Cardiology: Dual Strategy Increases Cardiac Rehab Participation

A combination referral strategy could increase cardiac rehabilitation participation by 45 percent

Clinicians who used a multi-faceted strategy that included discussions with patients and automated reminders proved more effective at motivating patients to join a cardiac rehabilitation program than either approach alone, according to the results of a study published recently in the Archives of Internal Medicine.

The reason cardiovascular disease (CVD) remains the leading cause of death worldwide is chiefly because of modifiable risk factors. Cardiac rehabilitation (CR) offers a comprehensive approach to chronic disease management by addressing these risk factors. Patients who participate in CR programs experience reduced morbidity and mortality by approximately 25 percent over one to two years, compared to usual care. Although CR is the recommended standard of care in patients who experience acute coronary syndromes and revascularization, evidence from the United States, Canada, and the United Kingdom show that 70 to 80 percent of eligible patients do not receive CR. One reason, say the authors, is referral failure. Although research has indicated that automatic referral strategies are effective, the authors found no studies that compared different strategies. Thus, they undertook the current study, a comparison of four referral strategies, to determine their effects on CR referral and utilization.

The authors identified 2,635 stable cardiac inpatients from 16 wards in 11 hospitals in Ontario, Canada, who had acute coronary syndrome and underwent percutaneous coronary intervention or coronary artery bypass graft surgery, and who were followed for one year. Patients received either an automatic referral, had a conversation with a healthcare provider, received a combination of automatic referral and conversation, or received usual care (referral based on physician preference).

Referral strategy was significantly related to CR referral and enrollment. The referral and enrollment rates were:

• Combined automatic and conversation, 85.8 percent referral rate and 73.5 percent enrollment rate;
• Automatic only, 70.2 percent referral and 60 percent enrollment;
• Conversation only, 59 percent referral and 50.6 percent enrollment; and
• Usual referral, 32.2 percent referral and 29 percent enrollment.

The degree of CR participation did not differ by referral strategy among patients who received referrals, however, with 82.87 percent of classes attended.

The authors write that the combination strategy may be most effective because it targets both the healthcare provider and the patient, and that implementing the combination strategy could increase CR participation by 45 percent. They caution, however, that this approach “will require reexamination of our funding and service models. Most notably, CR programs may not have the capacity to quickly increase service provision, which may lead to longer wait times, and ultimately lower enrollment.” The results of the current study, they conclude, “provide strong and pragmatic evidence that innovative referral strategies can positively influence access to CR.”

Source: Grace SL, Russell KL, Reid RD, et al. 2011. Effect of cardiac rehabilitation strategies on utilization rates. A prospective, controlled study. Archives of Internal Medicine 171(3):235-241.