INCREASING PARTICIPATION IN CARDIAC REHAB
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Broken Hearts Need Work Too: Increasing Participation in Cardiac Rehabilitation Post Cardiac
Event
Heather L. Christensen
California State University Monterey Bay
CHHS 302
Professor Gayle Yamauchi-Gleason
April 2, 2012
INCREASING PARTICIPATION IN CARDIAC REHAB
Table of Contents
Table of Contents ……………........……….…………………………..……..…..… ii
American Detriment ………………………………………..……..…….………….. 3
Hurdles to Heart Health ……………….………………………...…………….….… 3
Beneficial Outcomes of Proper Cardiac Care .………………………..………….…. 5
Promoting the Means to a Better Life ……………………...……………………….. 7
Making a Change ……………………………………...………………………….… 10
References ………………………………………… ……………………………..… 11
Appendix ………………………………………………………..…………………... 13
ii
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American Detriment
Nearly one in three Americans have cardiovascular disease. Currently, cardiovascular
disease (CVD) or heart disease is the number one killer of both men and women in the U.S. The
older a person is, the greater their chances of having a cardiac event. Arena et al. (2012) reports,
“the prevalence of CVD is on the rise as a function of increased longevity and the mounting
effects of cardiac risk factors that typically accumulate over a lifetime” (para. 1) Arena et al. are
pointing out that there is a larger population of older adults and a longer life expectancy, which is
leading to a greater number of patients with CVD. The Centers for Disease Control and
Prevention (CDC) and The Merck Company Foundation’s The State of Aging and Health in
America 2007 reports that, “By 2030, the number of older Americans is expected to reach 71
million, or roughly 20% of the U.S. population” (p. 1). They also claim that due to this
population shift, “healthcare spending” will increase 25% (p. 5). Price reports in her article
“Cardiac Rehabilitation: Patient Referral and Enrollment” (2012) that cardiovascular disease
(CVD) “costs the Canadian economy more than $22.2 billion every year in physician services,
hospital costs, lost wages and decreased productivity” (p. 7). Many reports have similar statistics
in the United States, therefore it is important to utilize resources that are low cost and effective.
Cardiac rehabilitation (cardiac rehab) is a cost effective option for treatment of cardiac
patients. Numerous studies illustrate the benefits of cardiac rehab on decreasing mortality and
morbidity and the risk for a follow-on cardiac event. Braverman (2011) celebrates the fact that,
“This substantial risk reduction equals or exceeds the benefits of most drugs and procedural
interventions.”(p. 605). So why does referral, enrollment, and participation in cardiac rehab
remain so low? Healthcare professionals play an important role in getting patients out of the
hospital and into cardiac rehab. Healthcare professionals should inform cardiac patients of the
importance of post-event rehabilitation (physical and emotional) in order to emphasize to
patients the necessity of rehabilitation in avoiding another cardiac event and improving the
overall quality of their life.
Hurdles to Heart Health
Numerous studies illustrate the benefits of cardiac rehab on decreasing mortality and
morbidity. With the benefits well known, participation is still lacking. Farley, Wade, &
Birchmore (2003) emphasize that the number of patients who participate in cardiac rehab
typically ranges between 30 and 45% with a high percentage of those dropping out before
finishing the cardiac rehab program (p. 205). Basically, there is a small number of cardiac
patients who are participating and an even smaller number of those patients finishing their rehab
program. Many barriers to patient enrollment and participation continue to exist despite the
decades that have passed since they were first acknowledged.
Lack of Referrals
A referral must be obtained before the patient can enroll in a cardiac rehab program.
Cardiac rehab referral is an American College of Cardiology/ American Heart Association class I
indication. This means that there is evidence and agreement that cardiac rehab is effective and
there is a strong recommendation from these prominent organizations for eligible heart patients
to be prescribed to cardiac rehab. Surprisingly, research indicates that a major barrier for patients
is lack of physician referral. (Braverman (2011), p. 608) Brown, et al (2009) conducted a study
to determine physician referral rate to cardiac rehab in hospitals that are part of the American
INCREASING PARTICIPATION IN CARDIAC REHAB
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Heart Association’s (AHA) Get With The Guidelines (GWTG) program. Brown et al. (2009)
describes the program as “a voluntary, observational data collection and quality-improvement
initiative …” where hospitals “submit clinical information regarding in-hospital care and
outcomes of patients hospitalized for coronary artery disease (CAD), stroke or heart failure” (p.
516). They found that only 56% of the patients that qualified for cardiac rehab were referred.
Cardiac events that qualify a patient for cardiac rehab are myocardial infarction (MI),
percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery, stable
angina, heart transplant, and heart valve surgery. Furthermore, Brown et al. believe that their
results are overestimating the overall referral rate in the U.S. because their information is from
hospitals with a high adherence to general guidelines. In other words, doctors are referring less
than half of all eligible patients for cardiac rehab.
The results of the study by Brown and associates (2009) discovered that patients who
were younger, male, and white had a higher referral rate. Referred patients were also less likely
to have Medicare, comorbidities and more likely to have had a procedure such as coronary artery
bypass graft (CABG) (p. 517). In contrast, patients with dyslipidemia and smokers were more
likely to be referred (Brown et al., 2009, p. 520). Balady, et al. (2011) assert that females, older
adults, and minorities are less likely to be referred (p. 2952). This under referred population
often times need and can benefit the most from cardiac rehab. In conjunction, Balady, et al.
(2011) report, “women and minorities are significantly more likely to die within 5 years after a
first MI compared with white male patients” (p.2952).
Referral alone, however, does not guarantee participation. In their study, Keib, Reynolds,
and Ahijevych (2010) found that perception of illness plays a large role in participation. Patients
who choose not to attend CR are more apt to “down play the seriousness of their illness” and feel
that they have less controllability of their illness (Everett et al., 2009, 1843). The way that
healthcare professionals explain the patient’s illness and their recommendation and referral of
cardiac rehab greatly influences the participation in cardiac rehab. Ades, Waldman, McCann and
Weaver found that when patient perception of the physician’s referral was strong 66% of the
patients participated in CR. Conversely, when the perception of the referral was weak there was
only a 1.8% participation rate (as cited in Johnson, Inder, Nagle, and Wiggers, 2010, p. 32). In
fact, numerous articles corroborate that a physician’s support and referral to cardiac rehab is a
strong predictor of patient participation. Although this report focuses on healthcare
professionals’ role in patient participation in cardiac rehab, it is also important to be aware of
barriers that patients face.
Patient Barriers
In a study looking at factors influencing attendance to cardiac rehab conducted by Farley
et al. (2003), they report that of the 165 eligible patients, only 39% attended cardiac rehab (p.
208). In other words, six in ten of the patients who are referred to cardiac rehab are not
attending. In addition, the main reason that patients gave for non-attendance was that the patient
felt that they could ‘deal with it on their own’ (Farley et al., 2003, p. 208). This idea of self-care
demonstrates the previous discussion of the physician’s referral influencing patient participation
in cardiac rehab. Braverman (2011) observes in his review that, “patient-related barriers include
logistics, inadequate financial resources, lack of personal support system, and the patient’s
personal preference not to exercise or participate in risk intervention” (p. 608). Factors that are
associated with limited referral and enrollment in cardiac rehabilitation are detailed in table 1.
INCREASING PARTICIPATION IN CARDIAC REHAB
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Many cardiac patients have responsibilities that they feel they need to return to. These
responsibilities can distract the patient from focusing on his/her own health.
As mentioned earlier,
Brown and associates (2009)
found that less than 50% of
eligible cardiac patients are
being referred to cardiac
rehab and as Farley et al.
(2003) reports, 39% of those
that are referred are actually
attending. By extension,
approximately 20% of cardiac
patients are reaping the
benefits of cardiac rehab.
Braverman (2011)
emphasizes that a metaanalysis discovered, “that
cardiac rehabilitation reduced
recurrent myocardial
infarction by 17% at 12
[months] and reduced
mortality by 47% at 2 yrs” (p.
604). To put it bluntly, 80%
of cardiac patients are not
going to fully recover from
their cardiac event.
Furthermore, they are at an
increased risk of having a
follow-on event and/or dying
within 2 years after their first
cardiac event. Having just
demonstrated the
underutilization of cardiac
rehab, the next section will
discuss why cardiac rehab is
important for cardiac patients
in making a full recovery.
Note. Balady, G., Ades, P., Bittner, V., Franklin, B., Gordon, N., Thomas,
R.,…Yancy, C., (2011). Referral enrollment and delivery of cardiac
rehabilitation/secondary prevention programs at clinical centers and
beyond: A presidential advisory from the American Heart Association.
Circulation. 124. 2952. doi: 10.1161/CIR.0b013e31823b21e2
INCREASING PARTICIPATION IN CARDIAC REHAB
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Beneficial Outcomes of Proper Cardiac Care
Physical Impairments/ Morbidity/ Cardiac Event Risks
When someone has a cardiac event, steps should be taken to improve their health and
allow them to have a long, rich life. Keib et al. (2010) emphasize that for older adults cardiac
rehab can reduce the risk of mortality by 26-31%, can modify cardiac risk factors, improve
quality of life, physical function, and psychological well-being, and decrease healthcare costs
associated with cardiac related rehospitalization (p. 504). Simply, cardiac rehab will decrease
cardiac patients’ risk of dying from another cardiac event. It will improve their quality of life
physically and mentally as well as reduce healthcare costs. Farley et al. (2003) further affirm
these benefits by stating, “A comparison of risk reduction associated with behavioural therapies
([cardiac rehab] programs), and medical therapies (e.g. administration of beta blockers) found
that the behavioural therapies were far superior to medical therapies in the reduction of recurrent
fatal and non-fatal myocardial infarctions (MIs)…” (p. 205). It stands to reason that cardiac
rehab is the best treatment for recovery post cardiac event.
Recently many cardiac rehab programs have expanded to become a multidisciplinary
program that emphasize making healthy lifestyle changes in patients including dietary intake,
weight management and smoking cessation. However, the main focus remains on exercise.
Exercise can dramatically improve survival through many mechanisms, which are represented in
figure 1. Dorosz (2009) explains that exercise in cardiac rehab has been proven to be safe even
for patients with a severe cardiac illness (p. 724). Braverman (2011) supports this by stating that,
“…the risk of any major adverse cardiac event during cardiac rehabilitation, including
myocardial infarction, cardiac arrest, or death [is] one event in 60,000 to 80,000 hrs of
supervised exercise.” She states that the most recognizable event to occur during rehab is
arrhythmias, but emphasizes that the inclusion of a “warm-up and cool-down decreases the
frequency of arrhythmias by promoting coronary perfusion” (p. 605). In short, the benefits of
exercise for cardiac patients are much greater than any of the risks.
INCREASING PARTICIPATION IN CARDIAC REHAB
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Note. Franklin, B., Goel, K., (2011, Dec. 16). Underutilization of exercise-based cardiac
rehabilitation: Barriers to referral, participation, and delivery. Cardiovascular Daily. Retrieved
from http://my.americanheart.org/professional/General/Underutilization-of-Exercise-BasedCardiac-Rehabilitation_UCM_434567_Article.jsp#.T2_vPxwrlDQ
Quality of Life and Reemployment
Dorosz (2009) acknowledges that an important goal for cardiac rehab is to increase
patients’ “functional capacity” and for older adults, “reduce frailty” (p. 726). Exercise training is
pivotal to increasing the quality of life in cardiac patients. Dorosz (2009) further explains that
with exercise training cardiac patients have less physical symptoms of depression, anxiety, and
stress and patients report less pain, more energy and better health in general. These benefits are
even more substantial in the elderly who have a lower tolerance for exercise at the beginning of
the program (p. 727). Dorosz (2009) stresses strength training can reduce the risks of falling and
allow patients opportunity for independence by increasing their ability to do activities of daily
living without assistance. When patients are functional they can return to activities they were
doing prior to the cardiac event.
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There has not been much research on the link between cardiac rehab participation and
patients returning to work, but by increasing their functional capacity it can improve the
likelihood of the patients returning to work. Currently of all the cardiac patients who were
working before the event, only 65% go back to work (Dorosz, 2009, p.727). Programs that are
designed with exercises that stimulate the patient’s work movements can be especially effective.
With an increased number of people having cardiac events, there is not only personal benefits,
but societal benefits to get cardiac patients back to work instead of them relying on disability.
Consequently, the lack of referral to and participation in cardiac rehab could cause a major
burden to the healthcare system and ultimately the American people if action is not taken.
Promoting the Means to a Better Life
Systematic Referral Plus a Liaison
Researchers have recognized the importance of increasing referral. There have been a
great deal of studies looking into the effect systematic referral has on encouraging physician’s to
refer their patients to cardiac rehab. Grace et al. (2012) conducted a multicenter observational
study to determine whether systematic referral provided more referrals of sub populations to
cardiac rehab compared to nonsystematic referral. Grace et al. (2012) define systematic referral
strategies as using electronic medical records or discharge paper work to prompt cardiac rehab
referral (p. 42). Their observation was that systematic referral increased the rate of referral of all
socio-demographic and clinical characteristic variables except family income. The increased
referral led to higher enrollment of “patients with lower educational, of lower subjective
[socioeconomic status], who were obese, and had lower activity status” (p. 43). Grace and
colleagues (2012) emphasize the most important finding was more cardiac rehab enrollments of
patients of low education and of lower socioeconomic status (p. 44). Although referral and
enrollment were higher with systematic referral, participation in CR was similar in both groups.
While these findings are preliminary and warrant further research, the essence of Grace et al.’s
study is that systematic referral can increase referral of all cardiac patients regardless of sociodemographics or cardiac morbidity/ies.
Grace et al. (2011) reviewed studies that looked at different systems put in place to
increase referral and enrollment in cardiac rehab. They compared five different strategies: usual
care (physician initiating and following through the process of referral), systematic (electronic
referral), liaison (discussion of cardiac rehab by healthcare professional to the patient in the
hospital), systematic referral plus liaison, and other (includes letters of encouragement to the
patient) and identified their overall enrollment rates. Price (2012) summarized their findings in
her article; usual care had an overall enrollment rate of 24%, liaison enrollment was 44% while
systematic referral was 45%. Combined systematic referral and liaison improved enrollment
with a rate of 66% (p. 8). Grace and associates (2011) determined that letters sent to the patient
had the highest enrollment rate at 73%, conversely these studies are few and inconsistent (p. 19495). They emphasize that research supports the use of systematic referral with a liaison to
increase referral and enrollment to cardiac rehab. Research on healthcare professionals best
suited as liaison has been limited, but Arena et al. (2012) emphasize the importance of all
healthcare professionals involved with cardiac patients in the hospital to encourage participation
in cardiac rehab.
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Health Team Support and Enthusiasm
There are many healthcare professionals that are involved with cardiac patients in the
hospital and they can all play a key role in informing and referring patients to cardiac rehab.
Arena et al. (2012) advocate that, “consistent communication of the importance of outpatient
[cardiac rehab] from multiple health professionals is likely to increase the perceived value of this
lifestyle intervention by a given patient” (Sec. Defining Key Professions in the Acute Care
Setting, Para. 1). To put it another way, the more cardiac rehab is mentioned to the patient the
more likely they are to think that cardiac rehab is important for their recovery. Arena et al.
(2012) explains the importance of each healthcare professional has in increasing a patient’s
awareness and participation in cardiac rehab (CR). In the paragraphs following, the involvement
in cardiac patients’ care and role in emphasizing cardiac rehab for some of the healthcare
professionals who may have the most interaction with the patients are explained.
Nurses are involved in many parts of the patients care during hospitalization therefore
they are in a prime position to discuss the option of cardiac rehab. While more research is still
needed, a study by Johnson et al. (2010) found that cardiac rehab recommendation by a cardiac
rehab (CR) nurse positively correlates with patient attendance to cardiac rehab. Arena et al.
(2012) urge nurses to, “discuss the reasons for obtaining a referral for outpatient CR and
facilitate the process, the components of an outpatient CR program and how they pertain to the
individual patient, the well-documented benefits of outpatient CR, how outpatient CR provides a
safe environment for exercise, and how attending outpatient CR builds a network of resources
for the future” (Sec. Defining Key Professions in the Acute Care Setting: Nursing). Although
other healthcare professionals can discuss some of these points, Johnson et al. and Arena et al.
are saying that their consistent interaction with the patient allows them many opportunities to
continually promote cardiac rehab and increase patient attendance.
Arena et al. (2012) urges all physicians, physician’s assistants (PA) and nurse
practitioners involved in the care of cardiac patients to coordinate with the cardiac team in
promoting CR in all eligible patients. They further explain that physicians need to ensure that a
referral system is in place and the members responsible for referral are identified (Sec. Defining
Key Professions in the Acute Care Setting: Physicians). As mentioned earlier physicians have a
strong influence on patient’s perception of and participation in CR. Therefore it is critical that
they express the importance of and encourage the participation in CR to the patient, their families
and their caregivers. While nurses and physicians have a major impact on cardiac patients
participation in cardiac rehab, there are other healthcare professionals on the cardiac team that
may be key to increasing referral to and participation in cardiac rehab programs.
Arena et al. (2012) reports that referral to a Physical therapist (PT) for “inpatient
intervention and discharge assessment” determines the patient’s readiness for discharge and
participation in a CR program. This inpatient assessment affords a strong base for referral to
outpatient cardiac rehab. They explain that, “The inpatient PT should embrace the role of
advocate for outpatient CR, educating patients on the value of participating in this important
lifestyle intervention and ensuring that a referral has been secured on discharge” (Sec. Defining
Professions in the Acute Care Setting: Physical Therapy). In other words Arena and associates
are saying that inpatient PTs have important interactions with cardiac patients that can boost
referral and enrollment in cardiac rehab.
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Clinical exercise physiologists (CEPs) typically work in outpatient CR, but they can have
responsibilities with an affiliating inpatient program. CEPs involved with the inpatient team can
have regular contact with the patients and can provide a “link between the inpatient experience
and the outpatient program.” Through their affiliation CEPs can help ensure that all eligible
patients are being referred. (Arena et al., 2012, Sec. Defining Professions in the Acute Care
Setting: Clinical Exercise Physiologist)
It is important for any healthcare professional who is involved with cardiac patients to be
educated about cardiac rehab and consistently encouraging the patient’s participation in and out
patient cardiac rehab. Once the referral is issued, it is extremely important for the cardiac team to
make sure that the patient is aware of the referral. The inpatient cardiac team should have a
strong relationship with CR programs surrounding their area. They should understand as well as
be able to inform the patient that a program can be designed to fit them, not that the patient has
to fit into the program.
Options: Home Based or Hospital Based
As illustrated previously in table 1 a barrier for patient participation is accessibility to
cardiac rehab. Patients often report that rehab doesn’t fit with their schedule or the facility is too
far away. Healthcare professionals need to be aware of alternative rehab programs that can get
the patients involved. Many programs are tailored towards the individual. For those patients
where access to cardiac rehab is a barrier, a home based program may be beneficial to get them
to participate.
Balady et al. (2012) defines home based cardiac rehab as “ a structured program with
clear objectives for the participants, including monitoring, follow-up visits, letters or telephone
calls from staff, and the use of self-monitoring diaries” (p. 2955). In a Cochrane review, Dalal,
Zawada, Jolly, Moxham, & Taylor (2010) reviewed multiple studies that looked at the
effectiveness of home based cardiac rehab programs compared to center based. The outcomes
Dalal et al. (2010) compared include, “exercise capacity, modifiable risk factors (BP,
concentration of lipids in blood, and smoking), health related quality of life and cardiac events
(including mortality, revascularization and readmission to hospital)” (Sec. Discussion, para. 1).
Their review found no difference of these outcomes in patients who were in a home based
program or a center based program. They also observed no significant cost difference in the two
methods. Dalal et al. (2010) concede that most of the studies they reviewed only included low
risk patients. Therefore, a home based cardiac rehab program is a safe, cost-effective option for
stable, low risk cardiac patients.
Making a Change
Cardiac rehabilitation is necessary for cardiac patients. Barriers to get patients into
cardiac rehab are as prominent today as they were thirty years ago. The most significant barrier
is physician referral and may be the easiest one to fix. Systematic referral strategies have been
proven effective at getting more heart patients to cardiac rehab. The healthcare team should work
together to ensure that all eligible patients are referred to cardiac rehab. While referral alone
may not increase patient participation, healthcare professionals have the power to persuade
patients that cardiac rehab is important for their health. Healthcare professionals need to
promote cardiac rehab and make sure all eligible patients are referred so that heart patients have
INCREASING PARTICIPATION IN CARDIAC REHAB
the best opportunity to make a full recovery post cardiac event.
11
INCREASING PARTICIPATION IN CARDIAC REHAB
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References
Arena, R., Williams, M., Forman, D., Cahalin, L., Coke, L., Myers, J., . . . Lavie, C., (2012).
Increasing referral and participation rates to outpatient cardiac rehabilitation: The
valuable role of healthcare professionals in the inpatient and home health settings: A
science advisory from the American Heart Association. Circulation, 125.
doi:10.1161/CIR.0b013e318246b1e5
Balady, G., Ades, P., Bittner, V., Franklin, B., Gordon, N., Thomas, R., Tomaselli, G., & Yancy,
C. (2011). Referral, enrollment and delivery of cardiac rehabilitation/secondary
prevention programs at clinical centers and beyond: A Presidential advisory from the
American Heart Association. Circulation, 124, 2951-2960.
doi:10.1161/CIR.0b013e31823b21e2
Braverman, D. (2011). Cardiac rehabilitation: A contemporary review. American Journal of
Physical Medicine & Rehabilitation, 90, 599-611. doi: 10.1097/PHM.0b013e31821f71a6
Brown, T., Hernandez, A., Bittner, V., Cannon, C., Ellrodt, G., Liang, L.,…Fonarow, G., (2009).
Predictor of cardiac rehabilitation referral in coronary artery disease patients. Journal of
the American College of Cardiology, 54, 515-521. doi:10.1016/j.jacc.2009.02.080
Center for Disease Control and Prevention, The Merck Company Foundation. (2007). The state
of aging and health in America 2007. Whitehouse Station, NJ: The Merck Company
Foundation. Retrieved from http://www.cdc.gov/Aging/pdf/saha_2007.pdf
Dalal, H., Zawada, A., Jolly, K., Moxham, T., & Taylor, R., (2010). Home based versus centre
based cardiac rehabilitation: Cochrane systematic review and meta-analysis. British
Medical Journal. 340. doi: 10.1136/bmj.b5631
Dorosz, J. (2009). Updates in cardiac rehabilitation. Physical Medicine and Rehabilitation
Clinics of North America. 20. 719-736. doi: 10.1016/j.pmr.2009.06.006
Everett, B., Salamonson, Y., Zechin, R., & Davidson, P., (2009). Reframing the dilemma of
poor attendance at cardiac rehabilitation: An exploration of ambivalence and decisional
balance. Journal of Clinical Nursing. 18. 1842-1849. doi: 10.1111/j.13652702.2008.02612.x
Farley, R., Wade, T., & Birchmore, L. (2003). Factors influencing attendance at cardiac
rehabilitation among coronary heart disease patients. European Journal of
Cardiovascular Nursing, 2, 205-212. doi:10.1016/S1474-5151(03)00060-4
Franklin, B., Goel, K., (2011, Dec. 16). Underutilization of exercise-based cardiac
rehabilitation: Barriers to referral, participation and delivery. Cardiovascular Daily.
Retrieved from http://my.americanheart.org/professional/General/Underutilization-ofExercise-Based-Cardiac-Rehabilitation_UCM_434567_Article.jsp#.T2_vPxwrlDQ
INCREASING PARTICIPATION IN CARDIAC REHAB
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Grace, S., Chessex, C., Arthur, H., Chan, S., Cyr, C., Dafoe, W.,…Suskin, N., (2011).
Systematizing inpatient referral to cardiac rehabilitation 2010: Canadian Association of
Cardiac Rehabilitation and Canadian Cardiovascular Society joint position paper.
Canadian Journal of Cardiology, 27, 192-199. doi:10.1016/j.cjca.2010.12.007
Grace, S., Leung, Y., Reid, R., Oh, P., Wu, G., & Alter, D., (2012). The role of systematic
inpatient cardiac rehabilitation referral in increasing equitable access and utilization.
Journal of Cardiopulmonary Rehabilitation and Prevention, 32, 41-47. doi:
10.1097/HCR.0b013e31823be13b
Johnson, N., Inder, K., & Wiggers, J., (2010). Attendance at outpatient cardiac rehabilitation: Is
it enhanced by specialist nurse referral?. Australian Journal of Advanced Nursing. 27(4),
31-37. Retrieved from http://www.cinahl.com/cgibin/refsvc?jid=385&accno=2010717470
Keib, C., Reynolds, N., & Ahijevych, K. (2010). Poor use of cardiac rehabilitation among older
adults: A self-regulatory model for tailored interventions. Heart & Lung: The Journal of
Acute and Critical Care, 39, 504-511. doi:10.1016/j.hrtlng.2009.11.006
Price, J. (2012). Cardiac rehabilitation: Patient referral and enrollment. Canadian Journal of
Cardiovascular Nursing, 22, 7-9.
INCREASING PARTICIPATION IN CARDIAC REHAB
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Appendix
Note. Grace, S., Leung, Y., Reid, R., Oh, P., Wu, G., & Alter, D., (2012), The role of systematic
inpatient cardiac rehabilitation referral in increasing equitable access and utilization. Journal of
Cardiopulmonary Rehabilitation and Prevention, 32, 44. doi: 10.1097/HCR.0b013e31823be13b
This table illustrates the referral rate of patients to cardiac rehab based on referral strategy
(systematic vs. nonsystematic) and different characteristics of the patients. It shows that
systematic referral increases the referral rate of minority and low socioeconomic patients.