Cardiac rehab participation low in US, varies widely by region

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Fewer than one in six American patients undergoes cardiac rehabilitation after MI, PCI or coronary artery bypass graft (CABG) surgery, and participation varies widely by state and region, a new study in Circulation found.

“Despite substantial advocacy and improvements in cardiac rehabilitation referral, there has been little improvement in cardiac rehabilitation participation over time,” wrote lead author Alexis L. Beatty, MD, and colleagues.

The researchers used administrative data from the Veterans Affairs (VA) health system and a 5 percent Medicare sample to identify patients who were hospitalized for MI, PCI or CABG from 2007 to 2011. Both health insurances cover cardiac rehabilitation, which includes exercise training, risk factor modification and psychosocial counseling and has been proven to reduce cardiovascular mortality and subsequent hospitalizations.

But among patients who survived at least a month after hospital discharge, only 16.3 percent of Medicare beneficiaries and 10.3 percent of VA patients attended at least one cardiac rehab in the year following discharge. By state, participation rates varied from 3.2 percent to 41.8 percent in Medicare patients and 1.2 percent to 47.6 percent in VA patients.

For both groups, participation was highest in the West North Central region—containing the Dakotas, Kansas, Nebraska, Iowa, Missouri and Minnesota—and was lowest for the Pacific region including the West Coast and Hawaii.

“There is remarkably similar regional variation, with some regions and hospitals achieving high rates of participation in both populations,” Beatty et al. wrote. “This provides an opportunity to identify best practices from higher-performing hospitals and regions that could be used to improve cardiac rehabilitation participation in lower-performing hospitals and regions.”

The authors noted hospitals with the best rates of participation were more likely to be larger, academically affiliated and have onsite cardiac rehabilitation. Participation varied by race, particularly in the Medicare population, where 17.6 percent of whites attended cardiac rehab versus 7.3 percent of blacks and 3.8 percent of Hispanics. In the VA group, participation was 10.4 percent for whites, 8.9 percent for blacks and 12 percent for Hispanics.

“Though it is not possible to determine from administrative data what factors explain these differences or to examine all the socio-cultural variables that might contribute to these differences, it is possible that the uniformity of VA health coverage may contribute to fewer racial and ethnic disparities in care,” the authors wrote.

The researchers noted their analysis couldn’t rule out patients who may have been deemed ineligible for cardiac rehab, although rates of ineligibility have been reported at less than 10 percent.

Beatty et al. said automatic referral and early staff follow-up communication to possible rehab participants should be instituted at all hospitals. In addition, they believe Medicare incentives aimed at reducing rehospitalizations, partially through cardiac rehab, could spur growth in referral, enrollment and participation.

“Future research should focus on novel approaches to improving cardiac rehabilitation participation that can be easily delivered across diverse regions and healthcare settings,” they wrote.