Nearly half of patients leave the hospital post-PCI without a referral to cardiac rehabilitation. From MedPage Today.
Approximately 60% of U.S. patients who underwent percutaneous coronary intervention (PCI) were referred for cardiac rehabilitation before hospital discharge, researchers reported.
The low rates of referral were more strongly influenced by hospital-level factors than patient-specific ones, wrote Krishna Aragam, MD, a cardiology fellow at Massachusetts General Hospital in Boston, and colleagues in the Journal of the American College of Cardiology.
Hospitals that were larger, had a greater PCI volume, and were private or community-based significantly increased the likelihood that a patient was referred to cardiac rehabilitation.
But more than one-quarter of hospitals had referral rates of less than 20%.
"Our results support a need to identify and assist underperforming hospitals," Aragam said. Interventions at the institutional level could improve referral rates at those sites.
For example, making referrals part of routine discharge paperwork is simple and straightforward and has been associated with increased referral rates. "If you're forced at least to think about it as part of your discharge paperwork, then the mindset is there. There's a greater likelihood that you'll initiate the [referral] process for that patient," Aragam said.
Getting referral on a physician's radar can also encourage endorsement, or telling a patient that rehabilitation is important. That in itself makes it more likely that patients participate, he added.
The increased rates of referral at higher volume hospitals may reflect more protocolized care and a greater cognizance of outcomes, Charles Davidson, MD, director of the interventional cardiology program at Northwestern Memorial Hospital in Chicago, told MedPage Today.
"Centers that are paying attention to their outcomes want to ... perform well against peer hospitals," said Davidson, who was not involved in the study.
Davidson's hospital now makes cardiac rehabilitation referral part of a routine orderset for post-PCI patients. The system was put in place several years ago, after the hospital evaluated National Cardiovascular Data Registry (NCDR) outcomes and saw that its cardiac rehabilitation referrals were not as high as they should have been.
"I looked at that and said, 'This is very easy to change,'" Davidson said. "Adding this in is such a simple piece to the equation. [The current study] should motivate centers to pay attention to outcomes."
Using data from the NCDR CathPCI database, the researchers looked at 1,432,399 patients who underwent PCI at 1,310 hospitals nationwide from July 2009 to March 2012.
Patients who presented with the following were significantly more likely to be referred to rehabilitation:
- ST-segment elevation acute myocardial infarction (STEMI): OR 2.99 (95% CI 2.92-3.06)
- Non-STEMI: OR 1.99 (95% CI 1.94-2.03)
- Unstable angina: OR 1.12 (95% CI 1.10-1.14)
- Periprocedural MI: OR 1.42 (95% CI 1.37-1.47)
Other patient characteristics associated with increased referral rates were being male, young, white, and having few comorbidities, though the effect was small.
Contrary to popular belief, the authors found that a patient's insurance coverage only had a modest association with referral rates. Those with private insurance were more likely to receive referrals compared with those with Medicaid.
The authors noted that lack of socioeconomic data may have confounded the patient-specific factors.
Nearly every type of patient benefits from cardiac rehabilitation programs, which provide exercise training as well as education, Margaret Hall, MD, medical director of cardiac rehabilitation at the University of Washington's Northwest Hospital in Seattle, told MedPage Today.
But since hospital lengths of stay are getting shorter, patients appear healthier upon discharge. "They don't appear to be debilitated and therefore people don't think of rehabilitation," Hall said.
As with Davidson's institution, Hall's center uses automatic referrals. But rehabilitation must be prescribed by a physician, and this could present a barrier in systems where nurse practitioners or physician assistants take care of patients post-PCI, Hall added.
One limitation resulting from the study's large size was the inability to drill down on specific institutional issues that drive cardiac rehabilitation referrals, Hall said.
Aragam agreed, explaining that various unmeasured hospital characteristics could have accounted for the referral patterns or confounded the results. "We should not just assume that the [characteristics] we identified are the ones. They may just be indicating that other hospital factors are important," he said.
For example, for reasons that authors could not explain, Midwestern hospitals fared particularly well (OR 7.363, 95% CI 5.083-10.667).
In an accompanying editorial, Randal Thomas, MD, a preventive cardiologist at the Mayo Clinic in Rochester, Minn., ventured a reason: "The local concentration of CR [cardiac rehabilitation] programs has been shown to predict CR participation, and is higher in the Midwest than in other regions of the U.S.," he wrote.
"Those localities that prioritize resources to provide CR services ... are the localities most likely to achieve high performance in CR referral and participation," Thomas wrote.
A resource could be as simple as cheap and abundant parking, said Daniel Malone, PT, PhD, a physical therapist at the University of Colorado in Aurora.
The difference was noticeable compared with Philadelphia, where Malone used to practice. "Our patients had tremendous difficulty getting to our cardiac rehab site," he said. "If you could find a parking spot within two or three blocks from the rehab center, you were lucky."
When patients are attending sessions two to three times a week for several hours each time, the dollars and minutes add up, Malone said. "It becomes a job."
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