Chapters Transcript Video Pritikin Cardiac Rehab Program PreOperative Clearance Dr. Deepak Talreja discusses Sentara's Pritikin Cardiac Rehab Program. Hey, good morning everybody. Um We're gonna get started. Um Thank you so much for uh taking the time out of your busy schedule to uh join us on this topic of uh cardiac rehab program and preoperative clearance with Doctor Tale Asia. Um He is our chief of cardiology and his uh resume and uh impressive accolades speak for themselves, but a couple of uh interesting uh fun facts about him. Uh One, he's an amazing multitasker. I'm not sure how he does it, but somehow he does, he's also an avid reader and he is, he can give you a topic, a book on any topic. He is a great storyteller and a joke teller and he also does magic tricks. So he's pretty fun to hang out with. Um But uh thank you all for your support and for joining us. Um, uh Please send in any topics of interest that you would like to hear for future um talks and um, I'm gonna turn it over to doctor Tarea. We're gonna get started. Thank you so much for inviting me and thank you guys for logging on early in the morning amongst busy schedules to, to do a little bit of learning and education. So I, I have two topics. I'm gonna move through at a fairly quick pace. And before I do that, I do want to take a second just to say, thank you to all of you in my capacity as a chief of cardiology, as I took over from Dr Stein. One thing I've seen it again and again is how amazing a team we have here And a lot of that's really due to you guys and the hard work that you do. And I say that sincerely, you know, it's interesting. Uh I sit on so many meetings nowadays that I hear things that no other people here at times, including the very positive things our team says about each other behind their backs. So it's always a tragedy when someone really compliments another uh person or a colleague or group of colleagues happens to you all the time when you guys aren't there. You probably don't appreciate it. And it's always sad that the people it's about don't get to hear it. But I sincerely say that and I sincerely say on behalf of all the docs, thank you for all you do for the community, for us and as partners. All right, let's talk about these two topics, the Pritikin cardiac rehab program first and then preoperative clearance. I'm gonna do probably 10 minutes and 15 minutes. I'm gonna move at a fast pace. There's no need to take any notes or do anything like that. Uh Marianne and I talked earlier and I'm gonna make all the slides available to you for anything that you might want them for, for the future. So, Pritikin is our new cardiac rehab program. That's what sa health uses in all hospitals, in all of our outpatient cardiac rehab programs. Many of you know, we had a traditional cardiac rehab program and the orangish program, which was available at two sites on South Side. It was at the Princess Anne Hospital um led by Dr Panny and his team and that was an incredible program. Um It sunset it and was taken over by Pritikin. And I still find to this day there's a lot of people who don't really understand exactly what the difference is. And so it's worth spending a minute talking about it. First of all, why is this important? Why should everyone in this in this uh discussion know about Pritikin. If you look at the class one, a interventions, class one a means you have to do this. It is the right thing to do for your patients in the setting of an A CS or after A PC I, right. These class means if you don't do it, you're you're really not doing the right thing for your patients. Use of aspirin has a relative risk reduction in CD mortality uh of about 30% right. The side effect ratio is about 17% discharge use across the country is about 95% beta blockers. Very significant reduction again in total C and CV mortality side effect risk, 40% report reports some side effect but we do it all the time. 81% of patients get it statins again, 25 to 30% reduction in risk side effects in some patients. But 90% of patients leave the hospital on statins and a again, a 20 30% reduction in risk, 70% of patients leave the hospital on it. Cardiac rehab has about a 30 to 50% reduction in CV. And total mortality. Frankly, 0% side effects, right, fully covered for these patients. And our discharge use and discharge use nationally is about 10 to 20%. That is terrible for such an effective intervention. Now, it's not all on us patients. It, but it's surprising how often we hear from that. Oh, my doc or my provider didn't really think it was a great idea or didn't think I needed it or didn't bring it up at all. And we're being tracked on this metric for us. And the reason is because it saves lives and it absolutely should be something we think about. Let's keep going. So those are impressive numbers, no side effect, significant reduction in total and CD mortality but clearly way underutilized in our system. Um The Million Hearts Initiative by the American Heart Association, the American College of Cardiology C MS CDC. Wants to increase cardiac rehab participation to over 70%. The idea is the focus is keeping people healthy, reducing sodium intake, decreasing or eliminating tobacco and increasing physical activity, cardiac rehab. In particular, optimizes care around ABC S that's appropriate blood pressure control, aspirin, use cholesterol management and smoking cessation. And also we want to engage patients in heart healthy behaviors that will reduce the overload we face in the er S in the inpatient services in offices. A qualifying event for the predict program is the same as for any cardiac rehab, any acute my, any cabbage, any stable angina, that's when we probably underutilized patients that were saying I'm gonna increase your nitro, I'm not doing a calf, I'm not doing a bypass, I'm not putting in stents, but you are having angina. That is a very reasonable indication, heart valve repair or replacement, stent, heart or lung transplant. And the newest one is any form of chronic heart failure with reduced EF hef PF is not currently covered, although you can try to refer patients in and they can certainly pay for it out of pocket. But in terms of C MS coverage, these are the indications Pritikin has been around for a long time and uh both the original Pritikin and his son, Nathan Pritikin and his son have really done a lot to continue the Pritikin Longevity Center. And so from the 19 seventies to the present, there's been a lot of great research that has shown tremendous benefits to this. And we launched our program as you can see around 2020 here and really expanded it more recently. So, so for C MS approval, the reason C MS is in favor of this is it reduces the need for cabbage, it slows disease progression and it lowers risk factors at the end of the day. So for all these reasons, there's tremendous benefit to this therapy. Uh The uh therapeutic prescriptions, decreasing diol blood pressure, decreasing systolic blood pressure, de decreasing BM I, decreasing triglycerides and decreasing LDL have all been systematically proven in studies that have been controlled. So what is the difference between the traditional cardiac rehab and the intensive cardiac rehab, which is both Brian and Ornish. Traditional cardiac rehab is 36 sessions and it's really focused just around exercise. Pretium pays for 72 sessions with exercise and education. And what do I mean by that? There's a series of videos, workshops, cooking classes, 1 to 1 consults for health uh health education and other resources that are made available to patients that are part of this program. And the pillars are regular exercise, heart healthy nutrition and a healthy mindset. Um If you look at that, these are some of the videos we make available to patients and again, they don't have to do all of them. But there's training across the spectrum of those three entities. And I've been in touch with the pretty good folks. One thing we did, some of you participated in as did some of the physicians, um, is, uh, uh, or for providers program. We did last year, there was a handful of us, maybe about a dozen who participated and did four sessions where we actually went through what our patients go through. But it was only providers. We are gonna do the same thing in 2025 with the predicting program. Those of you remember the grand rounds we gave afterwards. We all loved it. My wife actually participated, Doctor mckechnie and his wife, uh Doctor Panny, I think Scott and a number of other people participated in this and, and, and everyone gave their testimonials in there. I would encourage you when we do it. It will probably be 2 to 4 sessions and we'll do it after hours. It's really worth doing. We might even repeat it if there's enough uh enough folks interested, but it really is life changing for our patients. And these group workshops are really pretty amazing as we talk about stress reduction, go through exercise and learn what to do. That's right and wrong. The other thing about Pritikin is a vegan program. Pritikin has a vegan option. But the idea behind Pritikin is that's not for everyone. They have a spectrum of choices you can make. You can be vegan or you can be someone who is more like a keto type. You can do anything you want within Pritikin. And what they teach you to do is within the the framework you want to adopt, you know, how much red meat, how much non red meat, all those kind of things, they try to help you make the best decisions and just make it a bit more healthy. They have cooking school workshops that are really impressive. They're taught by a dietitian or a chef. They talk about easy, affordable tasty and healthy meals and again how to add flavor without sodium making soups. And you can see the list here. Um having eaten the orangish food, it really is amazing when someone that knows what they're doing can teach you how to put together in a quick and easy fashion. And that's what we're doing for our patients. And the idea behind the Pretium program is plentiful plant based foods. Now, that doesn't mean it's vegan, there's meat options included, but the more fruits, the more veggies we get that tends to give us a better outcome, nutrient dense uh considerations of foods around nutrient density, um M minimizing or moderating animal protein. Again, it's not meant to be a vegan diet, but there are vegan and non vegan options and low sodium. And so at the end of the day, this is something we really should be adopting for our patients. Both inpatient and outpatient, one should leave having gone through a Cath lab with the definition of any coronary disease, any angina, any uh hef ref without a referral to predicate. And frankly, we can do it just as easily from our offices. The paperwork is really minimal and it really saves lives. At the end of the day, we know that if you look at Centa cardiology and most cardiology programs of our caliber around the country, we fo follow almost all the guidelines except for adequate use of cardiac rehab. And that's very much on the service lines, radar screen. So one of the things as I told the service line, I was going to be presenting this to you that I was told is make sure everyone realizes just how important this is. We really are under utilizing this and some things are gray area. There's some things you can say, well, I don't have to do this. I maybe should, but this is a class one indication. So let's all participate. Let's prescribe cardiac rehab to our patients, encourage them to try it. Even if they don't think they want to do 72 sessions. If they'll just do a couple, they'll learn something. And then let's continue educating around this. All right, I'm gonna keep moving to my next topic and then at the end, open up for questions just in the interest of flow. This is a timely topic. And when Mariana asked me to talk to you about preoperative um cardiac clearance, I thought I'd take you through the most recent guidelines that were just introduced a few months ago, this guideline sets about 100 pages. I'm gonna summarize in 15 minutes what you really need to know practically to do this for patients. Now, before I get into the guidelines, a big topic has been cardiac clearance for patients are going dental work or other surgeries. And let me tell you, I don't know how many of you are using the new smart texts we built out. I use them routinely in the office. They're great because they even provide some remuneration to cento cardiology. Um It's a small number but some RV US for the time it takes to fill out the forms. They're very easy and straightforward. A lot of people initially are reluctant to fill them out because they wonder, what kind of risk are we exposing to? You are never actually clearing a patient for surgery with this risk stratification tool we've built. All you're saying is if the surgeon thinks that the risks outweigh the benefits, the patient's risk status is low, medium or high. For example, the patient that's never had any cardiac disease and is exercising vigorously. That's a low risk patient. The patient who's had four bypasses and three stents and is still smoking. That's a high risk patient. And they have to decide, do they think their surgery is gonna outweigh the risks they entail you're not making that decision, you're making the decision. What's the risk? Do they need some sort of stress testing And then also the other question we often answer is if they're on, for example, Plavix or Coumadin, you know, can they stop it and hold it? And there are, there are plenty of guidelines around that and we can help around that. So this is it. If there's one slide, you have to know, you can't read a single word on it. But this is the 2024 preoperative guideline. The end I finished earlier than we thought. OK. Not really, not really. Let's go in a little bit of detail. But at the end of the day, if you understand the basics of this algorithm, you know, everything you need to even go a step further, which is truly to clear patients. This is all in the slide deck. I'll send you out. Let me quickly give you uh some, some definitions. So when we think about surgery, there are different uh categorizations and timings of surgery. Emergent surgery means the patient is likely to die or lose limb or life without an emergent intervention, they typically need surgery in less than two hours. And for this, there is really no cardiac clearance. The answer is the patients if we don't do it. So whatever the risk, you probably have to do the surgery unless the patient says, I I simply don't want it urgent. Typically gives you a 2 to 24 hour window, there's a threat, but the patient's not dying. And you know, we might think about what can we do that will reduce risk. Ultimately, the decision to proceed or not is really the patient's decision based on adequate counseling from the person performing the procedure. But we can help them get a feel for, you know, is this a high risk or a low risk patient, time sensitive means the surgery kind of needs to be done, but it can be delayed up to a few months if needed. And those are the patients we decide, you know, do we want to do a stress test or something else? We have plenty of time to do it, usually urgent and emergent surgeries. There's no stress risk stratification that you're gonna additionally do. You're just gonna use basic principles and then you're gonna try to mitigate risks and an elective means for your surgery can be done anytime we have to do whatever preoperative evaluation we want. And we'll talk about that. Surgeries are generally defined as low risk or elevated risk. Low risk means the risk of major adverse cards during the procedure is less than 1%. Elevated risk is when it's greater than equal to 1%. This is not something you're ever expected to define. Although I'll give you some examples of what falls where that's really up to the surgeon or operator performing the procedure in. This is a very hard, I'm not intending you to read it. I just want to show you that there exist multiple scoring systems to figure out is a patient, higher risk or low risk. There's the Goldman index of cardiac risk developed in the 19 seventies on the far left and then multiple other ones to the right. And what I just want to show you is if you generally look at what's going, the things that generally tend to classify risk are age, age greater than 70 is one of the numbers that starts to give you points, stroke or heart attack or stent that's gonna increase risk to some extent. Do they have heart failure? Are there a lot of ectopy arrhythmia? Uh A FB things like that, do they have aortic stenosis or other significant valve disease? And is the surgery emergent? Those are some of the things that in general uh help you decide is a patient, higher risk or lower risk. There is value to doing formal risk scarring. I'll be honest, I don't tend to do that. I tend to have a gestalt in my head and say, you know, this is a 50 year old who has never had a problem and that's probably gonna be a low risk. This is a 90 year old who, you know, has hypertension hyperlipidemia has never had a a known cardiac problem. They're probably gonna be at least intermediate and maybe high risk. And then that patient with the super high risk is the one with multiple events and interventions. But there are scoring tools that give you specific point classifications and they're available in the stuff. I'll send you. The other thing I really like is this uh well validated Duke Activity status Index? Dassy. We, we use uh you know, unfortunately, a lot of acronyms, repeat, uh repeat again and again, Marianna are laughing because we're looking at a tool called doy. But this is the long standing duke activity scoring index. And here's some questions you ask the patient or yourself. Can you take care of yourself? That gives you basically almost three points. That means eating, dressing, bathing. Can you walk indoors around the house? That's about two points. Can you walk a block or two on level ground? That's about three points. Again, can you climb a flight of stairs or not? Or made me bunch of times? That's like 5 to 6 points, run a short distance, eight points, light work around the house, three points, moderate work around the house, 3 to 4 points, heavy work in the house, eight points. Um hard work is almost five points, sexual relations, five points, um moderate recreational activities, golf, bowling, doubles, tennis, six points and strenuous activity is close to eight points. The idea is functionally calculate this out, you add up all the points, all right. And if the score is higher, then that means the patient's functional capacity is greater. And so in this, this is a subjective assessment of functional capacity, clinician and the patients and the when it purely subjective. It wasn't associated with outcomes. But when you use the dossi score at 30 days, there was a very significant prediction of death M I and stroke. And in general, the range can be from 0 to 58 the higher the number, the less the risk, the more functional they are. So let's take all that we've just talked about and let's go through this guideline set. So I'm gonna take it and break it into three parts. We're gonna go through these three parts quickly. Again, you're not expected to do this with your standard, you know, preoperative risk stratification. But if we're going further to think about what testing we need and so forth, this can help inform the decisions we make along the way. So if we have a patient that we're looking at with cardiovascular risk factors for disease or symptoms, then the first question is, um, uh, are they, are they having any symptoms or risk factors if they don't? Then the answer is easy. You see on the right, you just go to surgery if they have no risk factors and they don't really have any symptoms, nothing further needed if they do have symptoms. Then your next question is, is this an emergency surgery? If it is, then really the answer to the surgeon is you decide if the patient wants to do it and you really think this is emergent and potentially life saving, then you go on to surgery if it's not emergent, then the next set of questions is, does the patient have any of these three things? An acute coronary syndrome, unstable arrhythmias or decompensated heart failure, if they do have those things and the surgery is not emergent, then really, you need to treat their heart first. Get them out of heart failure, treat the unstable arrhythmia, treat the A CS, take them to the Cath lab, put a stent or put them on medical therapy and then you redecide, do you wanna do surgery once they've stabilized? But in the absence of an acute unstable symptom, then we go on to really per operative risk assessment. The recommendation two a recommendation meaning it generally is a good idea, right? Class one means you have to do it. Class three means definitely don't do it. Class two means most people would say it's a good idea is use a risk calculator like I just showed you for cardiovascular events, ask the functional scoring and figure out are they older or do they have uh those risk factors we talked about earlier. In particular, the guidelines address a specific group of risk modifiers. Those are severe valvular heart disease, severe pulmonary hypertension, elevated risk of uh congenital heart disease, prior stent or cabbage, recent stroke and then device presence like a pacemaker I CD and general frailty. And the guidelines go into a lot of detail if you want to know it for those patients. But I'll show you some of the more important ones that we see more commonly in general, any of those things would make you just have a little more hesitation and thought process. All right, now I'm going to the next step and I forgot to move the box, but this box should be a little bit lower. It's the middle segment. So now we've seen that group of patients where they have some symptoms, but it's not an unstable symptom. And what we do is if they are low risk by calculation and none of those risk modifiers, no valve disease or congenital disease. Then on the far left, you see they proceed to surgery. Um if you do the risk calculation and the risk is elevated and they don't have any specific risk modifiers, which we'll talk about in a second. Then the suggestion is get at least a 12 lead EKG on that patient or make sure you have an old recent 12 lead EKG consider initiation of guideline driven medical therapy, for example, aspirin statins beta blockers as able. So that's good for any patient, right? But you're also considered that for this patient and then ask what is their functional capacity if that DAI score is above 34 right? So they're, you know, you saw all the point scales, there are a bunch of eights and so forth, they're pretty active and they're able to do regular activities, get around the house, do light exercise get up a flight of stairs. Then the risk is really, uh, fairly low. You know, it's interesting. Um, when my grandfather, uh, ultimately expired from lung cancer, he came to have a surgery from Cypress and the sur a lot, a number of surgeons had turned him down, the one that ultimately did, the surgery didn't do a lot of fancy stuff. He basically walked up the stairs with him. At Beach General. There were three flights of stairs. They both made it to the top. The surgeon was out of breath. My grandfather wasn't out of breath and he said, I'll take him to surgery and my grandfather did great. So just knowing functional score met, generally, the answer is go ahead and proceed to surgery. Um, if they, if they don't have poor functional status, proceed to, they do functional status. Their dai score is less than 34 poor mets of activity. And again, you can classify METS nicely from a stress test if need be. Then the next question you have to ask yourself is will further testing, impact decision making or perioperative care. If the answer is no, the patient really wants surgery or the is low enough risk that it really doesn't matter or they need the surgery, then the answer is you don't really need a lot of testing because it's not gonna change what you're gonna do. Let the patient go into surgery. There is risk, you know, you're doing what you can to mitigate risk because you already initiated a guideline driven medical therapy, but you're gonna let them have surgery. On the other hand, elective, you know, the patients having symptoms that, that make you suspicious or risk factors that make you suspicious, then you do have time to do some per operative testing if you need to and look further. And that takes us to the third and final portion of this curve. So on the third portion, there's a suggestion that there's some benefit. Again, this is class two, meaning you don't have to do this. But one option is to get a BNP for us. That's an NT PRO B MP or a troponin. Now, for the vast majority of patients, those are gonna be normal. But if they're abnormal, then that might suggest in that poorly functional patient that they need. Again, some discussions about risks and benefits and additional cardiac testing. So you see on this algorithm, if you said, well, they have a, you get some and if the enzymes are normal, it is reasonable to proceed to surgery again, knowing that there are still risks, you can't take away all risks, but at least you've done what you need to, to make sure that you haven't missed something obvious. And if they really need the surgery and they want to have it done, they can go ahead if their bio abnormal, then guidelines say consider additional testing and what testing will depend on exactly what's abnormal. But in general, we think about getting an echo to assess ejection fraction valve status, getting a stress test, uh, either a nuclear or EKG or stress echo or considering a cardiac CT A. If you do pursue additional cardiac tests, it's low risk. They go into surgery, which is the far left. If they have high risk findings, then at that point, it's probably worth us discussing as a team and saying, gosh, you know, do they need the surgery? Should they hold up on the surgery? Do we need to consider something like a heart cath or additional medical therapy? And we go on from there. Um, if the team decides that again, you know, the patient doesn't want uh cardiac testing or uh they, they, they really need the surgery and they're not gonna do anything regardless of what the testing shows. But it is certainly reasonable to, again have those discussions and go on to the uh surgery and just surveil post op. So I didn't, I don't expect you to in one. And the idea is if you're doing the full evaluation and you start meeting these higher risk criteria, that's when you start thinking about either blood tests or diagnostic testing to look further. And again, I want to be clear that really, in our practice, we have two different situations we encounter one is where ac a surgeon is asking us to do a wrist stratification. That's frankly a lot easier than going through this whole guideline because all you're saying is they're on these blood thinners or other medicines and they need to hold stop, continue taking A B do they need SB prophylaxis? If they have artificial valves or artificial material and C's wrist status, it's not our job in that situation to say I'm clearing them for surgery because we're not only the person doing the procedure can ultimately do that. All you're saying is I'm advising that person that this is a low intermediate or high risk patient and how to guide their cardiac meds. This is a deeper dive where we're actually helping, collaborate in the decision as to what other testing can even, you know, make them at lower risk for having an event during surgery and most patients won't actually need a lot of tests for those that do this. Lays that out a couple of other things real quickly. The question comes up as to blood thinners and there are many different uh practice patterns, all of which are, but this is guideline out if they had balloon angioplasty only for example, that a CS patient who has a balloon only if they need the surgery law for 14 days. Yeah, it has to be done. You do it because that's all they can do. But if it's, they've tried to hold off 14 days for noncardiac surgery if they get a bare metal stent, which we rarely use. Nowadays, we say 30 days, they get a juggle. The question is, did they get in the setting of an A A CS? In which case, ideally, you would delay noncardiac surgery for 12 months. But if they have to, they could do it within three months, preferably not within one month. And if it was chronic stable angina on the far right side, then we say try to delay for six months, continue dual antiplatelet therapy for that six months and then do surgery. But again, ideally, you could delay for three months. If you just put a fresh stent in, sometimes you can't wait that long and you have to make the decision, you're gonna accept some level of risk and you know, the patient's part of that decision. Uh Stress testing, the ESC on the left, that's the European Society Cardiology and the American Heart Association on the right. These are their general guidelines. And what they generally say is you don't need to do this for all patients. It's really for the high risk patient who's undergoing an elective noncardiac surgery and has poor functional capacity with a high likelihood of coronary disease that you're really thinking about stress testing. Certainly, if a patient wants it and is adamant, they want it, I will almost always get it for the patient. But stress testing is not routinely recommended in both sets of guidelines. That's a class three indication, meaning there's no real benefit to just putting everyone through a stress test. If your instincts tell you need it, it's certainly reasonable to do so. But hopefully this uh mitigates some of that. I'm not gonna go through a lot more guideline sets. But the patients we need to think a little about are those, for example, with severe aortic stenosis, they probably need at least some further evaluation with, for example, a uh echo and the structural heart team is always happy to help play a role in deciding, you know, do we need to do something? First, do we do, for example, balloon vop plasty or a VR Tver or Saber and then go on to surgery or do we do something temporizing and just watch them through it and there's always risk. And this is the final slide on the on the abbreviation, always manage the disease processes. So if they have coronary disease, heart failure, hypertrophic cardiomyopathy, valve disease, congenital disease or pulmonary hypertension treat as well as you can. And the testing to consider is it's always useful to have a baseline EKG. Anything can happen where later they get an EKG and if they have a left bundle branch block, that's new. You're kind of wondering, huh? Did they have this before the surgery or not? So, an EKG within the month prior is always very helpful or stress testing, but they're probably over utilized again, clinician judgment always trumps everything else. And there's a potential role for BNP and for troponin, that's on my slide, I'll, like I said, I'll just what we've talked about in this five minutes is one, not what we've talked about. Number one pre and why we should be using it more and programs in general. And then two, we talked about the perioperative uh guidelines from the end of 2024. Those are fresh hot off the press. Just a couple journal of the American College of Cardiology editions ago. You now have seen them. I don't expect you to internalize it. But what you've learned is there are risk scoring tools you can use if you want to do it. And we have calculated and also available on our phones and just paper versions. Number in general, the paperwork for risk stratification is pretty easy to do and that helps our colleagues a lot. And number three, if you have to do full risk ratification, there's a very clean set of guidelines that make that possible. Mayor and I are sitting here together. And so um we'll take any questions or comments or anything else you guys want to do? Oh, let's hear. Um from Shelby. Currently. A PPS cannot prescribe cardiac rehab. Is there any discussion in changing this? And, and Shelby, you know more about that than I do. I thought A PPS certainly could prescribe it just like anything else if that's true and it can't be uh let, let me work with you offline. I'm gonna email our uh predic team because they had actually told me to emphasize you guys. So my assumption was you could. However, I would say that, oh Jessica Wedell just said, uh they're changing it. OK, perfect. So Jessica is a step ahead of me. But for now, if uh would 100% say it, I think uh reach out to your, your uh your physician colleague who you're working with and they should back you 100% of this. Great question. What else? Uh Scott Burns said many of patients I see aren't going to commit to coming in three times a week for several weeks. This is regarding cardiac rehab. Should we still try to encourage these patients to attend at least one or two sessions? Yeah, Scott, I think you, you nailed it. That's a great idea. There are patients. It sounds overwhelming to and what I find personally is pretty much every single patient that I mentioned cardiac to gets that look on their face like, oh God, this doesn't sound like fun. And I tell them, yeah, I've seen that face before. Everyone always tells me this, but I am shocked how often when I push a patient to do it, they come back and many patients I'd say maybe one and three are like, oh my God, I love it. I wanna do this forever and we tell them, well, you can't do it forever. You gotta graduate at some 0.2 and three, at least do some of it and I think your point is well taken. What I always sell them on is go try it for two weeks. If after two weeks, you say I can do this at home and you don't want to finish it, no one's gonna force you to finish it. But go try it and learn some stuff. And usually I find if the, if the patient isn't enthusiastic at that point, their spouse is happily nodding in the background and acts as the enforcer. So I like the point you made and I'm in complete agreement, try to sell it as not, you know, three days a week forever. Try to sell it as why don't you go and see what they have to offer, try it at least try it. If you don't like it, you can stop. This is covered by insurance and it could save your life. And, and for a lot of patients who are reluctant to get out, the two groups of patients that benefit the most are one those who are reluctant to get out because they're scared because since they're getting actual monitoring and Scott, you know, this from when we did the Orange program together, you know, the monitoring you're getting while you're on the treadmills and bikes and all this equipment is tremendous. And then the second thing is, most of us are by nature lazier than we should be. And so having someone jumpstart you and get you on a routine, I think is helpful. It's a great comment. Um All right, a couple more things on, um, cardiac rehab. Uh One is, are we tracking referrals and enrollment? And then the other is, are there any after hour session options? Because that is a complaint from, for patients? We hear that all the time. Those two are great questions. Number one, we're absolutely tracking it. That's how we know that our numbers are absolutely terrible. That's how we know we're in the 10 to 20% referral range. And that is a, a metric. In fact, I'm aware, case going up to peer review because, uh, um, the provider was systematically not referring anyone. And so anyway, you know, we got to do the right thing for our patients. And then the second point that was, uh, oh, after hours after hours is complex because again, you know, there's a staff and team that works there, they don't have super late hours. But again, someone, for example, who's had an M I or has a reduced TF what I try to convince them is even though you're a busy executive or whatever it is you're doing that, you know, your schedule is important, you know, what's more important to you at the end of the day, you should be able to call out for a two week period that you're not supposed to be working anyway, time to go and at least try it. Um, I know, there's work to, to build more, uh, sessions at off hours and they do start pretty early and end reasonably late. It's not truly after hours and weekends. But I think if we really started referring all the appropriate patients, it would fill up all available space. So there would be incentive to hire night and weekend teams. So maybe we can help with that. What else? Ok. Well, don't hesitate to reach out to me. I'll share slides for sure. And Maron, I think this is a really great program you put together. I know all the docs will be excited to participate. We work together in a lot of education. You guys did a great job with uh helping with conferences and everything else and keep doing that. And again, thank you for all you guys do for the community and for the practice. And I don't think any of us says that enough. It's an honor to be with you today. Published December 12, 2024 Created by Related Presenters Deepak Talreja, M.D. Sentara Cardiology Specialists View full profile
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