Cardiac rehabilitation referral strategies: effects on referral and enrollment

Despite recommendations in clinical practice guidelines, evidence suggests cardiac rehabilitation (CR) utilization following indicated cardiac events is 15-20%. Referral strategies such as automatic referral have been advocated to improve CR utilization. This Review evaluated the effects of referral strategies on CR referral and enrollment. Referral strategies were categorized as ‘automatic’ based on use of electronic health records or systematic discharge order sets, as ‘liaison’ based on discussions with allied healthcare providers, or ‘other’. The highest rates of CR referral were achieved in studies implementing automatic referral orders, where referral reached 85%. The highest rates of CR enrollment were achieved with a combination of automatic and liaison methods (78% and 86%). Although there were some null findings, overall results suggest that innovative referral strategies significantly increase CR utilization. Automatic referral methods, such as the ‘Get With the Guidelines’ initiative, show promise for improving referral rates. The additional incorporation of a CR discussion resulted in enrollment rates that are double the rates seen after usual referral. While further investigation is needed, institutions should evaluate their CR referral practice in light of these findings

Post-traumatic growth among cardiac outpatients: Degree comparison with other chronic illness samples and correlates.

This study evaluated the sociodemographic, clinical and behavioral correlates of Post-Traumatic Growth (PTG) in coronary artery disease (CAD) patients, and the degree of PTG compared to other patient groups. Using a prospective design, 1497 CAD outpatients completed a survey assessing potential PTG correlates. 1268 responded to a 9-month follow-up survey assessing PTG. Significant correlates of greater PTG were being non-white, having lower income, functional status, and depressive symptoms, greater social support, and positive illness perceptions. The degree of PTG was equivalent to that of cardiac patients in other countries, but was lower than that of breast cancer and multiple sclerosis patients

Effects of cardiac rehabilitation referral strategies on referral and enrollment rates

Despite recommendations in clinical practice guidelines, evidence suggests that utilization of cardiac rehabilitation (CR) following indicated cardiac events is low. Referral strategies, such as automatic referral, have been advocated to improve CR utilization. In this Review, we evaluate the effects of referral strategies on rates of CR referral and enrollment. Referral strategies are categorized as ‘automatic’ (the use of electronic health records or systematic discharge order sets), as ‘liaison’ (discussions with allied healthcare providers), or as ‘other’ (for example, the use of motivational letter to patients). The highest rates of CR referral have been achieved in studies implementing automatic referral orders, whereas the highest rates of CR enrollment have resulted from a combination of automatic and liaison methods. Overall, innovative referral strategies significantly increase CR utilization. While further investigation is needed, institutions should evaluate their CR referral practice in light of these findings

A simultaneous test of the relationship between identified psychosocial risk factors and recurrent events in coronary artery disease patients

Psychosocial factors are increasingly recognized as risk indicators for coronary artery disease (CAD) prognosis, and they are likely interrelated. The objective of this study is to simultaneously test the relationship between key psychosocial constructs as independent factor scores, and recurrent events in CAD patients. One thousand two hundred and sixty eight CAD outpatients of 97 cardiologists were surveyed at two points. Recurrent events or hospitalization in the intervening 9 months were reported. Factor analysis of items from the Hospital Anxiety and Depression Scale, Perceived Stress Scale, the ENRICHD Social Support Inventory, and Hostile Attitudes Scale was performed, to generate orthogonal factor scores. With adjustment for prognostic variables, logistic regression analysis was performed to examine the relationship between these factor scores and recurrent events. Factor analysis resulted in a six-factor solution: hostility, stress, anxiety, depressive symptoms, support and resilience. Logistic regression revealed that functional status and anxiety, with a trend for depressive symptoms, were related to experiencing a recurrent event. In this simultaneous test of psychosocial constructs hypothesized to relate to cardiac prognosis, anxiety may be a particularly hazardous psychosocial factor. While replication is warranted, efforts to investigate the potential benefits of screening and investigate treatments is needed

Cardiologists' charting varied by risk factor, and was often discordant with patient report

Objective: To assess the completeness of cardiac risk factor documentation by cardiologists, and agreement with patient report. Study Design and Setting: A total of 68 Ontario cardiologists and 789 of their ambulatory cardiology patients were randomly selected. Cardiac risk factor data were systematically extracted from medical charts, and a survey was mailed to participants to assess risk factor concordance. Results: With regard to completeness of risk factor documentation, 90.4% of charts contained a report of hypertension, 87.2% of diabetes, 80.5% of dyslipidemia, 78.6% of smoking behavior, 73.0% of other comorbidities, 48.7% of family history of heart disease, and 45.9% of body mass index or obesity. Using Cohen's K, there was a concordance of 87.7% between physician charts and patient self-report of diabetes, 69.5% for obesity, 56.8% for smoking status, 49% for hypertension, and 48.4% for family history. Conclusion: Two of four major cardiac risk factors (hypertension and diabetes) were recorded in 90% of patient records; however, arguably the most important reversible risk factors for cardiac disease (dyslipidemia and smoking) were only reported 80% of the time. The results suggest that physician chart report may not be the criterion standard for quality assessment in cardiac risk factor reporting.Canadian Institutes of Health Research, grant # MOP-74431Canadian Institutes of Health Research, grant # MOP-7443