Cardiac rehabilitation (CR) remains underused and inconsistently accessed, particularly for women and minorities. This study examined the factors associated with CR enrollment within the context of an automatic referral system through a retrospective chart review plus survey. Through the Behavioral Model of Health Services Utilization, it was postulated that enabling and perceived need factors, but not predisposing factors, would significantly predict patient enrollment.
A random sample of all atherosclerotic heart disease (AHD) patients treated at a tertiary care center (Trillium Health Centre, Ontario, Canada) from April 2001 to May 2002 (n = 501) were mailed a survey using a modified Dillman method (71% response rate).
Predisposing measures consisted of sociodemographics such as age, sex, ethnocultural background, work status, level of education, and income. Enabling factors consisted of barriers and facilitators to CR attendance, exercise benefits and barriers (EBBS), and social support (MOS). Perceived need factors consisted of illness perceptions (IPQ) and body mass index.
Of the 272 participants, 199 (73.2%) attended a CR assessment. Lower denial/minimization, fewer logistical barriers to CR (eg, distance, cost), and lower perceptions of AHD as cyclical or episodic reliably predicted CR enrollment among cardiac patients who were automatically referred.
Because none of the predisposing factors were significant in the final model, this suggests that factors associated with CR enrollment within the context of an automatic referral model relate to enabling factors and perceived need. A prospective controlled evaluation of automatic referral is warranted.
Substantial health risks continue following coronary revascularization, and cardiac rehabilitation (CR) plays a large role in enhancing prognosis. However, fewer women than men are referred to and participate in CR. This study prospectively evaluates a psycho-educational intervention designed to increase patient-initiation of CR referral discussion with their physician, It was hypothesized that an educational brochure along with a motivational interview would facilitate the discussion of CR between physicians and female patients, ultimately resulting in increased referral of women to CR when compared to a control group. Eighty female percutaneous coronary intervention patients were recruited from two acute care sites in Toronto, Ontario. Eight weeks later, a second research assistant blind to condition telephoned participants to assess aftercare and CR referral processes. Results showed that patients in the experimental group more often discussed CR with a health care provider (chi2(1)=5.99, p=.01), and there was a trend toward increased referral when compared to control patients (chi2(1)=2.83, p=.09). Gaps in secondary prevention are noted, and areas for improved referral of women patients to CR are discussed.
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Cardiac rehabilitation (CR) is an evidence-based intervention that has been shown to reduce both morbidity and mortality. However, CR is widely underused due to multiple factors, including physician referral practices.
To describe physicians' preferences in managing cardiac patients and the barriers they face in referring patients to CR.
A cross-sectional survey of a stratified random sample of 510 primary care physicians, cardiologists and cardiovascular surgeons in Ontario was conducted. One hundred seventy-nine physicians responded (40% response rate through repeat mailings) to the survey that investigated medical, demographic and attitudinal factors affecting referral. A hypothetical case scenario that elicited open-ended factors affecting physician management preferences was incorporated.
Physicians identified geographic access, uncertainty regarding which provider was responsible for referral and perceptions of patient motivation as important factors affecting referral to CR. Through principal components analysis, several attitudes affecting referral emerged, including beliefs about the efficacy of CR, referral norms, ease of the referral process and desire to manage the patient independently. A hierarchical logistic regression analysis showed that 75% of the variance in referral was attributable to medical specialty, availability of CR and practice norms.
Increased communication among health care providers is needed to ensure CR referral. Due to geographic dispersion, alternatives to site-based CR are necessary to meet the needs of cardiac patients.