The rates of initiating participation in a cardiac rehabilitation (CR) program continue to be low across the U.S., with a wide geographic variation in these rates, which was found to be related to poor availability of CR programs, according to a study published March 13 in JACC.

Only about 10% to 40% of eligible patients at the state level initiate CR and initiation is tied to better adherence. To examine the role of access to CR programs on these rates, Meredith S. Duncan, MS, et al., compared initiation rates at the hospital referral region level among 1,133,657 eligible Medicare beneficiaries from 2014 to 2017.

Results showed that 23% of eligible patients started CR, with the highest adjusted initiation rate (35.4%) and highest density of CR programs (6.58 per 1,000 eligible Medicare beneficiaries) occurring in the West North Central Census Division.

The density of CR programs was found to account for 21.2% of geographic variation in program initiation (p<0.0001). Additional factors impacting CR initiation were average distance to the nearest CR center (11.0% of geographic variation) and eligible diagnosis (4.5% of geographic variation). Researchers found that "40 largely urban counties comprising 14% of the [U.S.] population age ≥65 years had disproportionately low [CR] access," and were therefore identified as CR deserts.

On multivariable adjustment, several groups were found to have a lower likelihood of starting CR: women (odds ratio [OR], 0.81); Blacks (OR, 0.79); Asians (OR, 0.91); Hispanics (OR, 0.76); North American Natives (OR, 0.63). Patients who had cardiac valve surgery or CABG had the highest odds of starting CR. Factors associated with decreased odds of starting rehab were more comorbidities, Medicaid eligibility and increasing social deprivation.

Of patients who initiated CR, they attended an average of 26 sessions and the median wait time from hospital discharge to starting CR was 39 days. At the county level, shorter wait times were associated with increased CR initiation.

In an accompanying editorial comment, Todd M. Brown, MD, FACC, writes, "The future of [CR] will necessarily involve a hybrid of delivery strategies, in-person, virtual, and remote, to meet the needs of our patients, improve access, and eliminate disparities in care. The current analysis by Duncan, et al., helps to inform these strategies by highlighting the roles that [CR] deserts and reduced [CR] center density have in limiting access to and widening inequalities in [CR] services."

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention

Keywords: Aged, United States, Female, Medicaid, Medicare, Odds Ratio, Patient Discharge, Waiting Lists, African Americans, Censuses, Referral and Consultation, Coronary Artery Bypass

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