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Cardiac rehabilitation referral rates low for patients undergoing PCI
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Less than 60% of a large cohort of patients was referred to cardiac rehabilitation services after PCI, according to recent findings.
Researchers investigated the prevalence and factors, including the role of health insurance status, associated with referral to cardiac rehabilitation in a cohort of 1,432,399 consecutive patients undergoing PCI.
Eligible participants underwent procedures at 1,310 participating centers in the National Cardiovascular Data Registry CathPCI program and survived to hospital discharge from July 2009 to March 2012.
Results indicated that 59.2% of the overall cohort were referred for cardiac rehabilitation. STEMI (OR = 2.99; 95% CI, 2.92-3.06) and non-STEMI (OR = 1.99; 95% CI, 1.94-2.03) increased the likelihood of referral for rehabilitation, according to results of a multivariate analysis.
Patients presenting with unstable angina (OR = 1.12; 95% CI, 1.1-1.14) and periprocedural MI (OR = 1.42; 95% CI, 1.37-1.47) also were more likely to be referred for cardiac rehabilitation.
Covariates such as older age, diabetes, peripheral artery disease, previous congestive HF and chronic lung disease were associated with decreased rates of rehabilitation. A history of PCI, CABG or valve surgery also decreased the likelihood of referral. However, the researchers reported that the effects of these associations were minimal.
Models adjusting for insurance status indicated that referral rates varied significantly from hospital to hospital. More than 25% of hospitals referred less than 20% of patients for rehabilitation, according to the findings.
Hospitals in the Midwest region (OR = 7.36; 95% CI, 5.08-10.67) and those designated as private/community hospitals (OR = 2.33; 95% CI, 1.34-4.05) were more likely to refer patients for cardiac rehabilitation. Other hospital characteristics associated with referral included greater PCI volume, larger size and designation as a private or community hospital.
“Our study highlights significant inter-hospital variability in referral rates and suggests that unidentified, hospital-level factors may have a stronger influence on referral rates than most patient-specific factors, including insurance coverage for rehabilitation programs,” the researchers wrote. “The findings support a call to identify and assist underperforming institutions through hospital-level interventions and ongoing efforts to monitor for future improvements in national cardiac rehabilitation referral rates.”
In an accompanying editorial, Randal J. Thomas, MD, MS, of the cardiovascular rehabilitation program at the Mayo Clinic in Rochester, Minnesota, suggested three basic ways to improve and homogenize cardiac rehabilitation referral practices: The clinical community should prioritize resources for these services, use systematic referral and be held accountable for performance.
“Those localities that prioritize resources to provide [cardiac rehabilitation] services — whether with traditional center-based [cardiac rehabilitation] programs or with alternative [cardiac rehabilitation] delivery models (ie, home-based [cardiac rehabilitation]) — are the localities most likely to achieve high performance in [cardiac rehabilitation] referral and participation,” he wrote.
Thomas added that automatic referral and use of a staff member to help facilitate referral practices also increased the number of patients who received this care.
“Nationally, accountability efforts are also being implemented to help improve the delivery of [cardiac rehabilitation] to eligible patients, including performance measures for [cardiac rehabilitation] referral that have been included in national data registries … in key cardiovascular performance measure sets, including PCI performance measures, and in the Physician Quality Reporting System, a quality improvement program that is maintained by [CMS],” he wrote.
The current study is a call to action, according to Thomas. “In the decades ahead, what types of studies will be published in the field of [cardiac rehabilitation]? Will we continue to publish reports on the chronic gap in the delivery of [cardiac rehabilitation] services, or will we instead publish reports on the successful, system-based reduction in the [cardiac rehabilitation] referral gap, and its positive impact on patient outcomes?” – by Rob Volansky
Disclosure: The researchers report associations with a number of device and pharmaceutical companies. Thomas reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
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