Contribution of Patient and Physician Factors to Cardiac Rehabilitation Referral: A Prospective Multi-Level Study

Introduction: Cardiac rehabilitation (CR) is a proven means of reducing mortality, yet is grossly under-utilized. This is due to both health system and patient-level factors, issues which have yet to be investigated concurrently. This study utilized a hierarchical design to examine physician and patient-level factors affecting verified CR referral.

Methods: This was a prospective study using a multi-level design of 1490 CAD outpatients nested within 97 cardiology practices. Cardiologists completed a survey regarding CR attitudes. Outpatients were surveyed prospectively to assess sociodemographic, clinical, behavioral, psychosocial and health system factors affecting CR referral. CR referral was verified 9 months later with 40 sites.

Results: 550 (43.4%) outpatients were referred to CR. Factors affecting verified referral in mixed logistic regression analyses were positive physician perceptions of CR (p=.03), shorter patient distance to the closest CR site (p=.003), fewer perceived CR barriers (p<.001) and personal control (p=.001).

Conclusions: Both physician and patient factors play a role in CR referral. Not only is referral to CR affected by physician perceptions of such programs, including quality and perceived benefit, but is affected by patient’s perceived CR barriers which they may convey during CR discussions. Distance to CR was related to physician referral practice, despite the availability of home-based services.