Interhospital Variability in Cardiac Rehabilitation Use After Cardiac Surgery Among Medicare Beneficiaries

Maximilian A Fliegner; Hechuan Hou; Tyler M Bauer; Temilolaoluwa Daramola; Jeffrey S McCullough; Francis D Pagani; Devraj Sukul; Donald S Likosky; Steven J Keteyian; Michael P Thompson

doi:10.1016/j.jtcvs.2024.04.019

Interhospital Variability in Cardiac Rehabilitation Use After Cardiac Surgery Among Medicare Beneficiaries

J Thorac Cardiovasc Surg. 2024 Apr 20:S0022-5223(24)00363-5. doi: 10.1016/j.jtcvs.2024.04.019. Online ahead of print.

Affiliations

¹ Oakland University William Beaumont School of Medicine, Auburn Hills, MI.
² Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI.
³ Department of Surgery, University of Michigan, Ann Arbor, MI.
⁴ Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI.
⁵ Division of Cardiovascular Medicine, Department of General Internal Medicine, Michigan Medicine, Ann Arbor, MI.
⁶ Division of Cardiovascular Medicine, Henry Ford Health, Detroit, MI.
⁷ Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI. Electronic address: mthomps@med.umich.edu.

PMID: 38649110
DOI: 10.1016/j.jtcvs.2024.04.019

Abstract

Objective: Despite guideline recommendation, cardiac rehabilitation (CR) following cardiac surgery remains underutilized, and the extent of interhospital variability is not well understood. This study evaluated determinants of interhospital variability in CR use and outcomes.

Methods: This retrospective cohort study included 166,809 Medicare beneficiaries undergoing cardiac surgery who were discharged alive between 07/01/2016 and 12/31/2018. CR participation was identified in outpatient facility claims within a year of discharge. Hospital-level CR rates were tabulated, and multilevel models evaluated the extent to which patient, organizational, and regional factors accounted for interhospital variability. Adjusted 1-year mortality and readmission rates were also calculated for each hospital quartile of CR use.

Results: Overall, 90,171 (54.1%) participated in at least one CR session within a year of discharge. Interhospital CR rates ranged from 0.0% to 96.8%. Hospital factors that predicted CR use included non-teaching status and lower hospital volume. Before adjusting for patient, organizational, and regional factors, 19.3% of interhospital variability was attributable to the admitting hospital. After accounting for covariates, 12.3% of variation was attributable to the admitting hospital. Patient (0.5%), structural (2.8%), and regional (3.7%) factors accounted for the remaining explained variation. Hospitals in the lowest quartile of CR use had higher adjusted 1-year mortality rates (Q1 = 6.7%, Q4 = 5.2%, p < 0.001) and readmission rates (Q1 = 37.6%, Q4 = 33.9%, p<0.001).

Conclusion: Identifying best practices among high CR use facilities and barriers to access in low CR use hospitals may reduce interhospital variability in CR use and advance national improvement efforts.

Keywords: CABG; Cardiac rehabilitation; SAVR; cardiac surgery.