The benefits of comprehensive cardiac rehabilitation have been proven in a wide spectrum of eligible patient groups. These groups have included women, patients with diabetes, obese persons, those with high or low baseline exercise capacity, and elderly patients well into their ninth decade of life. 1-3 Cardiac rehabilitation reduces cardiovascular 4,5 and all-cause mortality, 4 disability, recurrent cardiac complications, and hospitalizations. It also improves quality of life, physical functioning, depression scores, and overall psychological well-being. Based on these observations, cardiac rehabilitation has become a key component of secondary prevention strategies. 6-8

Despite these observations, multiple publications show that physician referral remains low, and many referred patients fail to attend or complete the program. 9,10 One national survey of 500 randomly selected cardiac rehabilitation programs showed that only a minority of eligible coronary heart disease patients enrolled in programs and that enrollment was generally lowest for nonwhites, those over age 65, and those living in the southern United States. 11 Our recent assessment of the prevalence of self-reported participation in cardiac rehabilitation services among persons in 19 states and the District of Columbia (DC) who have had a heart attack showed that fewer than 1 in 3 heart attack survivors received cardiac rehabilitation. 12 So what rhyme or reason underlies the continued under-referral and underutilization of cardiac rehabilitation? What is the current magnitude of this problem, and what should be the healthcare provider's reaction and response?

MAGNITUDE OF THE PROBLEM AND LESSONS LEARNED

The authors of a series of 4 articles in this issue shed new light on the magnitude of the problem of under-referral and underutilization, and offer insights into ways to address the problem. In the first article, Roblin et al 13 highlight the serious problem of under-referral and underutilization in their prospective cohort study of outpatient cardiac rehabilitation for patients discharged after acute myocardial infarction or coronary revascularization in one managed care setting. They showed that only 24.4% of patients who had at least one outpatient cardiologist visit were referred and only 7.1% participated in the program. As expected, enrollment was significantly higher in patients who received a referral.

These findings contrast sharply with those in a program where referral is automated and not dependent on individual physician practices. Grace et al 14 demonstrated in a large urban tertiary care facility in the Canadian universal healthcare system that computer-prompted automatic referral resulted in more than a doubling of participation rates in comparison to usual referral. In addition, disparities in participation based on type of referral event were eliminated in automatic referral. Women failed to complete rehabilitation more often than men. Using a physician-directed, nurse-managed, home-based, case-managed cardiac rehabilitation program in a group-model health maintenance organization, Ratchford et al 15 demonstrated a high participation and program graduation rates that were similar in men and women; however, these rates were lower in older persons.

In the fourth article in this series, Johnson et al 16 identified key factors that are associated with referral to outpatient cardiac rehabilitation services. They included younger age, previous participation in cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery, and admission to a hospital that provided cardiac rehabilitation services. Ratchford et al 15 also demonstrated that patients who underwent surgery or had the occurrence of two or more events during the first 4 weeks of the index cardiac event were also more likely to be referred for cardiac rehabilitation. Taken together, these four papers not only highlight the burden of under-referral and underutilization in usual practices for cardiac rehabilitation, but they also point to some of the underlying reasons and key determining factors.

RHYME AND REASON FOR UNDER-REFERRAL AND UNDERUTILIZATION

Although often discussed in the same vein, under-referral and under-utilization have very different but interrelated underlying determinants. The reasons for both need to be examined and addressed. In under-referral, the important determinants include physicians and the healthcare systems within which they practice. Physician awareness and knowledge of available evidence supporting the benefits of cardiac rehabilitation and their commitment to guideline adherence are crucial. Physician beliefs about which patients are likely to benefit from rehabilitation also impact referral rates. Underutilization, on the other hand, is largely influenced by patient-related factors. If patients are unaware of the benefits of rehabilitation, especially relative to the impact on their physical functioning and quality of life, they will be less likely to enroll in rehabilitation programs. Affordability and access to rehabilitation programs are important, although as Grace et al 14 demonstrated, these alone are not enough to guarantee high referral or utilization rates. Patient education, language skills, literacy level and patient preferences also play a important roles in whether a referred patient actually enrolls and completes the rehabilitation program. These preferences include access to facilities close to home, availability of flexible exercise approaches especially for patients with comorbidities such as arthritis, overweight or obesity and physical disabilities, and patient choices in program goals and targets. The overall psychosocial status, self-efficacy, availability of social support, and patient expectations are proven factors that also influence individual adherence. 17,18 Understanding and effectively addressing these issues will improve program utilization and patient outcomes.

REACTION AND RESPONSE

The greatest impact on referral rates will likely come from interventions at the systems level and from increased and efficient use of information technology. Crucial among these will be the institution and widespread use of comprehensive electronic medical records interfaced with robust decision support algorithms and automated rehabilitation referral of all eligible patients based on widely accepted clinical practice guidelines. The available evidence suggests that this intervention alone is likely to double referral rates. These systems must also allow automated communication between healthcare departments to improve continuity of care and reduce time required for referral. The use of geographic information system (GIS) technology can also help in identifying facilities and resources closest to where patients live. Subsequent health services analysis of the GIS data can help prioritize areas most in need of new or expanded facilities for cardiac rehabilitation.

Other needed systems-level changes include policy development and policy change that lead to increased access, improved reimbursement for rehabilitation services, increased support for non-physician providers, and assistance with transportation to and from rehabilitation facilities. Additionally, paying for quality-an issue that is increasingly being discussed in other areas of cardiovascular care-will have to be addressed. Ideally, cardiac rehabilitation centers that demonstrate optimal referral and completion rates receive higher reimbursements than centers with lower rates. Cost effectiveness analysis will be important to incorporate into evaluation of such system changes.

PROGRAM-RELEVANT RESEARCH NEEDED

Increased support is needed for program-relevant research in this area to address key questions. For example, what motivates some patients to enroll and complete cardiac rehabilitation while other patients from similar backgrounds, diagnoses, comorbidity, and healthcare resources fail to enroll or complete rehabilitation programs? Why do some diagnoses and interventions engender increased referral and enrollment while others that carry similarly serious cardiovascular prognosis fail to motivate patient enrollment. What can be done to improve continuation of exercise beyond the structured phase II cardiac rehabilitation? Most importantly, what must be done to eliminate gender, age, and racial/ethnic disparities and the known barriers to referral and effective utilization of cardiac rehabilitation? The answers to these research questions have high relevance to successful implementation of cardiac rehabilitation programs.

CONCLUSION

The benefits of comprehensive cardiac rehabilitation are not in doubt. Neither are the magnitude and seriousness of its under-referral and underutilization. Although we may not have all the answers to these challenges, we do know enough about the key determinants. However, as Goethe stated so eloquently, "Knowing is not enough, we must apply. " The time to apply what we know to improve referral, utilization, and program completion rates is now.

References