Automatic Referrals Can Increase Use of Cardiac Rehab

Automatically referring patients with heart disease to cardiac rehabilitation—when followed by a discussion between patient and clinician—was associated with an increased rate at which patients use this beneficial service, according to a report published in the Archives of Internal Medicine.

"Cardiovascular disease remains the leading cause of mortality worldwide, and this is chiefly attributable to modifiable risk factors such as hypertension, dyslipidemia, obesity, smoking, unhealthy diet and a sedentary lifestyle," wrote the authors. "Cardiac rehabilitation offers a comprehensive approach to chronic disease management, by addressing these risk factors."

Evidence demonstrates that, compared with usual care, cardiac rehabilitation reduces illness and death by about one-fourth over one to two years. However, an estimated 70% to 80% of eligible patients being treated for cardiac disease in the United States, Canada and the United Kingdom do not receive cardiac rehabilitation after being discharged from the hospital.

Sherry L. Grace, PhD, of York University, Toronto, and colleagues in the Cardiac Rehabilitation Care Continuity Through Automatic Referral Evaluation (CRCARE) Investigators group studied 2,635 patients with coronary artery disease at 11 Canadian hospitals. Patients completed a survey with sociodemographic information while in the hospital, their clinical data were extracted from medical charts and 1,809 participants completed a follow-up survey one year later.

Each hospital used one of four referral strategies for cardiac rehabilitation: an automatic referral using electronic patient records or standard discharge orders; liaison referral, whereby the referral is facilitated by a personal discussion with a clinician; a combination of both automatic and liaison strategies; or "usual" referral, in which select patients are referred at the discretion of clinicians.

Overall, patients who were referred to cardiac rehabilitation had attended 82.8% of sessions during the year following hospitalization. The strategy used by the hospital was significantly associated with cardiac rehabilitation referral and enrollment. Combined automatic and liaison referral resulted in an eight-fold increase in the likelihood that patients would be referred to cardiac rehabilitation, and more than 70% of patients enrolled in a rehabilitation program.

In comparison, at hospitals using only automatic referrals, 70.2% of patients received referrals and 60% enrolled in cardiac rehabilitation. Among patients at hospitals using only a liaison referral strategy, 59% received a referral and 50.6% enrolled. Usual care resulted in a 32.2% referral rate and 29% enrollment rate.

The combined strategy may be most effective because it targets both clinicians and patients, the authors note: "the order set or electronic record prompts the referral, and the patient discussion ensures health care provider endorsement and clarifies any misconceptions or barriers patients may have about cardiac rehabilitation," they write. "Implementation could potentially raise cardiac rehabilitation use 45%, suggesting that major public health gains could be achieved in the population being treated for cardiac disease."