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  • Review Article
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Effects of cardiac rehabilitation referral strategies on referral and enrollment rates

Nature Reviews Cardiology volume 7, pages 87–96 (2010)Cite this article

Abstract

Despite recommendations in clinical practice guidelines, evidence suggests that utilization of cardiac rehabilitation (CR) following indicated cardiac events is low. Referral strategies, such as automatic referral, have been advocated to improve CR utilization. In this Review, we evaluate the effects of referral strategies on rates of CR referral and enrollment. Referral strategies are categorized as 'automatic' (the use of electronic health records or systematic discharge order sets), as 'liaison' (discussions with allied health-care providers), or as 'other' (for example, the use of motivational letter to patients). The highest rates of CR referral have been achieved in studies implementing automatic referral orders, whereas the highest rates of CR enrollment have resulted from a combination of automatic and liaison methods. Overall, innovative referral strategies significantly increase CR utilization. While further investigation is needed, institutions should evaluate their CR referral practice in light of these findings.

Key Points

  • Despite recommendations in clinical practice guidelines, evidence shows that only 15–20% of cardiac patients make use of cardiac rehabilitation services

  • The reasons for the disparity between evidence and care are complex but, arguably, the chief explanatory factors are referral failure and lack of provider encouragement

  • Innovative referral strategies can substantially increase cardiac rehabilitation referral and enrollment

  • Automatic referral methods, such as the AHA's Get With The Guidelines initiative, can appreciably increase referral rates

  • The incorporation of a cardiac rehabilitation referral discussion with an allied health-care provider can result in enrollment rates that are double the rates after usual referral

  • Innovative cardiac rehabilitation referral strategies should be considered by health-care providers, administrators and policy makers, although randomized trials are needed to clarify the role of each individual strategy

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Acknowledgements

This Review was supported by the Canadian Institutes of Health Research (CIHR) and The Heart and Stroke Foundation of Canada Grant # HOA-80676. S. Gravely-Witte is supported by an Ontario Women's Health Council/CIHR Institute of Gender and Health doctoral research award. Y. W. Leung is supported by a Canada Graduate Scholarship: Frederick Banting and Charles Best Canada doctoral award. S. L. Grace is supported by a CIHR New Investigator Award (# MSH-80489). We gratefully acknowledge Dr. Liane Ginsberg and Dr. Tamara Daly for their critiques on the proposal for this Review.

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Authors and Affiliations

  1. Faculty of Health, 368 Norman Bethune College, York University, 4700 Keele Street, Toronto, M3J 1P3, ON, Canada

    Shannon Gravely-Witte, Yvonne W. Leung, Rajiv Nariani, Hala Tamim & Sherry L. Grace

  2. Toronto Rehabilitation Institute, Rumsey Center, 347 Rumsey Road, Toronto, M4G 1R7, ON, Canada

    Paul Oh

  3. York Central Hospital, 10 Trench Street, Richmond Hill, L4C 4Z3, ON, Canada

    Victoria M. Chan

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Correspondence to Sherry L. Grace.

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Gravely-Witte, S., Leung, Y., Nariani, R. et al. Effects of cardiac rehabilitation referral strategies on referral and enrollment rates. Nat Rev Cardiol 7, 87–96 (2010). https://doi.org/10.1038/nrcardio.2009.223

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