Despite its proven benefits, CR/SP programs are substantially underutilized. According to data of Medicare beneficiaries from 1997, only 14% and 31% of individuals following a myocardial infarction and coronary artery bypass surgery, respectively, enrolled in CR/SP programs.24
This is particularly troubling as attending a singular session was sufficient to have been considered enrolled. A major factor contributing to underutilization of CR/SP services is that many qualifying patients are not referred. In a recent analysis from the AHA's Get With the Guidelines
(GWTG) program, only 56% of eligible individuals were referred to CR/SP programs prior to hospital discharge.5
Older individuals and those with most medical comorbidities were less likely to be referred to CR/SP programs.5
More troubling, the proportion of eligible individuals referred to CR/SP was lower than the proportion receiving other proven therapies such as aspirin use (98%), beta-blocker use (93%), and angiotensin converting enzyme inhibitor or angiotensin receptor blocker use (84%), suggesting that physician awareness of the importance of CR/SP services lags behind that of other proven therapies.5
Referral of eligible patients is a necessary first step to enrollment in a CR/SP program. Therefore, researchers have focused on increasing the number of eligible patients who are referred to CR/SP programs prior to hospital discharge. Quality improvement projects that track physician compliance with established treatment recommendations may improve practice habits. Accordingly, recommendations have been put forth that referral to CR/SP services should be a performance measure.25
Referral to CR/SP programs is currently endorsed as a quality improvement measure by the National Quality Forum, which endorses national consensus standards for measuring and publicly reporting on performance in healthcare delivery.
There is evidence that use of the established clinical pathway associated with GWTG results in improvements in referral to and enrollment in CR/SP programs.26
Patients on the GWTG clinical pathway had a 2.3 higher odds of obtaining a CR/SP program referral prior to hospital discharge than individuals not on the pathway. Despite increased referral, however, enrollment rates remained low as only 19% of eligible patients ultimately participated in a CR/SP program.26
An additional proven method to increase participation is the utilization of an automated computerized referral process of all eligible patients to CR/SP programs prior to hospital discharge. Automatic referral resulted in enrollment rates to as high as 43 to 73%.27-31
Automatically referring eligible patients is not, in and of itself, an adequately comprehensive intervention. In 1 study, 26% of individuals who were referred to a CR/SP program prior to discharge but did not subsequently enroll reported that they did not recall being referred.26
Contacting patients with a followup phone call shortly after discharge increased the proportion of individuals who ultimately enrolled in a CR/SP program by 50-80 %.32,33
In a randomized trial of several referral strategies, the combination of automatic referral followed by a discussion between a health care liaison and the patient about the benefits of CR/SP resulted in the highest enrollment rates.34
An emerging challenge for CR/SP providers is to meet the needs of an increasingly diverse society. Currently, over one-third of U.S. residents identify themselves as a racial or ethnic minority and this proportion continues to grow.35
Unfortunately, minority status predicts lower CR/SP program participation rates. In a study of Medicare patients, Suaya et al24
described significantly greater participation rates in whites than in non-whites (19.6% vs 7.8%). Similarly, in a nation-wide survey of 500 randomly chosen CR/SP programs, Thomas et al36
also found significantly higher participation rates in whites compared to minorities. Integration of diverse sociodemographic populations in CR/SP programs is essential not only for ethical considerations but also because cardiovascular disease is more prevalent in blacks and Hispanics37-39
and persons of low socioeconomic status.40
Higher prevalence of cardiac disease in those least likely to utilize CR/SP services underscores the importance of processes to identify, recruit and accommodate underserved populations.
It has been well described that women, ethnic minorities, older individuals, and patients with multiple comorbidities are less likely to be referred to and enroll in CR/SP programs.5,24,41
While there has been little research investigating methods to increase participation in these traditionally underserved groups, there is some evidence that programmatic changes may enhance CR/SP program utilization among woman. For example, females randomized to women-only CR/SP program attended more sessions42
and had greater improvements in quality of life scores43
and depressive symptoms44
than their counterparts who were randomized to traditional, nongender-tailored programs. Similarly, alternative programmatic changes should be considered to encourage greater participation in other underserved populations.