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. 2023 Mar 21;81(11):1049-1060.
doi: 10.1016/j.jacc.2023.01.016.

Geographic Variation in Access to Cardiac Rehabilitation

Meredith S Duncan  1 , Natalie N Robbins  2 , Steven A Wernke  3 , Robert A Greevy Jr  4 , Sandra L Jackson  5 , Alexis L Beatty  6 , Randal J Thomas  7 , Mary A Whooley  8 , Matthew S Freiberg  9 , Justin M Bachmann  10
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Geographic Variation in Access to Cardiac Rehabilitation

Meredith S Duncan et al. J Am Coll Cardiol. .

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  • Correction.
    [No authors listed] [No authors listed] J Am Coll Cardiol. 2023 Jun 13;81(23):2295-2297. doi: 10.1016/j.jacc.2023.04.025. J Am Coll Cardiol. 2023. PMID: 37286260 No abstract available.

Abstract

Background: There is marked geographic variation in cardiac rehabilitation (CR) initiation, ranging from 10% to 40% of eligible patients at the state level. The potential causes of this variation, such as patient access to CR centers, are not well studied.

Objectives: The authors sought to determine how access to CR centers affects CR initiation in Medicare beneficiaries.

Methods: The authors used Medicare files to identify CR-eligible Medicare beneficiaries and calculate CR initiation rates at the hospital referral region (HRR) level. We used linear regression to evaluate the percent variation in CR initiation accounted for by CR access across HRRs. We then employed geospatial hotspot analysis to identify CR deserts, or counties in which patient load per CR center is disproportionately high.

Results: A total of 1,133,657 Medicare beneficiaries were eligible for CR from 2014 to 2017, of whom 263,310 (23%) initiated CR. The West North Central Census Division had the highest adjusted CR initiation rate (35.4%) and the highest density of CR programs (6.58 per 1,000 CR-eligible Medicare beneficiaries). Density of CR programs accounted for 21.2% of geographic variation in CR initiation at the HRR level. A total of 40 largely urban counties comprising 14% of the United States population age ≥65 years had disproportionately low CR access and were identified as CR deserts.

Conclusions: A substantial proportion of geographic variation in CR initiation was related to access to CR programs, with a significant amount of the U.S. population living in CR deserts. These data invite further study on interventions to increase CR access.

Keywords: access to care; cardiac rehabilitation; geographic variation.

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Conflict of interest statement

Funding Support and Author Disclosures This project was supported by the Vanderbilt Clinical and Translational Science grant UL1TR000445 (Bachmann) and grant KL2TR001996 (Duncan) from the National Center for Advancing Translational Sciences at the National Institutes of Health, grant K12HS022990 (Bachmann) from the Agency for Healthcare Research and Quality, and grant 1IK2HX003021 (Bachmann) from the Health Services Research and Development Service of the Department of Veterans Affairs. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the above agencies, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. Dr Bachmann has served as a consultant for ZOLL Medical, Inc (modest). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

Figure 1
Figure 1. Proportion of Medicare Beneficiaries Participating in Cardiac Rehabilitation
Proportion of Medicare beneficiaries eligible for cardiac rehabilitation (CR) participating in CR programs by hospital referral region (n=306) from 2014 to 2018. Eligibility diagnoses include acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass surgery, cardiac valve surgery and heart or heart-lung transplant. CR initiation in each hospital referral region was adjusted for age, gender, race/ethnicity, eligibility diagnosis, socioeconomic status, and comorbidities.
Figure 2
Figure 2. Density of Cardiac Rehabilitation Programs by Hospital Referral Region
Density of cardiac rehabilitation programs per 1000 cardiac rehabilitation-eligible Medicare beneficiaries by hospital referral region (n=306) from 2014-2018 (2A). The proportion of cardiac rehabilitation (CR)-eligible Medicare beneficiaries in each hospital referral region was plotted by CR center density (B) and average distance to the nearest CR center (C). Figures were adjusted for age, gender, race/ethnicity, eligibility diagnosis, socioeconomic status and comorbidities. B was also adjusted for average distance to the nearest CR center, and C was also adjusted for CR center density per 1000 CR-eligible Medicare beneficiaries.
Figure 3
Figure 3. Cardiac Rehabilitation Deserts
Cardiac rehabilitation (CR) deserts (N=39), or counties with disproportionately high average patient loads per CR center. Patient load was estimated using Centers for Disease Control and Prevention coronary heart disease hospitalization rates and total population ≥65 for each county. CR deserts were defined as statistically significant county hot spots with a CI of 95% or above by Getis-Ord Gi* analysis.
Central Illustration
Central Illustration. Major Causes of Geographic Variation in Cardiac Rehabilitation Initiation
Regional variation in cardiac rehabilitation (CR) in the United States is caused by several factors, including density of CR centers, distance to the nearest CR center, eligibility diagnosis, and the presence of CR deserts, where CR access is disproportionately low.
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