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打造更强健心脏之路

更新时间:2014-4-17 21:26:27 来源:华尔街日报中文网 作者:佚名

The Path To A Stronger Heart
打造更强健心脏之路

Maurice Cloutier has chronic heart failure. He and his doctor credit his regular attendance at a cardiac rehabilitation program with keeping him out of the hospital.

Such rehabilitation programs are opening up to more people with chronic heart failure, one of medicine's most debilitating and costly illnesses, following a recent change in Medicare reimbursement rules. After nearly a decade of deliberation, Medicare officials decided to cover cardiac rehabilitation for these patients, clearing a big obstacle to supervised exercise and counseling programs for hundreds of thousands of people.

'This takes the most disabled heart patients and gives them a chance to improve their functional capacity and quality of life,' said Philip Ades, medical director of cardiac rehabilitation at Fletcher Allen Health Care in Burlington, Vt., and Mr. Cloutier's doctor. 'Twenty years ago we told them to go sit in an arm chair. Now we can hand you back part of your life.'

Heart failure is a chronic condition in which the heart can't pump a sufficient supply of blood to deliver oxygen to other organs in the body. It results in shortness of breath, fatigue and edema, a buildup of fluids in the lungs and extremities such as the ankles. Some 6.5 million Americans are living with heart failure. An additional 650,000 new cases are diagnosed each year, according to the American Heart Association, though Medicare data suggest the number is higher. Heart failure is the most common reason Medicare beneficiaries end up in the hospital. Though Medicare has long covered cardiac rehab for patients recovering from a heart attack or heart surgery, the burgeoning population of heart-failure patients has largely been left out.

A big factor in Medicare's decision was a 2,300-patient study called HF-Action, published five years ago. It found three weekly exercise sessions over 12 weeks were associated, after certain adjustments, with a modest 11% reduction in death and hospitalizations among patients with heart failure.

Dr. Ades, who is also a professor at University of Vermont College of Medicine, and other experts for the American Association of Cardiovascular and Pulmonary Rehabilitation, the American College of Cardiology, AHA and the Heart Failure Society of America, used the HF-Action data and other recent research as the basis of their argument to Medicare to extend coverage for cardiac rehab.

Medicare officials were persuaded by the quality of the study, the benefit of a physician-supervised exercise program, and the counseling component to guide lifestyle and other changes. 'When you look at the big picture, it was a positive step forward' to extend coverage, said Tamara Syrek-Jensen, acting director for the coverage and analysis group at the Centers for Medicare and Medicaid Services, which administers the Medicare program.

Patients and clinicians hope increased access to a structured exercise program will not only improve and prolong patients' lives but reduce hospital admissions -- and readmissions. An estimated 17% of the 42 million elderly beneficiaries of Medicare have a heart-failure diagnosis and account for about 800,000 hospital admissions a year.

But patients with heart failure are often frailand much sicker than the type of patients most cardiac-rehab programs are used to working with. 'They have low confidence in what they can do physically,' said Randal Thomas, preventive cardiologist at the Mayo Clinic in Rochester, Minn. 'To convince people they can benefit is going to be a bit of a challenge.'

Many heart-failure patients struggle to climb a flight of stairs, go grocery shopping or perform other routine daily activities. They commonly have other medical problems as well that complicate their treatment. Fifty percent of people diagnosed with heart failure die within five years.

Although patients recovering from a heart attack or open heart surgery are routinely urged to get on their feet and exercise as soon as they are stable, patients and doctors alike have been skeptical that it would be safe for people with heart failure to engage in strenuous activity. But 'the safety in the HF-Action trial was very significant,' said Nancy Houston Miller, associate director of the Stanford Cardiac Rehabilitation Program, Palo Alto, Calif., and an investigator on the study.

Mr. Cloutier, a 77-year-old retiree who says heart problems run in his family, has been in a cardiac-rehab program off and on since he suffered a heart attack in 1985 at age 48. Lately he has been paying about $100 every three months for exercise sessions but now it is possible he will be covered for a course of treatment under Medicare.

Mr. Cloutier had quadruple bypass surgery in 2000. He also had a defibrillator implanted in 2003 and a pacemaker put in three years ago. Since then, he has avoided being admitted to the hospital, an accomplishment he and Dr. Ades attribute to his regular physical activity. Until recently, Mr. Cloutier, a nonsmoker, organized regular 20-to-40-mile bicycle trips in the Vermont countryside. Last year, though, his heart-failure symptoms caught up with him and he said he was able to ride only 3 miles. He's hoping to get that to 5 to 10 miles weekly this summer. And he keeps up his rehab regimen, currently 20-minute treadmill sessions at 3 miles an hour and using a weight machine two to three times a week. On other days, he goes on 1 mile walks.

'The heart is a muscle,' he said. 'If you don't exercise it and keep it in reasonable shape then it's going to deteriorate and give you problems. That's why I keep going back.'

The Medicare decision extends coverage to patients whose heart-pumping function is compromised to a specific level and who have certain heart-failure symptoms despite being on an optimal drug therapy for at least six weeks. It offers one course of 36 sessions for up to 36 weeks, though two- or three-times-a-week sessions are optimal. Patients could apply for a second course of rehab, but generally, they would have to pay out of pocket after completing the first course.

The new decision affects about 50% of patients with chronic heart failure. Medicare officials said more data are need to determine whether cardiac rehab will benefit the others, who have a different form of the condition.

Doctors expect the trigger for coverage for many patients will be their first hospital admission for heart failure. At that time, doctors would discuss starting an exercise program with a patient after six weeks on medications.

The first episode 'is your teachable moment,' said Mariell Jessup, a heart failure doctor at University of Pennsylvania and president of the American Heart Association. Upon hearing the diagnosis, people think it is a death sentence. 'We say, 'you're not going to die. We're going to work on you living.'

莫里斯·克卢捷(Maurice Cloutier)患有慢性心力衰竭。他和他的医生将其不用住院的原因归功于定期参加心脏康复计划。

慢性心力衰竭是医学中最易使人衰弱、治疗成本最高的疾病之一。在“医疗保险计划”(Medicare)报销规定近期发生变化之后,此类康复计划开始向更多这类患者开放。经过近10年的仔细考虑后,“医疗保险计划”官员决定为这些患者偿付心脏康复费用,从而清除了数十万人进行有看护的锻炼及加入咨询计划的一大障碍。

佛蒙特州伯灵顿弗莱彻艾伦医疗中心(Fletcher Allen Health Care)心脏康复医务主任菲利普·埃兹(Philip Ades)说:“它囊括了行动最不便的心脏病患者,为他们提供了提高身体机能和改善生活质量的机会。在20年前我们会让他们在扶手椅中静坐,现在我们能让你恢复一部分正常生活。”

心力衰竭是一种慢性疾病,病因是心脏无法泵出足够的血液为其他身体器官提供氧气。它会引发呼吸短促、疲劳和水肿(即液体积聚在肺部和脚踝等手足部位)等症状。美国约有650万人患有心力衰竭。美国心脏协会(American Heart Association,简称“AHA”)的数据显示,每年还有65万人被新诊断出患上该疾病。不过“医疗保险计划”的数据显示,新患者的数目比这个数字更高。心力衰竭是“医疗保险计划”受益者住院最常见的原因。尽管“医疗保险计划”早就为因心脏病发作或心脏病手术而实施心脏康复的患者偿付费用,但队伍不断壮大的心力衰竭患者中的多数人都被排除在外。

美国“医疗保险计划”的官员之所以决定扩大偿付范围,一个重要因素是五年前发表的一项名为“HF-Action”的研究。它对2,300名患者展开了研究,结果发现经过某些调节后,每周三次、共持续12周的锻炼计划与心力衰竭患者的死亡率和住院率温和下降11%存在关联。

埃兹医生也是佛蒙特大学(University of Vermont)医学院的教授,他与来自美国心血管与肺康复协会(American Association of Cardiovascular and Pulmonary Rehabilitation)、美国心脏病学会(American College of Cardiology)、AHA、美国心力衰竭学会(Heart Failure Society of America)的其他专家运用了HF-Action的数据及其他的最新研究,将它们作为说服“医疗保险计划”官员扩大心脏康复报销范围的理据基础。

医疗保险计划的官员被该研究的质量、医生看护锻炼计划的好处,以及指导生活方式及其他变化的咨询计划所说服。医疗保险计划管理方——医疗保险与医疗救助服务中心(Centers for Medicare and Medicaid Services)负责偿付与分析的代理主任塔玛拉·希赖克-詹森(Tamara Syrek-Jensen)说:“从全局来看,(扩大偿付范围)是个积极的进步。”

患者与医生希望,提供更多的机会供患者参加有组织的锻炼计划,不仅会改善患者的生活,延长他们的寿命,还能降低住院以及再次住院的数量。医疗保险计划的4,200万名早期受益者中估计有17%的人被诊断患有心力衰竭,每年因此住院的数量为80万人次。

但是,心力衰竭患者往往比过去大多数心脏康复计划服务的患者更虚弱,病情更严重。明尼苏达州罗彻斯特梅约医院(Mayo Clinic)的心脏病预防医生兰德尔·托马斯(Randal Thomas)说:“他们对自己能从事什么体力活动信心不足,让他们相信他们能从中获益会有一定难度。”

许多心力衰竭患者爬一段楼梯、购买食品杂货或者做些其他日常活动时非常费力。他们通常还患有其他病症,这让他们的治疗变得更为复杂。被诊断患有心力衰竭的患者有50%的人在五年内去世。

心脏病发作或接受心脏手术的患者在恢复过程中常被敦促要站起来,一旦病情稳定就要马上开始锻炼,但患者与医生一直对心力衰竭患者参与激烈活动是否安全均持怀疑态度。加州帕洛阿托斯坦福(Stanford)心脏康复计划的副主任南希·休斯顿·米勒(Nancy Houston Miller)说:“HF-Action实验中的安全性是非常显著的。”她也是HF-Action研究的调研者之一。

今年77岁的克卢捷是一名退休人员,他说他的家族有心脏病史。自从在1985年48岁心脏病发作以来,他断断续续参加过心脏康复计划。不久之前他每三个月为锻炼计划支付约100美元,现在他的疗程费用有可能在“医疗保险计划”下得到报销。

克卢捷在2000年实施了冠状动脉搭桥术,后在2003年植入了一个心脏除颤器,三年前他又安了一个心脏起搏器。自那以后,他一直没有住过院,他和埃兹医生将这一成绩归功于定期的体育锻炼。直到不久前,不吸烟的克卢捷还一直定期组织在佛蒙特乡村骑自行车,每次骑20至40英里。然而,去年他出现了心力衰竭症状,他说他只能骑三英里了。他希望在今年夏天实现每周骑行五至10英里的目标。此外,他还坚持进行心脏康复治疗,目前是以每小时三英里的速度在跑步机上跑20分钟,并使用力量训练器械进行锻炼,频率为每周两到三次。在其他日子里,他会散一英里的步。

克卢捷说:“心脏是一团肌肉,如果你不锻炼它,使它一直处于良好的状况,接下来它就会变衰弱,给你带来麻烦。那就是我一直参加锻炼的原因。”

“医疗保险计划”的新规定将偿付范围扩大到心脏泵血功能减弱到某个水平,在进行了至少六周最佳药物治疗后仍出现某些心力衰竭症状的患者。它提供一个包含36次康复训练的疗程,最长可持续36周,但每周两到三次训练的疗程最佳。患者可申请报销第二个康复疗程的费用,但一般说来在完成第一个疗程后他们得自己掏腰包。

新规定影响了50%左右的心力衰竭患者。“医疗保险计划”官员称,其余的患者病症不同,要确定心脏康复是否有利于这些患者,还需研究更多数据。

医生预计,许多患者因心力衰竭第一次住院治疗时,就有可能纳入康复报销计划。在那时,医生会在六周的药物治疗后与患者讨论开始锻炼计划。

宾夕法尼亚大学(University of Pennsylvania)心力衰竭医生、AHA主席玛丽埃尔·杰瑟普(Mariell Jessup)称,第一阶段“是你可施教的时机。”一听到诊断结果后,人们就会觉得自己被判了死刑。杰瑟普说:“我们会告诉他们,‘你不会死的,我们会努力让你活下去。”

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