Abstract Body (Do not enter title and authors here): Background: Hospitalization is an opportunity to refer and recruit eligible patients to cardiac rehabilitation (CR). Despite national goals to enroll 70% of CR-eligible patients, enrollment remains low, and little is known about how hospitals influence CR enrollment at the national level.
Methods: We included fee-for-service Medicare beneficiaries older than 65 years who were hospitalized in 2017 for acute myocardial infarction (AMI), coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or heart valve repair/replacement. We examined the role of the hospital in CR enrollment using three different methods: 1.) a risk-standardized model to assess comparative hospital rates with bootstrap methods to group hospitals as above, at, or below national rates of CR (as might be done for quality incentives); 2.) a linear regression model to identify hospital factors associated with rates of risk-standardized CR; and 3.) a hierarchical generalized linear model to allow calculation of the hospital Median Odds Ratio (MOR).
Results: At 3,420 hospitals, we identified 264,970 eligible patients. While a minority of hospitals (1,446; 38%) performed cardiac surgery, these hospitals cared for the vast majority (242,875; 92%) of all eligible patients, and subsequent analyses were limited to these hospitals. The median risk-standardized CR enrollment rate was low (22%) and varied 10-fold across hospitals at the 10^th and 90^th percentiles (3%, 42%). Bootstrap methods to group hospitals as above, at, or below national average demonstrated that about one-fifth of hospitals [301, 21%] had worse performance than the national mean and about one-third [453, 31%] had better performance than the national mean. Factors associated with higher hospital performance were Midwest location, higher number of hospital beds, directly affiliated CR program, and <1 mile distance between the hospital and closest CR facility. The national hospital MOR was 2.1, similar in effect size as Midwest location.
Discussion: The referring hospital plays a key role in facilitating CR enrollment after discharge, Fewer than 1% of US hospitals achieved a risk-standardized CR enrollment rate of >70%. Hospitals with cardiac surgery capability care for more than 90% of all CR-eligible patients, and may be a logical place to focus improvement efforts.