Contribution of patient and physician factors to cardiac rehabilitation referral: a prospective multilevel study.

York University, Toronto, ON, Canada.
Nature Clinical Practice Cardiovascular Medicine (Impact Factor: 7.04). 07/2008; 5(10):653-62. DOI: 10.1038/ncpcardio1272
Source: PubMed

ABSTRACT 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.
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.
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).
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.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: When patient selection processes determine who can and cannot use healthcare there can be inequalities and inequities in individuals' opportunities to benefit. This paper evaluates the influence of a hospital selection process on opportunities to access outpatient cardiac rehabilitation (CR). A secondary data analysis was conducted on a cohort of inpatients (n = 2,375) who were all eligible for invitation to an Australian CR program. Eligibility was determined by hospital discharge diagnosis codes. Only invited patients could attend. Logistic regression analysis tested the extent to which individual patient characteristics were statistically significantly associated with the outcome 'invitation' after adjusting for cardiac disease and other factors. Less than half of the eligible patients were invited to the CR program. After allowing for known factors that may have justified not being selected, there was bias towards inviting males, younger patients, married patients, and patients who nominated English as their preferred language. Health service managers typically monitor service utilisation patterns as indicators of access but often pay little attention to ways in which locally determined system factors influence access to care. The paper shows how a hospital selection process can unreasonably influence patients' opportunities to benefit from an evidence-based healthcare program.
    International Journal for Equity in Health 01/2010; 9:2. · 1.71 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Despite its proven benefits and need, women are significantly less likely than men to participate in and complete cardiac rehabilitation (CR). The purpose of this study was to quantitatively investigate sex differences in CR barriers by participation status. Cardiac outpatients (1496, 430 female, 28.7%) of 97 cardiologists completed a mailed survey to discern CR participation. Respondents were asked to rate 19 CR barriers on a 5-point Likert scale. Five hundred twenty-nine (43%) respondents self-reported participating in CR, with men being more likely to participate (p < 0.05). There was no significant sex difference in total number of CR barriers, but differences in individual barriers were found. For CR participants, t tests revealed significant sex differences in the perception of exercise as tiring or painful (p = 0.042) and work responsibilities (p = 0.013). For CR nonparticipants, women rated the following barriers as greater than men: transportation (p = 0.025), family responsibilities (p = 0.039), lack of CR awareness (p = 0.036), experiencing exercise as tiring or painful (p = 0.002), and comorbidities (p = 0.009). Overall, women do not perceive greater barriers to CR participation than men, but the nature of their barriers differs, particularly among nonparticipants. Beliefs about the value of CR, awareness, and exercise parameters are all modifiable barriers that should be addressed among women.
    Journal of Women's Health 02/2009; 18(2):209-16. · 1.90 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND:: Much attention has been paid to improving the care of patients with cardiovascular disease by focusing attention on delivery system redesign and payment reforms that encompass the healthcare spectrum, from an acute episode to maintenance of care. However, 1 area of cardiovascular disease care that has received little attention in the advancement of quality is cardiac rehabilitation (CR), a comprehensive secondary prevention program that is significantly underused despite evidence-based guidelines that recommending its use. PURPOSE:: The purpose of this article was to analyze the applicability of 2 payment and reimbursement models-pay-for-performance and bundled payments for episodes of care - that can promote the use of CR. CONCLUSIONS:: We conclude that a payment model combining elements of both pay-for-performance and episodes of care would increase the use of CR, which would both improve quality and increase efficiency in cardiac care. Specific elements would need to be clearly defined, however, including: (a) how an episode is defined, (b) how to hold providers accountable for the care they provider, (c) how to encourage participation among CR providers, and (d) how to determine an equitable distribution of payment. CLINICAL IMPLICATIONS:: Demonstrations testing new payment models must be implemented to generate empirical evidence that a melded pay-for-performance and episode-based care payment model will improve quality and efficiency.
    The Journal of cardiovascular nursing 02/2013; · 1.47 Impact Factor


Available from