Cardiac rehabilitation (CR) reduces morbidity and mortality associated with cardiovascular disease by addressing modifiable risk factors.1-3 Due to its effects of reducing subsequent hospitalizations and complications, CR can also be cost-effective.4 However, CR is underutilized due to lack of referrals and patient-specific barriers.4-6 Cardiac rehabilitation is underprescribed, with referral rates after percutaneous coronary intervention of only 59-66%.4 Participation is particularly low in minority groups and persons of lower socioeconomic status.7
Traditionally, patients are referred to phase II CR on discharge from the hospital following an acute cardiovascular event.3,8 Based on the Million Hearts Program, the Agency for Healthcare Research and Quality recently selected opt-out electronic health record referrals and the use of liaisons to facilitate CR referral at discharge.3 However, many eligible patients with chronic stable angina, chronic stable heart failure, or peripheral arterial disease may not require hospitalization. Furthermore, many patients who are not referred after hospitalization (or are referred but decline to attend) are still likely to be seen in outpatient follow-up.
Academic cardiology programs represent a unique arena for CR referrals, as they typically care for patients from groups with low CR utilization: lower socioeconomic status and minority groups.8 Furthermore, specific barriers to referral exist for fellows-in-training, including complicated logistics, limited communication between CR staff and fellows, limited time with patients, and presumed patient-specific barriers to CR.9 Since fellows develop lifelong practice patterns while in training, this is a crucial stage to emphasize the importance of CR referral.
Therefore, we designed an intervention utilizing a CR liaison in the outpatient setting to increase CR referral rates from a cardiology fellow clinic and educate cardiology fellows about CR.
METHODS
A CR staff member liaison was physically present at a university-based fellow cardiology safety-net clinic once/wk between January 1, 2016, and December 31, 2019. The liaison pre-screened the daily patient roster via electronic medical record for CR eligibility per Medicare Part B criteria, with exclusion criteria of CR participation in the last 12 mo. If inclusion criteria were met, the liaison suggested referral. After the physician assessment, and if referred, the liaison then determined insurance eligibility and copay, spoke with patients to address concerns and barriers to care, and scheduled patients for assessment at the CR facility.
Frequency data were collected including referrals, enrollment, attendance, and graduation from CR defined as attendance of >12 classes. Only de-identified, aggregate data were collected, which did not require institutional review board approval.
RESULTS
From July 1, 2015, to December 31, 2016, there were no CR referrals from our clinic. Over the intervention period from January 1, 2016, to December 31, 2019, 1358 patient charts were pre-screened. Of those screened, 505 patients did not present to clinic and could not be assessed for eligibility. In total, 481 patients were not eligible for CR, with 98 due to patient-specific factors such as physical, social, or financial reasons. The remaining 372 patients (44%) were deemed eligible and met with the CR liaison during the appointment. Of eligible patients, 20% (73/372) declined CR, 69% (256/372) were scheduled for in-network CR intake assessment, and 9% (35/372) were scheduled at an unassociated facility of their preference. The eight unaccounted patients deferred CR due to upcoming surgical procedures and were serially reassessed. Of patients scheduled in-network, 64% (164/256) attended the initial assessment and 36% (92/256) did not. Final outcomes included 48% of in-network patients (124/256) attending >=1 CR session with 18% (45/256) graduating. Composite data and chronologic trends are represented in the Figure.
DISCUSSION
The Million Hearts initiative is a U.S. national program designed to prevent 1 million cardiovascular deaths in 5 yr by increasing preventative measures, including >=70% CR utilization.3,10 However, program strategies focused on the inpatient setting, where combined automatic and liaison-initiated referral to phase II CR was the most successful.1,10
Our outpatient clinic intervention adds a new strategy for increasing CR referrals, using the evidence-based CR liaison approach applied to the outpatient setting. Our outpatient intervention was able to identify patients not referred at discharge, address barriers to care in those who were referred at discharge but did not attend CR, and identify patients who were eligible but did not require hospitalization. Our data indicate that a large portion of patients seen in our clinic (44%) were eligible for CR and had not attended in the past 12 mo.
The effects of having an onsite CR liaison were multiple. First, the CR liaison pre-screened patient charts, outsourcing work from clinicians. The CR liaison also simplified the referral process for physicians. These steps specifically addressed factors previously identified as barriers to referral, including limited time with patients, lack of communication between CR staff and physicians, and complicated referral process or logistics.9
The liaison also discussed CR with each patient to clarify misconceptions about CR, identify barriers to care, and emphasize physician endorsement. Therefore, this intervention effectively targeted both patients and physicians.
Our rates of CR participation (64%) were higher compared with the Medicaid registry (20%),6 which we attribute to the CR liaison individualizing care and speaking with each patient directly. However, completion rates were lower than reported averages.5,6 This could be due to our clinic primarily treating underserved, uninsured, and underinsured patients (82% Medicare/Medicaid), a population likely to have substantial barriers to attending and completing CR.4,7 Further interventions should address session attendance and barriers to completing CR.
During the intervention, referrals were lower from July to December compared with January to June, perhaps indicating that new fellows were not as familiar with the indications for CR or the referral process. This lack of referrals demonstrates an opportunity for cardiology fellows, who are developing their lifelong practice patterns, to include CR referral.
A clinic-based intervention consisting of onsite CR liaison was able to offload logistical work from physicians, simplify the referral process, increase communication, and address patient-specific barriers resulting in increased CR referrals and greater inclusion of CR in fellow education.
Jeffrey Fraser Spindel, DO
Department of Internal Medicine, University of Louisville
School of Medicine, Louisville, Kentucky
Lauren Albers, MD
Division of Cardiovascular Medicine, University of
Louisville School of Medicine, Louisville, Kentucky
Gregory Brislin, MS
Department of Internal Medicine, University of Louisville
School of Medicine, Louisville, Kentucky
Lorrel Elizabeth Brown Toft, MD
Division of Cardiovascular Medicine,
University of Louisville School of Medicine,
Louisville, Kentucky, and Department of Medicine,
Cardiology, University of Nevada, Reno, Reno, Nevada
ACKNOWLEDGMENTS
The authors wish to acknowledge the KentuckyOne Healthy Lifestyles Center for removing barriers and offering an individualized CR experience.
REFERENCES