Cardiac Rehabilitation Referral Rates Research Articles

Abstract 18105: Lean Six Sigma Approach to Improve Post Percutaneous Coronary Intervention Cardiac Rehab Referral Rates

Background: Cardiac rehabilitation referral rates remain low despite known benefits including decreased mortality and improved quality of life. Studies have identified factors tied to both positive and negative predictors of referral rates, however, overall, it appears to be due to site-specific variation demonstrating the need for hospital-level intervention. Aims: This quality improvement study aimed to improve cardiac rehabilitation referral rates after PCI at our institution utilizing the Lean Sigma Six (LSS) approach, which has been described as a means to improving the quality of healthcare delivery. Methods: An interdisciplinary team used the Define-Measure-Analyze-Improve-Control (DMAIC) framework to implement this study. A GEMBA walk i.e., personal observation of workflow was performed. We Define d and Measure d process of cardiac rehabilitation and the referral rates. We Analyzed to identify that the orders were being placed by multiple team members including residents, general and interventional cardiology fellows, attendings, and nurse practitioners. Process maps were created, and our Intervention was to involve interventional cardiology fellows as stakeholders best suited to place orders since they are involved in all PCIs at our institution. Education was provided specifically to them beginning in July 2022. Statistical Process Control charts were used to analyze data trends from 2019 - 2022 where a total of 3046 PCIs were performed. Control process involved reinforcing the effect of intervention in quarterly meetings. Results: Baseline referral rates ranged from 10-60%. A significant increase in cardiac rehabilitation referral rate achieving a target referral greater than 90% was observed and maintained through the subsequent quarters. Conclusion: LSS is a powerful methodology to examine causes of delay in care. Intervention using LSS principles and tools, may help improve system processes to achieve desired quality outcomes.

Patterns of Referral and Postdischarge Utilization of Cardiac Rehabilitation Among Patients Hospitalized With Heart Failure: An Analysis From the GWTG-HF Registry.

Coverage for cardiac rehabilitation (CR) for patients with heart failure with reduced ejection fraction was expanded in 2014, but contemporary referral and participation rates remain unknown. Patients hospitalized for heart failure with reduced ejection fraction (≤35%) in the American Heart Association Get With The Guidelines-Heart Failure registry from 2010 to 2020 were included, and CR referral status was described as yes, no, or not captured. Temporal trends in CR referral were assessed in the overall cohort. Patient and hospital-level predictors of CR referral were assessed using multivariable-adjusted logistic regression models. Additionally, CR referral and proportional utilization of CR within 1-year of referral were evaluated among patients aged >65 years with available Medicare administrative claims data who were clinically stable for 6-weeks postdischarge. Finally, the association of CR referral with the risk of 1-year death and readmission was evaluated using multivariable-adjusted Cox models. Of 69,441 patients with heart failure with reduced ejection fraction who were eligible for CR (median age 67 years; 33% women; 30% Black), 17,076 (24.6%) were referred to CR, and referral rates increased from 8.1% in 2010 to 24.1% in 2020 (Ptrend<0.001). Of 8310 patients with Medicare who remained clinically stable 6-weeks after discharge, the CR referral rate was 25.8%, and utilization of CR among referred patients was 4.1% (mean sessions attended: 6.7). Patients not referred were more likely to be older, of Black race, and with a higher burden of comorbidities. In adjusted analysis, eligible patients with heart failure with reduced ejection fraction who were referred to CR (versus not referred) had a lower risk of 1-year death (hazard ratio, 0.84 [95% CI, 0.70-1.00]; P=0.049) without significant differences in 1-year readmission. CR referral rates have increased from 2010 to 2020. However, only 1 in 4 patients are referred to CR. Among eligible patients who received CR referral, participation was low, with <1 of 20 participating in CR.

Trends and Predictors of Cardiac Rehabilitation Referral Following Percutaneous Coronary Intervention: AProspective, Multi-Site Study of 41,739 Patients From the Victorian Cardiac Outcomes Registry (2017-2020).

Following percutaneous coronary intervention (PCI), outpatient cardiac rehabilitation (CR) is essential for secondary prevention. However uptake of CR is suboptimal, despite strong evidence demonstrating benefits. The aim of this study was to identify contemporary trends and predictors of CR referral of PCI patients in Victoria. A prospective, observational study using data extracted from the Victorian Cardiac Outcomes Registry was undertaken. A total of 41,739 patients were discharged following PCI over the study period (2017-2020) and included for analysis. Cardiac rehabilitation referral was 85%, with an increasing trend over time (p<0.001). Multivariable modelling identifying the independent predictors of CR referral included hospitals with high volumes of ST-elevation myocardial infarction patients (STEMI) (OR 4.89, 95% CI 4.41-5.20), STEMI diagnosis (OR 1.90, 95% CI 1.69-2.14), or treatment in a private hospital (OR 1.45, 95% CI 1.33-1.57). Predictors of non-referral included cardiogenic shock (OR 0.54, 95% CI 0.41-0.71), aged over 75 years (OR 0.62, 95% CI 0.57-0.68) and previous PCI (OR 0.66, 95% CI 0.62-0.70). Percutaneous coronary intervention patients with an acute coronary syndrome who were referred to CR were also more likely to be prescribed four or more major preventive pharmacotherapies, compared to those who were not referred (90% vs 82.1%, p<0.001). Our contemporary multicentre analysis showed generally high CR referral rates which have increased over time. However, more effort is needed to target patients treated in the public sector, low volume STEMI hospitals or with short lengths of stay.

Internal medicine resident education improves cardiac rehabilitation knowledge, attitudes, and referral rates: A pilot study

BackgroundReferrals to cardiac rehabilitation (CR) remain low despite evidence showing reduction in cardiovascular mortality and hospital readmissions. Resident education and awareness may be an opportunity to address barriers to CR referrals. MethodsThis pilot study involves 20 internal medicine residents rotating at an ambulatory primary care clinic. Voluntary surveys were sent through an online-based survey platform. Following survey completion, residents received a 10-minute scripted lecture and an educational handout outlining CR components, availability, indications, insurance eligibility criteria, and referral process. Surveys were redistributed 2 months post-education to assess changes in mean aggregate knowledge scores and attitude ratings on a 5-point Likert scale. CR referral rates of eligible patients pre- and post-education were obtained through review of electronic medical records. ResultsSixteen (80%) residents completed both pre and post surveys, and 13 (81%) reported no education on CR in the prior year. There was a significant increase in mean aggregate knowledge scores on CR components (5.1 versus 7.0, P = 0.001), insurance coverage (2.4 versus 5.6, P< 0.001), and eligible diagnoses (7.1 versus 9.9, P = 0.03) following education. Attitudes towards CR also improved following education, particularly in self-reported comfort level with explaining CR to patients (3.69 versus 2.06, P<0.001) and perceived familiarity with CR referral process (4.00 versus 2.18, P<0.001). CR referrals increased from 0% (0 out of 10 eligible patients) to 33% (3 out of 9 eligible patients) over a 2-month period before and after education, respectively (P = 0.09). ConclusionsInternal medicine resident knowledge and attitudes towards CR significantly improved after formal education. Although there was a modest increase in the rates of CR referrals following resident education, this pilot study was not powered to detect statistical significance.

Referral Rates for Cardiac Rehabilitation Among Eligible Inpatients After Implementation of a Default Opt-Out Decision Pathway in the Electronic Medical Record

This quality improvement study assesses referral rates for cardiac rehabilitation after a default opt-out option is added to the decision pathway in the electronic medical record.

The Letting Die of the South Asian Body: a Foucauldian Analysis of White Hegemony in Western Cardiovascular Medicine

Cardiovascular disease is the second leading cause of death in Canada and disproportionately affects those of South Asian ancestry. Anecdotally, stories of missed signs and emergency bypass surgeries are abound; empirically, medical research has identified a series of distinct risk factors for South Asian individuals. However, these factors are typically unrecognized by healthcare workers who are typically trained to use recommendations that are founded research done using Caucasian participants. The consequence of this omission is the normalization of the Caucasian body as 'the body' in medicine through disciplinary and regulatory mechanisms, and the 'letting die' of the South Asian body as a result. In taking a Foucauldian approach to this issue, this essay first maps the empirical evidence for the heightened CVD risk in South Asians, namely their predisposition to developing type 2 diabetes mellitus, metabolic syndrome, and dyslipidemia, among other factors. Disciplinary mechanisms to enforce social cohesion discount these differences as exceptions, and attempt to rehabilitate the South Asian body towards the Caucasian norm. These actions are often subconscious, but result in real actions like spending less time with South Asian patients, misuse of assessment metrics, and lower cardiac rehabilitation referral rates. On a population level, research funding is rarely given to studies investigating disease in particular ethnic groups. Hence, clinical practice guidelines must rely on incomplete data to create population-level recommendations. These guidelines act as if they apply to all individuals, but are in fact partisan; thus, the biopolitical control of populations is made apparent through the racist undertones that thrum beneath the veneer of an equal society. Ultimately, this essay serves a counterhistorical function, and demands recognition of the South Asian body in the medical literature. The current medical regime routinely discounts populations who exist outside the norm. Future research and acknowledgement of these groups is necessary to ensure equitable treatment of all patients, regardless of their background.

Utilization of Cardiac Rehabilitation Among Cardiac Intensive Care Unit Survivors

Cardiac rehabilitation (CR) is associated with decreased mortality and rehospitalization rates for patients with a variety of cardiac conditions. Although CR referral rates for STEMI patients have improved, rates for heart failure have remained low. Many of these patients are admitted to the cardiac intensive care unit (CICU). However, it is unknown how often CICU survivors qualify for cardiac rehabilitation, how often they are referred, and why eligible patients are not referred. This is a retrospective single-center study of 417 consecutive patients admitted to CICU for >48 hours from March 30, 2016 to March 30, 2017. We excluded patients with in-hospital mortality or those discharged AMA, to hospice or transferred. Chart abstraction was used to determine CR indications based on known American College of Cardiology/American Heart Association guidelines. If CR was indicated, medical records through September 2017 were reviewed to determine both referral and participation rates. In the absence of a referral, medical records were reviewed for potential barriers. A total of 296 CICU survivors were identified upon discharge with 185 (63%) having guideline-directed indications for CR referral. The most common indications were heart failure with reduced ejection fraction (HFrEF, 38%), cardiothoracic surgery (26%), and STEMI (23%). Upon discharge, only 30% of patients were referred to CR. The referral rate increased by 33% to 63% by 18 months postdischarge. CR referrals were most frequently placed following STEMI (91%), NSTEMI (80%), and postpercutaneous coronary intervention (80%). Only 35% of HFrEF discharges were referred to CR. Of patients not referred to CR, no explanation for a lack of referral was documented 87% of the time. In conclusion, nearly 2 of 3 patients discharged from the CICU had CR indications, most commonly HFrEF. CR referrals are frequently not placed and reason for nonreferral is rarely documented. CICU admission may provide a defined event to prompt referral.

Assessing Physician Barriers to Cardiac Rehabilitation Referral Rates in a Tertiary Teaching Centre

Introduction: Cardiac rehabilitation (CR) has a proven morbidity and mortality benefit, yet rates of referral remain low. We sought to elucidate the knowledge, utilization, referral, and endorsement practices of cardiac rehabilitation in a tertiary care centre. Methods: A 13-question survey was electronically distributed to all Internal Medicine residents, Cardiology residents and subspecialty fellows, General Internal Medicine attendings and Cardiology attendings practising in a tertiary care centre. The survey assessed the physicians’ knowledge of what CR entails, its benefits, patient eligibility and personal practices with respect to CR referral. Results: The survey was distributed to 153 physicians with a response rate of nearly 60 percent. Compared to their medicine counterparts, Cardiology residents and staff had significantly improved knowledge with respect to what CR entails and eligibility criteria for referral (6.92 vs. 6.11 out of 9, p=0.036; 12.04 vs. 10.76 out of 17, p = 0.013). Medicine residents and staff were less likely to be familiar with CR guidelines (72.02 vs. 32.69, p<0.01), and were less likely to discuss the importance of CR attendance with their patients (43.28 vs. 71.15, p=0.0002). A higher proportion of those in Medicine also reported being unsure of both how to refer eligible patients (59.12 vs. 13.46, p<0.0001) and which patients were eligible for CR (64.92 vs. 23.08, p<0.0001). Higher knowledge scores and familiarity with CR guidelines was associated with higher self-reported referral rates. Conclusion: This survey has identified clear physician barriers, most significant among internal medicine residents and staff. These barriers can help inform interventions to improve CR referral and enrolment rates.

Temporal Trends and Factors Associated With Cardiac Rehabilitation Referral Among Patients Hospitalized With Heart Failure: Findings From Get With The Guidelines–Heart Failure Registry

BackgroundCurrent guidelines recommend cardiac rehabilitation (CR) in medically stable outpatients with heart failure (HF); however, temporal trends and factors associated with CR referral among these patients in real-world practice are not entirely known. ObjectivesThe purpose of this study was to assess proportional use, temporal trends, and factors associated with CR referral at discharge among patients admitted with decompensated HF. MethodsUsing data from a national Get With the Guidelines–Heart Failure registry, we assessed the temporal trends in CR referral among eligible patients with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) at discharge after HF hospitalization between 2005 and 2014. On multivariable analysis, we also assessed patient- and hospital-level characteristics that are associated with CR referral. ResultsAmong 105,619 HF patients (48% with HFrEF, 52% with HFpEF), 10.4% (12.2% with HFrEF, 8.8% with HFpEF) received CR referral at discharge. A significant increase in CR referral rates was observed among both HFpEF and HFrEF patients over the study period (ptrend <0.0001 for HFrEF, HFpEF, and overall). Compared with patients discharged without CR referral, patients referred for CR were younger, predominantly men, and more likely to receive evidence-based HF therapies at discharge. On multivariable analysis, younger age, fewer comorbid conditions, and in-hospital procedures such as coronary artery bypass grafting, percutaneous coronary intervention, and cardiac valve surgery were most strongly associated with CR referral. ConclusionsOnly one-tenth of eligible HF patients received CR referral at discharge after hospitalization for HF. The proportional use of CR referral is increasing over time among both HFrEF and HFpEF patients. Further strategies to improve physician and patient awareness in regard to the benefit of CR should be used to increase CR referral among patients with HF.

Gaps in Referral to Cardiac Rehabilitation of Patients Undergoing Percutaneous Coronary Intervention in the United States

BackgroundRates 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. ObjectivesThis 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. MethodsConsecutive 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. ResultsPatients 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. ConclusionsApproximately 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.

Sex bias in referral of women to outpatient cardiac rehabilitation? A meta-analysis

Cardiovascular disease continues to be among the leading causes of morbidity and mortality among men and women globally. However, research suggests that women are significantly underrepresented in cardiac rehabilitation (CR), programmes which are shown to reduce recurrent cardiac events and related premature death. However, sex differences in referral rates have not been systematically and quantitatively reviewed. Hence, the objective of the study was to assess whether a significant sex difference exists. We searched Scopus, MEDLINE, CINAHL, PsycINFO, PubMed, and The Cochrane Library databases for studies reporting CR referral rates in women and men published between July 2000 and July 2011. Titles and abstracts were screened, and the selected full-text articles were independently screened based on predefined inclusion/exclusion criteria. Included articles were assessed for quality using STROBE. Of 623 screened articles, 19 observational studies reporting data for 241,613 participants (80,505 women) met the inclusion criteria. In the pooled analysis, women (39.6%) were significantly less likely to be referred to CR compared to men (49.4%; odds ratio 0.68, 95% confidence interval 0.62-0.74). Heterogeneity was considered significant (I (2 )= 90%). There was no change in significant findings when subgroup analyses were conducted, examining fee for service vs. no fee, high-quality studies vs. others, or studies pooled by different study methodologies. CR referral remains low for all patients, but is significantly lower for women than men. Evidence-based interventions to increase referral for all patients, including women, need to be instituted. It is time to ensure broader implementation of these strategies.

Temporal Trends and Referral Factors for Cardiac Rehabilitation Post-Acute Coronary Syndrome in Ontario: Insights From the Canadian Global Registry of Acute Coronary Events

BackgroundDespite the beneficial effects of cardiac rehabilitation (CR) on morbidity and mortality after an acute coronary syndrome (ACS), CR referral rates have been lower than recommended. Using the Canadian Global Registry of Acute Coronary Events (GRACE) database, we examined the temporal trends of CR referral rates in Ontario and its associated factors. MethodsFrom the main Canadian GRACE, we retrospectively analyzed data from 11 Ontario hospitals. CR referral rates were analyzed over time. Using multivariate logistic regression, we examined patient characteristics, in-hospital diagnosis, clinical events, and investigations associated with CR referral. ResultsFrom 2000 to 2007, 3338 ACS patients (median age, 64 years; 32% women) were assessed. CR referral rate increased from 2.7% in 2000 to 51.2% in 2007 (P < 0.0001 for trend). Multivariate analysis identified increasing age per decade (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.14-1.29), presentation Killip class ≥ 2 (OR, 1.42; 95% CI, 1.09-1.84), non–ST-elevation ACS (OR, 1.60; 95% CI, 1.35-1.89), no left ventricular function assessment (OR, 1.33; 95% CI, 1.11-1.59), heart failure during hospital admission (OR, 1.48; 95% CI, 1.10-2.00), and in-patient cardiac revascularization (OR, 1.70; 95% CI, 1.38-2.09) as independently associated with lack of CR referral. ConclusionsCR referral rate after ACS in Ontario continues to be lower than recommended, although there has been a steady increase over time. Factors independently associated with lack of CR referral include advanced age, higher Killip class, non–ST-elevation ACS, lack of left ventricular function assessment, in-hospital heart failure, and revascularization. Targeting nonreferred populations might improve quality of care and close care gaps in secondary prevention.

Abstract 335: Cardiac Rehabilitation Referral After Acute Myocardial Infarction: Variation in Referral Rates and Association with Core Components of Risk Factor Management

Background: Although currently an endorsed performance measure of quality, cardiac rehabilitation (CR) referral rates remain quite low. Established guidelines describe recommended core components of CR programs for risk factor management: nutritional counseling; physical activity counseling; exercise training; smoking cessation; and weight, hypertension, lipid, diabetes, and psychosocial management. We sought to determine the variability in hospital referral rates for CR and assess whether patients are more likely to be referred who have risk factors that are intervention targets of the core components of CR. Methods: We assessed referral to outpatient CR among 3632 MI patients from 22 US hospitals in the TRIUMPH study who were discharged home with risk factor data available. Variation in CR referral rates across hospitals was quantified by the median rate ratio (MRR). The prediction of CR referral by 8 individual risk factors that are intervention targets of CR was assessed using hierarchical modified Poisson regression, adjusting for study site and 16 demographic and clinical patient characteristics. Results: Upon hospital discharge, only 39.1% (n=1420) of patients were referred to CR. Referral rates varied greatly across sites, ranging from 2.6% to 88.2%. After adjusting for potentially confounding patient factors, the MRR was 2.47 (95% CI 1.67, 3.23), indicating an average 2.5 times greater likelihood of 2 hypothetically identical patients being referred to CR upon discharge from 1 random hospital as compared with another. Only 1 of 8 risk factors modifiable by CR core components was associated with increased referral (see figure), with overweight patients (BMI &gt; 25 or waist circumference &gt; 40 in. for men, &gt; 35 in. for women) being more likely to be referred than non-overweight patients (RR 1.09; 95% CI 1.03, 1.15; p&lt;0.01). Conclusion: Among patients discharged home after MI hospitalization, there are marked differences in outpatient CR referral rates by study site, but relatively little association with patient risk factors that the core components of CR programs are specifically designed to modify. This suggests that site-specific factors strongly influence CR referral and site-level interventions to improve referral are likely to most effectively improve compliance with this performance measure.

Abstract 126: Trends in Cardiac Rehabilitation Referral after Myocardial Infarction: Data from the National Cardiovascular Data Registry (NCDR®)

Background: Cardiac rehabilitation reduces mortality in patients with recent myocardial infarction (MI), but rates of referral to cardiac rehabilitation in the United States have been low, with referral of only 53% of post-MI patients in a quality improvement registry from 2000-2007. In 2007, the American Heart Association and American College of Cardiology introduced new performance measures for post-MI patients that included referral to cardiac rehabilitation prior to discharge. Objective: We sought to investigate whether cardiac rehabilitation referral rates after MI have changed since publication of this performance measure. Methods: We examined referral to cardiac rehabilitation among 301,247 eligible patients with non-ST segment elevation MI or ST-segment elevation MI from 624 hospitals contributing to the NCDR® ACTION Registry® - Get with the Guidelines (GWTG)™ from January 1, 2007 to June 30, 2012. We evaluated the trend in referral to cardiac rehabilitation using the Cochran-Armitage trend test. Results: Following the inclusion of cardiac rehabilitation referral in performance measures, the percentage of eligible post-MI patients referred to cardiac rehabilitation increased from 73% in 2007 to 81% in 2012 (p&lt;0.0001 for trend) (Table). Patients referred to cardiac rehabilitation were more likely to have undergone catheterization (95.1% vs. 82.8%, p&lt;0.0001) or revascularization (73.6% vs. 44.4%, p&lt;.0001) during the hospitalization than patients who were not referred. Hospitals with a higher rank in performance metrics (not including cardiac rehabilitation referral) had a higher percentage of patients referred to cardiac rehabilitation (86.5% in the highest quartile vs. 61.2% in the lowest quartile, p&lt;0.0001). Conclusions: A significant increase in the proportion of post-MI patients referred to cardiac rehabilitation was observed after referral to cardiac rehabilitation was included in published performance measures.

Abstract 19130: Referral to Cardiac Rehabilitation: A Quality Indicator Associated with Reduced Mortality

Background: Cardiac Rehabilitation (CR) is an efficacious, evidence based treatment for reducing mortality and hospitalization in subjects with coronary artery disease (CAD). CR referral is an indicator of quality care in CAD patients. However, not all eligible subjects are referred for CR. The objective of this study was to assess predictors of referral to CR and the association between referral and mortality. Methods: All subjects who underwent coronary angiography between 1995 and 2009 and were found to have CAD were included in this study (n=25,958, 24.6% female). Referral to CR and subsequent attendance were evaluated. Baseline characteristics were compared between those who were referred and not. Logistic regression models predicting referral were developed. Using cox proportional hazards models, survival was then compared across those who were not referred (NR), referred and did not attend, and referred and did attend. Results: Of those subjects with CAD, 10236 (39.4%) were referred to CR; 58.4% of those referred attended CR. Rates of referral increased from 20.7 to 65.3% over the course of the study (p&lt;0.0001). In multivariate models, older age, being female, and diabetes all predicted non-referral (all p&lt;0.0001). Relative to the NR, those who were referred and did not attend had a hazard ratio (HR) for mortality of 0.55 (95% CI 0.51, 0.60); those who were referred and attended had a HR of 0.26 (95% CI 0.24, 0.29). When adjusted for age, sex, CAD severity, treatment (surgical, interventional, medical) and all clinical covariates, subjects who were referred and did not attend had a HR of 0.76 (95% CI 0.70, 0.82) and subjects who were referred and attended had a HR of 0.42 (95% CI 0.38, 0.46) for death relative to those who were NR. Conclusion: While CR referral rates have improved over time, they remain suboptimal. High-risk subjects are the most likely to remain un-referred. Given the association between CR referral and reduced mortality, referral to CR is a justifiable quality indicator for CAD patient care. Efforts to improve referral should be undertaken.

Management and outcomes following an acute coronary event in patients with chronic heart failure 1999–2007

The outcome of patients with chronic heart failure (CHF) following an ischaemic event is poorly understood. We evaluated the management and outcomes of CHF patients presenting with an acute coronary syndrome (ACS) and explored changes in outcomes over time. A total of 5556 patients enrolled in the Australia-New Zealand population of the Global Registry of Acute Coronary Events (GRACE) between 1999 and 2007 were included. Patients with CHF (n = 609) were compared with those without CHF (n = 4947). Patients with CHF were on average 10 years older, were more likely to be female, had more co-morbidities and cardiac risk factors, and were more likely to have a prior history of angina, myocardial infarction, and revascularization by coronary artery bypass graft (CABG) when compared with those without CHF. CHF was associated with a substantial increase in in-hospital renal failure [odds ratio (OR) 1.76, 95% confidence interval (CI) 1.15-2.71], readmission post-discharge (OR 1.47, 95% CI 1.17-1.90), and 6-month mortality (OR 2.25, 95% CI 1.55-3.27). Over the 9 year study period, in-hospital and 6 month mortality in those with CHF declined by absolute rates of 7.5% and 14%, respectively. This was temporally associated with an increase in prescription of thienopyridines, beta-blockers, statins, and angiotensin II receptor blockers, increased rates of coronary angiography, and 31.8% absolute increase in referral rates for cardiac rehabilitation. Acute coronary syndrome patients with pre-existing CHF are a very high risk group and carry a disproportionate mortality burden. Encouragingly, there was a marked temporal improvement in outcomes over a 9 year period with an increase in evidence-based treatments and secondary preventative measures.

Abstract 255: Temporal Trends and Factors Associated with Referral for Cardiac Rehabilitation Post Acute Coronary Syndrome: Insights from the Canadian Global Registry of Acute Coronary Events (GRACE)

Introduction: The beneficial effects of cardiac rehabilitation (CR) on morbidity and mortality after an acute coronary syndrome (ACS) are well established. Despite guidelines, CR referral rates have been low. Determining factors associated with CR referral would assist in closing this care gap and improve outcomes. Using the Canadian Global Registry of Acute Coronary Events (GRACE) database, we examined 1) the temporal trends of CR referral rates in Canada and its associated factors in a contemporary setting; 2) use of evidence-based medical therapies after ACS and its relationship with CR referral during index hospitalization. Hypothesis: CR referral rates have increased over time but remain below current guideline recommendations. Methods: From the Canadian GRACE registry, we retrospectively analyzed data from 11 Canadian centers during 2000 - 2007. CR referral rates were established and analyzed over time. We compared the CR Referral group to the Non-CR Referral group using univariate logistic regression in regards to patient characteristics, in-hospital diagnosis, clinical events and investigations. Categorical and continuous variables were compared using the chi-square and the Wilcoxon rank sum tests, respectively, with statistical significance at p&lt;0.05. Data of guideline-recommended medication use at discharge and 6 months post-discharge were also analyzed. Results: In the 8-year period, 3338 patients (median age 64 years, 32% women) were assessed. Initial CR referral rate in 2000 was 2.7% (6/219) and increased to 51.2% (220/430) in 2007 (p&lt;0.0001). Univariate factors for CR referral include younger age, larger infarct size, and a diagnosis of STE-ACS. Univariate factors for non-CR referral include CHF, higher GRACE score, and previous CAD. Hospitals with on-site supervised CR facilities had higher CR referral rates. CR Referral group had higher usage of evidence-based medications at time of discharge as well as 6 months post-discharge (all p&lt; 0.0001). Conclusions: There has been a steady increase in CR referrals; however, contemporary numbers are still below the current recommendation of an 85% referral rate. Higher usage of recommended medications in the CR Referral group were noted, likely reflecting the association of CR referral with overall quality of care. Factors associated with CR referral include younger age, larger infarct size, and STE-ACS. Lack of referral was associated with CHF, previous CAD and high GRACE score. Targeting non-referred populations may improve quality of care and close care gaps in secondary prevention.

Trends and disparities in referral to cardiac rehabilitation after percutaneous coronary intervention

Despite the known benefits of cardiac rehabilitation in patients with coronary artery disease, referral rates to rehabilitation programs remain low. We determined the incidence and determinants of cardiac rehabilitation referral rates for patients undergoing percutaneous coronary intervention (PCI). The incidence and predictors of referral to cardiac rehabilitation were assessed among 145,661 consecutive patients undergoing PCI and surviving to hospital discharge across 31 hospitals in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium between 2003 and 2008. The 6-year cardiac rehabilitation referral rate was 60.2%. Younger age, male gender, white race, and presentation with acute or severe disease (ie, acute myocardial infarction [AMI] in the previous 24 hours and ST-elevation myocardial infarction) were associated with increased referral to rehabilitation (all P < .0001). Most medical comorbidities were associated with decreased referral. Referral rates for cardiac rehabilitation were below the rates of other AMI quality-of-care indicators and more variable across hospital sites. Race-specific referral rates differed significantly in the lowest referring hospitals (P < .0001) but not in the highest referring hospitals (P = .16). Women had a 0.7% relative decrease in referral as compared to men (P = .0188) in the highest referring hospitals but a 26.7% relative decrease in referral in the lowest referring hospitals (P = .02). Over one third of patients undergoing PCI are not referred for cardiac rehabilitation. Referral rates are below the rates of other AMI quality-of-care performance measures and more variable across sites. Racial and gender disparities in referral to rehabilitation exist but are concentrated at the lowest referring hospitals.

Factors associated with referral to outpatient cardiac rehabilitation services.

Although practice guidelines and policy statements for cardiac rehabilitation recommend that it be offered to all patients with cardiovascular disease, the participation rates in most Western countries are low. This study aimed to determine the factors associated with referral to outpatient cardiac rehabilitation in the Hunter region of New South Wales, Australia. The study sample comprised 1933 patients discharged from public hospitals in the Hunter region between March 1, 1998 and February 28, 1999 who were eligible for cardiac rehabilitation, and for inclusion on the Hunter Area Heart and Stroke Register (the Register). Data were obtained from the Register database (gender, age, clinical information) and via a self-completed questionnaire eliciting referral, sociodemographic, and cardiovascular disease risk factor information. Multiple logistic regression analysis was conducted to determine the factors independently associated with referral. : Of the respondents (1202/1933), 41% (493/1202; 95% confidence interval, 38-44%) reported that they had been referred to outpatient cardiac rehabilitation. The factors independently associated with referral were age younger than 65 years, previous participation in an outpatient cardiac rehabilitation program, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery. Younger age, previous participation in outpatient cardiac rehabilitation, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery were associated with referral to cardiac rehabilitation. Research testing strategies designed to increase cardiac rehabilitation referral rates are needed and could include testing the potential role of modern quality management methods.

Assessing Physician Barriers to Cardiac Rehabilitation Referral Rates in a Tertiary Teaching Centre

Introduction: Cardiac rehabilitation (CR) has a proven morbidity and mortality benefit, yet rates of referral remain low. We sought to elucidate the knowledge, utilization, referral, and endorsement practices of cardiac rehabilitation in a tertiary care centre.Methods: A 13-question survey was electronically distributed to all Internal Medicine residents, Cardiology residents and subspecialty fellows, General Internal Medicine attendings and Cardiology attendings practising in a tertiary care centre. The survey assessed the physicians’ knowledge of what CR entails, its benefits, patient eligibility and personal practices with respect to CR referral.Results: The survey was distributed to 153 physicians with a response rate of nearly 60 percent. Compared to their medicine counterparts, Cardiology residents and staff had significantly improved knowledge with respect to what CR entails and eligibility criteria for referral (6.92 vs. 6.11 out of 9, p=0.036; 12.04 vs. 10.76 out of 17, p = 0.013). Medicine residents and staff were less likely to be familiar with CR guidelines (72.02 vs. 32.69, p&lt;0.01), and were less likely to discuss the importance of CR attendance with their patients (43.28 vs. 71.15, p=0.0002). A higher proportion of those in Medicine also reported being unsure of both how to refer eligible patients (59.12 vs. 13.46, p&lt;0.0001) and which patients were eligible for CR (64.92 vs. 23.08, p&lt;0.0001). Higher knowledge scores and familiarity with CR guidelines was associated with higher self-reported referral rates. Conclusion: This survey has identified clear physician barriers, most significant among internal medicine residents and staff. These barriers can help inform interventions to improve CR referral and enrolment rates.