title: Gaps in referral to cardiac rehabilitation of patients undergoing percutaneous coronary intervention in the United States.
abstract: BACKGROUND
  Rates of referral to cardiac rehabilitation after percutaneous coronary intervention (PCI) have been historically low despite the evidence that rehabilitation is associated with lower mortality in PCI patients.
  
  
  OBJECTIVE
  This study sought to determine the prevalence of and factors associated with referral to cardiac rehabilitation in a national PCI cohort, and to assess the association between insurance status and referral patterns.
  
  
  METHODS
  Consecutive patients who underwent PCI and survived to hospital discharge in the National Cardiovascular Data Registry between July 1, 2009 and March 31, 2012 were analyzed. Cardiac rehabilitation referral rates, and patient and institutional factors associated with referral were evaluated for the total study population and for a subset of Medicare patients presenting with acute myocardial infarction.
  
  
  RESULTS
  Patients who underwent PCI (n = 1,432,399) at 1,310 participating hospitals were assessed. Cardiac rehabilitation referral rates were 59.2% and 66.0% for the overall population and the AMI/Medicare subgroup, respectively. In multivariable analyses, presentation with ST-segment elevation myocardial infarction (odds ratio 2.99; 95% confidence interval: 2.92 to 3.06) and non-ST-segment elevation myocardial infarction (odds ratio: 1.99; 95% confidence interval: 1.94 to 2.03) were associated with increased odds of referral to cardiac rehabilitation. Models adjusted for insurance status showed significant site-specific variability in referral rates, with more than one-quarter of all hospitals referring <20% of patients.
  
  
  CONCLUSIONS
  Approximately 60% of patients undergoing PCI in the United States are referred for cardiac rehabilitation. Site-specific variation in referral rates is significant and is unexplained by insurance coverage. These findings highlight the potential need for hospital-level interventions to improve cardiac rehabilitation referral rates after PCI.
authors.affiliation: Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts. Electronic address: karagam@gmail.com.
authors.forename: Krishna G
authors.initials: KG
authors.lastname: Aragam
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Dadi
authors.initials: D
authors.lastname: Dai
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Megan L
authors.initials: ML
authors.lastname: Neely
authors.affiliation: Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
authors.affiliation: Denver Veterans Affairs Medical Center, Denver, Colorado.
authors.forename: John S
authors.initials: JS
authors.lastname: Rumsfeld
authors.affiliation: Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, Michigan.
authors.forename: Hitinder S
authors.initials: HS
authors.lastname: Gurm
mesh_terms: D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000534:rehabilitation / Q000601:surgery*; D062645:Percutaneous Coronary Intervention / Q000401:mortality / Q000534:rehabilitation*; D011785:Quality Assurance, Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology
keywords: cardiac rehabilitation; percutaneous coronary intervention; quality of care; secondary prevention