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.

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    ABSTRACT: BACKGROUND: Patient and provider-related factors affecting access to cardiac rehabilitation (CR) have been extensively studied, but health-system administration factors have not. The objectives of this study were to investigate hospital administrators' (HA) awareness and knowledge of cardiac rehabilitation (CR), perceptions regarding resources for and benefit of CR, and attitudes toward and implementation of inpatient transition planning for outpatient CR. METHODS: A cross-sectional and observational design was used. A survey was administered to 679 HAs through Canadian and Ontario databases. A descriptive examination was performed, and differences in HAs' perceptions by role, institution type and presence of within-institution CR were compared using t-tests. RESULTS: 195 (28.7%) Canadian HAs completed the survey. Respondents reported good knowledge of what CR entails (mean=3.42+/-1.15/5). Awareness of the closest site was lower among HAs working in community versus academic institutions (3.88+/-1.24 vs. 4.34+/-0.90/5 respectively; p=.01). HAs in non-executive roles (4.77+/-0.46/5) perceived greater CR importance for patients' care than executives (4.52+/-0.57; p=.001). HAs perceived CR programs should be situated in both hospitals and community settings (n=134, 71.7%). CONCLUSIONS: HAs value CR as part of patients' care, and are supportive of greater CR provision. Those working in community settings and executives may not be as aware of, or less-likely to value, CR services. CR leaders from academic institutions might consider liaising with community hospitals to raise awareness of CR benefits, and advocate for it with the executives in their home institutions.
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    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.
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    ABSTRACT: Physicians play an important role in CR referral and enrollment. Despite established benefits and recommendations, cardiac rehabilitation (CR) enrollment rates are pervasively low. The reasons cardiac patients are missing from CR programs are multifactorial and include provider factors. A number of studies have now investigated physician factors associated with referral to CR programs and patient enrollment. The objective of this study was to qualitatively and systematically review this literature. A literature search of MEDLINE, PsycINFO, CINAHL, Embase, and EBM was conducted for published articles from database inception to October 2011. Overall, 17 articles were included following a process of independent review of each article by 2 authors. Seven (41.2%) were graded as good quality according to Downs and Black criteria. There were no randomized controlled trials. Results showed that medical specialty (ie, cardiac specialists more likely to refer; n = 8 studies) and other physician-reported reasons (eg, physician report of their reasons for CR referral and physician sex) were related to referral. Physician factors related to patient enrollment in CR were physician endorsement, medical specialty, being referred, and physician attitudes toward CR. Physician factors are consistently related to CR referral and enrollment. The role of physician endorsements in promoting patient enrollment should be optimized and exploited.
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