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

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

  • Cardiac rehabilitation (CR) is shown to improve patient outcomes, but many physicians do not always refer their patients when indicated

  • Through multilevel analysis, this study shows that both physician and patient factors have roles in CR referral

  • The most relevant perceptions of physicians relate to CR programs' quality and benefit, and for patients relate to CR barriers

  • Patients might try to convey concerns during pre-referral CR discussions, and physicians should be trained to identify and address them

  • Distance from the patient's home to the CR site was related to physician referral practice, despite the availability of home-based services

  • 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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Figure 1: Participant recruitment and outcomes of cardiac rehabilitation referral.

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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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Correspondence to Sherry L Grace.

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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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