Disparities in Cardiac Rehabilitation Use:
Exploring the Reasons for Minorities’
Underutilization
Hannah Katch
Holly Mead, PhD
Department of Health Policy
The George Washington University
AcademyHealth Annual Research Meeting
June 26-29,, 2010
Background

Minorities receive lower quality CV health care1
 Minorities are less likely to receive specific interventions2
 Minorities are less likely to receive timely care3
 Minorities
Mi iti are less
l likely
lik l to
t receive
i all
ll recommended
d d care4
 Minorities have higher rates of mortality following CVD procedures5

Minorities less likely to participate in cardiac
rehabilitation (CR) programs
1

Overall rates of use are low – 18% utilization5

Disparities are significant
What is Cardiac Rehabilitation?

Comprehensive secondary prevention program
 Targets physical, psychosocial functioning
 Teaches
e c es risk-management
s
ge e skills
s s

Effective in improving health outcomes
 Reduces mortality by 20% to 25%8
Recommended standard of care for 6 CVD diagnoses
 Evidence-based
E id
b d care: Cli
Clinical
i l Practice
P ti Guidelines
G id li
for
f CR:
CR
AHCPR 1995

2
Objectives

To explore underlying reasons for minorities’
underuse of cardiac rehab
Patient barriers
 Provider referral procedures
 Delivery system challenges


3
To inform development, implementation of policies,
procedures to address disparate use
Study
y Design
g
Three-Pronged Approach
Clinician Interviews
Focus on provider, system
barriers that lead to lower
use, disparate
di
t ttreatment
t
t
Patient FGs, interviews
Explore awareness of CR
services, obstacles that
I
Impede
d use
Medicare Claims Data
Analysis of CR utilization
in studyy state to
examine variation by race
4
Study
S
udy Design
es g

Three study sites selected
 Bronx, New York: Montefiore Medical Center
 Washington, DC: Washington Hospital Center
 Hollywood, FL: Memorial Medical Center

Criteria for selection
 Availability of cardiac rehabilitation services
 Racial,
Racial ethnic diversity
 Volume of cardiac patients
 Demonstrated
D
t t d supportt off minority
i it health
h lth care
5
Methods: Q
Qualitative Analysis
y

Why
y a qqualitative study?
y
 FG, interviews offer unique perspective as experienced
by participants

Conducted 19 clinician interviews
 Snowball
S
b ll sampling
li off clinicians
li i i
 Targeted CR directors, CR staff, cardiologists practicing
in study communities
6
Methods:
e ods: Qua
Qualitative
a ve Analysis
a ys s
 Thematic content analysis of qualitative
interviews
 Generated an index of themes that emerged from data
collection, analytical process
q
y and
 Identified themes as “dominant” based on frequency
length of discussion
 Triangulation of investigators, data sources improve
validity of findings
7
Methods:
e ods: Limitations
a o s

Providers may have self
self-selected
selected
Providers we interviewed may be more aware of CR

Market,
k ddelivery
li
system characteristics
h
i i may drive
di
variation in referral practices, physician support,
patient experience
 Integrated systems vs. diffuse markets

8
Despite limitations, results can be used to inform
development of programs, policy interventions
Preliminary Results

Cli i i interviews
Clinician
i
i
3 key
k themes
h
 Lack of consistent referral practices
p
Stereotyping, cultural unawareness that contribute to
referral decisions
 Financial challenges undermine CR referrals
9
Rehab
e ab Directors
ec o s and
a d Staff
Sa
 Inconsistent
Referral
Practices
“What
What I found is that each cardiologist has
their typical patient that they’ll refer. So
there’s one who sends fat people and one
who sends women and one who sends
people
p
p who are disabled and one who
sends people who like to exercise. I don’t
think they’re even aware that they do
that…. I don’t really have anyone who
sends everyone the way they should.”

Financial Challenges
Undermine Referrals
10
“Most cardiologists think rehab is
voodoo…. Anything
y
g that isn’t angioplasty
g p
y
is voodoo…and so, you know, you’re
always going to get cardiologists that
basically say, ‘Ah, you know, I tell my
patients to exercise and they just do it.
it ”
 Physician
Ph i i
Stereotypes,
St
t
Cultural Unawareness
“I think the real underlying reason…is
because cardiac rehab programs are not
profitable and they’re not typically…part
of the cardiology
gy department.
p
I think
when they’re part of the cardiology
department, then the referrals are more
seamless. You know we’d have to support
our program.
program ”
Conclusions

Enforce evidence-based g
guidelines around CR
 Provides clinical basis for referral; eliminated
subjectivity
 Provide consistency, predictability, objectivity
 Adopt
Ad
QI tools
l to automate referral
f
l
CMS requirements could highlight low utilization,
disparities and create incentives to improve
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Conclusions

Develop a sustainable business model that increases
availability; limits disincentives
 Higher
g
reimbursement rates

Develop, test, reimburse different modalities of CR
 Incorporate
I
t multidisciplinary
ltidi i li
teams
t
 Combine monitored programs with at-home routines
 Provide more flexibility to patient, provider
12
References
1
1.
Institute of Medicine
Medicine. Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care. 2002. Washington, DC: National Academies Press.
2.
Jha A, et al. Racial Trends in the Use of Major Procedures among the Elderly.
N England
New
E l d Journal
J
l off Medicine,
M di i 2005;353(7).
2005 353(7)
3.
Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care. 2002. Washington, DC: National Academies Press.
4.
Thomas KL, Al-Khatib SM, Kelsey RC, Bush H, Brosius L, Velazquez EJ,
Peterson ED, and Gilliam FR. Racial Disparity in the Utilization of ImplantableCardioverter Defibrillators Among Patients With Prior Myocardial Infarction and
an Ejection Fraction of ≤35%. The American Journal of Cardiology, 2007: 100
(16); 924-929.
5.
y JA, Shepard
p
DS, Normand SL, Ades PA, Prottas J, Stason WB. Use of
Suaya
cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or
coronary bypass surgery. Circulation 2007;116:1653-62.
13
Questions?
Contact me at hannah.katch@gwumc.edu
or contact
t t Dr.
D Holly
H ll Mead
M d att khmead@gwu.edu
kh
d@
d
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