database, factors associated with discharge to PAC for older adults after an MI were the discharge hospital provision of HHC and severity of illness (Bronskill et al., 2002). Hospital discharge abstracts from patients hospitalized in Alberta, Canada, for MI found that the predictors of HHC were length of stay, prior HHC use, and amount of hospital care received (Quan, Cujec, Jin, & Johnson, 2004). Other characteristics related to PAC use have been identified for older adults. For older hip fracture patients and older hospitalized medical patients, predictors of PAC use were living alone, older age, and poor physical function (Campbell, Seymour, & Primrose, 2004; de Pablo et al., 2004). Other characteristics not identified in these large database studies also may be related to PAC use. For example, depression is associated with disability in cardiac patients (Ades et al., 2002; Koenig & George, 1998; Marchionni et al., 2000) and may contribute to PAC use.
Characteristics of older adults participating in a CR program include younger age (Evenson, Rosamond, & Luepker, 1998; Johnson, Fisher, Nagle, Inder, & Wiggers, 2004), male gender (Ades et al., 1992; Caulin-Glaser et al., 2001), white race (Gregory, LaVeist, & Simpson, 2006), higher education, employment (Lane, Carroll, Ring, Beevers, & Lip, 2001), family or physician support to attend (Husak et al., 2004; Lieberman, Meana, & Stewart, 1998), and personal beliefs about the benefits of CR (Cooper, Weinman, Hankins, Jackson, & Horne, 2007). The relationship between physical function status and participation in CR is unclear. Both better baseline physical function measured with the Duke Activity Status Index (Harlan, Sandler, Lee, Lam, & Mark, 1995) and being physically inactive with leisure activities (Burns, Camaione, Froman, & Clark, 1998) have been found to be related to participation in CR.
The Andersen model was developed to help explain service use and proposes that patient and environmental characteristics predict use of services (Andersen, 1995). Patient characteristics are classified as predisposing (age, gender, and comorbidity), need (illness severity, complications, depression, and physical function), and enabling (insurance). Environmental characteristics are factors outside the patient such as living arrangements. The Andersen model of healthcare service use was used to guide the current study. The following study questions were posed:
In this study, a longitudinal prospective design was used to identify the proportion and characteristics of older adults using PAC and outpatient CR services after a hospitalization for a cardiac event. The study was approved by the institutional review board at an urban and suburban hospital. During hospitalization, data were collected on demographics, illness severity, complications, depression, physical function, and living arrangements. Follow-up visits were performed at 3 and 6 weeks after hospitalization; the aforementioned measures were repeated, and PAC use was assessed. Additional follow-up phone interviews were conducted at 4 and 6 months to assess outpatient CR participation.
Sample and Setting
The sample consisted of 60 older adults who agreed to participate and met the following inclusion criteria: 70 years and older, currently hospitalized for a cardiac event (MI, coronary artery bypass surgery, or cardiac valve surgery), able to communicate in English, living within a 60-mile radius of Cleveland, and cognitively intact. The sample ranged in age from 70 to 89 years, with an average age of 78; participants were predominantly white (90%), 83% had at least a high school education, and 51% were female. The majority of the sample (90%) had cardiac surgery (bypass or valve). All participants had a Medicare HMO plan or Medicare plus supplemental insurance.
Informed consent was obtained from older adults by the researcher or research assistant. At baseline (within 24 hours before discharge), the researcher or research assistant obtained demographic information and completed the Charlson Co-morbidity Index using data from medical records. In a 40-minute face-to-face interview, illness severity, complications, physical function, depression, and living arrangements were assessed. Follow-up home interviews at 3 and 6 weeks after discharge collected the same data along with information on PAC use. Follow-up phone interviews at 4 and 6 months included information on PAC and CR use.
PAC use was measured by participants’ reported HHC, SNF, or IRF use. For HHC, the number of visits from a nurse, physical therapist, or occupational therapist was documented. For SNF, the number of days was documented. CR was measured as the participants’ reports of attending a CR program and the number of sessions attended.
Comorbidity was measured by the Charlson Co-morbidity Index (Charlson, Pompei, Ales, & Mac-Kenzie, 1986), a weighted index that measures the number and seriousness of comorbid diseases. The total score is derived by adding the weighted comorbid conditions. Interrater reliability in the current study was .96. Illness severity was measured by the number of days in an intensive care unit during the hospitalization. Complications were measured by a count of the following complications during hospitalization: intraaortic balloon pump use, cerebrovascular accident, infection, hemorrhage, atelectasis, pulmonary edema, and pacemaker insertion. Scores ranged from 0 to 6 complications. Physical function was measured objectively as the time in seconds that it took to walk 4 meters (using assistive devices as needed) (Guralnik et al., 1994). Gait speed has been found to be related to disability. Physical function was also measured by a self-report of difficulty performing ADLs and instrumental ADL (IADLs) (Akpom, Katz, & Densen, 1973; Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963). The ADL items were bathing, dressing, getting in and out of bed, and using the toilet. IADLs were movement around the house, light housework, heavy housework, grocery shopping, and preparing meals. This measure was obtained for pre-event physical function (participants were asked in the hospital to report pre-event status), and current status was obtained at the 6-week interview. Depression was measured using the Geriatric Depression Scale (Guralnik et al., 1994; Yesavage et al., 1983). The scale consists of 15 items representing depressed mood that do not include physical symptoms that might be present in older adults after cardiac events. Patients identify items that best reflect their feelings in the past week (1 = felt like this and 0 = did not feel like this). The score is the sum of these responses, and higher scores indicate more depression. Internal consistency reliability in the current study was an alpha of .93.
Living arrangements were assessed by the question, “Do you live alone or with someone?”
Descriptive statistics were used to describe the proportion and characteristics of older adults going home without PAC, using PAC (HHC, SNF, or IRF), and participating in a CR program after hospitalization for a cardiac event. No participants were discharged to an IRF; therefore, this category was dropped from subsequent analyses. Comparisons were made using an analysis of variance for PAC and t tests for CR.
Proportion of Adults Who Used PAC
The proportions of older adults discharged home without PAC, discharged home with HHC, and discharged to an SNF after a cardiac event are listed in Table 1. Only 26.7% of the sample went home without the use of PAC services, 33.3% used an SNF, and 40% used HHC. The average number of HHC visits was 9.5 and ranged from 2 to 20. The average number of days in an SNF was 16.5 and ranged from 5 to 37 days. Twenty-five percent participated in CR, and all of these participants completed the 12-week program.
Characteristics of Older Adults
The characteristics of older adults discharged home without PAC and those using HHC and SNF are listed in Tables 2 and 3. All study variables were found to be different between older adults who did not use PAC and those who did except for age and comorbidity. More men used HHC, and more women used SNF. Older adults living with someone used more HHC than those who lived alone. Post hoc analyses using the Tukey method revealed that older adults discharged to their homes without PAC were less depressed and had fewer complications than those who received PAC. Older adults discharged to an SNF were older, had more complications, and had more physical problems (slower gait and poorer pre-event physical function).
The characteristics of older adults who did and did not participate in CR are listed in Tables 4 and 5. Only 13% of the women attended CR, and only one person who lived alone attended. For older adults discharged to an SNF, only 10% attended CR. There were no differences in regard to age or comorbidities. However, older adults who had difficulties with ADLs and IADLs before their event and those continuing to have difficulty 6 weeks after the event were less likely to attend. Those who attended CR had a much faster gait speed for the 4-meter walk than those who did not attend. There was no difference in regard to depression and use of outpatient CR.
Traditional PAC was used by 73% of the participants in the study. This is a significant increase from trends reported in the 1990s, when only 17%–37% of older adults after a cardiac event used traditional PAC services (Bohmer et al., 2002; Bronskill et al., 2002). Unfortunately, despite the well-known aging of the population and an increase in the number of older adults surviving hospitalization for a cardiac event such as an MI (Fox et al., 2007), there are currently no Medicare-reimbursed CR services provided during traditional PAC services between hospital discharge from a cardiac event and the start of outpatient CR, approximately 6 weeks later. PAC may be a valuable opportunity for the integration of CR principles to enhance the care of older cardiac patients.
It is surprising that no older adults reported use of IRF services. This may be due to restrictions on reimbursement of IRF care and the fact that cardiac events are not one of the 13 diagnoses reimbursed by the Centers for Medicare and Medicaid Services (CMS). The CMS 1984 Federal Regulation (Regulation 412.30) specifies that 75% of the patients served in an IRF must have one of 13 diagnoses (including stroke, spinal cord injury, amputation, trauma, hip fracture, brain injury, polyarthritis, neurological disorder, and burns) (MEDPAC, 2006). If significant numbers of older adults use PAC after a cardiac event and these older adults would benefit from IRF services, policy changes are needed to include a cardiac diagnosis as one of the qualifying diagnoses for CMS reimbursement.
The proportion of older adults who participated in CR was similar to that of other studies in the literature. The underuse of CR by older adults is a cause for concern because the American Heart Association, the American College of Cardiologists, and the Centers for Disease Control recommend that all eligible patients participate in CR as part of a standard recovery protocol (LaBresh, 2004; Leon et al., 2005; Smith et al., 2006). Use of an automatic referral process or a nurse-generated phone call after hospital discharge can improve participation in CR (Grace et al., 2006; Harkness et al., 2005; Smith et al., 2006). In addition, older adults may not use CR because CR programs were developed for younger adults returning to work and may not meet the needs of older adults (Dolansky, Moore, & Visovsky, 2006).
Although women have been identified as being less likely to attend CR, the current study found that older adults with self-reported pre-event and current difficulty with ADLs, slower gait speed, and living alone also were less likely to attend CR. In addition, only 10% of the older adults who were discharged to an SNF participated in outpatient CR. Thus, older adults are less likely to attend CR when they have physical function limitations. The current CR model (outpatient CR 6 weeks after discharge) may be sufficient for older adults who do well after cardiac events but may not be optimal for those who have physical function limitations and use SNF services after a cardiac event. This is a concern because it has been established that older adults with compromised physical function benefit the most from CR (Ades et al., 1999). The integration of CR principles into PAC may promote the physical improvement of older adults so that they are better prepared to attend outpatient CR.
The current study found that characteristics were different between older adults who used PAC and those who did not. Women used SNF services more than men; men used HHC services more than women. This finding was not reported in previous studies with cardiac patients but was found in studies with hospitalized patients in general (Campbell et al., 2005). In the current study there was a difference in living arrangements between those returning home and those being discharged to an SNF. More older adults living alone were discharged to an SNF than returned home, and this has been documented in the literature for patients with hip fracture or stroke (Bond et al., 2000; de Pablo et al., 2004). Age did not vary with service use. This may be because the current study included only patients 70 years and older. This restriction may have made age differences difficult to detect. There was no statistically significant difference in comorbidity between the service use categories, although the mean comorbidity score was lowest for patients receiving no PAC services, increased for those in HHC, and increased still more for those in an SNF, indicating a trend that as comorbidity increases, service intensity increases. Illness severity, measured by length of stay in intensive care and number of hospital complications, was higher for patients who used HHC and an SNF, indicating that as illness severity and complications increase, so does PAC service use. This finding was consistent with previous work that examined service use after MI (Bronskill et al., 2002; Quan et al., 2004) and blunt trauma (Gabbe et al., 2005).
Physical function for those who did not use PAC and those who did also differed, and although physical function was not assessed in the previous cardiac studies, this finding was consistent with findings for stroke and hip fracture patients (Bond et al., 2000; de Pablo et al., 2004) and hospitalized patients (Campbell et al., 2004, 2005). As in hip fracture and stroke patients (Bond et al., 2000), higher depression was found in older patients after a cardiac event who used PAC services. Although cognitive status has been found to predict PAC service use (Campbell et al., 2005), it did not apply in the current sample because all participants were cognitively intact.
The findings of this study must be interpreted with caution because it had a small sample size and was limited to older adults willing to participate. The current sample may have included patients with higher acuity and more complications than the general Medicare population, and therefore the PAC service use may have been inflated. In addition, because of the multiple comparisons made, a statistically significant difference due to chance alone (type 1 error) may have occurred.
A future research study that identifies the current trends in PAC for older cardiac patients is necessary to establish that the current study reflects the entire Medicare population. In addition, the effects of gait speed and prior difficulty with ADLs and IADLs will be important for future efforts by the CMS to create a PAC discharge patient assessment instrument. This CMS initiative responds to a mandate under Section 5008 of the Deficit Reduction Act of 2005 to establish a demonstration program that uses a comprehensive assessment instrument at hospital discharge to help determine appropriate PAC (CMS Provider Resource, 2005). Older cardiac patients identified as being at high risk for disability using such an assessment instrument can be appropriately referred to PAC services, such as home physical therapy or an SNF to facilitate recovery and rehabilitation.
In summary, the majority of older adults used PAC services, and as in previous research, only 25% participated in outpatient CR. Those who did not attend CR had poorer physical function than those who attended. Thus, despite the high level of need for assistance with recovery, older adults are not getting the documented benefits of CR. The timing of rehabilitation services has led to fragmented specialized cardiac care for older adults with physical function limitations after cardiac events. Older adults who use PAC, especially SNF care, are less likely to receive specialized CR services. For these less physically able older adults, optimal recovery that includes both traditional and specialized cardiac services is necessary. The application of CR principles throughout the PAC trajectory may optimize recovery and prepare older adults so that they are able to attend outpatient CR.
This study was supported by the John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Scholarship Program and the Ohio Nurses Foundation. Special thanks to colleagues in the multidisciplinary clinical research training program.
About the Authors
Mary A. Dolansky, PhD RN, is a postdoctoral fellow in the multidisciplinary clinical research training program at Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland. Address correspondence to her at 10900 Euclid Avenue, Cleveland, OH 44106 or at firstname.lastname@example.org.
Shirley M. Moore, PhD RN FAAN, is an associate dean for research at Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland.
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