Under-utilization of cardiac rehabilitation (CR) by Medicare beneficiaries: Implications for racial/ethnic minorities

CR, a medically-supervised outpatient program, reduces morbidity and mortality in patients with established cardiac disease. Despite its many well-established benefits, participation is very low. An analysis of national Medicare claims undertaken for the Brandeis evaluation of Medicare's Lifestyle Modification Program Demonstration (LMPD) demonstrates a national CR utilization rate of 12.2% among eligible Medicare beneficiaries. We present quantitative findings on significant variations by race/ethnicity, gender, and region of the country. This is attributed to a range of factors including those at the provider-level (e.g. low physician referral rates), patient-level (e.g. perception of severity of illness), and system-level (e.g. distance and low geographic availability of CR programs). Next, we conducted a qualitative study of 27 CR programs to determine the organizational factors impacting utilization of CR, and describe technical, political, and cultural attributes influencing uptake of CR, including ways in which it differentially impacts racial/ethnic minority groups. Overall, the organizational culture or ideology around CR and belief in its clinical efficacy among patient types was found to be important. Increasingly, policy makers and providers recognize the central role that organizations play in ensuring quality, especially when the care involves coordinating and facilitating access across multiple service settings, as is the case with C.R. Given the growing burden of chronic illness, the need for tertiary prevention, and disparities in health status and outcomes among R/E minorities, it is important to understand how organizational factors influence utilization of interventions such as CR in general, and specifically among higher-risk groups such as R/E minorities.