Cardiac Rehabilitation Uptake After Myocardial Infarction: Why Referral Is Not the Bottleneck
DOI:
https://doi.org/10.5281/zenodo.22305517Keywords:
Cardiac rehabilitation, Myocardial infarction, Referral, Health disparities, Secondary preventionAbstract
Referral to cardiac rehabilitation after myocardial infarction is widely treated as the policy target that matters most, and
quality-improvement effort has followed accordingly. National US registry data show why that framing is increasingly
incomplete: referral after myocardial infarction rose from 72.9% to 80.7% between 2007 and 2012, and exceeded 85% at the
best-performing hospitals well before this review's timeframe. Yet among Medicare beneficiaries eligible for cardiac
rehabilitation in 2016, only around one in four attended even a single session, and roughly one in twenty completed the full
recommended course. The gap between referral and attendance, not between eligibility and referral, is now where most of the
loss occurs. This review sets out the referral-enrollment-completion cascade, the demographic and structural barriers that
concentrate at the enrollment step — sex, race, age, distance, cost and psychological comorbidity — and the intervention
evidence, which shows that changing how enrollment itself is scheduled and delivered (automatic pre-approved referral, early
outpatient education, home-based delivery) moves attendance far more than any further push on referral rates could. It closes
with two honest complications: the trial-level evidence for exercise-based cardiac rehabilitation shows a clear cardiovascular
mortality and readmission benefit but no significant all-cause mortality benefit, a more modest claim than the observational
dose-response data that motivate completion targets; and higher-dose completers in observational cohorts are probably also
healthier and more mobile to begin with, a confounding-by-indication problem the field has not fully resolved.
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