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Circulation. 2018 May 1;137(18):1899-1908. doi: 10.1161/CIRCULATIONAHA.117.029471. Epub 2018 Jan 5.

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

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VA Puget Sound Health Care System, Seattle, WA (A.L.B.).
Department of Medicine, University of Washington, Seattle (A.L.B., M.T.).
San Francisco VA Medical Center, CA (D.W.S., H.S., M.A.W.).
Department of Medicine, University of California, San Francisco (D.W.S., M.A.W.).
Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (J.M.B.).
Department of Epidemiology and Biostatistics, University of California, San Francisco (M.A.W.).



Cardiac rehabilitation is strongly recommended after myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery, but it 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 International Classification of Diseases, 9th Revision codes to identify patients hospitalized for myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery from 2007 to 2011. After excluding patients who died in ≤30 days of hospitalization, we calculated the percentage of patients who participated in ≥1 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% (9123/88 826) 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, whereas those in the Pacific region (Alaska, California, Hawaii, Oregon, and Washington) had the lowest participation in both Medicare (33.7% versus 10.6%) and VA (16.6% versus 5.1%) populations. Significant hospital-level variation was also present, with participation ranging from 3% to 75% in Medicare and 1% to 43% in VA.


Cardiac rehabilitation participation remains low overall in both Medicare and VA populations. However, remarkably similar regional variation exists, 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.


cardiac rehabilitation; cardiovascular surgery; coronary artery disease; percutaneous coronary intervention; quality of health care

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