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. 2023 Nov;16(11):e010148.
doi: 10.1161/CIRCOUTCOMES.123.010148. Epub 2023 Oct 19.

Relationship Between Community-Level Distress and Cardiac Rehabilitation Participation, Facility Access, and Clinical Outcomes After Inpatient Coronary Revascularization

Michael P Thompson  1   2 , Hechuan Hou  1 , James W Stewart 2nd  3 , Francis D Pagani  1 , Robert B Hawkins  1 , Steven J Keteyian  4 , Devraj Sukul  5 , Donald S Likosky  1   2
Affiliations

Relationship Between Community-Level Distress and Cardiac Rehabilitation Participation, Facility Access, and Clinical Outcomes After Inpatient Coronary Revascularization

Michael P Thompson et al. Circ Cardiovasc Qual Outcomes. 2023 Nov.

Abstract

Background: Although disparities in cardiac rehabilitation (CR) participation are well documented, the role of community-level distress is poorly understood. This study evaluated the relationship between community-level distress and CR participation, access to CR facilities, and clinical outcomes.

Methods: A retrospective cohort study was conducted on a 100% sample of Medicare beneficiaries undergoing inpatient coronary revascularization between July 2016 and December 2018. Community-level distress was defined using the Distressed Community Index quintile at the beneficiary zip code level, with the first and fifth quintiles representing prosperous and distressed communities, respectively. Outpatient claims were used to identify any CR use within 1 year of discharge. Beneficiary and CR facility zip codes were used to describe access to CR facilities. Adjusted logistic regression models evaluated the association between Distressed Community Index quintiles, CR use, and clinical outcomes, including one-year mortality, all-cause hospitalization, and acute myocardial infarction hospitalization.

Results: A total of 414 730 beneficiaries were identified, with 96 929 (23.4%) located in the first and 67 900 (16.4%) in the fifth quintiles, respectively. Any CR use was lower for beneficiaries in distressed compared with prosperous communities (26.0% versus 46.1%, P<0.001), which was significant after multivariable adjustment (odds ratio, 0.41 [95% CI, 0.40-0.42]). A total of 98 458 (23.7%) beneficiaries had a CR facility within their zip code, which increased from 16.3% in prosperous communities to 26.6% in distressed communities. Any CR use was associated with absolute reductions in mortality (-6.8% [95% CI, -7.0% to -6.7%]), all-cause hospitalization (-5.9% [95% CI, -6.3% to -5.6%]), and acute myocardial infarction hospitalization (-1.3% [95% CI, -1.5% to -1.1%]), which were similar across each Distressed Community Index quintiles.

Conclusions: Although community-level distress was associated with lower CR participation, the clinical benefits were universally received. Addressing barriers to CR in distressed communities should be considered a significant priority to improve survival after coronary revascularization and reduce disparities.

Keywords: cardiac rehabilitation; coronary artery disease; quality of health care; social determinants of health.

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Conflict of interest statement

Disclosures Drs Thompson, Pagani, Sukul, and Likosky receive partial salary support from Blue Cross Blue Shield of Michigan as part of the Value Partnerships portfolio. Dr Pagani is an ad hoc, noncompensated scientific advisor for Medtronic, Abbott, FineHeart, and CH Biomedical and a member of the Data Safety Monitoring Board for Carmat and the National Heart, Lung, and Blood Institute PumpKIN Study. Dr Stewart is receiving full salary support from the Veterans Affairs (VA) as a National Clinician Scholars Program (NCSP) research fellow at the University of Michigan. Outside of this work, Dr Likosky receives extramural support from the Agency for Healthcare Research and Quality and the National Heart, Lung, and Blood Institute, and is a consultant to the American Society of ExtraCorporeal Technology. The views of this article do not represent the VA. The other authors report no conflicts.

Figures

Figure 1.
Figure 1.
Measures of cardiac rehabilitation participation across Distressed Community Index quintile.
Figure 2.
Figure 2.
Crude rates of clinical outcomes among beneficiaries by cardiac rehabilitation participation across Distressed Community Index quintiles.
Figure 3.
Figure 3.
Adjusted absolute marginal changes in clinical outcomes associated with any cardiac rehabilitation use for the overall sample and stratified by Distressed Community Index quintile.
See this image and copyright information in PMC

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