Use of Cardiac Rehab Improved by Reminders


Cardiac rehabilitation (CR) referrals and utilization rates remain low in spite of having been shown to reduce mortality and is a recommended component in clinical practice guidelines.

Sherry Grace, PhD, of York University in Toronto, and colleagues have found that combining automated reminders with one-on-one conversations with a healthcare provider may be the best way to get heart patients to take advantage of cardiac rehabilitation.

Grace and co-authors reported their comparison of referral strategies in the Feb. 14 issue of Archives of Internal Medicine. The four referral strategies evaluated included: "automatic" only via discharge order or electronic record, health care provider liaison only, a combined approach, or the "usual" referral at the discretion of health care providers.

The researchers conducted a prospective controlled study of inpatients with coronary artery disease from 11 Ontario, Canada, hospitals using 1 of the 4 referral strategies. Of the 5767 inpatients approached, 2635 consented to participate, and 1449 were ineligible (a 61.0% response rate). At 1 year after recruitment, 1809 individuals completed the follow-up survey, and 389 (14.8%) were deemed ineligible (a 80.5% retention rate).

Reasons for ineligibility were as follows: they could not be contacted (n = 246 [63.2%]), were deceased (n = 107 [27.5%]), were too ill to participate (n = 8 [2.1%]), or there were other reasons (n = 28 [7.2%]).

The researchers found the dual approach combining automated reminders with one-on-one conversations with a healthcare provider led to the highest rates of referral to and enrollment in cardiac rehab (85.3% and 74%, respectively) than either strategy alone.


Automatic only was better than liaison only, resulting in 70.2% referral and 60.0% enrollment compared to 59.0% referral and 50.6% enrollment.

The “usual” referral resulted in a dismal 32.2% referral and only 29.0% enrollment.

Once patients were referred, however, the percentage of rehab sessions attended did not differ based on the referral approach.

"Wider adoption of such strategies could ensure that 45% more patients being treated for cardiac disease would have access to and realize the benefits of cardiac rehabilitation," they wrote.

Cardiac rehabilitation -- which addresses risk factors like obesity, smoking, and a sedentary lifestyle -- has been shown in previous studies to have effects on morbidity and mortality among heart patients similar to taking statins, aspirin, and beta-blockers.

To compare various approaches to addressing that problem, the group prospectively examined data from 16 wards in 11 Ontario hospitals. Three wards used automated reminders to refer patients to cardiac rehab at discharge, six used one-on-one conversations with the patients, five used a combination of the two, and two referred patients at the discretion of the physician (usual referral).

The authors acknowledged some limitations of the study, including the quasi-experimental design and the reliance on self-reported referral and usage rates.

Source reference:
Grace S, et al "Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study" Arch Intern Med 2011; 171: 235-241.