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Minnesotans who survive heart attacks skip rehab and risk their lives

Most Minnesotans who survive a heart attack or other cardiac episodes skip rehabilitation, despite its benefits in stimulating healing and reducing mortality.

The Minnesota Department of Health promoted the finding earlier this month to improve the state’s 48% participation rate in cardiac rehabilitation after hospitalization. While the national rate is less than 25%, the goal is 70% and Minnesota won’t reach it unless it convinces thousands more people to sign up after a heart attack, heart surgery or other heart problems.

“It has a powerful impact on individuals’ quality of life and length of life,” said James Peacock, co-author and supervisor of the state Department of Health’s cardiovascular disease unit. “We want to show that.”

Rehabilitation typically involves one to three sessions per week of fitness and strength training, scheduled in a group setting to reduce costs and increase camaraderie and support. Many programs also offer counseling on diet, depression, and other consequences of cardiac events.

Unlike many health care issues, lack of participation in cardiac rehabilitation is not caused by a lack of access. All but eight Minnesota counties have outpatient cardiac rehabilitation programs. Health plans also routinely cover up to 36 rehab sessions, although the cost of repeat copays can be a deterrent.

State leaders have urged hospitals to do a better job providing rehabilitation when heart patients are discharged and following up with those patients even if their doctors are affiliated with competing health systems.

Some patients refuse because they think they can recover on their own, while others are afraid or suffering from depression, said Aaron Pergolski, who directs M Health Fairview’s cardiac and pulmonary rehabilitation programs.

“They think we’re going to force them to run on treadmills and do things they’ve never done before,” said Pergolski, co-author of the national report.

The exercises are tailored to patients’ rehabilitation goals, whether they want to play hockey again or simply climb stairs without exhaustion, he said.

One memorable patient was being pressured by loved ones to move into an assisted living facility after her heart attack, Pergolski recalls. “She used weights of up to 8 pounds to be able to lift her trash and take it down the street. That was her goal and she achieved it. Her family was happy because she could still live independently , and she was super happy because her family was no longer on her back.”

The Minnesota study analyzed the vast “all-payer” database of public and private insurance claims for 2017 and 2018. Information on race and ethnicity was not collected, researchers did not were therefore unable to verify disparities based on these demographic data. However, they found that heart attack patients were less interested in rehabilitation than surgery patients and that women were less likely to participate than men.

Many programs only offer weekday sessions, which can make it difficult to commit time, Pergolski said, especially for women who feel pressure after cardiac events to return to family caregiver roles.

Josh Verhelst is in the demographic most likely to participate: a 43-year-old recovering from a heart attack and surgery to implant a pump that increases blood flow. The Woodbury man wanted to be able to run with his daughter again and coach his son’s football and basketball teams.

Rehab was frustrating at first, as Verhelst was beaten by older patients who were further along in their progression, he said. “You ask questions like, ‘How did I get here? Am I going to get better?’ And then, little by little, you start to progress.”

Verhelst said he benefits from the flexibility of owning his own IT business and setting his hours, and that he exceeded his strength and fitness goals in 20 sessions. He graduated Wednesday and brought cupcakes to his coaches.

“I was barely able to walk up a hill or even stairs in my house,” he said. “Now I’m able to do all that.”

Avoidance by other patients is frustrating to state leaders because the evidence for the benefits of rehabilitation is strong. A 2020 study showed that heart patients who completed rehabilitation had a 32% lower risk of death from any cause about five years later than those who skipped it.

Health systems don’t get paid much for rehabilitation, but they get financial incentives because it keeps heart patients from returning to the hospital, Peacock said. The federal government reduces Medicare payments to hospitals for excessive readmissions.

The Mayo Clinic in Rochester used its large epidemiologic database for Olmsted County a decade ago and was among the first to prove that rehabilitation could reduce readmissions.

Cardiac Rehab in Princeton, Minnesota, helped Paul Leonard, 62, recover from emergency quadruple heart bypass surgery in 2018. Now, Leonard volunteers to help others, visiting heart patients in hospitals to show that healing is possible.

“I can’t give medical advice,” he said, “but I can talk about the patient’s future journey.”

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