title: System-level factors and use of cardiac rehabilitation.
abstract: OBJECTIVE
  Despite well-established benefits, only 10% to 20% of eligible candidates in the United States currently use formal cardiac rehabilitation (CR) services. Existing studies identify both patient- and provider-level barriers to physician referral and patient uptake. This study, which was driven by new evidence indicating that utilization rates vary enormously from state to state, within states, and from hospital to hospital, explores the relationship between system-level factors and CR use.
  
  
  METHODS
  Using a qualitative design with semistructured questions, we telephone-interviewed both directors of CR facility programs and presidents of CR state associations operating in states with high and low rates of CR use. We explored the political and cultural environment in which CR facilities operate and the technical capacity to secure referrals and convert referrals to enrollment.
  
  
  RESULTS
  We identified 4 system-level factors that may help explain regional variation in CR use. These included the degree of automation and assertiveness around securing CR referrals, level of integration of CR within the hospital setting and physician community, relationship to other CR facilities, and capacity constraints.
  
  
  CONCLUSIONS
  As some of the identified system-level factors can be altered by public and hospital-level policy, study results suggest opportunities for interventions and directions for future research that could increase the use of CR.
authors.affiliation: Brandeis University, Waltham, Massachusetts 02454, USA. gurewich@brandeis.edu
authors.forename: Deborah
authors.initials: D
authors.lastname: Gurewich
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Prottas
authors.forename: Sarita
authors.initials: S
authors.lastname: Bhalotra
authors.forename: Jose A
authors.initials: JA
authors.lastname: Suaya
authors.forename: Donald S
authors.initials: DS
authors.lastname: Shepard
mesh_terms: D005081:Exercise Therapy / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006331:Heart Diseases / Q000534:rehabilitation*; D006801:Humans; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012046:Rehabilitation / Q000706:statistics & numerical data*; D014481:United States