Education of Physicians and Implementation of a Formal Referral System Can Improve Cardiac Rehabilitation Referral and Participation Rates after Percutaneous Coronary Intervention

Improved Cardiac Rehabilitation Referral Rate Utilizing a Multidisciplinary Quality Improvement Team

Introduction Cardiac rehabilitation (CR) is an underutilized resource in patients with ischemic heart disease, despite being a Class IA recommendation. In this study, a multidisciplinary quality improvement (QI) team aimed to improve CR referrals by standardizing the ordering process at our hospital system. Method By using a collaborative approach involving the electronic medical record (EMR), medical provider education, and hospital protocols, our two-hospital healthcare system was able to successfully identify barriers to CR referral rates and implement interventions for these barriers. All physicians and medical providers, including ancillary staff, were educated on the EMR order sets to improve compliance by using automated order sets in the EMR. The CR referral order in the EMR included a statement regarding the application of evidence-based medicine, and a computerized provider order entry was included as a reminder to the ordering provider. The use of EMR was monitored monthly by the QI committee. Chi-square test and odds ratios were obtained for statistical analysis. Results Through provider-EMR education and patient education on discharge, CR referral rates significantly improved from 51.2 to 87.1% (p = 0.0001) in a 12-month period. The study included 1,499 patients in total. The improvement was statistically significant regardless of patient gender, race, or insurance coverage. Additionally, subgroup analysis in this study found that prior to standardization of the ordering process, African American patients were significantly less likely to be referred to CR compared to Caucasian patients. (51.2% vs. 41.0%, p=0.01). There was no statistically significant difference in the likelihood of CR referral between Caucasian and African American patients following the intervention (84.0% vs. 78.0%, p = 0.166). Conclusion This study shows that CR is an underutilized resource and that effective QI initiatives may not only increase CR referral rates but also close the gap between racial inequities in referral rates. Future research with multi-center randomized control trials is needed to further enhance its external generalizability to other institutions.

[Effectiveness of tertiary prevention on quality of life and control of risk factors in patients with ischemic coronary heart disease]

Objective

Determine the effectiveness of cardiac rehabilitation (CR) as a tertiary prevention strategy in the quality of life and control of risk factors of patients with ischemic coronary heart disease (ICC) of the National Cardiovascular Institute (INCOR) of EsSalud- Lima during the year 2018.

Materials and methods

A retrospective cohort of 280 patients with a diagnosis of CCI was studied who, after medical, interventional, or surgical treatment, were referred to the INCOR CR program for tertiary prevention (PT) in 2018. The program was developed according to the institutional guide for eight weeks with exercise sessions and educational, psychological, nutritional, and recreational workshops. At the beginning and at the end of this, the QLMI-2 quality of life test was applied, and anthropometric, laboratory, and risk factor control measurements were performed.

Results

Quality of life levels at the end of CR showed a statistically significant improvement in the emotional, social, physical, and global dimensions (p < 0.001). The same behavior was observed for the nutritional variables of weight, abdominal circumference, and BMI (p < 0.001). Physical capacity showed a statistically significant improvement in the aspects of muscle strength (12.2%), physical activity (38.0%), and functional capability (25.4%) (p < 0.001). The result was not homogeneous for the biochemical metabolic variables, where glycosylated hemoglobin, glycemia, and lipid profile did not show significant improvement, except for HDL, which raised its levels statistically significantly (p < 0.001).

Conclusions

CR is effective as a central strategy to perform tertiary prevention in patients with ICC since it notably improves quality of life and coronary risk factors.

Unmet Needs for Cardiac Rehabilitation in Africa: A Perennial Gap in the Management of Individuals with Cardiac Diseases

Cardiac rehabilitation (CR) is a standard model of care, and an established component of comprehensive care that has been proven to reduce mortality and morbidity in patients with cardiac diseases. International clinical practice guidelines routinely recommend that cardiac patients participate in CR programs for comprehensive secondary prevention. However, there is scant guidance on how to deliver these programs in low-resourced settings. This dearth of clinical practice guidelines may be an indication of low emphasis placed on CR as a component of cardiac health services in low-income countries, especially in Africa. Indeed, CR programs are almost non-existent in Africa despite the unmet need for CR in patients with ischemic heart disease in Africa reported to be about one million. This figure represents the highest unmet need of any World Health Organization region, and is colossal given the projected accelerated increases in incidence of cardiovascular diseases (CVD) in the region. This narrative review explored the availability of CR programs, potential barriers to CR and strategies that can mitigate such barriers in Africa.

Internal medicine resident education improves cardiac rehabilitation knowledge, attitudes, and referral rates: A pilot study

Background

Referrals to cardiac rehabilitation (CR) remain low despite evidence showing reduction in cardiovascular mortality and hospital readmissions. Resident education and awareness may be an opportunity to address barriers to CR referrals.

Methods

This pilot study involves 20 internal medicine residents rotating at an ambulatory primary care clinic. Voluntary surveys were sent through an online-based survey platform. Following survey completion, residents received a 10-minute scripted lecture and an educational handout outlining CR components, availability, indications, insurance eligibility criteria, and referral process. Surveys were redistributed 2 months post-education to assess changes in mean aggregate knowledge scores and attitude ratings on a 5-point Likert scale. CR referral rates of eligible patients pre- and post-education were obtained through review of electronic medical records.

Results

Sixteen (80%) residents completed both pre and post surveys, and 13 (81%) reported no education on CR in the prior year. There was a significant increase in mean aggregate knowledge scores on CR components (5.1 versus 7.0, P = 0.001), insurance coverage (2.4 versus 5.6, P< 0.001), and eligible diagnoses (7.1 versus 9.9, P = 0.03) following education. Attitudes towards CR also improved following education, particularly in self-reported comfort level with explaining CR to patients (3.69 versus 2.06, P<0.001) and perceived familiarity with CR referral process (4.00 versus 2.18, P<0.001). CR referrals increased from 0% (0 out of 10 eligible patients) to 33% (3 out of 9 eligible patients) over a 2-month period before and after education, respectively (P = 0.09).

Conclusions

Internal medicine resident knowledge and attitudes towards CR significantly improved after formal education. Although there was a modest increase in the rates of CR referrals following resident education, this pilot study was not powered to detect statistical significance.

Associations Between Physician Continuous Professional Development and Referral Patterns: A Systematic Review and Meta-Analysis

PURPOSE

Both overuse and underuse of clinician referrals can compromise high-value health care. The authors sought to systematically identify and synthesize published research examining associations between physician continuous professional development (CPD) and referral patterns.

METHOD

The authors searched MEDLINE, Embase, PsycInfo, and the Cochrane Database on April 23, 2020, for comparative studies evaluating CPD for practicing physicians and reporting physician referral outcomes. Two reviewers, working independently, screened all articles for inclusion. Two reviewers reviewed all included articles to extract information, including data on participants, educational interventions, study design, and outcomes (referral rate, intended direction of change, appropriateness of referral). Quantitative results were pooled using meta-analysis.

RESULTS

Of 3,338 articles screened, 31 were included. These studies enrolled at least 14,458 physicians and reported 381,165 referral events. Among studies comparing CPD with no intervention, 17 studies with intent to increase referrals had a pooled risk ratio of 1.91 (95% confidence interval: 1.50, 2.44; P < .001), and 7 studies with intent to decrease referrals had a pooled risk ratio of 0.68 (95% confidence interval: 0.55, 0.83; P < .001). Five studies did not indicate the intended direction of change. Subgroup analyses revealed similarly favorable effects for specific instructional approaches (including lectures, small groups, Internet-based instruction, and audit/feedback) and for activities of varying duration. Four studies reported head-to-head comparisons of alternate CPD approaches, revealing no clear superiority for any approach. Seven studies adjudicated the appropriateness of referral, and 9 studies counted referrals that were actually completed (versus merely requested).

CONCLUSIONS

Although between-study differences are large, CPD is associated with statistically significant changes in patient referral rates in the intended direction of impact. There are few head-to-head comparisons of alternate CPD interventions using referrals as outcomes.

Effectiveness of micro-lecture based cardiac rehabilitation education on health status in individuals with coronary artery disease: A randomized clinical trial

OBJECTIVE

To explore the effectiveness of the micro-lecture education on the ability of self-management and lifestyle changes in patients with coronary artery disease.

DESIGN

A randomized control trial with a 12-week follow-up.

SETTING

Cardiology wards of a large Chinese University Hospital.

SUBJECTS

One hundred eligible inpatients with coronary artery disease were recruited.

INTERVENTION

Intervention group received the micro-lecture education, while the control group received the traditional cardiac rehabilitation education.

MAIN MEASURES

Primary outcome of the ability of coronary self-management was assessed by the Coronary self-management scaleat baseline, 12-week after discharge. Secondary outcomes of smoking status, exercise status, and six-minute walk distance were evaluated at the baseline, week4 and week 12 after discharge. The chi-square test,Fisher's exact test, group t-test and the repeated measure variance were used for the data analysis.

RESULTS

Eighty-nine of 100 eligible participants responded, and mean age was 60.2 ± 11.3 years.After the intervention, the mean score of the coronary self-management scale (3.84 ± 0.36) was higher than that in the control group (2.78 ± 0.57).At week 12, the rate of re-smoked in the intervention group (6%) was significantly lower than that in the control group (43%),the frequency of the exercise (85%), and the 6MWD (495.55 ± 85.94) in the intervention group were better than the control group.

CONCLUSION

Micro-lecture education program presented a positive effect on promoting the ability of self-management, and apotential effect on the therapeutic lifestyle changes for the coronary artery disease patients.

Cardiac rehabilitation in women, challenges and opportunities

Cardiac rehabilitation(CR) has known proven benefits in reducing mortality related to cardiovascular disease (CVD), improving quality of life (QoL), and preventing CVD-related readmissions. Despite these known benefits, CR remains underutilized among women relative to men. Disparities exist at the level of referral, enrollment, and program completion. Much is left to be understood regarding the utility of CR in female-predominant CVD such as postpartum cardiomyopathy and Spontaneous Coronary Artery Dissection. This review identifies the benefits of CR for specific populations of women and elucidates on the barriers to CR. We also describe current recommendations to overcome barriers to CR in women.

Cardiac Specialists' Perspectives on Barriers to Cardiac Rehabilitation Referral and Participation in a Low-Resource Setting

Background:

Cardiac specialists are arguably the most influential providers in ensuring patients access cardiac rehabilitation (CR). Physician barriers to referral have been scantly investigated outside of high-income settings, and not qualitatively.

Aim:

This study investigated cardiac specialists’ perceptions of barriers and facilitators to patient CR participation in a low-resource setting, with a focus on referral.

Methods:

In this qualitative study, focus groups were conducted with conventional content analysis. Thirteen of 14 eligible cardiac specialists working in Yazd, Iran, participated in 1 or both focus groups (n = 9 and n = 10, respectively). The recording of the first focus group was transcribed into a word file verbatim, and the accuracy of the content of all field notes and the transcripts was approved by the research team, which was then analyzed inductively. Following a similar process, saturation was achieved with the second focus group.

Results:

Four themes emerged: “physician factors,” “center factors,” “patient factors,” and “cultural factors.” Regarding “physician factors,” most participants mentioned shortage of time. Regarding “center factors,” most participants mentioned poor physician-patient-center coordination. In “patient factors,” the subcategories that arose were socioeconomic challenges and clinical condition of the patients. “Cultural factors” related to lack of belief in behavioral/preventive medicine.

Conclusions:

Barriers to CR referral and participation were multilevel, as in high-resource settings. However, relative recency of the introduction of CR in these settings seemed to cause great lack of awareness. Cultural beliefs may differ, and communication from CR programs to referring providers was a particular challenge in this setting.

Successful Implementation and Development of a Phase II Cardiac Rehabilitation Program: A China-Wide Cross-Sectional Study Tracking In-service Training Clinical Staff

Background: Despite the benefits of cardiac rehabilitation (CR), phase II CR remains highly unavailable; the factors influential to the successful implementation and development of phase II CR programs have not been fully explored.

Methods: A cross-sectional survey was completed by 168 nationwide clinical staff. Parameters associated with the successful implementation and development of phase II CR and the factors associated with the quality of CR were explored by multivariable logistic regression.

Results: One hundred and eighteen of 168 respondents' institutions had successfully developed phase II CR programs, 41 of which delivered high-quality CR. Independent factors associated with successful implementation and development of CR were leadership support from hospital administrators, support from resident physicians, staff perception in CR increasing medical risk, and department type (cardiology vs. rehabilitation department). Independent factors associated with CR quality were the availability of “professional CR providers” and staff perceptions of CR improving physician–patient relationships. The medical system factors did not affect the development and quality of CR, including hospital level, funding type, academic type, general/specialized hospital, located city, medical insurance, the existence of a CR outpatient clinic and independent space, the availability of professional CR providers, staff structure, and the availability of regular training and standard procedure.

Conclusions: The development and quality of a phase II CR program may benefit from factors including support from administrators and resident physicians, adequately training more CR providers, without viewing medical system factors as a major issue.

Gains, losses, and uncertainties from computerizing referrals and consultations

Consultations entail transitions in care between referrers and consultants, as patients visit different clinicians and care sites. This complex process has been consistently prone to communication breakdowns. Despite expectations and benefits of electronic health records (EHRs), incomplete, vague, or inappropriate referrals continue to hinder consultations; referrals can be sent to the wrong specialty service; and consultation findings frequently fail to reach referrers. Due to the inadequate support of interpersonal communication afforded by EHRs, these issues persist. Important aspects of ergonomics and human factors engineering frequently appear overlooked during the design and implementation of EHRs. Usability issues have contributed to delays in medical diagnosis, treatment, and follow-up. Some of these delays contribute to patient harms. Our multidisciplinary team of clinicians and ergonomics professionals reflects on referral and consultation. We describe how computerization in healthcare should benefit from approaches informed and developed through applied ergonomics and human factors.

Current challenges in cardiac rehabilitation: strategies to overcome social factors and attendance barriers

INTRODUCTION

Cardiac rehabilitation (CR) significantly reduces secondary cardiovascular events and mortality and is a class 1A recommendation by the American Heart Association (AHA) and American College of Cardiology (ACC). However, it remains an underutilized intervention and many eligible patients fail to enroll or complete CR programs. The aim of this review is to identify barriers to CR attendance and discuss strategies to overcome them.

AREAS COVERED

Specific barriers to CR attendance and participation will be reviewed. This will be followed by a discussion of solutions/strategies to help overcome these barriers with a particular focus on home-based CR (HBCR).

EXPERT OPINION

HBCR alone or in combination with center-based CR (CBCR) can help overcome many barriers to traditional CBCR participation, such as schedule flexibility, time commitment, travel distance, cost, and patient preference. Using remote coaching with indirect exercise supervision, HBCR has been shown to have comparable benefits to CBCR. At this time, however, funding remains the main barrier to universal incorporation of HBCR into health systems, necessitating the need for additional cost benefit analysis and outcome studies. Ultimately, the choice for HBCR should be based on patient preference and availability of resources.

Sex- and Gender-Related Factors Associated With Cardiac Rehabilitation Enrollment: A SECONDARY ANALYSIS AMONG SYSTEMATICALLY REFERRED PATIENTS

PURPOSE

To assess sex- and gender-related factors associated with cardiac rehabilitation (CR) enrollment following acute coronary syndrome among systematically referred patients.

METHODS

This secondary analysis of a randomized controlled trial used an exploratory approach to examine the TRANSITion process for patients between the coronary care unit and CR (TRANSIT-UC). The present analysis examined the relationship between sex- and gender-related factors and CR enrollment in systematically referred women (n = 35) and men (n = 207). We performed χ and logistic regression analyses to identify statistically significant results. Using the Bonferroni method, a P value of .002 or less was considered a significant statistical result. A raw difference of 15% or more between enrolled and nonenrolled participants was considered a difference worthy of further investigation.

RESULTS

Men who were regularly engaged in physical activity prior to their hospitalization and who lived near the CR center showed a statistically higher CR enrollment rate. In women and men, a radial entry site for percutaneous coronary intervention resulted in a clinically significant difference in favor of CR enrollment. In women, 3 sex-related and 9 gender-related variables were associated with a difference of 15% or more between enrolled and nonenrolled participants.

CONCLUSION

Factors related to CR enrollment in women and men are suggested. As women keep showing a lower rate of CR enrolment, the investigation of these factors in a larger sample of patients may hold valuable insights to improve CR enrolment.

Introduction of a novel service model to improve uptake and adherence with cardiac rehabilitation within Buckinghamshire Healthcare NHS Trust

Background

Buckinghamshire Healthcare NHS Trust (BHT) carried out a cardiac rehabilitation (CR) service redesign aimed at optimising patient recruitment and retention and decreasing readmissions.

Methods

A single centre observational study and local service evaluation were carried out to describe the impact of the novel technology-enabled CR model. Data were collected for adult patients referred for CR at BHT, retrospectively for patients referred during the 12-month pre-implementation period (Cohort 1) and prospectively for patients referred during the 12-month post-implementation period (Cohort 2). The observational study included 350 patients in each cohort, seasonally matched; the service evaluation included all eligible patients. No data imputation was performed.

Results

In the observational study, a higher proportion of referred patients entered CR in Cohort 2 (84.3%) than Cohort 1 (76.0%, P = 0.006). Fewer patients in Cohort 2 had ≥1 cardiac-related emergency readmission within 6 months of discharge (4.3%) than Cohort 1 (8.9%, P = 0.015); readmissions within 30 days and 12 months were not significantly different. Median time to CR entry from discharge was significantly shorter in Cohort 2 (35.0 days) than Cohort 1 (46.0 days, P < 0.001). The CR completion rate was significantly higher in Cohort 2 (75.6%) than Cohort 1 (47.4%, P < 0.001); median CR duration for completing patients was significantly longer in Cohort 2 (80.0 days) than Cohort 1 (49.0 days, P < 0.001). Overall, similar results were observed in the service evaluation.

Conclusions

Introduction of the novel technology-enabled CR model was associated with short-term improvements in emergency readmissions and sustained increases in CR entry, duration and completion.

Practices and attitudes of doctors and patients to downward referral in Shanghai, China

OBJECTIVES

In China, the rate of downward referral is relatively low, as most people are unwilling to be referred from hospitals to community health systems (CHSs). The aim of this study was to explore the effect of doctors' and patients' practices and attitudes on their willingness for downward referral and the relationship between downward referral and sociodemographic characteristics.

METHODS

Doctors and patients of 13 tertiary hospitals in Shanghai were stratified through random sampling. The questionnaire surveyed their sociodemographic characteristics, attitudes towards CHSs and hospitals, understanding of downward referral, recognition of the community first treatment system, and downward referral practices and willingness. Descriptive statistics, χ2 test and stepwise logistic regression analysis were employed for statistical analysis.

RESULTS

Only 20.8% (161/773) of doctors were willing to accept downward referrals, although this proportion was higher among patients (37.6%, 326/866). Doctors' willingness was influenced by education, understanding of downward referral, and perception of health resources in hospitals. Patients' willingness was influenced by marital status, economic factors and recognition of the community first treatment system. Well-educated doctors who do not consider downward referral would increase their workloads and those with a more comprehensive understanding of hospitals and downward referral process were more likely to make a downward referral decision. Single-injury patients fully recognising the community first treatment system were more willing to accept downward referral. Patients' willingness was significantly increased if downward referral was cost-saving. A better medical insurance system was another key factor for patients to accept downward referral decisions, especially for the floating population.

CONCLUSIONS

To increase the rate of downward referral, the Chinese government should optimise the current referral system and conduct universal publicity for downward referral. Doctors and patients should promote understandings of downward referral. Hospitals should realise the necessity of downward referral, effectively reduce workloads and provide continuing education for doctors. Increasing monetary reimbursement is urgent, as is improving the medical insurance system.

Cardiac Rehabilitation for Women: A Systematic Review of Barriers and Solutions

Cardiac rehabilitation (CR) services improve various clinical outcomes in patients with cardiovascular disease, but such services are underutilized, particularly in women. The aim of this study was to identify evidence-based barriers and solutions for CR participation in women. A literature search was carried out using PubMed, EMBASE, Cochrane, OVID/Medline, and CINAHL to identify studies that have assessed barriers and/or solutions to CR participation. Titles and abstracts were screened, and then the full-text of articles that met study criteria were reviewed. We identified 24 studies that studied barriers to CR participation in women and 31 studies that assessed the impact of various interventions to improve CR referral, enrollment, and/or completion of CR in women. Patient-level barriers included lower education level, multiple comorbid conditions, non-English native language, lack of social support, and high burden of family responsibilities. We found support for the use of automatic referral and assisted enrollment to improve CR participation. A small number of studies suggest that incentive-based strategies, as well as home-based programs, may contribute to improving CR attendance and completion rates. A systematic approach to CR referral, including automatic CR referral, may help overcome barriers to CR referral in women and should be implemented in clinical practice. However, more studies are needed to help identify the best methods to improve CR attendance and completion of CR rates in women.