Background: Cardiac rehabilitation (CR) is associated with improved outcomes for patients with coronary artery disease (CAD). However, CR enrollment remains low and there is a dearth of real-world data on hospital-level variation in CR enrollment. We sought to explore determinants of hospital variability in CR enrollment during CAD episodes of care: medical management of acute myocardial infarction (AMI-MM), percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Methods: A cohort of 71 703 CAD episodes of care were identified from 33 hospitals in the Michigan Value Collaborative statewide multipayer registry (2015 to 2018). CR enrollment was defined using professional and facility claims and compared across treatment strategies: AMI-MM (n=18 678), PCI (n=41 986), and CABG (n=11 039). Hierarchical logistic regression was used to estimate effects of predictors and hospital risk-adjusted rates of CR enrollment. Results: Overall, 20 613 (28.8%) patients enrolled in CR, with significant differences by treatment strategy: AMI-MM=13.4%, PCI=29.0%, CABG=53.8% ( P <0.001). There were significant differences in CR enrollment across age groups, comorbidity status, and payer status. At the hospital-level, there was over 5-fold variation in hospital risk-adjusted CR enrollment rates (9.8%–51.6%). Hospital-level CR enrollment rates were highly correlated across treatment strategy, with the strongest correlation between AMI-MM versus PCI (R 2 =0.72), followed by PCI versus CABG (R 2 =0.51) and AMI-MM versus CABG (R 2 =0.46, all P <0.001). Conclusions: Substantial variation exists in CR enrollment during CAD episodes of care across hospitals. However, within-hospital CR enrollment rates were significantly correlated across all treatment strategies. These findings suggest that CR enrollment during CAD episodes of care is the product of hospital-specific rather than treatment-specific practice patterns.

Background: Despite its established benefit and strong endorsement in international guidelines, cardiac rehabilitation (CR) use remains low. Identifying determinants of CR referral and use may help develop targeted policies and quality improvement efforts. We evaluated the variation in CR referral and use across percutaneous coronary intervention (PCI) hospitals and operators. Methods: We performed a retrospective observational cohort study of all patients who underwent PCI at 48 nonfederal Michigan hospitals between January 1, 2012 and March 31, 2018 and who had their PCI clinical registry record linked to administrative claims data. The primary outcomes included in-hospital CR referral and CR participation, defined as at least one outpatient CR visit within 90 days of discharge. Bayesian hierarchical regression models were fit to evaluate the association between PCI hospital and operator with CR referral and use after adjusting for patient characteristics. Results: Among 54 217 patients who underwent PCI, 76.3% received an in-hospital referral for CR, and 27.1% attended CR within 90 days after discharge. There was significant hospital and operator level variation in in-hospital CR referral with median odds ratios of 3.88 (95% credible interval [CI], 3.06–5.42) and 1.64 (95% CI, 1.55–1.75), respectively, and in CR participation with median odds ratios of 1.83 (95% CI, 1.63–2.15) and 1.40 (95% CI, 1.35–1.47), respectively. In-hospital CR referral was significantly associated with an increased likelihood of CR participation (adjusted odds ratio, 1.75 [95% CI, 1.52–2.01]), and this association varied by treating PCI hospital (odds ratio range, 0.92–3.75) and operator (odds ratio range, 1.26–2.82). Conclusions: In-hospital CR referral and 90-day CR use after PCI varied significantly by hospital and operator. The association of in-hospital CR referral with downstream CR use also varied across hospitals and less so across operators suggesting that specific hospitals and operators may more effectively translate CR referrals into downstream use. Understanding the factors that explain this variation will be critical to developing strategies to improve CR participation overall.

Statewide Collaboration to Improve CR E75 E xercise-based cardiac rehabilitation (CR) is an underutilized service with well-documented clinical and functional benefits for patients with cardiovascular disease. 1-4 Despite strong recommendations supporting its use across a spectrum of cardiovascular conditions and procedures, only a quarter of eligible patients attend a single session of CR and even fewer patients complete the recommended 36 CR sessions. [5][6][7][8][9] Participation in CR varies on the basis of age, race, sex, type of qualifying event, type of health insurance, discharging hospital, and geographic region, suggesting opportunities for targeted quality improvement efforts. [10][11][12][13][14][15][16][17][18][19] Professional societies and federal agencies have set national goals for CR enrollment, developed a road map and resources to achieve this goal, and created valid and reliable performance measures to benchmark CR performance, yet significant and sustained improvement in CR participation remains elusive. [20][21][22] Regional quality improvement collaboratives may provide one solution to improving CR participation and quality through benchmarking performance and facilitating quality improvement efforts. In Michigan, statewide collaborative quality initiatives (CQIs) were developed as a partnership between hospitals, physicians, and a large private insurer with the goal of improving quality and costs of care through data collection and the sharing of best practices. 23 For almost 25 yr, the CQI model has demonstrated success in evaluating and improving the quality of care for patients undergoing cardiovascular procedures. [24][25][26][27][28][29] For example, the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2), a CQI focused on improving outcomes after percutaneous coronary intervention (PCI), reduced the risk-adjusted rate of acute kidney injury after PCI from 3.3% in 2010 to 2.5% in 2016 through the development and sharing of best practices around identifying patient-specific contrast thresholds and emphasizing periprocedural hydration. 30 In this spirit, the BMC2 partnered with another CQI, the Michigan Value Collaborative (MVC), to identify and evaluate variation in the use of CR after PCI, coronary artery bypass grafting (CABG), and medically managed acute myocardial infarction (AMI) using clinical and claims data registries. 10,11,31 Establishing engagement across inpatient and outpatient settings using the CQI model is a needed step to assist with improving CR enrollment and quality.

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Background: Despite reported benefit in the setting of aortic valve replacement (AVR), cardiac rehabilitation (CR) utilization remains low, with few studies evaluating hospital and patient-level variation in CR participation. We explored determinants of CR variability during AVR episodes of care: transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). Methods: A cohort of 10,124 AVR episodes of care (TAVR n=5,121 from 24 hospitals; SAVR n=5,003 from 32 hospitals) were identified from the Michigan Value Collaborative statewide multipayer registry (2015 to 2019). CR enrollment was defined as the presence of a single professional or facility claim within 90 days of discharge: 93797, 93798, G0422, G0423. Annual trends and hospital variation in CR were described for TAVR, SAVR, and all AVR. Multilevel logistic regression was used to estimate effects of predictors and hospital risk-adjusted rates of CR enrollment. Results: Overall, 4,027 (39.8%) patients enrolled in CR, with significant differences by treatment strategy: SAVR=50.9%, TAVR=28.9% (p<0.001). CR use after SAVR was significantly higher than after TAVR and increased over time for both modalities (p<0.001). There were significant differences in CR enrollment across age, gender, payer, and some comorbidities (p<.05). At the hospital-level, CR participation rates for all AVR varied 10-fold (4.8% to 68.7%) and were moderately correlated between SAVR and TAVR (Pearson r =0.56, p<0.01). Conclusions: Substantial variation exists in CR participation during AVR episodes of care across hospitals. However, within-hospital CR participation rates were significantly correlated across treatment strategies. These findings suggest that CR participation is the product of hospital-specific practice patterns. Identifying hospital practices associated with higher CR participation can help assist future quality improvement efforts to increase CR use after AVR.

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Intro: Despite providing benefit in the setting of aortic valve replacement (AVR), cardiac rehabilitation (CR) utilization remains low, with few studies evaluating hospital and patient-level variation in CR enrollment. We explored determinants of CR variability during AVR episodes of care: transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). Methods/Results: A cohort of 10,124 AVR episodes of care (TAVR n=5,121 from 24 hospitals; SAVR n=5,003 from 32 hospitals) were identified from the Michigan Value Collaborative statewide multipayer registry (2015 to 2019). CR enrollment was defined as the presence of a professional or facility claim (93797, 93798, G0422, G0423) within 90 days of discharge. Annual trends in CR were evaluated for TAVR, SAVR, and all AVR. CR use in SAVR was significantly higher than TAVR and increased over time for all modalities (p<0.001, Figure 1). Multilevel logistic regression analysis identified significant differences in CR enrollment across age groups, comorbidities, and payer status. At the hospital-level, CR enrollment rates for all AVR varied 10-fold (4.8% to 68.7%) and moderately correlated between SAVR and TAVR (Pearson r=0.56, p<0.01, Figure 2). Conclusions: Substantial variation exists in CR enrollment during AVR episodes of care across hospitals. However, within-hospital CR enrollment rates were significantly correlated across treatment strategies. These findings suggest that CR enrollment is the product of hospital-specific practice patterns. Identifying hospital practices associated with higher CR enrollment can help assist future quality improvement efforts to increase CR use after AVR.