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Cardiac rehabilitation (CR) use is lower for racial and ethnic minorities than White patients. The purpose of this study was to identify factors that drive this disparity at the system, provider, and patient levels. A mixed methods study combined descriptive analysis of 2007 Medicare claims data and thematic analysis of 19 clinician interviews, 8 minority patient focus groups and 8 one-on-one interviews with minority heart patients across three communities. The disparity between White and non-White CR use ranged from 7 to 11 percentage points among study sites (p < .05). Key themes suggest disparities are driven by (a) flawed financing and reimbursement that creates disincentives to invest in CR programs, (b) a health care system whose priorities are misaligned with the needs of patients, and (c) subjective decision-making around referral processes. These findings suggest that the health care system needs to address multiple levels of problems to mitigate disparities in CR use.

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Although the career span of a PA is only vaguely understood, a small but significant portion of clinicians appear to remain in the workforce into their seventh decade. They distinguish themselves by working proportionally more in primary care and nonurban areas than younger PAs. Older PAs may represent an American trend by remaining employed longer than historically observed. Gaps in the understanding of role behavior of PAs could be improved with longitudinal databases.