Author + information
- Rosanna Tavella, BSc (Hons), PhD,
- Margaret Arstall, MBBS, PhD and
- John F. Beltrame, BSc, BMBS, PhD∗ ()
- ↵∗Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, 5011 South Australia, Australia
Pharmacological guideline–recommended therapies (i.e., aspirin, statins) are prescribed in >90% of patients undergoing percutaneous coronary interventions (PCIs); however, cardiac rehabilitation (CR) referral occurs in only 60% of these patients. Using CathPCI Registry data, Aragam et al. (1) demonstrated that this “CR referral gap” is endemic, with hospital characteristics being highly influential, patient factors playing less of a role, and insurance status the least influential. Whether this is a reflection of the U.S. health care system or an international phenomenon requires further consideration.
The CADOSA (Coronary Angiogram Database of South Australia) (2) mimics the CathPCI data elements and provides an opportunity to examine the CR referral gap in a universal health care system. CADOSA captures all public hospital PCIs performed in the state of South Australia (population 1.5 million). Patients are not charged for in-hospital services, and each hospital conducts a no-charge CR program. Independent of the differences in health care systems, analysis of CADOSA data during the period 2012 through 2013 (2,624 PCI patients) revealed findings similar to those of Aragam et al. (1), with only 53% of all PCI patients referred for CR. Also similar to the U.S. data, this referral gap was greater than that observed for other quality measures (Figure 1). Furthermore, the CADOSA data confirm the relative contribution of predictors of CR referral including: 1) hospital characteristics: site-specific variability ranging from 24% to 86%; 2) patient-level factors: ST-segment elevation MI (odds ratio: 2.7, 95% confidence interval: 2.2 to 3.2; p < 0.01) or non-ST-segment elevation MI (odds ratio: 1.5, 95% confidence interval: 1.3 to 1.8; p < 0.01) were key predictors in multivariable analyses; and 3) insurance status: irrelevant in this public system. Thus, the CR referral gap appears to be a universal phenomenon with similar characteristics.
As described by Thomas (3), the work by Aragam et al. (1) is a call to action to create system-based solutions to improve the barriers to CR referral. These data suggest that this is universally applicable, and individual hospitals need to adopt innovative strategies that optimize referral.
Please note: The CADOSA registry is funded by the National Heart Foundation of Australia and the South Australian Department of Health. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
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