Cardiac Rehabilitation Patient Referral Cardiac rehabilitation is a multidisciplinary exercise-based out- patient service that has been proved to provide patient benefit in terms of improved functional status, quality of life, medi- cal resource use, and, ultimately, mortality rate reduction.39 46 Patients with coronary artery disease treated with PCI are at high risk of recurrent events and are particularly suitable for risk reduction via cardiac rehabilitation. Unfortunately, cardiac rehabilitation is a vastly underutilized service, with available Nallamothu et al ACC/AHA/SCAI/AMA-PCPI/NCQA 2013 PCI Performance Measure 937 data indicating that less than half of eligible patients ultimately enroll in a program.47 There are numerous barriers to referral, entry, and completion of cardiac rehabilitation by patients. Although some of these barriers are financial or system related (eg, lack of a geographically convenient program), physician referral is a modifiable barrier. Explicit physician referral of patients to cardiac rehabilitation has been shown to substan- tially increase the likelihood of patient enrollment.47,48 Although it could be argued that referral is the responsibility of a patient's primary physician or other members of the healthcare team, the writing committee believes that cardiac rehabilitation referral should be part of the comprehensive care of a patient under- going PCI and should be the responsibility of the providers involved with that procedure, in a manner similar to treatment of dyslipidemia. Referral during the index hospitalization for PCI is therefore optimal. The performance measure takes into account appropriate exclusions, such as medical nonsuitability (eg, history of comorbidities), patient preference, and lack of availability of a suitable program. This performance measure harmonizes closely with the corresponding measure from the ACCF/AHA/PCPI coronary artery disease performance mea- sure set. In the future, broadening this measure to assess levels of participation on the basis of attendance, rather than simply referral, might be examined. 5.9. 