ACC: Referral rates for PCI patient rehab remain low, disparities exist
ATLANTA--Referring PCI patients for cardiac rehabilitation can help improve care; however, the rates of referral remain low and large disparities exist between hospital sites, said Krishna G. Aragam, of the University of Michigan in Ann Arbor, during a poster presentation at the 59th annual American College of Cardiology (ACC) scientific sessions.

Aragam et al used data from the BMC2 registry to study 145,000 PCI patients at 32 facilities across the state of Michigan between 2003 and 2008 to analyze trends in cardiac rehabilitation referrals.

“Referral rates across the board are low,” said Aragam.  "We were trying to see what the overall rates look like in Michigan,” he said.

During the study, Aragam and colleagues studied various sites throughout the state to assess factors that could be associated with increased, as well as decreased, rates of referral. The researchers then compared referral rates to other acute MI quality indicators such as beta blockers, aspirin, referral for smoking cessation counseling, etc.

Researchers found that while the rates increased significantly from 2003 to 2008, resting at rates of approximately 60 percent, Aragam said research shows that there is still room for a 30 to 40 percent improvement.

After Aragam evaluated a subgroup of AMI patients, research showed referral rates for this population to be “higher across the board.” These overall referral rates for the AMI patient population were reported to be 73.5 percent.

“These numbers are still not as high as we would like them to be,” he said. “Ideally, we would like to see referral rates at 100 percent, and would like to see every one of these patients going to rehab, given that it improves functional status."

Additionally, the study evaluated trends in referrals by assessing patient demographics. According to Aragam, results showed that older patients (70 years of age or older) and female patients were less likely to be referred for cardiac rehabilitation.

For other characteristics such as medical history of MI or other previous medical procedures, patients were less likely to be referred. Aragam said that the reasoning for this may be because patients who had previously undergone a cardiac procedure had a good chance of being admitted to the hospital for rehab at one time. He said that physicians may feel as though a patient “already underwent rehab and they don’t need it again.”

“On the flip-side,” said Aragam, “more patients are referred for rehab if they need emergency PCI, if their MI is more recent, had a STEMI, been in heart failure or required a stent,” he explained. “All these things suggest severe acute disease and are associated with increased referral.”

Additionally, researchers compared cardiac rehab referral rates to other AMI quality of care measures. “We noticed that while there is an overall 60 percent cardiac rehab referral rate, we found much higher rates for other quality of care measures, including statins, Plavix and aspirin use, as well as referral for smoking cessation counseling—rates in the 80 and 90 percent range,” said Aragam.

Significant differences occurred between patients who are referred, compared to those who were not, because those who are referred are usually treated with the acute MI quality of care measures. “If you are referred for cardiac rehab, it’s also more likely that you are going to get your aspirin, beta blocker, statin and Plavix at discharge and you will more often be referred for smoking cessation counseling.”

Aragam said that the crux of the referral issue lays in particular hospital sites. During a substudy, Aragam and colleagues broke down cardiac rehab referral for each of the 32 sites across the state. Results were “very broad” and showed that while several sights saw an 80 to 90 percent referral range, many sites had mediocre results in the teens and 20 percent ranges, and some even fell below 5 percent.

Lastly, the researchers looked at how smoking cessation referral correlated to cardiac rehab referral at the included sites. Researchers found great disparity. For some sites, cardiac rehab referral rates were less than 5 percent, while rates of referral for smoking cessation reached 98 percent.

“One theory is that smoking cessation referral is a Centers for Medicare & Medicaid Services/Joint Commission core measure, while cardiac referral is not. This may be a reason why people more routinely refer for smoking cessation counseling—it’s a more automated quality of care measure,” said Aragam.”

“The take home message here is that there’s a huge disparity in cardiac rehab referral rates across sites,” said Aragam. “The next step is to get a sense of which hospital-specific factors might be associated with increased or decreased referral rates because that will be important for targeting specific sites and coming up with sound strategies to improve or add to core measures of care,” he concluded.