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Medicare coverage for cardiac rehabilitation for some people with heart failure was expanded almost a decade ago, and medical guidelines recommend it. Yet those who could benefit often don't get it, a new study finds.

Only 1 in 4 people in a nationwide registry received cardiac rehabilitation referrals after being hospitalized for heart failure with reduced ejection fraction, in which the heart doesn't contract effectively. Among them, about 1 in 25 actually participated in a rehab program. The findings were published Tuesday in the journal .

The good news, researchers said, is that referrals increased over time – from 8% in 2010 to 32% by 2018. But disparities persisted for certain groups. People not referred for cardiac rehabilitation were more likely to be older, Black, have multiple health problems or live in rural areas.

Cardiac rehabilitation, a medically supervised program that includes exercise training and healthy lifestyle education, has been shown in previous research to improve quality of life and exercise levels and to lower the risk of heart failure hospitalization or death from any cause. So, not getting it could make a big difference in someone's overall outcomes, said Dr. Ambarish Pandey, the study's senior author and a cardiologist at UT Southwestern Medical Center in Dallas.

"Patients who are older are often considered too frail for cardiac rehabilitation," Pandey said. "This bias regarding these patients has allowed disparities to develop" despite evidence that patients with frailty issues may benefit more from cardiac rehab than those without.

Contributing to the lower referral rates for Black patients may be the perception of socioeconomic disadvantage as a challenge to participating in cardiac rehabilitation, as well as other conscious and subconscious biases related to race, the researchers said.

Pandey said for patients with multiple co-existing health problems like chronic kidney disease, high blood pressure or chronic lung disease, "it's thought that a patient can't do exercise." But that's not always the case, he said.

The Centers for Medicare and Medicaid Services expanded coverage for cardiac rehabilitation in 2014 for people with chronic, stable heart failure with reduced ejection fraction who remain out of the hospital for six weeks. That's the population researchers analyzed in the new study that included 8,310 patients hospitalized between 2010 and 2020.

About 26% were referred to cardiac rehabilitation but only 4% of those participated, attending about seven sessions on average. (A complete course of cardiac rehab is typically considered 36 sessions.) Those who were referred for the program had a 16% lower risk of dying within a year compared to those without a referral. But there was no statistically significant difference in the risk of rehospitalization for heart failure or another cause.

The number of U.S. adults with heart failure is on the rise, with an estimated 6.7 million living with the condition, according to . Patients may be hospitalized, sometimes multiple times. from the AHA and American College of Cardiology say cardiac rehab should be part of a patient's post-discharge care plan.

It's during hospitalization when cardiac rehabilitation care needs to be quickly arranged, said Steven Keteyian, Ph.D., director of preventive cardiology at Henry Ford Hospital in Detroit. "This paper sheds a very important light," he said. "After hospital discharge, it's important to schedule these patients for rehab within three to four weeks."

To overcome barriers to access, Pandey said options such as telehealth could help people lacking transportation or who live in rural areas where rehab programs are limited or require long-distance travel to get to a clinic.

Good doctor-patient communication also is essential, Keteyian said.

"Physicians and patient care teams need to make sure their patients' needs are met," he said. That means "having a frank discussion with a patient, which should include helping them navigate the essentials of disease management and getting them started in rehab. For example, if transportation is difficult for a patient, then perhaps a solution could be that the patient comes to rehab in person one time a week and follows a structured, prescribed program of walking on other days at home."

The bottom line, both experts said, is that if someone with heart failure has not been told cardiac rehabilitation is available to them, they should be proactive and ask. "All patients should be offered (cardiac rehabilitation) on follow-up," Pandey said.