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Updated: Jun 4, 2026
A Novel Digital Platform for a Monitored Home-based Cardiac Rehabilitation Program
Published on: April 19, 2019
Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study
Sherry L Grace1, Kelly L Russell, Robert D Reid
1School of Kinesiology and Health Sciences, Faculty of Health, York University, 368 Bethune, 4700 Keele St, Toronto, ON M3J 1P3, Canada. sgrace@yorku.ca
Insights
Implementing a combined automatic and liaison referral strategy significantly increased cardiac rehabilitation (CR) use. This approach maximizes CR referral and enrollment, improving patient access to vital post-cardiac disease care.
Area of Science:
- Cardiology
- Public Health
- Health Services Research
Background:
- Cardiac rehabilitation (CR) is proven to reduce mortality but suffers from low referral and utilization rates.
- Existing referral strategies to boost CR use lack concurrent comparative data.
- This study aimed to identify the optimal strategy for maximizing CR referral, enrollment, and participation.
Purpose of the Study:
- To compare the effectiveness of three CR referral strategies against usual care.
- To determine the optimal approach for increasing CR referral, enrollment, and participation.
- To inform clinical practice guidelines and improve patient access to CR.
Main Methods:
- A prospective controlled study involving 2635 inpatients with coronary artery disease across 11 Ontario hospitals.
- Four referral strategies were implemented: usual care, automatic referral, healthcare provider liaison, and a combined approach.
- Clinical data and sociodemographic surveys were collected, with CR utilization assessed via mailed surveys one year later.
Main Results:
- Referral strategy significantly impacted CR referral and enrollment (P<.001).
- The combined automatic and liaison referral strategy yielded the highest CR use (85.8% referral, 73.5% enrollment).
- Participation rates among referred patients did not differ significantly by referral strategy (82.87% attendance).
Conclusions:
- A combined automatic referral and patient discussion strategy achieves high CR referral rates.
- Widespread adoption of optimized referral strategies could increase CR access by an estimated 45% for cardiac patients.
- Improved referral processes are crucial for ensuring more patients benefit from cardiac rehabilitation.
Background:
Although cardiac rehabilitation (CR) has been shown to reduce mortality and is a recommended component in clinical practice guidelines, CR referral and utilization rates remain low. Referral strategies have been implemented to increase CR use but have yet to be compared concurrently. To determine the optimal strategy to maximize CR referral, enrollment, and participation, we evaluated 3 referral strategies compared with usual care: "automatic" only via discharge order or electronic record, health care provider liaison only, or a combined approach.
Methods:
In this prospective controlled study, 2635 inpatients with coronary artery disease from 11 Ontario, Canada, hospitals using 1 of the 4 referral strategies completed a sociodemographic survey, and clinical data were extracted from medical charts. One year later, 1809 participants completed a mailed survey that assessed CR utilization. Referral strategies were compared using generalized estimating equations to control for effect of hospital.
Results:
Adjusted analyses revealed referral strategy was significantly related to CR referral and enrollment (P<.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=.88).
Conclusions:
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.
