Benefit of in-hospital cardiac rehabilitation on mortality and readmissions in heart failure

The results from the Lombardy healthcare administrative database study of more than 140,000 patients were published in this issue of European Journal of Preventive Cardiology.1 The authors of this analysis conducted a retrospective data review in a cohort that was sufficiently powered to detect reductions in mortality and hospital readmission rates between those heart failure patients undertaking in-hospital cardiac rehabilitation versus no cardiac rehabilitation referral. In-patient cardiac rehabilitation is not widely available, but may be offered, in some parts of the world, to patients undertaking planned cardiac surgery; moreover the duration is usually limited to 5–7 days. While in-patient cardiac rehabilitation for people with heart failure has been attempted previously, with very impressive prognostic results,2,3 only a relatively small number of patients were studied and end-points lacked event, and time to event, data. The Lombardy analysis, for the first time, presents the possibility of offering in-patient cardiac rehabilitation on a larger scale. During recovery for an acute episode of heart failure in the Lombardy region 2005–2012, the referral to in-patient cardiac rehabilitation or to the patient's own General Practitioner was really entirely at the discretion of the treating physician. The in-hospital cardiac rehabilitation program (InH-CRP) remains a multidisciplinary program of cardiac rehabilitation for a maximum period of 20 days that includes: clinical assistance and optimized medical or interventional treatment to relieve symptoms; appropriate cardiovascular risk evaluation; exercise training; education and counseling regarding risk reduction and lifestyle changes. As the Lombardy authors correctly state, the 2016 European Guidelines for the Diagnosis and Treatment of Heart Failure classified cardiac rehabilitation as a mandatory class I intervention. Nevertheless sub-optimal cardiac rehabilitation referral and subsequent adherence rates remain ongoing problems that adversely impact the potential health benefits that may be elicited even when a comprehensive program of lifestyle therapy is available. The Lombard study illustrates that provision of an InH-CRP program may overcome the issue of poor adherence. While exact cardiac rehabilitation adherence data are not provided, the mortality and hospital readmission data, from the Lombardy analysis, indicate the program is extremely effective in delaying mortality and hospital readmissions. Other previous works have employed a residential cardiac rehabilitation program for cardiac patients; Dubach et al. in 19972 and Berent et al. in 20093 showed impressive 23% and 15% improvements in peak oxygen uptake (VO2) respectively. Both of these studies were approximately four weeks in duration and while peak VO2 is a strong prognostic indicator for heart failure, the mortality and hospitalization data of the Lombardy study are substantially superior healthcare end-points. In the Lombardy region, from 2005 to 2012, there was a reduction of new, incident cases, with increasing age at first hospitalization. Meanwhile, both in-hospital and one-year mortality decreased in patients aged <75 years, possibly due to improved preventative treatment, which may be at least partially due to the InH-CRP. There are two fairly obvious barriers to providing InH-CRP in other European countries and beyond. The first is the in-patient cost of approximately 20 days (using the Lombardy model) for each heart failure patient. A health economics analysis is required to establish whether the reduced number of heart failure hospitalizations offset the additional in-patient stays required to deliver InH-CRP, and if not, then one must question if it is possible to justify the additional healthcare expenditure in exchange for the reduced healthcare burden. The second barrier is perhaps an ethical issue, as it appears that heart failure patient prognosis may be dependent on the allocation to the treating physician. In the Lombardy model it appears feasible that certain patients may have been advantaged by treatment from a physician who may be likely to refer to InH-CRP, as opposed to a physician who places less emphasis on InH-CRP. To roll out in-patient cardiac rehabilitation in a wider context may require consensus on which clinical indicators constitute medical grounds to warrant InH-CRP referral. In summary, this novel population-based analysis provides a treatment model that offers a reduced heart failure healthcare burden. While it remains to be seen if the Lombardy InH-CRP model also offers reductions in heart failure-related healthcare treatment costs, the potential benefit is significant. Further work in this area should include robust healthcare economic analyses to examine long-term feasibility of this innovative approach. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) received no financial support for the research, authorship, and/or publication of this article.