Response to Letter Regarding Article, “Impact of Cardiac Rehabilitation on Mortality and Cardiovascular Events After Percutaneous Coronary Intervention in the Community”
We thank Lis Neubeck and colleagues for their interest in our article.1 We agree with them that the participation in cardiac rehabilitation (CR) after percutaneous coronary intervention is low, and that nationwide efforts are needed to increase the participation and maximize the benefits of CR. A collaborative effort is required from the national administration and physician groups to increase the participation rate. One of the steps toward this was taken by the Centers for Medicare and Medicaid Services,2 when they included percutaneous coronary intervention as a covered indication for CR services in 2006.2 Accordingly, our data showed increased CR participation in the group of patients who were undergoing elective percutaneous coronary intervention after 2006. A recent study from a state-level database in Michigan reported that the overall referral rate after percutaneous coronary intervention was 60%, and that disparities exist in referral patterns based on sex and ethnicity.3 The implementation of automated referral systems has been shown to improve the referral patterns and enrollment rate in CR significantly.4,5
Clinicians can also help increase CR participation by recommending CR to their eligible patients early after a cardiac event, and by supporting efforts to improve referral rates to CR programs. Indeed, the strength of the primary physician's referral is an important predictor of CR participation.6
We also recognize the validity of the concerns of Neubeck et al about the potential impact of patient selection bias on the beneficial outcomes noted in CR participants. For this precise reason, we used 3 different analytic techniques that used propensity score adjustment to help reduce the potential impact of bias in our results. In particular, the matched-pair analysis used in our study matched the CR participants with nonparticipants based on their important baseline factors.
Finally, we agree wholeheartedly with the recommendation of Neubeck et al that policy makers, researchers, and clinicians should continue to work together to expand the reach of CR services by developing, implementing, and covering more flexible CR and secondary prevention delivery models. Such efforts will help to increase the delivery of optimal CR and secondary prevention therapies to eligible patients.
Kashish Goel, MBBS
R. Thomas Tilbury, MD
Ray W. Squires, PhD
Randal J. Thomas, MD, MS
Cardiovascular Health Clinic
Division of Cardiovascular Diseases
Department of Medicine
Mayo Clinic and Foundation
Ryan J. Lennon, MS
Division of Biomedical Statistics and Informatics
Mayo Clinic and Foundation
- © 2011 American Heart Association, Inc.
- Goel K,
- Lennon RJ,
- Tilbury RT,
- Squires RW,
- Thomas RJ
Decision memo for cardiac rehabilitation programs (cag-00089r). Baltimore, MD: Centers for Medicare and Medicaid Services; 2006.