Cascade of Cardiac Rehabilitation Referral, Enrollment, and Completion and Its Major Predictors in a Large Hospital System

Purpose: Cardiac rehabilitation (CR) is an effective but underused secondary prevention strategy. We evaluated where the relative gap in the implementation of CR occurs and characteristics related to CR utilization. Methods: We analyzed electronic health records from a large academic health system (2017–2019). We included patients aged ≥18 years, hospitalized with a cardiac event, with an indication for CR. We evaluated crude proportions and used mixed-effects logistic regression to examine the association of characteristics with referral, enrollment (≥1 session), and completion (≥36 sessions), accounting for multiple admissions. Results: Among 4084 patient encounters (mean age: 65.3 ± 14.6 years, 45% female, and 42% Black), 25% were referred, 29% of those referred, enrolled, and 21% of those enrolled, completed CR. We identified characteristics associated with lower CR referral, for example, Black patients (OR = 0.64: 95% CI, 0.50–0.80), female patients (OR = 0.68: 95% CI, 0.56–0.83), and discharge from noncardiology services (eg, OR = 0.07: 95% CI, 0.05–0.10 for general medicine). Post-discharge outpatient visits were associated with higher CR referrals (eg, OR = 1.94: 95% CI, 1.56–2.41 for cardiology follow-up visits). The pattern was largely similar for enrollment and completion, except for higher enrollment for cardiac surgery and lower enrollment for lower-income patients. Conclusions: In the CR care cascade, significant bottlenecks exist at each step, with the narrowest bottleneck noted at the completion stage. We also identified demographic and health system characteristics related to lower CR utilization, which can guide system- and individual-level efforts to promote CR use.