Background and Aims: Despite the documented benefits of cardiac rehabilitation (CR), participation rates have been reported in the literature between 12-25% for cardiac patients. Patients, health care providers, and the health care system are all factors affecting attendance rates. The purpose of the submission is 1) to present data between 2001-2008 for the acute myocardial infarction (AMI) population at a Canadian CR program; 2) to reflect upon interventions to improve participation rates; and 3) to explore initiatives to facilitate a seamless approach to cardiac care. This dialogue is timely as the management of chronic disease is at the forefront of public policy.

Methods and Materials: In 2001, a regional AMI care map was authored to address care gaps, including CR participation. In 2006, the care map was revised to include an automatic CR referral process. During the past 7 years, referral, demographic, risk stratification, outcomes, and evaluation data was prospectively analyzed. In response, innovative interventions including promotional, audiovisual, and educational initiatives were implemented.

Results: A total of 5,924 AMI patients were discharged to a home setting within the ( ) during 2001-2008. 25-27% were female and 73-75% were male (mean age was 60.52 years for both genders). CR program starts ranged from 20-28% with a significant increase in program starts (P <= .01) from 2003/04-2004/05 (22-28%). A sample from 2005/06 demonstrated that 32% of patients were high-risk (AACVPR Risk Stratification Tool), 14% were moderate-risk and 54% were assessed as low-risk. Data analysis offer insights as to reasons why patients agree to, or decline to participate in a CR program. The 2002 survey indicates that 85% of members attend CR because of advice by a health care professional. Patients declined participation due to factors including lack of support, additional health problems and lack of interest. A 2008 telephone follow-up revealed that the majority of patients who declined CR felt that they were managing their recovery on their own and furthermore, would not consider participating in a home based CR program.

Conclusions: Multimodal interventions during 2003/04-2004/05 may have influenced participation rates. Ongoing research is needed to determine the relationship and magnitude between interventions and program starts for this patient population. The impact of an automatic referral process in and of itself is unclear and warrants further investigation. Promotional, audiovisual, and educational initiatives were effective strategies to improve participation rates. Modified program delivery such as home based CR programs and tele-health systems may be viable complements to traditional CR programs. Lastly, from a Canadian perspective, discussion is needed in regards to an acceptable target for comprehensive CR participation. Perhaps this look at a CR program demonstrates that for this population, this is as good as it gets.