Trends and Disparities in Referral to Cardiac Rehabilitation After Percutaneous Coronary Intervention

Study Questions:

What are the incidence and determinants of cardiac rehabilitation referral rates for patients undergoing percutaneous coronary intervention (PCI)?


The incidence and predictors of referral to cardiac rehabilitation were assessed among 145,661 consecutive patients undergoing PCI and surviving to hospital discharge across 31 hospitals in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium between 2003 and 2008. The main outcome measure was referral to cardiac rehabilitation during hospital stay.


The 6-year cardiac rehabilitation referral rate was 60.2%. Younger age, male gender, white race, and presentation with acute or severe disease (i.e., acute myocardial infarction [AMI] in the previous 24 hours and ST-elevation myocardial infarction) were associated with increased referral to rehabilitation (all p < 0.0001). Most medical comorbidities were associated with decreased referral. Referral rates for cardiac rehabilitation were below the rates of other AMI quality-of-care indicators and more variable across hospital sites. Race-specific referral rates differed significantly in the lowest referring hospitals (p < 0.0001), but not in the highest referring hospitals (p = 0.16). Women had a 0.7% relative decrease in referral, as compared to men (p = 0.0188) in the highest referring hospitals, but a 26.7% relative decrease in referral in the lowest referring hospitals (p = 0.02).


The authors concluded that over one third of patients undergoing PCI are not referred for cardiac rehabilitation.


The current study demonstrates a relatively low (~60%) overall rate of referral to cardiac rehabilitation after PCI, which although suboptimal, is better than that in previously reported studies where less than one third of patients received cardiac rehabilitation after an MI or coronary artery bypass surgery (Circulation 2007;116:1653-62). In addition, the study suggests site-specific variability in cardiac rehabilitation referral rates beyond that seen with other AMI performance measures, and significant racial and gender disparities in referral patterns concentrated at the lowest referring hospital sites. Broad measures such as electronic reminders, automated discharge sets, education to physicians on the importance of cardiac rehabilitation, and improving reimbursement for rehabilitation services with a more focused approach targeted at underperforming sites may be an optimal strategy to increase referral rates for cardiac rehabilitation.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery

Keywords: Myocardial Infarction, Michigan, Referral and Consultation, Coronary Artery Bypass, Percutaneous Coronary Intervention

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