Will increasing referral to cardiac rehabilitation improve participation?

Exercise-based cardiac rehabilitation (CR) programs have been a part of the secondary prevention landscape for more than 50 years. Multiple controlled trials and meta-analyses have confirmed its proven benefits with regard to mortality and, to a lesser extent, morbidity. Due to the strong evidence supporting its role in secondary prevention, CR is recognized as a class I recommendation. Despite the clear benefit of this treatment strategy, CR continues to be vastly underutilized. Most published reports document referral rates of approximately 20%. Impressive referral rates from the American Heart Association’s (AHA’s) ‘‘Get with the Guidelines’’ (GWTG) initiative show that slightly more than half of eligible patients are referred to CR. Yet, this improved referral rate still trails other secondary prevention interventions such as cardioprotective prescriptions at hospital discharge. Although referral rates remain a relevant issue, equally concerning are participation rates of patients referred. Many published analyses of participation show a drop-off from referral to enrollment by more than 50%. An extensive Medicare analysis showed that approximately 19% of eligible patients actually participate in CR programs. Previous studies that examined the barriers to CR utilization have predominately focused on patient, physician, and health system characteristics that predict referral, including age, sex, race, comorbidities, qualifying diagnosis, specialty of physician, and type of insurance. These reports identify areas where referral could be improved; however, they do not provide solutions to the utilization problem.