Despite its known benefits, only approximately 30% of eligible inpatients subsequently utilize outpatient CR
[11, 13]. Accordingly, the American Heart Association recently issued both a Science and Presidential Advisory on the importance of expanding access to CR and the valuable role of healthcare professionals in increasing referral to CR
[7, 24]. Fittingly, through interviews conducted with clinical staff, the present study identified and subsequently evaluated the effect of three untested strategies used by inpatient units and CR programs to improve CR referral and utilization. The inpatient strategy of pre-approved referral significantly increased referral and enrollment in these evidence-based programs. Provision of early outpatient education at the CR program was also related to significantly greater enrollment. Ultimately, the strategies resulted in rates of use around 65% to 84%, which was approximately two to five times greater than usual practice. The rates of CR referral and enrollment observed in this study are encouraging and come close to the Canadian national published targets of 85% referral and 70% enrollment
. The positive effect of these strategies on referral and enrollment rates are concordant with studies published examining the effect of innovative referral strategies
[15–18]. Degree of CR participation was uniformly high after enrollment, which suggests that ‘if we refer, they will come.’ It is incumbent on the healthcare community to adopt these strategies to ensure universal access to this evidence-based care.
Buy-in of standard CR referrals by healthcare providers and administrators likely has the advantage of making the referral process habitual and ensuring all members of the patient care team are supporting the referral process. Some physicians may be reticent to have their patients uniformly referred, as indeed it has been shown that some physicians have less than positive perceptions of the benefits of CR
[25, 26]. Ultimately though, the referral is made to education, as exercise is not initiated until another careful medical assessment occurs at the CR site. Moreover, a patient’s health status will generally change from the time of discharge to the time of CR intake, so degree of readiness for exercise at the time of discharge should not necessarily negate referral. CR programs undertake extensive medical assessments at program initiation to ensure patients are indeed suitable for the program and to tailor services to their health status at that time. In addition, there is a physician present at the intake stress test to ensure safety. Finally, while a referring physician may not consider their patient to be an appropriate candidate, many CR programs offer alternative models of care to meet diverse patient needs and are aware of other outpatient resources available with which the physician may not be familiar. Overall, any healthcare provider should have the ability to refer a patient to education at CR based on clinical criteria.
As hypothesized, provision of early outpatient education by CR programs prior to enrollment was shown to increase the likelihood of patients subsequently enrolling in CR. Results are supported by a recently-published manuscript from another Canadian province
. Indeed, provision of early outpatient education likely also has ancillary benefits of encouraging earlier adoption of heart-health promoting behaviours, providing reassurance to patients and family members, verifying discharge instructions, and ensuring identification of any clinical issues which may have arisen such as infection. Cardiac patients are often ready to exercise somewhat later than when they need information. Moreover, there can be delays in booking intake exercise stress tests needed to initiate an exercise program, and thus offering an early education session can circumvent any delays this causes.
Moreover, this approach may potentially mitigate any wait time delays in commencing the CR program. Wait time benchmarks have been established by cardiac indication in Canada through clinical consensus
. Access delays may reduce enrollment rates because patients may have returned to work, or perceive less need for these services over time following an acute cardiac hospitalization. Of course, the potential impact on CR program capacity warrants further exploration.
Caution is warranted when interpreting these findings, chiefly due to study design. This was a quasi-experimental study. For ethical reasons, cardiac patients could not be randomized to acute care site or ward, nor could we randomize strategy within site due to the potential for contamination. The results herein nevertheless present the pragmatic or real-world effects of strategies to increase CR utilization. There were significant differences in sociodemographic and clinical characteristics of patients by strategy which may have biased results. We controlled for these in subsequent analyses, however a randomized design would be needed to definitively establish the effects of strategy on CR use. In addition, because the referral strategies were not mutually exclusive, interaction between the interventions may have affected the results. Some participants used as the comparison group for a specific strategy may have been exposed to one of the other CR strategies. Overall, there were four (23.5%) inpatient wards offering both strategies. In addition, some participants exposed to EARLY ED were recruited from a ward offering PRE-BOOKED or PRE-APPROVED strategies, possibly influencing the odds ratio for EARLY ED. The authors attempted to mitigate this threat by incorporating all relevant referral strategies in each model. The compelling results of this pragmatic observational study warrant replication in a cluster randomized controlled trial.
The second limitation pertains to measurement. Although self-reported CR referral and enrollment was not verified, there is evidence that supports the ‘almost-perfect’ congruence between self-report and CR site-report data
. However, the potential for social desirability biases in participant responses cannot be ruled out. The final limitation pertains to generalizability. The initial response rate and the retention rate suggest some degree of caution in interpreting the findings is warranted. In addition, the present study was conducted in a region where CR services are reimbursed through provincial healthcare coverage, and therefore enrollment rates attained may not be applicable to other regions where patients must pay out-of-pocket for CR.
In conclusion, two readily-implementable strategies were shown to increase CR enrollment, up to 65-84%. This is approximately two to five times greater access than under usual care, suggesting wider adoption of these strategies should be promoted. Randomized controlled trials are needed to confirm the robustness of these strategies in manualized form, as well as comparative effectiveness studies to ascertain the strategy or combination of strategies which can consistently optimize utilization.