The relationship between discharge location and cardiac rehabilitation use after cardiac surgery.

Background: Cardiac rehabilitation (CR) is a guideline-recommended risk-reduction program offered to cardiac surgical patients. Despite CR's association with better outcomes, attendance remains poor. The relationship between discharge location and CR use is poorly understood.
Methods: This study was a nationwide, retrospective cohort analysis of Medicare fee-for-service claims for beneficiaries undergoing coronary artery bypass grafting and/or surgical aortic valve repair between July 1, 2016, and December 31, 2018. The primary outcome was attendance of any CR session. Discharge location was categorized as home discharge or discharge to extended care facility (ECF) (including skilled nursing facility, inpatient rehabilitation, and long-term acute care). Multivariable logistic regression models evaluated the association between discharge location, CR attendance, and 1-year mortality.
Results: Of the 167,966 patients who met inclusion criteria, 34.1% discharged to an ECF. Overall CR usage rate was 53.9%. Unadjusted and adjusted CR use was lower among patients discharged ECFs versus those discharged home (42.1% vs 60.0%; adjusted odds ratio, 0.66; P < .001). Patients discharged to long-term acute care were less likely to use CR than those discharged to skilled nursing facility or inpatient rehabilitation (reference category: home; adjusted odds ratio for long-term acute care, 0.36, adjusted odds ratio for skilled nursing facility, 0.69, and adjusted odds ratio for inpatient rehabilitation, 0.71; P < .001). CR attendance was associated with a greater reduction in adjusted 1-year mortality in patients discharged to ECFs (9.7% reduction) versus those discharged home (4.3% reduction).
Conclusions: In this national analysis of Medicare beneficiaries, discharge to ECF was associated with lower CR use, despite a greater association with improved 1-year mortality. Interventions aimed at increasing CR enrollment at ECFs may improve CR use and advance surgical quality.
Competing Interests: Conflicts of Interest Statement Dr Thompson receives funding from the Agency for Healthcare Research and Quality (AHRQ) (K01HS027830 and R01HS028397) and from Blue Cross Blue Shield of Michigan (BCBSM) for his role as codirector of the Michigan Value Collaborative. Outside of this work, Dr Likosky reports a relationship with AHRQ and the National Institutes of Health (NIH) that includes funding grants, receives salary support from BCBSM, and is a consultant to the American Society of Extracorporeal Technology. Dr Pagani is an ad hoc uncompensated scientific advisor for Medtronic, Abbott, FineHeart, and CH Biomedical, an uncompensated medical monitor for Abiomed, and a member of the Data Safety Monitoring Board for Carmat and the National Heart, Lung, and Blood Institute PumpKIN Study. Dr Keteyian receives funding from the National Heart, Lung, and Blood Institute (No. R33HL143099) and has received consulting fees from Kento Health Inc. Dr McCullough received consulting fees and provided health care antitrust consulting for state attorneys general offices funded by the State Center for Antitrust. The opinions, beliefs, and viewpoints expressed by authors do not necessarily reflect those of AHRQ, NIH, the US Department of Health and Human Services, BCBSM, or its employees. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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