Quality Improvement Study: Referral to Cardiac Rehabilitation After Percutaneous Coronary Intervention

Background Cardiac rehabilitation (CR) is a key post-percutaneous coronary intervention (PCI) quality metric and is known to improve cardiovascular outcomes. Although referral rates after PCI have been described, far less is known about what occurs after a referral order is placed, specifically whether patients are successfully contacted, whether they enroll, and the barriers they encounter. This quality improvement (QI) project aimed to determine referral and enrollment rates following PCI, compare referral timing at discharge versus the first follow-up visit, and identify patient-reported and system-level barriers contributing to low CR participation. Methods We performed a retrospective chart review of 200 consecutive patients who were at least three months post-percutaneous coronary intervention. All patients not enrolled in the CR program at our center were prospectively contacted at home to confirm if they were referred to, and whether they were doing CR. If patients were not enrolled, reasons were explored. Results A total of 194 patients were discharged. The mean age was 68±11 years, and 34% (n=65) were female. The overall referral rate was 55% (n=107), including 21.6% (n=42) at hospital discharge and 33.5% (n=65) at the first outpatient clinic visit. After at least three months post-PCI, only 35 patients (18% of the entire group and 33% of those referred) were enrolled in CR. Of those with a referral order placed at discharge, only 10 (24%) were doing CR. The most common reason for non-enrollment in cardiac rehabilitation was lack of awareness of the need to enroll, reported by 58% (n=92) of respondents. In a multivariate analysis, PCI in an urgent setting and prior PCI were the only independent predictors of non-referral. Not private insurance and diabetes were independent predictors of lack of CR participation. Conclusions Referral to, and especially enrollment in, the CR programs post-PCI remained markedly low. Enrollment tended to be lower when referrals were placed at discharge, highlighting limitations of current quality metrics that focus solely on referral placement. Improving patient and physician education and strengthening system-level processes may help support higher enrollment and more effective use of CR.