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Low Rates of Referrals

Only one in five Americans who qualify for CR gets the life-saving intervention.

Each year, over 1 million Americans have a coronary event or undergo a cardiac-related procedure that qualifies them for CR. Despite this high number, many eligible patients do not receive a referral. While the problem of low referral rates occurs across patient populations, women, minorities, and people with low incomes and education levels are even less likely to be given a referral to CR.

Barriers to referral include gaps in physician awareness of who needs CR and the benefits of it, inconsistency in referral patterns, the absence of a system in hospitals that automatically refers eligible patients, and lack of clinician knowledge about available local programs.

Barriers to Enrollment

Unfortunately, many patients who are referred to CR do not enroll in a program. Patients often face significant barriers that make CR difficult or unattractive. Some patients do not understand the important benefits of the intervention to their immediate and long-term health. Others may wish to enroll but face practical or logistical challenges such as lack of transportation or inconvenient hours of operation. Patients who live outside of a metropolitan area are 30 percent less likely to participate in CR programs. Still other patients may need help with completing the enrollment process.

The cost of CR is also an enrollment deterrent for some patients. Although Medicare and most private insurers cover the intervention for eligible individuals, patients typically face out-of-pocket costs, including deductibles or copayments. Uninsured patients face the prospect of covering the cost themselves. Individuals with lower incomes are significantly less likely to participate in CR.

Difficulty With Retention

Many patients who enroll in CR programs don’t complete the recommended course of 36 one-hour sessions. Reasons for this can include competing work or home responsibilities and transportation concerns. In addition, many programs do not meet the needs of all patients and do not take language and cultural considerations into account.

Medicare data can help to illustrate these retention challenges: Only 24.4% of Medicare-eligible heart attack patients attend at least one CR session; a mere 6.5% complete the recommended 36 sessions despite its proven benefits.

Although multiple factors contribute to low participation rates in CR, many effective strategies exist that can help hospitals meet the challenges at each stage—referral, enrollment, and retention.

Internet Citations

American Heart Association/American Stroke Association. Cardiac Rehabilitation: Putting More Patients on the Road to Recovery.

Wall HK, Stolp H, Lucido B, Graff K. Cardiac Rehabilitation Change Package: A Million Hearts Action Guide. Atlanta, GA: Centers for Disease Control and Prevention; July 2018.

Dahhan A, Maddox WR, Sharma GK. The gaps in cardiac rehabilitation referral: The elephant in the room. J Am Coll Cardiol. 2015 Dec 8;66(22):2574-75.

Dahhan A, Maddox WR, Krothapalli S, Farmer M, Shah A, Ford B, Rhodes M, Matthews L, Barnes VA, Sharma GK. Education of physicians and implementation of a formal referral system can improve cardiac rehabilitation referral and participation rates after percutaneous coronary intervention. Heart Lung Circ. 2015 Aug;24(8):806-16.

Ades PA, Keteyian SJ, Wright JS, Hamm LF, Lui K, Newlin K, Shepard DS, Thomas RJ. Increasing cardiac rehabilitation participation from 20% to 70%: a road map from the Million Hearts Rehabilitation Collaborative. Mayo Clinic Proceedings. 2017 Feb;92(2):234.

Menezes AR, Lavie CJ, DeSchutter A, Milani RV. Gender, race and cardiac rehabilitation in the United States: is there a difference in care? Am J Med Sci. 2014 Aug;348(2):146-152.

Li S, Fonarow GC, Mukamal K, Zu H, Matsouaka RA, Devore AD, Bhatt DL. Sex and racial disparities in cardiac rehabilitation referral at hospital discharge and gaps in long‐term mortality. J Am Heart Assoc. 2018 Apr 6;7(8). Is My Test, Item, or Service Covered? Cardiac Rehabilitation Programs. Accessed November 12, 2019.

Department of Health and Human Services. Million Hearts: Cardiac Rehabilitation.