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Publication Briefs

Study Shows Under-utilization of Cardiac Rehabilitation for Veterans Hospitalized for Ischemic Heart Disease

Referral to exercise-based cardiac rehabilitation (CR) is one of nine performance measures for the prevention of secondary cardiovascular events after hospitalization for myocardial infarction (MI), percutaneous coronary intervention (PCI), and/or coronary artery bypass grafting (CABG). Although CR programs significantly reduce morbidity and mortality in patients with ischemic heart disease (IHD), they are vastly underused among Medicare beneficiaries; however CR use among VA patients has not been described. Therefore, this study sought to determine: 1) the proportion of Veterans with IHD who participate in CR; 2) whether the presence of an onsite CR program was associated with greater participation; and 3) patient characteristics associated with participation. Using VA data, investigators identified 47,051 Veterans who had been hospitalized in the VA healthcare system for MI, PCI, or CABG during FY07 through FY11. To determine the presence or absence of an onsite CR program at each facility, investigators used data from the 2011 Survey of Cardiovascular Specialty Care Services. Of the 124 VA facilities in this study, 35 had an onsite CR program. The study's primary outcome was the number of Veterans who participated in one or more CR sessions within 12 months after hospitalization. Investigators also examined patient demographics, body mass index, distance from a VA facility, comorbidities (e.g., hypertension, diabetes), and medications (e.g., beta-blockers, statins).


  • Only 8% of the Veterans in this study who had been hospitalized for MI, PCI, or CABG participated in one or more sessions of outpatient cardiac rehabilitation.
  • Overall, Veterans were more likely to participate in CR if they had been hospitalized at a VA facility with an onsite CR program versus without one (11% vs. 7%). However, participation was extremely low regardless of the presence or absence of an onsite program.
  • Characteristics associated with greater participation in CR included: younger age, being married, higher BMI, living closer to a VA facility, hyperlipidemia, absence of heart failure, absence of chronic kidney disease, and hospitalization for CABG (vs. PCI or MI). After controlling for these variables, the presence of an onsite CR program was associated with 75% greater odds of attending a CR program.


  • Findings suggest that new, patient-centered delivery strategies must be developed to solve the challenge of CR under-utilization.

The study was funded through VA/HSR&D's Ischemic Heart Disease Quality Enhancement Research Initiative (IHD-QUERI; RRP 12-232). Drs. Helfrich, Ho, and Whooley are part of IHD-QUERI, co-located in Seattle, WA and Denver, CO.

PubMed Logo Schopfer D, Takemoto S, Allsup K, Helfrich C, Ho PM, Forman D, and Whooley M. Cardiac Rehabilitation Use among Veterans with Ischemic Heart Disease. (Research Letter) JAMA Internal Medicine. August 18, 2014;e-pub ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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