A new model for risk stratification and delivery of cardiovascular rehabilitation services in the long-term clinical management of patients with coronary artery disease.

This model for risk stratification includes variables that classify patients for Risk of Event similar to current models of risk stratification, as well as variables that stratify patients for Risk of Progression of Atherosclerosis by established risk factors. Categories of risk are established using accepted data from the literature for each risk factor that targets regression or plaque stabilization as the goal for Low Risk. A case-rate charging system and the proposed removal of time restrictions for length of cardiovascular rehabilitation fit neatly into the present climate for health care. Health maintenance organizations will be seeking programs that use similar models to address cost issues inherent in cardiovascular rehabilitation programs under current fee-for-service models. Improved outcomes will also be targets for these programs and case-management lends itself to disease management, thus, improved outcomes. Tracking outcomes becomes even more important to both the provider and the insurer because results drive referrals. Likewise, removal of the time restriction for cardiovascular rehabilitation allows programs to individualize care and to target risk factors that are not only most deleterious, but also where patients show readiness for change. The changing environment of health care virtually mandates change in cardiovascular rehabilitation. It is imperative that programs manage the disease process, are effective in achieving outcomes that affect both patient function and the disease process, and are cost effective. This model for risk stratification and delivery of services addresses these requirements and provides a beginning for implementing these changes in cardiovascular rehabilitation.

Exercise Prescription by Heart Rate and Met Methods.

The authors challenge methods of measuring exercise capacity based on mets or target heart rate. The most accurate criterion may be a percentage of maximum functional heart rate.