Geographic Variation in Cardiac Rehabilitation Participation in Medicare and Veterans Affairs Populations: An Opportunity for Improvement?

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Cardiac rehabilitation is strongly recommended after myocardial infarction (MI), percutaneous coronary intervention (PCI), or coronary artery bypass surgery (CABG), but is historically underused. We sought to evaluate variation in cardiac rehabilitation participation across the United States.


From administrative data from the Veterans Affairs (VA) healthcare system and a 5% Medicare sample, we used ICD-9 codes to identify patients hospitalized for MI, PCI, or CABG from 2007-2011. After excluding patients who died within 30 days of hospitalization, we calculated the percent of patients who participated in one or more outpatient visits for cardiac rehabilitation during the 12 months after hospitalization. We estimated adjusted and standardized rates of participation in cardiac rehabilitation by state using hierarchical logistic regression models.


Overall, participation in cardiac rehabilitation was 16.3% (23,403/143,756) in Medicare and 10.3% (9,123/88,826) in VA. However, participation rates varied widely across states, ranging from 3.2% to 41.8% in Medicare and 1.2% to 47.6% in VA. Similar regional variation was observed in both populations. Patients in the West North Central region (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota) had the highest participation, while those in the Pacific region (Alaska, California, Hawaii, Oregon, and Washington) had the lowest participation in both Medicare (33.7% vs. 10.6%) and VA (16.6% vs. 5.1%) populations. Significant hospital-level variation was also present, with participation ranging from 3-75% in Medicare and 1-43% in VA.


Cardiac rehabilitation participation remains low overall in both Medicare and VA populations. However, there is remarkably similar regional variation, with some regions and hospitals achieving high rates of participation in both populations. This provides an opportunity to identify best practices from higher-performing hospitals and regions that could be used to improve cardiac rehabilitation participation in lower-performing hospitals and regions.

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