Cardiac Rehab Referral Low, Inconsistent Across US Hospitals

Two in 5 patients undergoing PCI in the United States who survive through hospital discharge are not referred for cardiac rehabilitation, according to a study published in the May 19, 2015, issue of the Journal of the American College of Cardiology.

Take Home:  Cardiac Rehab Referral Low, Inconsistent Across US Hospitals

“Our study highlights significant interhospital 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,” write Krishna G. Aragam, MD, MS, of Massachusetts General Hospital (Boston, MA), and colleagues.

The researchers analyzed data from the National Cardiovascular Data Registry (NCDR) CathPCI Registry on 1,432,399 consecutive patients who underwent PCI and survived to discharge at 1,310 US hospitals between July 2009 and March 2012.

Overall, 59.2% of patients were referred for cardiac rehab after discharge (range over the study period, 57.9%-61.2%).

Patients referred for rehab were younger; more often male or white; and more likely to be smokers, have private insurance, and have higher BMIs. They were also less likely to have various comorbidities such as hypertension, dyslipidemia, cerebrovascular disease, PAD, chronic lung disease, and diabetes. Notably, nonreferred patients were less likely to present with acute MI or experience cardiogenic shock or cardiac arrest within 24 hours of PCI.

After multivariate adjustment for patient-level factors, more-urgent PCI presentation and periprocedural MI independently predicted the odds of rehab referral (table 1).

Table 1. Patient-Level Predictors of Referral to Cardiac Rehab After PCI

Older age; the presence of several comorbidities; and prior PCI, CABG, or valve surgery all decreased the likelihood of referral.

Hospitals with more beds or a higher PCI volume were more likely to refer patients for cardiac rehab. Location in the Midwest (OR 7.36; 95% CI 5.08-10.67) and designation as a private or community hospital (OR 2.33; 95% CI 1.34-4.05) robustly correlated with higher rates of rehab.

Results were confirmed in a subgroup analysis of 196,214 acute MI patients on Medicare, for whom the rehab referral rate was 66.0%.

On logistic regression analysis, patients’ insurance type had little influence on interhospital variation in rehab referral rates. The pattern persisted even after further adjustment for hospital-level characteristics, with more than one-quarter of all hospitals showing referral rates of less than 20%.

Focus on the Hospitals

“Despite the general notion that lack of insurance coverage is a major barrier to rehabilitation referral, our data suggest that other unidentified factors are the primary determinants of decreased referral,” Dr. Aragam and colleagues write.

Previous studies have clearly shown that cardiac rehab imparts “reductions in morbidity and mortality and improvements in functional status and quality of life; these are presumed to be a result of exercise training, psychological counseling, and a consistent emphasis on preventive strategies,” the authors say. However, inpatient referral, they add, is one of the strongest predictors that patients will actually enroll in a rehab program.

Contrary to previous studies, the current analysis shows “that older patients, women, those with the most comorbidities, and those with previous MI or revascularization were less likely to be referred to cardiac rehabilitation, despite data that suggest that these populations might benefit most from rehabilitation programs,” Dr. Aragam and colleagues observe. However, they acknowledge, the overall influence of patient factors on referral rates was minimal.

In addition, even hospital-level characteristics—which were strongly associated with rehab referral—were probably only “confounders for other unmeasured institutional characteristics, such as the presence of automated discharge sets, which have been associated with increased cardiac rehabilitation referral rates in previous studies,” the authors suggest. “[U]nfortunately, these data were unavailable for the present analysis.”

In addition, the researchers note that the type of insurance, or whether patients have insurance at all, “might also be a proxy for socioeconomic status.”

‘A Call to Action’

The 2014 initiative by the Centers for Medicare & Medicaid Services to incorporate referral to cardiac rehab as a publicly reported performance measure may “provide the impetus” to increase referral rates nationwide, they say. “As with other performance measures of accountability, the prospect of incentives for improved performance and penalties for poor compliance will likely motivate prompt identification of sites with deficient referral rates and concerted efforts (eg, incorporation of automated discharge checklists) to improve referral rates at underperforming hospitals.”

In an editorial accompanying the study, Randal J. Thomas, MD, MS, of the Mayo Clinic (Rochester, MN), makes 3 suggestions for hospitals looking to improve their referral rates. Such institutions can:


  • Prioritize resources for cardiac rehab services
  • Utilize systematic cardiac rehab referral
  • Collect, analyze, and respond to local performance data


The study “is a call to action,” Dr. Thomas concludes.

1. Aragam KG, Dai D, Neely ML, et al. Gaps in referral to cardiac rehabilitation of patients undergoing percutaneous coronary intervention in the United States. J Am Coll Cardiol. 2015;65:2079-2088.
2. Thomas RJ. The gap in cardiac rehabilitation referral: a system-based problem with system-based solutions [editorial]. J Am Coll Cardiol. 2015;65:2089-2090.

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  • Drs. Aragam and Thomas report no relevant conflicts of interest.