Systematizing Inpatient Referral to Cardiac Rehabilitation 2010: CANADIAN ASSOCIATION OF CARDIAC REHABILITATION AND CANADIAN CARDIOVASCULAR SOCIETY JOINT POSITION PAPER

Despite recommendations in clinical practice guidelines, evidence suggests cardiac rehabilitation (CR) referral and utilization following indicated cardiac events is low. Referral strategies such as systematic referral have been advocated to improve CR utilization. The objective of this policy position is to synthesize evidence and make recommendations on strategies to increase patient enrollment in CR. A systematic review of 6 databases from inception to January 2009 was conducted. Only primary, published, English-language studies were included. A meta-analysis was undertaken to synthesize the enrollment rates by referral strategy. Fourteen studies met inclusion criteria. Referral strategies were categorized as ‘systematic’ based on use of systematic discharge order sets, as ‘liaison’ based on discussions with allied healthcare providers, or ‘other’ based on patient letters. Overall, there were 7 positive studies, 5 without comparison groups, and 2 studies reported null findings. The combined effect sizes of the meta-analysis were: 73% (95% CI 39-92%) for the patient letters (Other), 66% (95% CI 54-77%) for the combined systematic and liaison strategy, 45% (95% CI 33-57%) for the systematic strategy alone, and 44% (95% CI 35-53%) for the liaison strategy alone. The results suggest that innovative referral strategies increase CR utilization. Although the use of patient letters looks promising, evidence for this strategy is sparse and inconsistent at present. Therefore, we suggest that inpatient units adopt systematic referral strategies including a discussion at the bedside for eligible patient groups in order to increase CR enrollment and participation. This should be considered best practice for further investigation.