Population Science
There Are Not Enough Facilities for Outpatient Cardiac Rehabilitation ― What Is the Solution? ―
2022 Volume 86 Issue 12 Pages 2008-2009
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2022 Volume 86 Issue 12 Pages 2008-2009
As weakness, especially muscle weakness in the lower extremities, progresses, the prognosis of patients with heart failure worsens.1 Therefore, cardiac rehabilitation (CR) is an essential therapeutic strategy, and improving skeletal function in patients with heart failure is associated with exercise tolerance and prognosis. Both European Society of Cardiology and Japanese Circulation Society and Japanese Association of Cardiac Rehabilitation guidelines recommend the use of exercise therapy in patients with heart failure as a Class I treatment.2,3 Surprisingly, prognosis of patients with heart failure with preserved ejection fraction also improved after CR, with reduced rates of death and heart failure hospitalization.1 Continuation of outpatient CR is expected to reduce cardiovascular events and readmission rates, but only 7% of Japanese hospitals with cardiologists are implementing outpatient CR. Moreover, there are still issues to be addressed regarding the continuation of CR.4
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In this issue of the Journal, Kanaoka et al report the results of a cross-sectional study using Diagnostic Procedure Combination (DPC) data.5 Kanaoka et al evaluated nationwide trends and associated factors for CR participation in patients with acute heart failure (AHF), acute coronary syndrome (ACS), or acute aortic dissection (AAD), as well as in patients who underwent cardiovascular surgery, and used mixed-effect logistic regression analysis to evaluate associations between CR participation and patient- and hospital-related factors.5 To the best of our knowledge, that study is the first to comprehensively evaluate the factors associated with participation in in- and outpatient CR using nationwide real-world databases in Japan. From 2013 to 2019, there was a 2.1-fold increase in CR for inpatients and a 2.2-fold increase for outpatients. There was a trend for increased CR in all age groups (≥75, 65–74, and 20–64 years), as well as in the number of facilities performing CR. However, the participation rates were lower for outpatient compared with inpatient CR.5
By disease, Kanaoka et al found that participation rates were lower for patients with AHF, AAD, and peripheral arterial disease (PAD) than those with other diseases, with a particularly low rate of 1.7% among patients with PAD.5 Although the Transatlantic Inter-Society Consensus (TASC) II guidelines for exercise therapy for patients with PAD recommend 30–60 min treadmill walking 3 times a week for 3 months (Class A recommendation),6 exercise therapy for PAD is associated with pain due to intermittent claudication, which we believe makes CR even less tolerable. These patients need comprehensive medical assistance.
Kanaoka et al describe access to CR facilities as a reason behind the low participation rate for outpatient compared with inpatient CR.5 The authors state that the number of CR facilities needs to be increased in areas where there are few. However, due to regional disparities, such as the uneven distribution of cardiologists, the number of cardiologists and the number of inpatients also affect the participation rate in outpatient CR. Moreover, large hospitals have introduced CR as both an in- and outpatient service, but there is a limited number of large hospitals, meaning that corresponding measures should be taken.
Some solutions to the poor participation rate in outpatient CR are as follows. First, the reform of the Japanese medical fee system in 2022 is expected to relax the criteria for facilities to perform late Phase II CR, which is expected to increase the CR participation rate. Second, the Japan Heart Club (JHC) was established as a non-profit organization in 2004 to serve Phase III CR and to publish educational materials for health promotion and the prevention of cardiovascular diseases. The JHC provides opportunities for participation in CR programs in the community through the activities of the “MedEX Club”, a multidisciplinary facility that provides supervised exercise sessions and education for patients, as well as training classes for citizens and health professionals. CR is expected to continue through the use of these private exercise facilities. Third, remote CR is a method of remotely supporting exercise at home, allowing participation even when access to CR facilities is poor. This is also expected to improve CR adherence. Remote CR for patients with cardiovascular diseases has been proved to be as effective as conventional monitored CR (Figure).7,8 Recently, remote CR, which avoids in-person interaction and can be performed at home, has become increasingly important because of the COVID-19 pandemic. One study of patients with heart failure who were regularly contacted by telephone or via chat using an application and taught how to exercise at home found that, after an 8-week intervention, there were improvements in both the 6-min walking test (from 305.8 to 372.9 m) and peak V̇O2 (from 16.3 to 19.8 mL/kg/min).9
With a well-educated team, cardiac telerehabilitation (CTR) is the solution to improve the low cardiac rehabilitation (CR) participation rate in Japan. CVD, cardiovascular disease. (Reproduced with permission from Kaihara et al.8)
Japan has had a superaging society since 2005, earlier than the rest of the world. Complications, comorbidities of frailty, and sarcopenia are also common in aged CR patients. There are 3 types of frailty, namely physical, social, and cognitive, and 86.6% of patients with CR have 1 type of frailty.10 Therefore, highly individualized exercise guidance and education are important in patients with CR. Japan has a well-developed long-term care insurance system, yet the environment for conducting CR is not sufficiently developed. Accordingly, the long-term care insurance system must be used as an environment where CR can be conducted outside of medical care. Further cooperation between medical and long-term care services and remote CR is desirable.
The authors thank K. Yoshizawa for administrative assistance. The authors also thank Editage (www.editage.com) for English language editing a draft of this manuscript.
The authors have no conflicts of interest to declare.
Not applicable.
