Study Identifies Strategies to Improve Cardiac Rehabilitation Referral Rates in Coronary Artery Disease

A Canadian study of patients hospitalized with coronary artery disease has reported that a combination of automatic referral for cardiac rehabilitation upon hospital discharge and liaison referral through healthcare providers improved referral rates for cardiac rehabilitation. The study was described in Archives of Internal Medicine [2011;171(3):235-241]. Cardiac rehabilitation has been proven to be effective in coronary artery disease patients but is still underutilized due to low rates of referral, according to the study authors. The prospective, observational study evaluated 4 referral strategies, including automatic referral using electronic patient records or standard orders by automatic prompt prior to hospital discharge, liaison referral (referral facilitated through a personal discussion with a healthcare professional), a combination of these 2 strategies, or usual practice at the discretion of the healthcare provider. A total of 5767 stable cardiac inpatients from 11 community and academic hospitals were recruited to participate; 2535 agreed to participate. At 1 year after recruitment, 1809 participants completed the follow-up survey. Patients were approached for inclusion in the study if they had a confirmed diagnosis of acute coronary syndrome, had undergone percutaneous coronary intervention or coronary artery bypass graft surgery, had a concomitant diagnosis of heart failure or arrhythmia, were eligible for cardiac rehabilitation based on guidelines from the Canadian Association of Cardiac Rehabilitation, and were proficient in English, French, or Punjabi, as patient surveys were translated into each of these languages. Patients were excluded if they had received cardiac rehabilitation services within the past 2 years, or had a clinically significant orthopedic, neuromuscular, visual, cognitive, or psychiatric condition that would interfere with participation in cardiac rehabilitation. To determine rates of cardiac rehabilitation referral and participation, patients self-reported whether they were referred for cardiac rehabilitation, whether they enrolled in a cardiac rehabilitation program, and an estimated percentage of the prescribed sessions that they attended. Patients were significantly more likely to be referred for cardiac rehabilitation when 1 of the 3 referral strategies was used (automatic referral, liaison referral, or a combination of these) compared with usual practice. The combination strategy was significantly more effective than the automatic strategy or liaison strategy alone. After adjusting for hospital site, patient socioeconomic status, and clinical status, the combination strategy resulted in the highest degree of referral and enrollment, followed by the automatic strategy alone and the liaison strategy alone. Among patients who reported being referred for cardiac rehabilitation, rates of enrollment and attendance at prescribed sessions did not differ significantly by referral strategy. Overall, the combination of automatic and liaison referral strategies resulted in an 8-fold increase in the likelihood of referral for cardiac rehabilitation, compared with usual referral practices at the discretion of the patient’s healthcare provider. More than 70% of patients receiving a combination of automatic and liaison intervention enrolled in cardiac rehabilitation. Once a patient was referred for cardiac rehabilitation, regardless of strategy, attendance rates of >80% of prescribed sessions were consistently reported. The study authors supported the widespread adoption of similar combination referral strategies for cardiac rehabilitation, noting that the success of the combination may be related to the fact that both the healthcare provider and patient were targeted. They estimated that the use of a similar combination in clinical practice could increase cardiac rehabilitation rates by 45%, and were encouraged by the high rates of patient participation in cardiac rehabilitation once referral was achieved. Study limitations identified by the authors included significant differences in socioeconomic and clinical characteristics between referral strategies, the potential for bias in patient-reported rates of cardiac rehabilitation referral and utilization, and the limited degree to which their findings could be generalized to other geographic regions or countries with different systems of healthcare coverage.