Hospital traits may explain deficiencies in PCI rehab referrals

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Only about 60 percent of PCI patients get referred to a cardiac rehabilitation program, according to a recent study, and the barrier is more likely due to hospital characteristics than insurance.  

In 2014, the Centers for Medicare & Medicaid Services added referral to cardiac rehab after an acute MI or PCI to its list of performance measures, based on evidence that suggested participation led to better clinical outcomes. Krishna G. Aragam, MD, MS, of Massachusetts General Hospital in Boston, and colleagues explored post-PCI cardiac rehab referral trends and predictors in the May 19 issue of the Journal of American College of Cardiology.

They used the National Cardiovascular Data Registry to assess 1.4 million patients who underwent PCIs at 1,310 participating hospitals between 2009 and 2012. Patients who died in the hospital, were discharged to a nursing home, acute care hospital or hospice, or left against medical advice were not included. Besides measuring referral status, they looked at other quality measures, insurance and patient and hospital factors.

In the two-year study period, 59.2 percent of patients received referrals to cardiac rehab programs, with little change in rates over time. Medicare beneficiaries had a slightly higher rate—66 percent—with little variation quarter to quarter.

At the same time, the rates for other measures of quality were high: 97.5 percent of PCI patients were discharged on aspirin, for instance, and 89.8 percent on statins. Rates for Medicare patients were as high or higher.

Insurance coverage for cardiac rehab had little effect of referral rates, as did patient factors. Having private insurance was associated with increased referral and having Medicaid with decreased referral, although Aragam et al called the effect negligible. Presenting with STEMI or non-STEMI increased the odds of rehab referral while older age, comorbidities and a history of PCI, CABG or valve surgery slightly decreased the odds.  

Referral rates among hospitals varied greatly, even after adjusting for insurance status.

“Conversely, hospital-level characteristics in our analysis demonstrated robust associations with referral patterns,” they wrote. In particular, being located in the Midwest or being a private/community hospital increased the odds for referral. But they added that institutional characteristics were limited in the dataset.

“Therefore, it is likely that the aforementioned hospital-level predictors of referral were 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; unfortunately, these data were unavailable for the present analysis,” they wrote.