Geographic Variation in Access to Cardiac Rehabilitation.

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.
Competing Interests: 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.
(Published by Elsevier Inc.)