Abstract
Background Cardiac rehabilitation (CR), in most developed countries, is a proven means of reducing mortality but it is grossly underutilized owing to factors involving both the health system and patients. These issues have not been investigated concurrently. To this end, we employed a hierarchical design to investigate physician and patient factors that affect verified CR referral.
Methods This study was prospective with a multilevel design. We assessed 1,490 outpatients with coronary artery disease attending 97 cardiology practices. Cardiologists completed a survey about attitudes to CR referral. Outpatients were surveyed prospectively to assess sociodemographic, clinical, behavioral, psychosocial and health system factors that affected CR referral. Responses were analyzed by mixed logistic regression analyses. After 9 months, CR referral was verified at 40 centers.
Results Health-care providers referred 550 (43.4%) outpatients to CR. Factors affecting verified referral included positive physician perceptions of CR (P = 0.03), short distance to the closest CR site (P = 0.003), the perception of fewer barriers to CR (P < 0.001) and a sense of personal control over their condition by the patient (P = 0.001).
Conclusions Physician-related and patient-related factors both contribute to CR referral. The most relevant physician perceptions of such programs are program quality and perceived benefit. For patients, the most relevant factors are perceived barriers to CR, which might be conveyed during prereferral discussions. Work to improve physicians' perceptions and patients' understanding might improve use of rehabilitation services.
Key Points
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Cardiac rehabilitation (CR) is shown to improve patient outcomes, but many physicians do not always refer their patients when indicated
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Through multilevel analysis, this study shows that both physician and patient factors have roles in CR referral
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The most relevant perceptions of physicians relate to CR programs' quality and benefit, and for patients relate to CR barriers
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Patients might try to convey concerns during pre-referral CR discussions, and physicians should be trained to identify and address them
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Distance from the patient's home to the CR site was related to physician referral practice, despite the availability of home-based services
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Efforts to improve physicians' perceptions of CR, referral to home-based CR where geographic barriers are evident and finding solutions to overcome CR barriers with patients could improve CR referral practice
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References
Jolliffe JA et al. Exercise-based rehabilitation for coronary heart disease (Cochrane review). Cochrane Database of Systemic Reviews 2001, Issue 4. Art. No.: CD001800. 10.1002/14651858.CD001800
Taylor RS et al. (2004) Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med 116: 682–692
Brown A . et al. (2003) Exercise-based cardiac rehabilitation programs for coronary artery disease: A systematic clinical and economic review. Canadian Coordinating Office for Health Technology Assessment: Report no. 34
Stone JA et al. (2004) Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention: Enhancing the Science, Refining the Art, edn 2. Winnipeg: CACRC
Thomas RJ et al. (2007) AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services endorsed by the American College of Chest Physicians, American College of Sports Medicine, American Physical Therapy Association, Canadian Association of Cardiac Rehabilitation, European Association for Cardiovascular Prevention and Rehabilitation, Inter-American Heart Foundation, National Association of Clinical Nurse Specialists, Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons. J Am Coll Cardiol 14: 1400–1433
Bittner V et al. (1999) Referral patterns to a university-based cardiac rehabilitation program. Am J Cardiol 83: 252–255
Wyer S et al. (2001) Predicting attendance at cardiac rehabilitation: A review and recommendations. Coronary Health Care 5: 171–177
Grace SL et al. (2002) Cardiac rehabilitation II: Referral and participation. Gen Hosp Psychiatry 24: 127–134
Bunker SJ and Goble AJ (2002) Cardiac rehabilitation: Under-referral and underutilisation. Med J Aust 179: 332–333
Suskin N . et al. (online September 30 2002) The Ontario cardiac rehabilitation pilot project: Report and recommendations [http://www.ccn.on.ca/pdfs/Rehab-Pilot-Project-Sep2002.pdf] (accessed 21 April 2008)
Suter P et al. (1992) Views of Arkansas physicians on cardiac rehabilitation. J Cardiopulm Rehabil 12: 32–35
Grace SL et al. (2004) Physician management preferences for cardiac patients: Factors affecting referral to cardiac rehabilitation. Can J Cardiol 20: 1101–1107
Scott LB and Allen JK (2004) Providers' perceptions of factors affecting women's referral to outpatient cardiac rehabilitation programs: an exploratory study. J Cardiopulm Rehabil 24: 387–391
Jackson L et al. (2005) Getting the most out of cardiac rehabilitation: A review of referral and adherence predictors. Heart 91: 10–14
Scott LA et al. (2002) Why are women missing from outpatient cardiac rehabilitation programs? A review of multilevel factors affecting referral, enrollment, and completion. J Womens Health 11: 773–791
Grace SL et al. (2004) Automatic referral to cardiac rehabilitation. Med Care 42: 661–669
Grace SL et al. (2007) A prospective comparison of cardiac rehabilitation enrolment following automatic versus usual referral. J Rehabil Med 39: 239–245
Hlatky MA et al. (1989) A brief self-administered questionnaire to determine functional capacity (the duke activity status index). Am J Cardiol 64: 651–654
Washburn RA et al. (1993) The Physical Activity Scale for the Elderly (PASE): development and evaluation. J Clin Epidemiol 46: 153–162
Sechrist KR et al. (1987) Development and psychometric evaluation of the exercise benefits/barriers scale. Res Nurs Health 10: 357–365
Beck AT et al. (1961) An inventory for measuring depression. Arch Gen Psychiatry 4: 561–571
Beck AT et al. (1996) Beck Depression Inventory-II Manual. San Antonio, TX: The Psychological Corporation
Frasure-Smith N et al. (1993) Depression following myocardial infarction. Impact on 6-month survival. JAMA 270: 1819–1825
Mitchell PH et al. (2003) A short social support measure for patients recovering from myocardial infarction: The ENRICHD social support inventory. J Cardiopulm Rehabil 23: 398–403
Moss-Morris R et al. (2002) The revised illness perception questionnaire (IPQ-R). Psychol Health 17: 1–16
SPSS for windows 13.0 (SPSS Inc., Chicago, IL, USA)
R: A language and environment for statistical computing 2006 (Development Core Team, University of Auckland, Auckland, New Zealand) http://www.R-project.org
Pinheiro J et al. (2006) NLME: linear and nonlinear mixed effects models. Addvc 3: 1–79
Stiller JJ and Holt MM (2004) Factors influencing referral of cardiac patients for cardiac rehabilitation. Rehabil Nurs 29: 18–23
Cooper AF et al. (2002) Factors associated with cardiac rehabilitation attendance: A systematic review of the literature. Clin Rehabil 16: 541–552
Daly J et al. (2002) Barriers to participation in and adherence to cardiac rehabilitation programs: A critical literature review. Prog Cardiovasc Nurs 17: 8–17
Caulin-Glaser T and Schmeizl R (2000) Impact of educational initiatives on gender referrals to cardiac rehabilitation [abstract]. J Cardiopulm Rehabil 20: 302
Petrie KJ et al. (1996) Role of patients' view of their illness in predicting return to work and functioning after myocardial infarction: Longitudinal study. BMJ 312: 1191–1194
Melville MR et al. (1999) Cardiac rehabilitation: Socially deprived patients are less likely to attend but patients ineligible for thrombolysis are less likely to be invited. Heart 82: 373–377
Johnson JE et al. (1998) Rural residents' use of cardiac rehabilitation programs. Public Health Nurs 15: 288–296
Taylor RS et al. (2007) Home-based cardiac rehabilitation versus hospital-based rehabilitation: A cost effectiveness analysis. Int J Cardiol 119: 196–201
Jolly K et al. (2006) Home-based cardiac rehabilitation compared with centre-based rehabilitation and usual care: A systematic review and meta-analysis. Int J Cardiol 111: 343–351
Beswick AD et al. (2005) Improving uptake and adherence in cardiac rehabilitation: Literature review. J Adv Nurs 49: 538–555
LaBresh KA et al. (2004) Get with the guidelines for cardiovascular secondary prevention: pilot results. Arch Intern Med 164: 203–209
Kellerman SE and Herold J (2001) Physician response to surveys. A review of the literature. Am J Prev Med 20: 61–67
Acknowledgements
This research was funded by the Canadian Institutes of Health Research (CIHR) grant MOP-74431. SL Grace is supported by CIHR award MSH-80489, and S Gravely-Witte is supported by the Ontario Women's Health Council/CIHR Institute of Gender and Health. J Brual is supported by the Heart and Stroke Foundation of Ontario. We thank S Kayaniyil for assistance with data entry and G Monette for assistance with hierarchical modeling.
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Grace, S., Gravely-Witte, S., Brual, J. et al. Contribution of patient and physician factors to cardiac rehabilitation referral: a prospective multilevel study. Nat Rev Cardiol 5, 653–662 (2008). https://doi.org/10.1038/ncpcardio1272
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DOI: https://doi.org/10.1038/ncpcardio1272
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