SAN FRANCISCO – U.S. patients are not getting referred to cardiac rehabilitation programs following percutaneous coronary interventions, despite clear guidelines calling for it.
A review of more than 1.4 million Americans who underwent percutaneous coronary intervention at more than 1,300 U.S. hospitals during 2009-2011 showed that 59% received cardiac rehabilitation referral, a rate that lagged far behind several other post-PCI interventions, Dr. Krishna G. Aragam and his associates reported in a poster at the annual meeting of the American College of Cardiology.
"Rates of cardiac rehabilitation referral are well below those of other acute myocardial infarction quality-of-care measures with little change over the past 3 years," said Dr. Aragam, a cardiologist at the University of Pennsylvania, Philadelphia, and his associates.
Analysis of data collected in the CathPCI Registry of the National Cardiovascular Data Registry of the ACC also showed "considerable" interhospital variation in the rates of rehabilitation referral, with a majority of hospitals having rates that either ran greater than 80% or less than 20%.
A relatively low rate of rehabilitation referral reflects inferior patient care based on the endorsements that rehabilitation programs have received for post-PCI patients. The most recent PCI guidelines of the ACC and other professional societies rate cardiac rehabilitation following PCI a class 1A recommendation, saying that cardiac rehabilitation "should be recommended to patients after PCI." (Circulation 2011:124:2574-609). And last year the Centers for Medicare and Medicaid Services announced that starting in 2014 it would make referral to cardiac rehabilitation for patients following PCI or a myocardial infarction a hospital-performance measure.
If the numbers collected following PCIs as recently as 2011 are a guide, many hospitals will need to act quickly to make rehabilitation referral routine.
Data from 1,432,399 PCIs done at 1,310 U.S. hospitals during the 3 years starting in 2009 showed that discharge referrals to a cardiac rehabilitation program occurred for about 57% of PCI patients in 2009, which upticked to 61% in 2011. The analysis excluded patients who died while hospitalized, and those discharged to a nursing home, acute-care hospital, or hospice.
In contrast, data reported by Dr. Aragam and his associates showed that the next-lowest level of compliance with post-PCI recommendations was discharge prescription of an ACE inhibitor or angiotensin-receptor blocker in patients with a left-ventricular ejection fraction of less than 40%, which happened for about 80% of patients. At discharge, 95% of patients received an aspirin prescription, 90% received a statin prescription, and 85% were prescribed a beta-blocker.
The analysis also identified several factors that significantly linked with either an increased or decreased likelihood of referral to cardiac rehabilitation. Factors linked with rehab being less likely included older age, diabetes, peripheral artery disease, or prior revascularization. Factors that boosted the likelihood that patients received a rehabilitation referral included having an ST elevation MI, which boosted the referral rate by 66% compared with other PCI patients, and having a non-ST elevation MI, which raised the referral rate by 38%.
Dr. Aragam said that he had no disclosures.