Related Experiment Video
Updated: May 9, 2026
A Novel Digital Platform for a Monitored Home-based Cardiac Rehabilitation Program
Published on: April 19, 2019
Factors influencing referral to cardiac rehabilitation and secondary prevention programs: a systematic review
Alexander M Clark1, Kathryn M King-Shier, Amanda Duncan
1Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada. alex.clark@ualberta.ca
Insights
Low referral to cardiac rehabilitation programs stems from professional, system, and patient barriers. Enabling non-physician referrals and automatic options could significantly increase patient access to secondary prevention programs.
Area of Science:
- Cardiology
- Public Health
- Health Services Research
Background:
- Referral rates to cardiac rehabilitation and secondary prevention programs are suboptimal despite proven clinical benefits.
- Understanding the multifaceted factors influencing referral is crucial for developing effective interventions.
Purpose of the Study:
- To systematically review and synthesize qualitative research on factors influencing referral to cardiac rehabilitation and secondary prevention programs.
Main Methods:
- A systematic review employing qualitative meta-synthesis.
- Searched 11 databases for studies with qualitative or mixed-methods components published from 1995 onwards.
- Included studies with extractable data on referral to programs for adults over 18.
Main Results:
- Healthcare professional barriers include low knowledge, skepticism about benefits, physician gatekeeping, and perceived patient non-participation.
- Systemic barriers involve geographical factors, reimbursement issues, and time constraints.
- Patient-level factors include limited program awareness and a confusing referral process, despite viewing physicians as key.
Conclusions:
- Increasing patient referral can be achieved by empowering non-physicians to refer or implementing automatic referral systems.
- Educational outreach, including workshops on ethical and clinical aspects, is recommended for all referring health professionals.
Background:
Referral to cardiac rehabilitation and secondary prevention programs remains very low, despite evidence suggesting strong clinical efficacy. To develop evidence-based interventions to promote referral, the complex factors and processes influencing referral need to be better understood.
Design:
We performed a systematic review using qualitative meta-synthesis.
Methods:
A comprehensive search of 11 databases was conducted. To be included, studies had to contain a qualitative research component wholly or in a mixed method design. Population specific data or themes had to be extractable for referral to programs. Studies had to contain extractable data from adults >18 years and published as full papers or theses during or after 1995.
Results:
A total of 2620 articles were retrieved: out of 1687 studies examined, 87 studies contained data pertaining to decisions to participate in programs, 34 of which included data on referral. Healthcare professional, system and patient factors influenced referrals. The main professional barriers were low knowledge or scepticism about benefits, an over-reliance on physicians as gatekeepers and judgments that patients were not likely to participate. Systems factors related to territory, remuneration and insufficient time and workload capacity. Patients had limited knowledge of programs and saw physicians as key elements of referral but found the process of attaining a referral confusing and challenging.
Conclusions:
The greatest increases in patient referral to programs could be achieved by allowing referral from non-physicians or alternatively, automatic referral to a choice of hospital or home-based programs. All referring health professionals should receive educational outreach visits or workshops around the ethical and clinical aspects of programs.
Related Concept Videos
01:26Coronary Artery Disease IV: Preventive Measures
01:28Acute Coronary Syndrome IV: Interprofessional Care
01:26Levels of Health Promotion and Illness Prevention
In primary prevention, actions taken before disease onset prevent the disease from...
01:27Coronary Artery Disease V: Interprofessional Care
01:21Rheumatic Heart Disease III: Medical Management
01:11Secondary Healthcare System