Background: Cardiac rehabilitation (CR) is a proven means of reducing risk and improving quality of life for patients, yet it is grossly under-utilized. This is due to both health system and patient-level issues. Both levels were addressed concurrently in this study, which examined factors affecting verified CR referral and enrollment.
Methods: 97 Ontario cardiologists, the most frequent CR referrers, and a subsample of approximately 15 their coronary artery disease (CAD) outpatients each (N = 1490, mean age 65.60 +/- 11.44; n = 430, 28.7% female), were surveyed prospectively to explore factors affecting CR referral and enrollment according to Andersen's model of healthcare utilization. 1268 outpatients (90% retention) responded to the follow-up survey assessing CR utilization. Participants' homes and CR sites were mapped by postal code, to generate distances in kilometers to the closest CR site using GIS. CR utilization was verified with 40 CR sites.
Results: 550 (43.4%) outpatients were referred, and 469 (37.0%) enrolled in CR. Factors affecting verified referral in hierarchical logistic regression analyses were positive physician perceptions of CR (P = .03), shorter patient distance to the closest CR site (P = .003), fewer perceived CR barriers (P < .001) and personal control (P = .001). Factors affecting verified CR enrollment were being married (P = .01), greater strength of physician endorsement (P = .005), shorter distance to CR (P = .001), and fewer perceived CR barriers (P = .03).
Conclusions: This is the first study to have concurrently examined physician and patient level factors affecting CR utilization, and results suggest that issues at both levels may interact. For instance, not only is referral to CR affected by physician perceptions of such programs, including quality and perceived benefit, but is affected by patient's perceived CR barriers which they may convey during CR discussions. When examining predictors of patient enrollment, not only is a patient's marital status integral, but the strength of physician endorsement is also crucial. Distance to CR was related to both physician referral practice and patient enrollment patterns. Such logistic health-system issues could be addressed through provision of alternative models of delivery, such as home-based CR. Finally, no need-related factors such as disease severity or risk factors were related to CR utilization in adjusted analyses. This suggests that CR utilization is more heavily weighted by physician perceptions of CR and logistical issues than patient need.