The participants were hospitalized October 1, 2006, to September 30, 2011. All differences were significant at P < .001. CABG indicates coronary artery bypass graft; IHD, ischemic heart disease; MI, myocardial infarction; and PCI, percutaneous coronary intervention.
Replacement Supplement With Errors Highlighted (eMethods, eTable 1, eTable 2, eTable 3).
eAppendix 1. Replacement Article With Corrections Highlighted
eAppendix 2. Retracted Article With Errors Highlighted
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Schopfer DW, Takemoto S, Allsup K, et al. Cardiac Rehabilitation Use Among Veterans With Ischemic Heart Disease. JAMA Intern Med. 2014;174(10):1687–1689. doi:10.1001/jamainternmed.2014.3441
Copyright 2014 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
Referral to exercise-based cardiac rehabilitation (CR) is 1 of 9 performance measures for secondary prevention after hospitalization for myocardial infarction (MI), percutaneous coronary intervention (PCI), and/or coronary artery bypass graft (CABG).1,2 Although CR programs significantly reduce morbidity and mortality in patients with ischemic heart disease (IHD),3 they are vastly underused among US Medicare beneficiaries.4 The use of CR programs in the Veterans Health Administration (VA) has not been described. Therefore, we sought to determine (1) the proportion of eligible veterans with IHD who participate in CR, (2) whether the presence of an on-site CR program is associated with greater participation, and (3) the characteristics of the CR participants.
National VA inpatient files were used to identify all patients discharged from VA facilities with a diagnosis of MI, PCI, and/or CABG during fiscal years 2007 to 2011 (eMethods in Supplement 1). The number of patients who participated in VA CR programs during the 12 months following hospitalization was determined from VA outpatient files. The number of eligible patients who participated in non-VA CR programs was determined from non-VA care files and from the Centers for Medicare and Medicaid Services data. Institutional review board approval was obtained from the San Francisco Veterans Affairs Medical Center and the University of California, San Francisco.
Between October 1, 2006, and September 30, 2011, a total of 88 826 unique patients were hospitalized for MI, PCI, or CABG at 124 VA facilities. Of these, 9123 patients (10.3%) participated in 1 or more sessions of outpatient CR during the 12 months after hospitalization (eTable 1 in Supplement 1). Overall, there was no significant difference in participation by sex: 10.3% of men (8976 of 87 359) and 10.0% of women (143 of 1426) received CR (P = .76), and 8.0% of whites (2093 of 26 150) and 8.3% of nonwhites (587 of 7068) received CR (P = .41). Overall, 10.4% of whites (7126 of 68 259) and 9.8% of nonwhites (1610 of 16 397) received any CR (P = .02). Whites were more likely than nonwhites to attend non-VA CR programs (5.7% vs 2.8%; P < .001) and less likely than nonwhites to attend on-site VA CR programs (4.9% vs 7.2%; P < .001).
From fiscal years 2007 to 2011, participation rates remained stable between 8.5% and 8.7% for all years. There was a significant interaction between the presence of an on-site CR program and the distance to the closest VA medical center (P < .001 for interaction). Therefore, we stratified analyses by the presence (35 VA facilities) or absence (89 VA facilities) of an on-site CR program (eTable 2 and eTable 3 in Supplement 1).
Overall, patients were more likely to participate in CR if they had been hospitalized at a VA facility with vs a facility without an on-site CR program (15.5% vs 7.5%; P < .001). Facilities with vs those without on-site CR programs had higher rates of participation (Figure). In multivariable models, the characteristics associated with greater participation were younger age, marriage, higher body mass index, living closer to a VA facility, hyperlipidemia, absence of stroke, chronic kidney disease, peripheral vascular disease, chronic lung disease, and hospitalization for CABG (vs PCI or MI) (Table). After controlling for these variables, the presence of an on-site CR program was associated with a greater odds of attending a CR program (odds ratio, 1.99; 95% CI, 1.89-2.10; P < .001).
In this study of 88 826 veterans hospitalized for MI, PCI, or CABG, 10.3% of eligible patients participated in 1 or more sessions of outpatient CR. Both the presence of an on-site CR program and patient proximity to a VA facility were associated with greater participation in CR. However, participation was low regardless of the presence (15.5%) or absence (7.5%) of an on-site program. These findings suggest that new patient-centered delivery strategies must be developed to solve the seemingly intractable challenge of CR underuse.5
Retraction and Replacement: This article was retracted and replaced on October 10, 2016, for errors in data in the text, tables, and figure (see Supplement 2 for a copy of the replacement article with corrections highlighted and a copy of the retracted article with errors highlighted).
Corresponding Author: David W. Schopfer, MD, MAS, San Francisco Veterans Affairs Medical Center, 4150 Clement St (111A1), San Francisco, CA 94121 (firstname.lastname@example.org).
Published Online: August 18, 2014. doi:10.1001/jamainternmed.2014.3441
Author Contributions: Drs Schopfer and Whooley had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Schopfer, Takemoto, Allsup, Helfrich, Forman, Whooley.
Acquisition, analysis, or interpretation of data: Schopfer, Takemoto, Ho, Whooley.
Drafting of the manuscript: Schopfer, Takemoto.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Schopfer, Takemoto, Whooley.
Obtained funding: Schopfer, Forman, Whooley.
Administrative, technical, or material support: Allsup, Helfrich.
Study supervision: Forman, Whooley.
Conflict of Interest Disclosures: Dr Whooley has received research funding from Janssen Healthcare Innovations.
Funding/Support: This study was supported by grant QUERI RRP 12-232 from the Veterans Health Administration (VA) Office of Health Services Research and Development. Dr Schopfer was supported by the VA Quality Scholars Fellowship Program.
Role of the Sponsor: The VA had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: John Rumsfeld, MD, PhD, administered the VA Survey of Cardiovascular Specialty Care Services and provided critical comments on the manuscript. No financial reimbursement was provided.