Gaps in Referral to Cardiac Rehabilitation of Patients Undergoing PCI | Journal Scan

Study Questions:

What factors are associated with referral to cardiac rehabilitation (CRehab) in a national percutaneous coronary intervention (PCI) cohort, and is there an association between insurance status and referral patterns?


Consecutive patients undergoing PCI and surviving to hospital discharge in the National Cardiovascular Data Registry (NCDR) between July 1, 2009 and March 31, 2012 were analyzed. CRehab referral rates and patient and institutional factors associated with referral were evaluated for the total study population and for a subset of Medicare patients presenting with acute myocardial infarction (AMI).


Patients undergoing PCI (n = 1,432,399) at 1,310 participating hospitals were assessed. CRehab referral rates were 59.2% and 66.0% for the overall population and the AMI/Medicare subgroup, respectively. In multivariable analyses, presentation with ST-segment elevation MI (STEMI) (odds ratio [OR], 2.99; 95% confidence interval [CI], 2.92-3.06) and non-STEMI (OR, 1.99; 95% CI, 1.94-2.03) was associated with increased odds of referral to CRehab. Models adjusted for insurance status showed significant site-specific variability in referral rates, with over one quarter of all hospitals referring <20%.


Approximately 60% of patients undergoing PCI in the United States are referred for CRehab. Site-specific variation in referral rates is significant and unexplained by insurance coverage. These findings highlight the potential and need for hospital-level interventions to improve CRehab referral rates after PCI.


The value of CRehab is comparable to statins and other evidence-based therapies, yet sadly underutilized. The results in this study are from institutions participating in a quality improvement initiative and exaggerate the true referral percentage in the United States. The national referral rate for all CRehab indications is <50% and participation rate is no more than 50% of those referred.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Prevention, Interventions and ACS

Keywords: Acute Coronary Syndrome, Hospitals, Insurance Coverage, Medicare, Myocardial Infarction, Percutaneous Coronary Intervention, Primary Prevention, Quality Improvement, Referral and Consultation, Registries, Rehabilitation

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