Effect of Referral Strategies on Access to Cardiac Rehabilitation Among Women

Background: Despite its proven benefits and need, women’s access to cardiac rehabilitation (CR) is suboptimal. Referral strategies, such as systematic referral, have been advocated to improve access to CR. This study examined sex differences in CR referral and enrollment by referral strategies; and the impact of referral strategies for referral and enrollment concordance among women. Design: Prospective cohort study. Methods: This prospective study included 2635 coronary artery disease inpatients from 11 Ontario hospitals that utilized 1 of 4 referral strategies. Participants completed a sociodemographic survey, and clinical data were extracted from charts. One year later, 1809 participants (452 [25%] women) completed a mailed survey that assessed CR utilization. Referral strategies were compared among women using generalized estimating equations to control for effect of hospital. Results: Overall, significantly more men than women were referred (67.2% and 57.8% respectively, p<.001), and enrolled in CR (58.6% and 49.3% respectively, p=.001). Of the retained women, combined systematic and liaison-facilitated referral resulted in significantly greater CR referral (Odds Ratio [OR]=10.3, 95% Confidence Interval [CI] = 4.11-25.58) and enrollment (OR=6.6, 95% CI = 4.34-9.92) among women when compared to usual referral. Conversely, concordance between referral and enrollment was greatest following usual referral (=.85), and decreased with referral intensity. Conclusions: While a lower proportion of referred patients enroll, systematic and liaison-facilitated inpatient referral strategies result in the greatest CR enrolment rates among women. Such strategies have the potential to improve access among women, and reduce “cherry picking” of patients for referral.