title: Factors influencing referral to cardiac rehabilitation and secondary prevention programs: a systematic review.
abstract: BACKGROUND
  Referral to cardiac rehabilitation and secondary prevention programs remains very low, despite evidence suggesting strong clinical efficacy. To develop evidence-based interventions to promote referral, the complex factors and processes influencing referral need to be better understood.
  
  
  METHODS
  We performed a systematic review using qualitative meta-synthesis.
  
  
  METHODS
  A comprehensive search of 11 databases was conducted. To be included, studies had to contain a qualitative research component wholly or in a mixed method design. Population specific data or themes had to be extractable for referral to programs. Studies had to contain extractable data from adults >18 years and published as full papers or theses during or after 1995.
  
  
  RESULTS
  A total of 2620 articles were retrieved: out of 1687 studies examined, 87 studies contained data pertaining to decisions to participate in programs, 34 of which included data on referral. Healthcare professional, system and patient factors influenced referrals. The main professional barriers were low knowledge or scepticism about benefits, an over-reliance on physicians as gatekeepers and judgments that patients were not likely to participate. Systems factors related to territory, remuneration and insufficient time and workload capacity. Patients had limited knowledge of programs and saw physicians as key elements of referral but found the process of attaining a referral confusing and challenging.
  
  
  CONCLUSIONS
  The greatest increases in patient referral to programs could be achieved by allowing referral from non-physicians or alternatively, automatic referral to a choice of hospital or home-based programs. All referring health professionals should receive educational outreach visits or workshops around the ethical and clinical aspects of programs.
authors.affiliation: Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada. alex.clark@ualberta.ca
authors.forename: Alexander M
authors.initials: AM
authors.lastname: Clark
authors.forename: Kathryn M
authors.initials: KM
authors.lastname: King-Shier
authors.forename: Amanda
authors.initials: A
authors.lastname: Duncan
authors.forename: Melisa
authors.initials: M
authors.lastname: Spaling
authors.forename: James A
authors.initials: JA
authors.lastname: Stone
authors.forename: Susan
authors.initials: S
authors.lastname: Jaglal
authors.forename: Jan
authors.initials: J
authors.lastname: Angus
mesh_terms: D001291:Attitude of Health Personnel; D003661:Decision Support Techniques; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006331:Heart Diseases / Q000175:diagnosis / Q000453:epidemiology / Q000534:rehabilitation*; D006801:Humans; D010353:Patient Education as Topic; D018579:Patient Selection; D012017:Referral and Consultation; D055502:Secondary Prevention / Q000379:methods; D016896:Treatment Outcome
keywords: Access; decision-making; decisions; health services; inequalities; usage