Latest / Becker’s Healthcare Podcast / Advancing Cardiac Prehab for Heart Failure and Transplant Patients with Dr. Radha Gopalan

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Advancing Cardiac Prehab for Heart Failure and Transplant Patients with Dr. Radha Gopalan · Becker’s Healthcare Podcast

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  - Welcome to the Becker's Healthcare Cardiology and Heart
• 1:01
  - Surgery podcast. I'm Mariah Taylor, assistant editor, and
• 1:04
  - I'm thrilled to be speaking with Radha Gopalan,
• 1:08
  - director of the Advanced Heart Failure and Transplant
• 1:11
  - Program at Banner University Medical Center Phoenix. Thank
• 1:14
  - you so much for joining me today. I'm
• 1:16
  - really excited to learn more about your cardiac
• 1:18
  - prehab program. But before we dive into that,
• 1:21
  - I'd love for you to introduce yourself and
• 1:22
  - tell us a little bit about your background.
• 1:25
  - Thank you so much for having me. I
• 1:27
  - am Radhika Palan. I'm a clinical professor of
• 1:30
  - medicine
• 1:31
  - at University of Arizona
• 1:33
  - and the center director for advanced heart failure
• 1:35
  - transplant and mechanical circulatory support at Banner University
• 1:39
  - Medical Center
• 1:40
  - in Phoenix, Arizona.
• 1:42
  - I have been at Banner University in this
• 1:44
  - position for the past ten years,
• 1:46
  - and I'm glad
• 1:48
  - to,
• 1:49
  - to join this,
• 1:52
  - conversation.
• 1:53
  - And we're so happy to have you. You've
• 1:55
  - been doing some really interesting stuff in cardiac
• 1:58
  - prehab, which is not something that I, as
• 2:01
  - a reporter, have seen a lot about. So
• 2:03
  - can you just give us a little bit
• 2:04
  - of that backstory on how cardiac prehab caught
• 2:07
  - your attention as a way to improve outcomes?
• 2:10
  - Thank you.
• 2:12
  - Yes.
• 2:12
  - So we have significant
• 2:15
  - amount of patients who are hospitalized
• 2:17
  - with acutely decompensated heart failure
• 2:20
  - month after month
• 2:21
  - at our hospital.
• 2:23
  - One of the things we noticed is that
• 2:25
  - at least a proportion of those patients are
• 2:28
  - hospitalized with achiridigumensin
• 2:29
  - heart failure
• 2:31
  - require advanced therapies,
• 2:33
  - but they do not have time to go
• 2:35
  - home or get discharged
• 2:37
  - to become eligible for advanced therapies
• 2:40
  - simply because their disease has progressed so far
• 2:44
  - that needed urgent advanced therapies.
• 2:47
  - So what we recognized,
• 2:49
  - while they are hospitalized,
• 2:51
  - they are losing
• 2:52
  - their functional capacity
• 2:54
  - and becoming more and more frail
• 2:56
  - by being bed bound.
• 2:58
  - The second point is any hospital on the
• 3:01
  - inpatient side
• 3:03
  - does not have
• 3:04
  - any ability to provide
• 3:06
  - improvement in physical therapy or functional capacity
• 3:10
  - by having an inpatient
• 3:12
  - cardiopulmonary
• 3:13
  - rehab. They do not have it. It's either,
• 3:17
  - a a patient gets discharged
• 3:19
  - and then wait for about
• 3:21
  - six weeks before they can have
• 3:24
  - outpatient rehabilitation,
• 3:26
  - from a cardiopulmonary
• 3:27
  - perspective.
• 3:28
  - So as you can see, there was a
• 3:30
  - conundrum that we encountered.
• 3:33
  - Medicare
• 3:34
  - actually does not pay for outpatient cardiac rehab
• 3:39
  - approximately
• 3:40
  - six weeks after the patient is discharged
• 3:44
  - based on their their rule. Their rule is
• 3:46
  - you have to meet a definition of stable
• 3:49
  - heart failure.
• 3:50
  - What that means is that the ejection fraction
• 3:53
  - less than 35%,
• 3:54
  - you have to be the patient has to
• 3:56
  - be invited to class two to four
• 3:58
  - and has to be
• 4:00
  - on optimal heart failure therapy for at least
• 4:02
  - six weeks. And then the final one is
• 4:05
  - the most difficult one, is that they have
• 4:07
  - to be considered
• 4:09
  - stable
• 4:10
  - heart failure status.
• 4:12
  - The way that Medicare defines stable heart failure
• 4:16
  - is by the following statement.
• 4:18
  - No recent hospitalization
• 4:20
  - or procedures within the last six weeks.
• 4:24
  - That automatically
• 4:25
  - excludes
• 4:26
  - a patient who is hospitalized with Achilles leukemia
• 4:29
  - heart failure
• 4:30
  - from receiving
• 4:32
  - cardiopulmonary
• 4:33
  - rehabilitation
• 4:35
  - in the outpatient setting for about six weeks.
• 4:38
  - This is a critical period where they decline.
• 4:41
  - But that is for patients who are able
• 4:43
  - to be discharged.
• 4:44
  - How about patients who cannot even go home,
• 4:47
  - but needs to undergo surgery
• 4:50
  - for either a direct transplant
• 4:52
  - or a mechanical circulatory support to be bridged
• 4:55
  - to transplant.
• 4:57
  - And these patients, because they are frail,
• 5:00
  - they are not eligible for immediate surgery. So
• 5:03
  - we cannot discharge them, but we cannot transplant
• 5:06
  - or do an MCS either. So we are
• 5:08
  - stuck between a rock and a hard place.
• 5:11
  - So this is how the idea of
• 5:14
  - creating an inpatient
• 5:16
  - rehab little prehab rehab center at Banner University.
• 5:21
  - That is fascinating and such a sticky situation
• 5:24
  - that I'm sure a lot of other hospitals
• 5:26
  - are handling or at least trying to. So
• 5:29
  - can you give us an overview of what
• 5:31
  - your inpatient
• 5:32
  - prehab program looks like, what it entails, and
• 5:35
  - how it differs from the standard approach?
• 5:38
  - Yeah.
• 5:39
  - So our program, we have a, inpatient cardiac
• 5:42
  - rehab,
• 5:43
  - facility in the hospital itself
• 5:46
  - that's available to patients who are currently hospitalized
• 5:50
  - and,
• 5:51
  - mainly hospitalized for a long time until they
• 5:53
  - get,
• 5:54
  - better from a functional perspective.
• 5:57
  - It is available to all hospitalized patients.
• 5:59
  - Our goals
• 6:01
  - are the following,
• 6:03
  - decreased frailty
• 6:05
  - and increased functional capacity. That is our first
• 6:07
  - and foremost goal
• 6:09
  - in these patients so that they can become
• 6:12
  - eligible to undergo either transplant
• 6:14
  - or mechanical circulatory support surgery.
• 6:18
  - In addition,
• 6:19
  - we also have other goals such as improve
• 6:22
  - quality of life
• 6:24
  - and then
• 6:25
  - get them ready to be discharged home in
• 6:28
  - a much better functional situation recognizing
• 6:31
  - for the next six weeks, they're not going
• 6:33
  - to be able to go to an outpatient
• 6:35
  - facility for rehab.
• 6:36
  - So this actually is aimed at preventing readmission
• 6:40
  - from falls
• 6:41
  - or decreased functional capacity
• 6:43
  - and
• 6:44
  - also aimed at reducing the length of stay
• 6:47
  - after a surgery.
• 6:48
  - So we combine both what we call prehab,
• 6:52
  - which is getting a patient ready for a
• 6:54
  - procedure
• 6:56
  - that they so direly deserve.
• 6:58
  - And then rehab is getting them ready to
• 7:01
  - go home after the surgery is completed.
• 7:05
  - And in the process, we were hoping to
• 7:08
  - reduce
• 7:09
  - discharging these patients
• 7:11
  - to either acute rehab or subacute rehab facility.
• 7:15
  - So that is what the program is aimed
• 7:17
  - at doing. Now how does it differ from
• 7:20
  - a outpatient
• 7:21
  - cardiopulmonary
• 7:22
  - exercise
• 7:23
  - rehab
• 7:24
  - facility?
• 7:26
  - One,
• 7:27
  - just by being within the hospital setting itself,
• 7:30
  - it's available to currently hospitalized patients. They don't
• 7:34
  - have to be discharged.
• 7:36
  - Two,
• 7:37
  - it improves
• 7:38
  - candidacy for advanced therapies
• 7:41
  - within that hospital setting
• 7:43
  - without having to be discharged.
• 7:45
  - Three,
• 7:46
  - it reduces,
• 7:49
  - length of stay by having a
• 7:51
  - rehab program after the surgery.
• 7:54
  - Four,
• 7:55
  - it avoids readmission.
• 7:57
  - And then five,
• 7:59
  - it reduces the number of patients potentially
• 8:02
  - who who have to be referred to acute
• 8:04
  - rehab or SNF.
• 8:06
  - We have a saying in in surgical patients
• 8:09
  - that
• 8:09
  - the the better condition you go into surgery,
• 8:13
  - the better condition you come out and less
• 8:16
  - complications you have and the better condition you
• 8:18
  - get discharged to home. So, hopefully,
• 8:22
  - that saying will
• 8:23
  - manifest
• 8:24
  - by having this program.
• 8:26
  - Absolutely.
• 8:28
  - Since launching, how many patients have completed prehab?
• 8:33
  - We launched it in late twenty twenty three,
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  - about thirty one patients,
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  - in two years and sixteen patients in the
• 8:42
  - second year.
• 8:43
  - And of those 16 patients in the second
• 8:45
  - year, thirteen of them were prehab patients
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  - who were, prepared before transplant,
• 8:52
  - and two patients were rehab
• 8:54
  - post total artificial heart implantation.
• 8:57
  - And one patient
• 8:59
  - is LVAD
• 9:00
  - post implant
• 9:02
  - and who went to transplant and got rehabilitated.
• 9:05
  - And then one patient in pre LVAD and
• 9:08
  - post LVAD. So all these patients, they received
• 9:12
  - this,
• 9:13
  - rehabilitation
• 9:14
  - in the hospital
• 9:15
  - pre and post.
• 9:18
  - So this includes all the patients.
• 9:20
  - And the results of this, most of the
• 9:22
  - patients, about sixty two, sorry, sixty nine percent
• 9:26
  - of these patients
• 9:28
  - attended more than one session of training
• 9:31
  - in the inpatient rehab rehab facility.
• 9:34
  - Fifty percent of those improved METs,
• 9:37
  - which is a measure of functional capacity,
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  - And forty four percent of them improved
• 9:44
  - frailty
• 9:45
  - or maintained
• 9:47
  - the same level of functional capacity without worsening
• 9:50
  - frailty
• 9:51
  - because most of the hospitalized patient tend to
• 9:54
  - become more and more frail
• 9:56
  - every day as they spend time in bed.
• 10:00
  - And of those patients,
• 10:02
  - when you combine both of them, we saw
• 10:05
  - ninety percent benefit.
• 10:07
  - Ninety percent of the patients
• 10:09
  - either improve METS,
• 10:10
  - frailty, or both together,
• 10:13
  - which is, from our perspective,
• 10:15
  - is a significant improvement
• 10:17
  - on these patients' functional capacity and eligibility for
• 10:21
  - either transplant or device implant.
• 10:24
  - But what I want to highlight
• 10:25
  - is most of the what we were worrying
• 10:28
  - about in the first two years is adverse
• 10:30
  - events and safety events.
• 10:32
  - What we saw, there were no adverse events
• 10:35
  - or any kind of safety concerns based on
• 10:38
  - our protocol
• 10:39
  - when the patients went through
• 10:41
  - rehab and rehab at this facility,
• 10:44
  - which is, I think, worth highlighting.
• 10:47
  - Absolutely.
• 10:47
  - Those are some incredible
• 10:49
  - results to have. You guys are clearly on
• 10:51
  - to something here.
• 10:53
  - I'd love to know kind of what is
• 10:54
  - the future of your prehab program. What's coming
• 10:57
  - next?
• 10:58
  - Now that we have established safety and,
• 11:01
  - less advanced, we want to open this up
• 11:04
  - by changing our protocol inclusion exclusion
• 11:07
  - to include more patients because we were very
• 11:11
  - cautious
• 11:12
  - in our inclusion
• 11:13
  - and exclusion,
• 11:15
  - creating our protocol for this, this program
• 11:18
  - for the first two years. So we have
• 11:20
  - now demonstrated there are no safety events. That
• 11:23
  - is the first thing, to change the protocol
• 11:25
  - to include more patients who can benefit.
• 11:28
  - The second is,
• 11:30
  - eliminate some of the barriers to participation.
• 11:33
  - Currently,
• 11:34
  - in our hospital,
• 11:36
  - patients are,
• 11:37
  - hospitalized,
• 11:38
  - or located at different floors.
• 11:41
  - At this point,
• 11:43
  - our program exists on one floor, so the
• 11:45
  - other patients and other floors have to be
• 11:48
  - transferred to the,
• 11:50
  - to this particular floor where the program is
• 11:52
  - located. So there's logistical issue. We want to
• 11:56
  - eliminate it. We want to eliminate it by
• 11:58
  - placing
• 11:59
  - the similar
• 12:00
  - resources
• 12:02
  - on at least the other two floors
• 12:04
  - where patients don't have to leave the floor
• 12:06
  - where they are located,
• 12:08
  - but can utilize
• 12:09
  - the, gym
• 12:11
  - on the same floor.
• 12:13
  - And the third,
• 12:15
  - more important one,
• 12:17
  - what where I see the need is, we
• 12:20
  - see
• 12:21
  - the intensive care patients,
• 12:23
  - although they receive physical therapy and occupational therapy,
• 12:27
  - they do not receive any intervention with regard
• 12:30
  - to improved functional capacity
• 12:32
  - or improved frailty.
• 12:34
  - The physical therapy and occupational therapy actually prepares
• 12:37
  - you to be able to go home and
• 12:39
  - try to be functional with daily activities, but
• 12:42
  - it doesn't focus on improving functional capacity beyond
• 12:45
  - that.
• 12:47
  - If the patient cannot go to the gym,
• 12:48
  - we want to see if we can bring
• 12:50
  - the gym to the patient. So we are
• 12:52
  - in the process of crafting a protocol
• 12:55
  - where
• 12:56
  - we could implement
• 12:58
  - rehab,
• 13:00
  - inpatient rehab on patients who
• 13:03
  - are in the intensive care unit, and also
• 13:06
  - inpatient
• 13:07
  - prehab
• 13:08
  - on patients who are in the intensive care
• 13:10
  - unit but cannot leave the intensive care unit.
• 13:13
  - They are stable
• 13:14
  - but cannot leave the intensive care unit.
• 13:16
  - So those are some of those things we
• 13:18
  - are looking for in the,
• 13:20
  - for our future
• 13:22
  - and also try to recruit more exercise physiologists
• 13:27
  - to, staff the program.
• 13:30
  - Very cool. This is such an interesting program,
• 13:32
  - and I really appreciate you being on the
• 13:34
  - podcast today to share all about it. So
• 13:37
  - thank you for joining.
• 13:38
  - Well, thank you for having me.