Effect of Cardiac Rehabilitation Referral Strategies on Utilization Rates: A Prospective, Controlled Study

Study Questions:

What is the optimal strategy to maximize cardiac rehabilitation’s (CR) referral, enrollment, and participation?


A prospective controlled study was conducted in 2,635 inpatients with coronary artery disease in 11 Ontario, Canada, hospitals. Inclusion criteria included an acute coronary syndrome, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), congestive heart failure, or an arrhythmia. Three referral strategies were compared with usual care: 1) “automatic” only via discharge order or electronic record, 2) health care provider (nurse or exercise specialist) liaison only, 3) a combined approach, or 4) primary care physician. Each of the wards in the 11 hospitals used a different strategy. Subjects who received one of the four referral strategies completed a sociodemographic survey, and clinical data were extracted from medical charts. One year later, 1,809 participants completed a mailed survey that assessed CR utilization. Referral strategies were compared using generalized estimating equations to control for effect of hospital.


Of the 5,767 inpatients approached, 2,635 consented to participate, of whom 61.0% completed the study. Retained participants were more likely married, post-CABG, and less likely to be a smoker or be diabetic. Nonparticipants were younger, working, nonwhite, a current smoker, and less likely to be married. Adjusted analyses revealed that referral strategy was significantly related to CR referral and enrollment (p < 0.001). 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 = 0.88).


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.


While less than 50% of patients approached for the study participated, and the results reflect the experience in a national single health payer system, there is good evidence that automated referral needs to be supplemented by recommendations and discussion by a health care professional. The percentage of those referred who participated in CR in this Canadian study is much higher than in clinical practice in the United States, and reflects the characteristics of those willing to enter the study. Considering the impact of CR on cardiovascular outcomes, until such studies are performed in the United States, individual institutions and health care systems should take heed and supplement automatic referral with predischarge individual or group discussions of the value of CR.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease

Keywords: Heart Diseases, Coronary Artery Disease, Acute Coronary Syndrome, Continuity of Patient Care, Referral and Consultation, Physicians, Primary Care, Canada, Heart Failure, Coronary Disease, Ontario, United States, Percutaneous Coronary Intervention

< Back to Listings