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Abstract

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 one of four 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 the effect of hospital.

Results

Overall, significantly more men than women were referred (67.2% and 57.8% respectively, p < 0.001), and enrolled in CR (58.6% and 49.3% respectively, p = 0.001). Of the retained women, combined systematic and liaison-facilitated referral resulted in significantly greater CR referral (OR 10.3, 95% CI 4.11–25.58) and enrollment (OR 6.6, 95% CI 4.34–9.92) among women when compared with usual referral. Conversely, concordance between referral and enrollment was greatest following usual referral (K = 0.85), 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.

Keywords

Cardiac rehabilitation cardiovascular diseases health services accessibility patient participation referral utilization

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References

Roger

Lloyd-Jones

. Heart disease and stroke statistics–2012 update: A report from the American Heart Association. Circulation 2012; 125: e2–e220.

World Health Organization. Women's health. 2009. Available at: http://www.who.int/mediacentre/factsheets/fs334/en/index.html.

Smith

SC Jr

Benjamin

Bonow

. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: A guideline from the American Heart Association and American College of Cardiology Foundation endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association. J Am Coll Cardiol 2011; 58: 2432–2446.

Stone JA, Arthur HM and Suskin N (Eds). Canadian guidelines for cardiac rehabilitation and cardiovascular disease prevention: Translating knowledge into action (3rd edition). Canadian Association of Cardiac Rehabilitation 2009; Winnipeg, MB. Available from: http://www.cacr.ca/resources/guidelines.cfm.

Heran

Chen

Ebrahim

. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011; (7CD001800–CD001800.

Bittner

Sanderson

. Women in cardiac rehabilitation. J Am Med Womens Assoc 2003; 58: 227–235.

Mosca

Benjamin

Berra

. Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: A guideline from the American Heart Association. Circulation 2011; 123: 1243–1262.

Jackson

Leclerc

Erskine

Linden

. Getting the most out of cardiac rehabilitation: A review of referral and adherence predictors. Heart 2005; 91: 10–14.

Ades

Waldmann

Polk

Coflesky

. Referral patterns and exercise response in the rehabilitation of female coronary patients aged greater than or equal to 62 years. Am J Cardiol 1992; 69: 1422–1425.

10.

Piepoli MF, Corra U, Adamopoulos S, et al. Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery. Eur J Prev Cardiol 2014; 21: 664–681.

11.

American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Cardiology Foundation, American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation), et al (2010) AACVPR/ACCF/AHA 2010 update: Performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services endorsed by the American College of Chest Physicians, the American College of Sports Medicine, the American Physical Therapy Association, the Canadian Association of Cardiac Rehabilitation, the Clinical Exercise Physiology Association, the European Association for Cardiovascular Prevention and Rehabilitation, the Inter-American Heart Foundation, the National Association of Clinical Nurse Specialists, the Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons. J Am Coll Cardiol 56: 1159–1167.

12.

De Vos C, Li X, Van Vlaenderen I, et al. Participating or not in a cardiac rehabilitation programme: Factors influencing a patient's decision. Eur J Prev Cardiol 2013; 20: 341–348.

13.

Neubeck

Freedman

Clark

. Participating in cardiac rehabilitation: A systematic review and meta-synthesis of qualitative data. Eur J Prev Cardiol 2012; 19: 494–503.

14.

Balady

Ades

Bittner

. Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: A presidential advisory from the American Heart Association. Circulation 2011; 124: 2951–11260.

15.

Beckie

Mendonca

Fletcher

. Examining the challenges of recruiting women into a cardiac rehabilitation clinical trial. J Cardiopulm Rehabil Prev 2009; 29: 13–21.

16.

Sanderson

Shewchuk

Bittner

. Cardiac rehabilitation and women: What keeps them away? J Cardiopulm Rehabil Prev 2010; 30: 12–21.

17.

Grace

Tan

Simpson

Chessex

. Perceptions of cardiac specialists and rehabilitation programs regarding patient access to cardiac rehabilitation and referral strategies. J Cardiopulm Rehabil Prev 2012; 32: 135–140.

18.

Pasquali

Alexander

Lytle

. Testing an intervention to increase cardiac rehabilitation enrollment after coronary artery bypass grafting. Am J Cardiol 2001; 88: 1415–1416.

19.

Grace

Abbey

Shnek

. Cardiac rehabilitation II: Referral and participation. Gen Hosp Psychiatry 2002; 24: 127–134.

20.

Scott

. Referral to outpatient cardiac rehabilitation: intervention research at the patient, provider, and health system levels. Nat Clin Pract Cardiovasc Med 2008; 5: 671–672.

21.

Stewart Williams

. Using non-linear decomposition to explain the discriminatory effects of male-female differentials in access to care: A cardiac rehabilitation case study. Soc Sci Med 2009; 69: 1072–1079.

22.

Aragam

Moscucci

Smith

. Trends and disparities in referral to cardiac rehabilitation after percutaneous coronary intervention. Am Heart J 2011; 162: 544–551.

23.

Arena

Williams

Forman

. 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 2012; 125: 1321–1329.

24.

Davies

Taylor

Beswick

. Promoting patient uptake and adherence in cardiac rehabilitation. Cochrane Database Syst Rev 2010; (7CD007131–CD007131.

25.

Gravely-Witte

Leung

Nariani

. Effects of cardiac rehabilitation referral strategies on referral and enrollment rates. Nat Rev Cardiol 2010; 7: 87–96.

26.

Grace

Arthur

Chan

. Systematizing inpatient referral to cardiac rehabilitation: A joint policy position of the Canadian Association of Cardiac Rehabilitation and Canadian Cardiovascular Society. Can J Cardiol 2011; 27: 192–199.

27.

Grace

Russell

Reid

. Effect of cardiac rehabilitation referral strategies on utilization rates: A prospective, controlled study. Arch Int Med 2011; 171: 235–241.

28.

Suskin

MacDonald

Swabey

. Cardiac rehabilitation and secondary prevention services in Ontario: Recommendations from a consensus panel. Can J Cardiol 2003; 19: 833–838.

29.

Beck

Steer

Brown

. Manual for the Beck depression inventory-II, San Antonio, Texas: Psychological Corporation, 1996.

30.

Grace

Leung

Reid

. The role of systematic inpatient cardiac rehabilitation referral in increasing equitable access and utilization. J Cardiopulm Rehabil Prev 2012; 32: 41–47.

31.

Tsui

Shanmugasegaram

Jamnik

. Variation in patient perceptions of healthcare provider endorsement of cardiac rehabilitation. J Cardiopulm Rehabil Prev 2012; 32: 192–197.

32.

Kayaniyil

Leung

Suskin

Concordance of self and program-reported rates of cardiac rehabilitation referral, enrollment and participation. 2009; 25: e96–e399.

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Effect of referral strategies on access to cardiac rehabilitation among women

Abstract

Background

Design

Methods

Results

Conclusions

Keywords

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References

Supplementary Material