Hi, everybody. Welcome to this afternoon's webinar. We're so grateful that you're able to join us. As it is just one o'clock, what we're going to do is give a couple more minutes because we see people joining the system right now. So we'd like to wait just a couple more minutes for beginning so that we can include everybody from the start. So thanks for your patience and we'll start in just a minute or two. Hi, everyone. We're going to take just one more minute and then we'll start the webinar. Thanks so much for your patience. Okay, everybody. I appreciate the extra couple of minutes so we could wait for others to log on. My name is Joe Sasson. I'm the Executive Vice President of MedAxiom Ventures, which is our industry relations arm, and grateful for you joining us today. Today's webinar is going to be the benefits of the first Pritikin outpatient ICR program brought to you by Dr. Susan Resett from Arizona State University. And before we dive into that, I want to make sure that everybody's familiar with how to use the actual Zoom webinars platform. And so what you'll see at the lower left hand side of your screen is a chat button. And what you'll be able to do in the chat is be able to have access to the slides. So we'll post slides now. So you'll be able to download those as well as post them a little bit into the webinar again. For those that join a little bit later, they'll then have access to it. So do expect to see an ability to download the slides there. We will not be able to use that chat as a communication tool for this webinar. Any communication with us will be able to be done through the Q&A on the right hand side of your screen. So if you have questions for us for a logistical standpoint, the host of the webinar will be able to answer those. If you have questions for the presenter, please send them in and we will bring those questions to Dr. Resett's attention at the end of the presentation during our Q&A. You'll also see a button there that says raise hand. We are not going to use that particular button for today's webinar. So thank you very much. I think it's a fairly simple platform to use, but just wanted to make sure we laid that out in terms of how you can communicate with us. So before we move forward, what I'd like to do is introduce Terry Rogers. Terry is the president of Pritikin. And Terry, I'm going to turn it over to you to introduce Dr. Resett and get us all kicked off today. So thank you so much for being here, Terry. Thanks, Joe. And thanks MedAxiom for hosting this webinar. So first of all, thank you everyone for joining us today. Like Joe said, let me share a short story about Dr. Resett that provides a broader perspective of her accomplishments beyond those of just academic and research credentials, which I'll outline shortly. But I first met Dr. Resett as part of a running group here in St. Louis. And we met five or six days a week to run different distances. And Tuesdays was speed work day at the local high school track. And Susan and her daughter, Sophia, routinely ran me in the ground on the track. Now there were a lot of us out there, but needless to say, like the saying goes, if you're not the lead dog, the scenery never changes. Well, my scenery never changed. But it did accomplish something. The fact that she and her young daughter at the time, and I will mention her daughter went on to run college track. So she was no slacker either. But it kind of ticked me off first, but it motivated me to train harder. And it also, you know, I grew to respect her and her daughter. And that was before I knew anything about her academic and research credentials. So fast forward to today. And I was reading her CV yesterday as part of this introduction. And she continues to motivate me today. Back then it was through her running skills. And today is through her academic and research credentials. So let me just tell you briefly a little bit about that. Her education, she has a BS in biology, with a minor in biochemistry from Bucknell University. She has a PhD in nutritional biology from the University of Chicago. She's a postdoctoral fellow in exercise physiology from Washington University School of Medicine. Her academic positions, she spent 25 years at Washington University School of Medicine with her last eight years serving as professor. And in 2022, she joined Arizona State University as professor with tenure, where she works and resides today. She's a member of a number of professional societies, which all of you will be very familiar with. And although I could go on and on describing her numerous accomplishments, the last and maybe most relevant component of her extensive CV relative to today's webinar is, Dr. Reset is an author, senior author, and principal investigator in 119 research studies and articles published in peer-reviewed scientific journals. So Susan, thank you for agreeing to speak today. And it's all yours. Thank you very much, Terry. I appreciate the introduction and welcome everyone. So I am going to be speaking about the first ICR program. So first let me start, I have no financial disclosures or conflicts of interest with respect to this presentation. And then way of background, I just want to talk a little bit about cardiovascular disease as the leading cause of death in the United States. And most of you are probably well aware of the burden of CBD. And every year, the American Heart Association comes out with an update report. And this, these statistics are from the 2023 update showing that the CBD prevalence, which includes coronary heart disease, heart failure, stroke, and hypertension affects 48.6% of adults aged 20 years and older in the U.S. 127.9 million in the U.S. in 2020, 606.6 million adults globally. So CBD is very prevalent. In terms of mortality, CBD really takes a toll. It's been the leading cause of death for decades and continues in that vein. 928,000 plus deaths are due to cardiovascular disease in the U.S. based on 2020 statistics, over 19 million globally. So this is a serious problem. On average, someone in the U.S. dies of CBD every 34 seconds. We know that CBD prevalence increases with age. And that's significant because we know the population is aging. And so what this graph shows is the prevalence among adults of different age categories in males and females with or without hypertension as part of the CBD definition. And what this graph really highlights is that for all groups, this is men with hypertension and the CBD definition, the striking increase with age. You can see the same is true for women, men without hypertension in the CBD definition, and women. So in all groups, we see a striking increase with age. We also know that this is going to be a problem financially, but first in terms of some projections. So by 2035, it's estimated that nearly half of the U.S. population will have some form of cardiovascular disease. And in terms of the financial burden, that is significant. So the projections in 2016, CBD cost America about $555 billion. But by 2035, it's estimated that this cost will skyrocket to $1.1 trillion. And this is shown here for all the various different CBD conditions. These are direct costs in billions of dollars from 2015 data projecting through to 2035. And you can see that there's a striking increase for all of these conditions, coronary heart disease, other classifications, hypertension, stroke, atrial fibrillation, and congestive heart failure. Importantly, we know that cardiac rehabilitation has dramatic benefits. It reduces hospital readmissions and mortality. And these statistics or highlights from the American Heart Association and American Stroke Association point out the really significant benefits. So cardiac rehabilitation reduces the risk of a future cardiac event by stabilizing, slowing, or even reversing the progression of CBD. This in turn leads to a reduction in hospital readmissions, reduces all-cause mortality, reduces CBD mortality, improves health-related quality of life. And we also know that patients with other conditions, such as heart failure, can also benefit from cardiac rehab. So what exactly is cardiac rehabilitation? This infographic from the American Heart Association highlights the five components of most cardiac rehab programs. The main focus is on regular exercise, supervised exercise in a controlled setting in cardiac rehab with the idea of people progressing on to an active lifestyle beyond their CR sessions. It also may include adopting a healthy diet, reducing stress, medical therapy to optimize medical management, and then smoking cessation for those who need it. So we know that cardiac rehab has all of these benefits of lowering the chances of a second heart attack or the need for heart surgery, reducing overall risk of dying of a cardiac event, lessening chest pain and medication needs, controlling risk factors, and helping with weight loss. So who is eligible for cardiac rehab? Well, there are seven diagnoses or conditions for which patients are eligible for CMS coverage. So the approved diagnoses include myocardial infarction, coronary artery bypass grafting, stable angina, heart valve repair or replacement, percutaneous coronary intervention, heart transplant, and heart failure. This is heart failure with reduced ejection fraction, less than 35 percent, and the heart failure was added as an indication in 2014. Now we know based on those benefits there are a lot of reasons that we want patients to enroll in cardiac rehab, but that's not really been so successful. So the Million Hearts initiative is really an initiative to help promote cardiac rehab enrollment, because the problem is that enrollment is low. Only 10 to 34 percent of eligible patients enroll in cardiac rehab, and the national goal is 70 percent. So we are quite a ways off from that. And so some of the Million Hearts initiatives are to prevent one million heart attacks and strokes within the next five years, so between January 2022 and December 2026. This is a national initiative led by the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services, and this began in 2012. And so there are various aspects of optimizing care in this initiative, but one of the very important ones is increasing the use of cardiac rehabilitation. That's what I think is going to help achieve some of this reduction. And the Cardiac Rehabilitation Collaborative is part of the Million Hearts initiative, and so this is an action plan with five objectives as shown here. The first is to increase awareness of the value of cardiac rehabilitation, then to increase use of best practices for referral, enrollment, adherence, and completion. Three is to build health equity in CR referral, participation, and program staffing, because we know that many individuals with minority status or other minoritized classes are not enrolling or maybe even not being referred to cardiac rehab. Four is to increase the CR financial sustainability, affordability, and accessibility, and five is to measure, monitor, evaluate, and report progress. So again, we know that cardiac rehab has many benefits, including improving health and preventing major adverse cardiovascular events. As shown here, there are many improvements, such as improving cardiovascular health, endurance, aerobic capacity, strength, physical function, independence, and quality of life. And while at the same time reducing all of these cardiovascular disease risk factors, depression, blood pressure, lipids, health care costs, and then the major outcomes, heart attack, hospitalization, and death. And strikingly, the reduction in death can be up to 47 percent, and it's dose dependent. And the dose dependency is a really important point when we talk about intensive cardiac rehabilitation. In terms of mortality, here are some data that actually graphically show the reduction in mortality attributable to cardiac rehab. What this shows is cumulative mortality rate on the y-axis, months from discharge on the x-axis, and what you can see is among those who use CR, who attend CR programs, they have much lower cumulative mortality than those in the red who do not participate in cardiac rehab. So what is intensive cardiac rehab? Here's some background on the Pritikin ICR program. So this shows the Pritikin timeline. So this history began nearly five decades ago when Nathan Pritikin, a pioneer in the field of lifestyle and chronic disease risk reduction, published Live Longer in 1974, and then opened the first Pritikin Longevity Center one year later. In 1981, research began at UCLA, leading to more than 100 peer-reviewed published scientific articles. And it was this research that resulted in Pritikin's 2010 Medicare approval for a new benefit class called Intensive Cardiac Rehabilitation, or ICR. Pritikin not only met but exceeded its rigorous approval criteria. This shows the CMS approval criteria, the reduced need for coronary bypass surgery, slowed disease progression, lowered risk factors for coronary artery disease, reduced LDL, triglycerides, BMI, blood pressure, and the need for medications. And then in 2013, the Washington University School of Medicine BJC Healthcare Heart Care Institute launched the first Pritikin ICR program in the nation. So now let's compare traditional cardiac rehab with Pritikin ICR. Traditional cardiac rehab is comprised traditionally of 36 sessions that are mostly exercise. With Pritikin ICR, there are 72 sessions of exercise and education. So patients have 72 reimbursable sessions, which not only include exercise but also an educational component at each visit. The educational curriculum is centered around Pritikin's three pillars, which are regular exercise, heart-healthy nutrition, and a healthy mindset. And it's delivered in three ways, through workshops, through cooking demos, and through videos. These components are very important and help reinforce all the messages around those three pillars. Patients have an opportunity to meet one-on-one with a registered dietician and, if needed, with a health coach. This personalized, comprehensive approach provides patients with the tools and knowledge that they need for success, both during cardiac rehab and long after the program is complete. Importantly, the qualifying events are the same for ICR as they are for traditional CI. As mentioned, there are three Pritikin pillars. The first pillar is regular exercise. Patients learn about cardiovascular endurance, strength, flexibility, and how these factors contribute to overall health. The second pillar is heart-healthy nutrition. Patients learn how to prepare affordable and satisfying meals, manage their weight, read nutrition labels when grocery shopping, and enjoy dining out while keeping their health goals in mind. The final pillar is a healthy mindset. This focuses on stress and anxiety management, strengthening communication skills, goal-setting, and tobacco cessation, if needed. The Pritikin eating plan is really focused on heart-healthy nutrition as a key component. This is really encouraging this as a lifestyle, not a temporary diet. The Pritikin eating plan closely mirrors the Mediterranean-style eating plan, as shown here, by being largely plant-based, having modest amounts of fish and seafood, minimal intake of red meat, animal products, full-fat dairy, and added sugar, scientifically proven to reduce the risk factors for major chronic diseases. In summary, cardiac rehab is a Class 1A recommendation, and Pritikin ICR takes its proven benefits a step further through comprehensive education focused on exercise, heart-healthy nutrition, and a healthy mindset. Through this educational curriculum and ongoing support for our cardiac rehab team, Pritikin ICR has helped us offer the highest level of patient care, consistent with the facility's mission statement, and finally, because it equips cardiac rehab patients with the tools and knowledge they need for long-term success, Pritikin ICR offers an opportunity for improved outcomes, which is what I'll be focusing on today. As I mentioned, the Washington University School of Medicine BJC Heart Care Institute was the first center to implement the Pritikin outpatient ICR program. This is located in St. Louis, Missouri. So, what are the benefits? This was the first research study that we did to really explore the important benefits of the Pritikin outpatient ICR program. So, the specifics of this study, which were published in JCRP, the study aim was to determine the benefits of the first Pritikin outpatient ICR program, and the clinical importance of addressing this question is optimizing patient health outcomes outcomes, expanding insurance coverage of ICR programs, and expanding the number of ICR programs. And these are important because many patients don't have insurance that covers ICR, and so they simply don't have access to it. The other issue is that there are only about 100 Pritikin ICR programs throughout the country, and so, and there are other, there's Ornish ICR as well, but the overall number is far lower than the number of programs that offer just CR. So, if there, in fact, are added benefits, then expanding that availability would be very important. The study design was a retrospective analysis of patients who were referred to ICR or traditional CR between 2013 and 2019 at the Heart Care Institute in St. Louis, and ICR began there in 2013, and that's why this was the range of dates chosen. We assessed anthropometrics, dietary patterns, physical function, and quality of life. The participants were 1,963 patients, 77% of those were in the ICR group, and 23% were in CR, and early on in 2013, the numbers were more favoring CR, and as time went on each year, more and more patients were enrolled in ICR. And the distinction, it was not a randomized trial, so what distinguished which group patients went into was largely insurance coverage. So, if their insurance covered ICR, then we encouraged them to enroll in ICR. The mean age was 66.1 years, and 68% of the sample was male. And here is the study in JCRP. So, demographic and baseline characteristics are shown here. There was a fair amount of balance between groups with respect to many things, but there were some differences. So, this column shows all, that 68% were male, that was matched across groups. This shows the racial distribution. They were predominantly white, but there were patients who were Black and other races in both groups. Relatively low Hispanic diversity. Mean age was a little bit older in the ICR group relative to CR. In terms of referral diagnosis, as shown here, 51% of the sample was referred for coronary angioplasty with or without stenting. And you can see the other distribution. So, the other large reasons were heart failure, heart valve replacement, myocardial infarction, and there were some differences between groups with more patients in CR having heart failure and more in the ICR group for coronary angioplasty or stenting. The outcome measures we were interested in were weight, BMI, and waist circumference, diet quality, quality of life, six-minute walk distance as an estimate of cardiorespiratory fitness, gait speed, chair rise, and balance, which were part of the short physical performance battery, and grip strength. That was hand grip strength. So, here are some of the results. What this shows is the physical, the anthropometric weight, BMI, waist circumference, physical function, six-minute walking, grip strength, and dietary measures rate your plate. And it shows the ICR group and CR group at baseline and the change. And an important point to point out here is that all of these metrics improved statistically significantly in the ICR group. They lost weight, improved their waist circumference, improved their physical function, and improved their diet quality. In terms of were these benefits greater than in the CR group, the CR group also had some benefits in terms of six-minute walk and rate your plate. So, some of these were statistically greater in the ICR group. The ICR group lost weight, whereas the CR group did not. They improved their waist circumference more, and they had greater improvements in diet quality. We further wanted to look at weight changes by weight category at baseline. So, what this graph shows is weight change in kilograms in the ICR group and the CR group by weight category at baseline. So, 18% of the sample was classified as having a normal or healthy weight at baseline, 38% were categorized as overweight, and 44% as obese. So, those with normal weight, we wouldn't So, those with normal weight, we wouldn't necessarily expect to lose weight. So, what we looked at here was did those who were classified as overweight or obese lose weight in response to the ICR program? And in fact, they did. This was statistically significant. And this was greater than in the CR group. The CR group did not show those weight changes. Importantly, 10% of ICR patients with obesity at baseline transitioned to the overweight category. 7% of ICR patients with overweight at baseline transitioned to the healthy weight category. In terms of six-minute walk distance, we also looked at this based on initial weight categorization. And what the data reflect are that all patients or all groups improved fitness based on walking further on a six-minute walk test. It did not differ by weight category, and it did not differ by ICR versus CR. All groups showed improvements. We also looked at the short physical performance battery as a measure of physical function. This was a tool developed at the National Institute on Aging. It's comprised of three tests, each with a score of 0 to 4. Those tests are balanced, and there are three balanced tests, gait speed, and a chair stand. And so if they score a 0, it means they're unable to complete it. If they score a 4 on each of those, that's the best score. So the optimal score on the total battery is 12. Higher scores reflect better functional ability. And scores of 0, whether it's on a subscore or total, reflect higher mortality in nursing home admissions. And so each of the patients underwent this series of tests, and then we tallied up the scores. So the results are shown here. And what this shows is ICR group at baseline and in follow-up. These are the total scores. So remember, the lowest score is going to be 0. We had no one score 0. The highest score is 12. And then these show the subscores. So the higher scores reflect better function. And the take-home message here is that at baseline, 50% of the sample, the patients in the ICR group had the best score, whereas at follow-up, 70% did. So many patients who did not have the top score on the total SPPB transitioned to having the highest score. And you can see there were improvements in all subcomponents in balance, in the 4-meter walk, and in the chair rise. In comparison, the CR group also showed almost identical results with improvements in those who scored the highest on the SPPB, increasing from 51% at baseline to 71%, also showing comparable improvements in the subscores. So all groups, both groups improved their physical function, but there was not a significant difference between groups. The rate-your-plate diet quality questionnaire was a very important metric because the Pritikin program focuses largely on heart-healthy nutrition. And so this is a 24-item questionnaire where patients choose A, B, or C for each of these 24 items. A reflects the best. That's they get three points when they choose A for a category. B reflects two points. And C reflects one point for the worst category. And so the total score ranges from 24 to 72, with 72 being the best. The results are shown here for the ICR group on the left and the CR group on the right. One of the ways that's recommended to use this tool is to categorize it into 24 to 40 points, which is the lowest, meaning there are many ways patients can improve their eating habits, 41 to 57, or 58 to 72. If we focus on this highest category of those who are making many healthy choices, you can see that this increased quite dramatically in the ICR group. 33% of patients were in that category at baseline. This increased to 73% who are making very healthy choices in their dietary patterns at follow-up. This was significantly greater than the CR group. In terms of completion, more than 1,100 patients overall completed, which was 58%. It was comparable in ICR with 59% of patients to CR 55%. ICR patients completed more exercise sessions, 22 versus 19. Education sessions were only available to ICR. They completed 18. So the total sessions for ICR averaged 41 sessions in 9.6 weeks, CR 19 sessions in 10.3 weeks. So when we talk about the dose effects of cardiac rehab, this is where you can see there's potentially a very striking benefit of ICR because those patients are having more sessions. I wanna also point out that we conducted a prospective study. So that particular article was on a retrospective analysis. This is a prospective study in which we obtained informed consent from all patients starting in 2017, all patients who were interested in enrolling, and we collected additional outcomes. And so that was published earlier this year in the American Journal of Cardiology and showing some of the benefits. And just to give you the conclusions, this prospective study of critic and outpatient ICR revealed significant improvements in diet quality, quality of life, adiposity, and other CBD risk factors. And the improvements in diet quality, body weight, and BMI were greater with ICR than with traditional CR. So this was similar to the retrospective, but we had some additional outcomes, including body composition and some other measures. And the results were consistent, showing that in fact ICR had some additional benefits beyond traditional CR. One of the other analyses that our group has done, led by Dr. Mustafa Husseini, was looking at utilization. And this was an analysis of Medicare beneficiaries. And what this was looking at was to see how much are eligible patients utilizing ICR and CR. And what you can see from this table, which is looking at ICR, CR, or no rehabilitation, whichever particular referral diagnosis you look at, ICR enrollment is very low, 0.1% of this 5% Medicare sample. CR enrollment was also low at about 16%. And you can see 84% of this very large sample did not enroll in any rehabilitation. It was a little better for PCI with 25% of CR patients, but still you can see very low for ICR. Cabin was a little bit higher, but again, the trends are similar, very low utilization of ICR broadly. And this shows it graphically here over time between 2012 and 2015, that you can see in the red, 86% did not enroll in any cardiac rehab. That improved a little bit to 81.9% by 2015. You can see for CR, it ranges from 14 to 18% and ICR quite low. So the key points, the Pritikin Outpatient ICR Program resulted in improvements in several cardiovascular health indices, including weight, BMI, and waist circumference, diet quality, six minute walk distance, SPV total score and subcomponents, grip strength, and health-related quality of life. The improvements in anthropometrics and dietary patterns were greater in ICR than in CR. Fitness, physical function, and quality of life improved comparably in ICR and CR. CR is underutilized and ICR is markedly underutilized. Future steps. We are assessing health outcomes after ICR. So we're very interested in cardiac events, hospitalizations, and mortality. So our prospective study started in 2017 and we obtained informed consent to be able to look in the electronic medical record. So we are tracking outcomes, including cardiac hospitalizations, mortality due to cardiovascular causes, all-cause mortality. And so we're really looking at that very comprehensively now as we track more of our patients further out now that it's been more than five years since the first patient enrolled. We are also using a larger Medicare database to look at Medicare beneficiaries' outcomes. And we have a paper led by Dr. Mustafa Husseini that is in review right now looking at the benefits of ICR over CR on mortality. Among those who, you know, the Medicare beneficiaries who had an eligible diagnosis and who enrolled in ICR or CR, and we have some favorable findings there. Another important future step is to increase enrollment in ICR and CR. Thank you very much for your attention and I will be happy to take any questions. Thanks, Dr. Resett. We're anxiously awaiting to see the results of your ongoing study that you said started in 17 and also the one that you mentioned that Dr. Husseini is one of the principal investigators on the larger retrospective analysis of ICR versus CR in the CMS database. So that'll be, we'll be interested to see that. Okay, so here's, I've got a few questions here. Let me look at this one. I wish I could stay at ICR. Okay, so first question I have is traditionally not many facilities test cardiac rehab patients' grip strength. How is grip strength measured at your facility and what's the correlation in grip strength to clinical outcomes? And is this something you would recommend to add as a standard pre and post rehab assessment? Okay, great, thank you for that. So grip strength is a remarkably great measure. And so this is measured with a handheld dynamometer and it can be done either standing or while a patient's sitting in a chair. We did it with a patient sitting in a chair. There are a few different protocols and it only takes a few minutes to do. Essentially, they're squeezing the dynamometer as hard as they can and it measures on there the force that they're applying and there are age and sex standards. And this has been shown to correlate very strongly with outcomes in large epidemiologic studies, including mortality. So as an example, the UK Biobank is a very large prospective epidemiologic study of almost 500,000 individuals. And when they did grip strength and then followed these individuals for 4.9 years, so almost five years of follow-up, they found that lower grip strength was associated with higher mortality. And so like cardiorespiratory fitness, which is like the best metric for assessing, predicting mortality, grip strength also correlated. And this has been shown in other studies. So it's a great measure. It doesn't take very long. It's inexpensive, it's non-invasive. And so, yeah, I think it's really a good metric and it's relatively easy to implement. And I realized cardiac rehab centers are busy, but it's feasible in many cases. Wow, well, that's interesting. And that's great information as well, because we don't see a lot of facilities doing it today, but it seems like it should become more standard given the low cost to administer and the predictive value of it. Right, absolutely. All right, I've got another one here. Can you tell us more about the short physical performance battery? Is it a standard pre and post rehab test used by providers and does it modify the patient's individualized treatment plan based on their pre-program score? Yeah, so the SPPV was really developed at the National Institute on Aging because it's a great metric for aging. So as adults become older, their balance, their strength in terms of rising from a chair is compromised as is their gait speed. And gait speed is another really great metric that correlates with outcomes. So higher gait speed, lower mortality, lower gait speed, higher mortality. So that's a really good metric. So this kind of battery was developed to try to capture some of those things that really impact people with aging. But what it was found is this is very applicable to a lot of chronic diseases, including cardiovascular diseases. And so this battery really is very useful. Now, if you have a relatively younger patient, they might have a ceiling effect where they score the highest, they're not gonna improve. But plenty of our patients, especially the older ones, do have some deficits in physical function. And it does guide care because for example, if their balance is poor, that's something to really work on. That's gonna be very important even with prescribing their aerobic exercise. The modalities you would choose for the aerobic exercise are gonna be important. And if the chair rise is problematic, then that's a strength issue. That's a lower body strength. And so strengthening those specific muscles is gonna be an important part of their rehabilitation. And then of course, if their gait speed is slow, then working on endurance, which is a typical component of cardiac rehab. But yeah, so it absolutely can really provide good information to establish the exercise prescription in an individualized manner. Super, thank you. Here's another one. The physical function measures that were comparable between or they were comparable between CR and ICR groups indicating exercise benefits of the program remain consistent. What elements of the ICR program do you believe contributed to the better results in weight, BMI and dietary behaviors in the ICR patients? Yeah, so we weren't very surprised that some of the physical function metrics weren't different between the groups in that timeframe that we were assessing it because the exercise modality, the exercise dose and the exercise intensity were matched across groups. And so they all showed improvements, which is great. But so the fact that there wasn't a difference in that short timeframe, it could be though that a longer term out after people leave cardiac rehab, if some of those educational components around physical activity and exercise do have an impact then they may be leading more active lives outside of cardiac rehab, we don't know that yet. But in terms of weight and BMI and diet quality, those were very favorable, but logical improvements that we expected to be greater in the intensive cardiac rehab group because the Pritikin program focuses so much on healthy diet. And we know that those are, it's critical, in terms of improving diet quality has so many implications for overall health and in terms of weight loss, weight management. And so all of those principles of the more wholesome eating kind of tailored around the Mediterranean diet, but individualized for the particular patient for their diagnosis, for their baseline BMI, for their other chronic conditions is really important. And the Pritikin program, the dietary aspects, we do believe were probably the key to facilitating weight loss in those patients, greater weight loss and improving their diet quality. Okay, thank you. Here's another one. The first part of this question, I would be impressed if you knew the answer. So we'll follow up on the first part because they were asking what the CPT codes are that are allowed for outpatient cardiac rehab. So we can follow up on that one. There are many. Yeah, I know. There are a lot. So we can follow up on that, but it says how many visits are allowed by Medicare and do other payers recognize these codes as well? Maybe you could talk to that. So for traditional cardiac rehab, it's 36 sessions that are covered for CR and 72 for ICR. One of the problems though that we have realized is that depending on the insurance, insurance may only cover 24 of the 36 sessions for CR. It may only cover 12. There may be a co-pay and the co-pay may vary. So these are some of the aspects that make it difficult, especially for patients of lower SES to be able to enroll in a full cardiac rehab program. And so if insurance is only covering half or less than half of those 36 sessions, and if insurance is not covering ICR at all, then those patients are just going to be at a disadvantage. And so the coverage aspect is really important. And then the patient's ability to pay that co-pay if they do have a co-pay is another aspect. And so making it more available to patients where they don't have a co-pay and where it covers the whole curriculum is really going to be key. And so by hopefully advertising more of the benefits and making more people aware of the benefits of not just cardiac rehab, but principal cardiac rehab, hopefully the insurers will realize that it actually would be cost savings for them to cover it, because if you're keeping a patient out of the hospital or preventing that subsequent heart attack or delaying some of those other problems, that can really have significant financial benefits. And maybe I'll add a little bit to that, Susan, since we have visibility to a broader group of clients and payers' coverage. So to further answer or enhance or piggyback on what Dr. Resett said is, what we see on average across our 100-plus providers is on average about 60% of the population that go through cardiac or intensive cardiac rehab are Medicare, either Medicare fee-for-service or Medicare Advantage. So that's 60% has full coverage. The balance, the 40% of the commercial population, and this varies per geography, but on average, we might see up to 20% of the commercial population having either no or limited coverage. So if you do the math, that ends up about 10% of the total eligible patient population may have no or limited coverage for ICR. And the balance typically do. Now that's going to vary by geography, but those are just some national stats that we see. Let's see, we've got another one. Okay, this one, again, I don't know that you can answer this, but I'll pose it just in case you can, because this can be regionally specific or it may be across the board. And I don't know what the UnitedHealthcare penetration is here or at HCI, but it says we're having trouble with UnitedHealthcare paying our claims, stating that specialty 31 needs to be on the claim. Have you heard anything about this? I don't have an answer for that one, Susan. Yeah, I mean, it's those, the medical team does the coding. And so, yeah, I don't know. Yeah, we can follow up on that one. We don't have an answer. I don't have an answer off top of my head at the moment, because there was a follow-on question and someone said it's UHC Optum that we're having these issues with. So we can follow up on that. Someone asked, can cardiac rehab be a profitable program for hospitals in terms of revenue? Can you speak to that? Or is that finances department, not yours? Yeah, I don't know if maybe you can address that better, but one of the problems I know that has come up, and this also was an issue during COVID, was that to be able to run a cardiac rehab facility, there are many resources that have to be provided. And so if there aren't enough patients coming in with their insurance coverage, then that center's not going to be able to run. And this is probably one of the reasons, and Terry, you can probably address this, why there's many rural areas are not gonna have cardiac rehab and certainly probably not ICR because of the extra resources that are needed to run an ICR program. And so if there's just not enough population to keep that center running with enough patients on a regular basis, then that's going to be potentially a problem. But I don't know about the revenue side and the actual profit, if you wanna speak to that. Yeah, I'll speak to that a little bit because we're gonna be approaching close to 200 contracted providers by the end of this year. So we've got a pretty good sample size of feedback from hospital administrators and executives and heart hospitals and physician groups. And in general, and this is in general, I'm making general statements because there are exceptions, but in general, cardiac rehab has historically been seen as a breakeven proposition at best, financially, if you just look at it on the cost to run the program. But the reason facilities or providers provided is for all the clinical benefits that Dr. Resett outlined earlier in her presentation that pay off in other areas of the hospital, whether it reduce readmissions, reduce other things, reductions in cardiovascular morbidity and mortality and those things that pay off in other ways to the hospital system or the heart hospital or the physician group. But traditionally, cardiac rehab has not been a profit center. Intensive cardiac rehab, on the other hand, because it doesn't take much in additional resources, allows you basically to double the number of sessions on a patient on average. And you saw in her stats earlier in the presentation, on average, their patients attended just over twice the number of sessions. And it doesn't mean twice the number of visits. They're still coming the same number of visits, but they're doing two sessions on each visit, an exercise and an education. So it allows you to, the provider, to double their revenue with very little incremental costs. So the ICR programs have proven to be profitable when you compare them strictly on a financial perspective to traditional cardiac rehab. And I'll give it just a minute in case there's any other questions, but that's all I have at the moment. We'll give it one more minute in case there's any last minute questions before we wrap. And I'll just put a plug in for any physicians out there that please refer eligible patients because we find that the physician's endorsement of cardiac rehab is a really important point at which patients are gonna make a decision and contemplate it and then make a decision to attend. So the power of their physicians endorsing it and encouraging them to attend is really important. Thanks, Dr. Rossette. So I'm not seeing any further questions. So first of all, thank you all who attended today. We appreciate your time and interest. And Dr. Rossette, especially thank you for taking the time to share the outcomes from your personal research at the Heart Care Institute. And we look forward to hearing more from you in the future as these additional studies are published. Great, thank you very much. Yes, thank you. Thank you, Dr. Rossette. Thank you very much, Terry. Appreciate both of you bringing this education to our membership. And thanks for your great work in this space. That will conclude our webinar for today. If there's any other follow-up questions, we're happy to facilitate those as MedAxium and make sure that you get the answers that you're looking for on this topic. And with that, we will conclude. So thank you, everybody. Have a wonderful afternoon.

Pritikin outpatient Intensive Cardiac Rehabilitation

exercise

heart-healthy nutrition

cardiac rehabilitation

cardiovascular health

weight loss

diet quality

Mediterranean-style eating plan

accessibility