title: Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study.
abstract: BACKGROUND
  Although cardiac rehabilitation (CR) has been shown to reduce mortality and is a recommended component in clinical practice guidelines, CR referral and utilization rates remain low. Referral strategies have been implemented to increase CR use but have yet to be compared concurrently. To determine the optimal strategy to maximize CR referral, enrollment, and participation, we evaluated 3 referral strategies compared with usual care: "automatic" only via discharge order or electronic record, health care provider liaison only, or a combined approach.
  
  
  METHODS
  In this prospective controlled study, 2635 inpatients with coronary artery disease from 11 Ontario, Canada, hospitals using 1 of the 4 referral strategies completed a sociodemographic survey, and clinical data were extracted from medical charts. One year later, 1809 participants completed a mailed survey that assessed CR utilization. Referral strategies were compared using generalized estimating equations to control for effect of hospital.
  
  
  RESULTS
  Adjusted analyses revealed referral strategy was significantly related to CR referral and enrollment (P<.001). Combined automatic and liaison referral resulted in the greatest CR use (odds ratio [OR], 8.41; 85.8% referral, 73.5% enrollment), followed by automatic only (OR, 3.27; 70.2% referral, 60.0% enrollment), and liaison only (OR, 3.35; 59.0% referral, 50.6% enrollment), compared with usual referral (32.2% referral, 29.0% enrollment). The degree of CR participation did not differ by referral strategy among referred participants (mean [SD] percentage of classes attended, 82.87% [27.20%]; P=.88).
  
  
  CONCLUSIONS
  Automatic referral combined with a patient discussion can achieve among the highest rates of CR referral reported. Wider adoption of such strategies could ensure that 45% more patients being treated for cardiac disease would have access to and realize the benefits of CR.
authors.affiliation: School of Kinesiology and Health Sciences, Faculty of Health, York University, 368 Bethune, 4700 Keele St, Toronto, ON M3J 1P3, Canada. sgrace@yorku.ca
authors.forename: Sherry L
authors.initials: SL
authors.lastname: Grace
authors.forename: Kelly L
authors.initials: KL
authors.lastname: Russell
authors.forename: Robert D
authors.initials: RD
authors.lastname: Reid
authors.forename: Paul
authors.initials: P
authors.lastname: Oh
authors.forename: Sonia
authors.initials: S
authors.lastname: Anand
authors.forename: James
authors.initials: J
authors.lastname: Rush
authors.forename: Karen
authors.initials: K
authors.lastname: Williamson
authors.forename: Milan
authors.initials: M
authors.lastname: Gupta
authors.forename: David A
authors.initials: DA
authors.lastname: Alter
authors.forename: Donna E
authors.initials: DE
authors.lastname: Stewart
mesh_terms: D054058:Acute Coronary Syndrome / Q000534:rehabilitation*; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000534:rehabilitation*; D003299:Cooperative Behavior; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D033183:Interdisciplinary Communication; D008297:Male; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data; D008875:Middle Aged; D016017:Odds Ratio; D009864:Ontario; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D010348:Patient Care Team; D010351:Patient Discharge / Q000706:statistics & numerical data; D010865:Pilot Projects; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012047:Rehabilitation Centers / Q000706:statistics & numerical data*; D013689:Telephone; D014600:Utilization Review / Q000706:statistics & numerical data