Author + information
- Krishna G. Aragam, MD, MS∗ (, )
- Milan Seth, MS and
- Hitinder S. Gurm, MBBS
- ↵∗Cardiology Division, Massachusetts General Hospital, 55 Fruit Street, GRB 8-852, Boston, Massachusetts 02114
We thank Drs. Tavella, Arstall, and Beltrame for their interest in our paper and for extending our findings regarding cardiac rehabilitation (CR) referral patterns after percutaneous coronary intervention (PCI) (1) beyond the United States. Through analysis of the Coronary Angiogram Database of South Australia (CADOSA), the authors establish under-referral to CR after PCI as an international problem influenced heavily by hospital-level determinants, as evidenced by considerable site-specific variability in referral rates.
We also thank Drs. Dahhan, Maddox, and Sharma for demonstrating the effects of a single-center intervention on CR referral rates. An initiative focused on formalizing the CR referral process and educating physicians on the indications for CR resulted in a 4-fold increase in CR referral rates within 6 months of study intervention, with an associated >30% relative increase in rates of CR participation and graduation (2).
Our previous analysis of CR referral rates for the period 2003 through 2008 in the Blue Cross Blue Shield of Michigan Cardiovascular Collaborative (BMC2), a statewide PCI registry in Michigan, demonstrated a CR referral rate of 60.2%, with significant variability across hospitals – referral rates >90% in the top quartile versus <20% in the bottom quartile of all sites (3). A collaborative-wide quality improvement initiative was implemented in 2010 to address the notable gap in CR referral, with operator- and institution-specific feedback provided to each site, including site-specific reports of patients who were not referred for CR. We observed a marked improvement in CR referral rates over the ensuing 3 years with an increase in the collaborative mean from 63.6% in 2010 to 78.2% by 2013. There was a corresponding reduction in site-specific variability over the same time period; by 2013, three-fourths of all sites had achieved referral rates higher than the 2010 collaborative mean. Notably, a few underperforming sites remained in 2013 with referral rates <20%, which appreciably tempered the improvements in overall referral rates (Figure 1).
We applaud the efforts of the aforementioned authors and agree wholeheartedly that the CR referral gap is a “system-based problem with system-based solutions” (4) and that enacting broad-scale changes in referral patterns begins with targeted interventions to improve referral rates at individual underperforming institutions. We are encouraged by the above experiences that simple interventions focused on increasing physician awareness, establishing measures of accountability, and formalizing the referral process can affect prompt improvements in statewide, national, and international CR referral rates with an ultimate increase in the use of CR services.
Please note: Dr. Gurm has received research funding from the National Institutes of Health and the Agency for Health Care Research and Quality (AHRQ). All other 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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