Since its early implementation cardiac rehabilitation has served as a successful, guideline-recommended therapy that has reduced the mortality of patients after suffering acute myocardial infarction (MI). Between 2000-2007 however, only 56 percent of eligible patients were referred to the therapy by physicians. To counteract this underutilization, in 2007 the ACC, American Heart Association (AHA), and the American Association of Cardiovascular and Pulmonary Rehabilitation established cardiac rehabilitation referrals from inpatient settings as a performance measure for acute MI.

An article published April 23 in the Journal of the American College of Cardiology, examined whether cardiac rehabilitation referral rates have changed since this new oversight, and found that referral to cardiac rehabilitation has significantly increased, with 81 percent of eligible patients now being referred. However, there remains room for improvement since "referral remains below achievable benchmarks."

The study was led by Alexis Beatty, MD, MAS, University of California, and used data from the ACTION Registry – GWTG to evaluate patients admitted with primary diagnosis of ST-Elevation MI (STEMI) or non-STEMI (NSTEMI) from Jan. 1 2007-June 30, 2012 who were discharged home and had cardiac rehabilitation referral data. Cardiac rehabilitation referral was defined as "an official communication between the health care provider and the patient to recommend and carry out a referral order to an early outpatient cardiac rehabilitation program... [that] includes the provision of all necessary information to the patient that will allow the patient to reenroll in an early outpatient cardiac rehabilitation program... [and] includes a communication between the health care provider or health care system and the cardiac rehabilitation program that includes the patient’s referral information for the program."

The investigation found that 329,698 registry patients with acute MI were discharged from participating hospitals with cardiac rehabilitation referral data. Of these 301,247 patients (91.4 percent) from 624 hospitals were reported eligible for cardiac rehabilitation, while 28,451 (8.6 percent) were reported to be ineligible. Ultimately cardiac rehabilitation referral increased by approximately eight percent (from 72.9 percent to 80.7 percent).

In addition, the study found that cardiac rehabilitation referral improved across gender and racial/ethnic groups, but remained highest in whites and males. Hospitals in the lowest quartile of adherence to ACC/AHA 2008 performances measures for adults with STEMI and NSTEMI (other than cardiac rehabilitation referrals) increased from 54 percent in 2007 to 64 percent in 2011, though this gain is still significantly behind the 87 percent referral rate in 2007 and 2011 for highest quality quartiles hospitals.

The authors note that compared to other acute MI discharge performance measures, cardiac rehabilitation referral has the lowest adherence. Moving forward, "improvement strategies may include identifying key personnel to direct the process of introducing cardiac rehabilitation in the inpatient setting and developing systems for automatic referral."

Keywords: Ethnic Groups, Registries, Myocardial Infarction, Referral and Consultation, European Continental Ancestry Group, Patient Discharge