Cardiac Rehabilitation Use After Percutaneous Coronary Intervention

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Coronary artery disease undergoing percutaneous coronary intervention (PCI) (n=26168). Intervention: Demographic, procedural, geographic, and socioeconomic factors (e.g., Medicare FFS insurance vs. BCBSM PPO insurance) vs. Blue Cross Blue Shield of Michigan preferred provider organization (BCBSM PPO) insurance. Primary outcome: Attendance at ≥1 outpatient cardiac rehabilitation session within 90 days after discharge (aOR 0.81, 95% CI 0.72-0.90, p=<0.001).

Q: What does this research mean for the field?

Only 31.5% of patients referred for cardiac rehabilitation after percutaneous coronary intervention attend at least one session within 90 days, with utilization significantly constrained by public insurance coverage, greater distance between the procedural hospital and the rehabilitation facility, and socioeconomic disadvantage. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

Q: What question did this study set out to answer?

To identify demographic, procedural, geographic, and socioeconomic factors associated with outpatient cardiac rehabilitation attendance among patients referred after percutaneous coronary intervention.

Devraj Sukul; Milan Seth; Geoffrey D. Barnes; James M. Dupree; John D. Syrjamaki; Simon R. Dixon; Ryan D. Madder; Daniel H. Lee; Hitinder Singh Gurm

doi:10.1016/j.jacc.2019.03.515

June 1, 2019Journal of the American College of CardiologyOpen Access

Cardiac Rehabilitation Use After Percutaneous Coronary Intervention

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Key result

Medicare FFS linked to ~19% lower cardiac rehabilitation attendance after PCI vs. private insurance.

aOR 0.81
95% CI 0.72-0.90
P<0.001
n=26,168

Why the study?

Despite guideline recommendations and increased emphasis on improving cardiac rehabilitation referral rates after PCI, research examining the link between referral and actual attendance, as well as the patient and socioeconomic factors associated with downstream utilization, remained limited.

What patient demographic, clinical, insurance, geographic, and socioeconomic factors are associated with outpatient cardiac rehabilitation utilization within 90 days among patients referred for cardiac rehabilitation after percutaneous coronary intervention?

Key Points

To identify demographic, procedural, geographic, and socioeconomic factors associated with outpatient cardiac rehabilitation attendance among patients referred after percutaneous coronary intervention.
Linked the prospective BMC2 clinical registry of percutaneous coronary intervention (PCI) procedures across 47 non-federal hospitals in Michigan with administrative claims data from January 2012 to October 2016.
Analyzed 26,168 patients discharged alive to home with a referral for cardiac rehabilitation and a valid residential ZIP code.
Assessed cardiac rehabilitation attendance (at least one session within 90 days after discharge) using billing claims, analyzing insurance type, socioeconomic factors, and travel distances.
A total of 8,246 of 26,168 referred patients (31.5%) attended at least one cardiac rehabilitation session within 90 days after discharge.
Compared with BCBSM PPO private insurance, Medicare FFS was associated with lower attendance (aOR: 0.81; 95% CI 0.72–0.90; p<0.001), with dual Medicare-Medicaid eligibility showing even lower odds (aOR: 0.44; 95% CI 0.38–0.51; p<0.001).

Study Design

Type

Cohort (n=26,168)

Multicenter

Yes

Structured PICO

What patient demographic, clinical, insurance, geographic, and socioeconomic factors are associated with outpatient cardiac rehabilitation utilization within 90 days among patients referred for cardiac rehabilitation after percutaneous coronary intervention?

P

Population

26,168 patients undergoing PCI at 47 hospitals in Michigan who were discharged home with a cardiac rehabilitation referral, followed for 90 days.

E

Exposure

Referral for outpatient cardiac rehabilitation (CR) prior to PCI discharge, evaluated across demographic, clinical, insurance (Medicare FFS, dual Medicare/Medicaid eligibility, BCBSM PPO), geographic (distance from PCI site to nearest CR facility >2 miles vs. ≤2 miles; distance from residential ZIP code centroid to nearest CR facility), and ZIP code-level socioeconomic factors (Area Deprivation Index, educational attainment, poverty status).

O

Outcome

Attendance at least one outpatient cardiac rehabilitation (CR) session within 90 days after PCI discharge, determined from administrative claims (CPT codes 93797, 93798; HCPCS codes G0422, G0423; revenue center code 943).

Main Result

Odds Ratio: 0.81 (95% CI 0.72–0.9)

p-value: p=<0.001

Despite in-hospital referral after PCI, fewer than one-third (31.5%) of patients attend outpatient cardiac rehabilitation within 90 days, with attendance strongly influenced by insurance type, socioeconomic status, and proximity of the PCI hospital to a cardiac rehabilitation facility.

Limitations

Limited to a single state (Michigan) with a long-standing quality improvement program, limiting generalizability.
Only evaluated cardiac rehabilitation use in patients insured by Medicare fee-for-service or Blue Cross Blue Shield of Michigan PPO.
Only had access to area-level, rather than patient-level, socioeconomic factors and geographic distances, potentially subjecting analyses to ecological fallacy and misclassification bias.
Limited to a single state (Michigan) with a long-standing quality improvement program, limiting generalizability to other states
Only evaluated CR use in patients insured by Medicare FFS or BCBSM PPO
Only had access to area-level, rather than patient-level, socioeconomic factors and geographic distances, potentially subjecting analyses to ecological fallacy and misclassification bias

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Implication

Insurance type and PCI site proximity influence post-referral cardiac rehabilitation attendance; leaves open targeted interventions to improve uptake.

Abstract

Among patients with coronary artery disease, participation in outpatient cardiac rehabilitation (CR) is associated with improved quality of life and reduced rates of readmission and cardiovascular mortality [(1)][1]. For these reasons, CR is recommended in international guidelines [(2,3)][2].

Discussion

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Cite This Study

Sukul et al. (2019) conducted a cohort in Coronary artery disease undergoing percutaneous coronary intervention (PCI) (n=26,168). Demographic, procedural, geographic, and socioeconomic factors (e.g., Medicare FFS insurance vs. BCBSM PPO insurance) vs. Blue Cross Blue Shield of Michigan preferred provider organization (BCBSM PPO) insurance was evaluated on Attendance at ≥1 outpatient cardiac rehabilitation session within 90 days after discharge (aOR 0.81, 95% CI 0.72-0.90, p=<0.001).

synapsesocial.com/papers/6af0e67a6a7c504774d4e745 https://doi.org/10.1016/j.jacc.2019.03.515

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Cardiac Rehabilitation Use After Percutaneous Coronary Intervention

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Cardiac Rehabilitation Use After Percutaneous Coronary Intervention

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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