Systematizing inpatient referral to cardiac rehabilitation 2010: Canadian Association of Cardiac Rehabilitation and Canadian Cardiovascular Society joint position paper endorsed by the Cardiac Care Network of Ontario

Despite recommendations in clinical practice guidelines, evidence suggests cardiac rehabilitation (CR) referral and use following indicated cardiac events is low. Referral strategies such as systematic referral have been advocated to improve CR use. The objective of this policy position is to synthesize evidence and make recommendations on strategies to increase patient enrollment in CR. A systematic review of 6 databases from inception to January 2009 was conducted. Only primary, published, English-language studies were included. A meta-analysis was undertaken to synthesize the enrollment rates by referral strategy. In all, 14 studies met inclusion criteria. Referral strategies were categorized as systematic on the basis of use of systematic discharge order sets, as liaison on the basis of discussions with allied health care providers, or as other on the basis of patient letters. Overall, there were 7 positive studies, 5 without comparison groups, and 2 studies that reported null findings. The combined effect sizes of the meta-analysis were as follows: 73% (95% CI, 39%-92%) for the patient letters ("other"), 66% (95% CI, 54%-77%) for the combined systematic and liaison strategy, 45% (95% CI, 33%-57%) for the systematic strategy alone, and 44% (95% CI, 35%-53%) for the liaison strategy alone. In conclusion, the results suggest that innovative referral strategies increase CR use. Although patient letters look promising, evidence for this strategy is sparse and inconsistent at present. Therefore we suggest that inpatient units adopt systematic referral strategies, including a discussion at the bedside, for eligible patient groups in order to increase CR enrollment and participation. This approach should be considered best practice for further investigation.