PROJECT SUMMARY
More than 6.5 million American adults have HF, which results in approximately 1 million hospital admissions
per year in patients 65 year and older. Hospitalized patients with HF have a 30-day mortality rate of
approximately 10%. Cardiac rehabilitation (CR), a multidisciplinary structured secondary prevention program
that applies effective lifestyle therapies (diet, exercise, stress reduction, smoking cessation, weight loss, etc.)
to reduce the risk of secondary cardiac events and improve functional status, has demonstrated a modest
reduction in all-cause mortality in patients with HF and reduced ejection fraction (HFrEF). Randomized
controlled studies of patients with HFrEF or HF with preserved ejection fraction have reported that CR
improves symptoms, increases aerobic capacity, endurance, improves self-reported quality of life, and reduces
rehospitalization. The American Heart Association and the American College of Cardiology recommend
exercise training for patients with HF, and, in 2014, the Centers for Medicare and Medicaid Services began to
cover CR for patients with HFrEF. However, national data suggest that only 2-10% of patients with HF attend
CR after a hospitalization and our preliminary data suggest that little improvement has occurred since 2014.
Our long-term goal is to identify effective delivery-system interventions that improve the health and outcomes
of patients with HF. The objective of this proposal is to identify implementation strategies that increase
participation in CR among patients with HF. Then with a group of clinicians, patient advocacy organizations,
CR leaders, policymakers, and payers, we will prioritize strategies that are the most acceptable, feasible, and
responsive to the needs of the community. In Aim 1, we will analyze Medicare claims among recently
hospitalized HF patients to identify hospital-referral regions (HRRs) that are most and least successful in
recruiting recently hospitalized patients with HF to CR. Beginning with these programs, we will use the
Consolidated Framework for Implementation Research (CFIR) to guide qualitative interviews of clinicians with
these HRRs, identifying facilitators and barriers to CR participation. We will present our findings to a panel of
stakeholders who will prioritize strategies. We will then pilot these strategies in a subset of CR practices in
order to refine the final set of recommendations that will inform practice (e.g., outpatient and inpatient
clinicians, CR programs, patients), policy (e.g., clinical practice guidelines and reimbursement strategies), and
future research (e.g., implementation trials). These activities are highly responsive to the STIMULATE RFA
because they are timely, engage a range of stakeholders, and examine implementation of an underutilized
evidence-based intervention. They are also consistent with National Heart, Lung, and Blood Institute's
Strategic Goals and Objectives, specifically objective 6, which aims to “optimize translational, clinical, and
implementation research to improve health and reduce disease.”
