C A R D I A C R E H A B I L I TAT I O N
Cardiac Rehabilitation Enrollment Among Referred Patients PATIENT AND ORGANIZATIONAL FACTORS
Karam I. Turk-Adawi, PhD; Neil B. Oldridge, PhD; Sergey S. Tarima, PhD; William B. Stason, MD; Donald S. Shepard, PhD
■ PURPOSE: Cardiac rehabilitation (CR) is underutilized despite welldocumented benefits for patients with coronary heart disease. The purpose of this study was to identify organizational and patient factors associated with CR enrollment. ■ METHODS: Facilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry (N = 38) were surveyed, and the records of referred patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities. ■ RESULTS: Of the 6874 patients referred to the 38 facilities, 67.6% (n = 4,644) enrolled in CR. Patients receiving coronary artery bypass grafting (adjusted odds ratio [OR], 1.72; 95% CI: 1.36-2.19) and those who possessed health insurance (OR, 3.04; 95% CI: 2.00-4.63) were more likely to enroll. Enrollment was also positively impacted by organizational factors, including promotion of CR program (OR, 2.35; 95% CI: 1.39-4.00), certification by the American Association of Cardiovascular Pulmonary Rehabilitation (OR, 2.63; 95% CI: 1.325.35), and a rural location (OR, 3.30; 95% CI: 2.35-4.64). Patients aged ≥65 years (OR, 0.81; 95% CI: 0.74-0.90) and patients with heart failure (OR, 0.40; 95% CI: 0.22-0.72), diabetes (OR, 0.58; 95% CI: 0.370.89), myocardial infarction without a cardiac procedure (OR, 0.78; 95% CI: 0.67-0.90), previous coronary artery bypass grafting (OR, 0.72; 95% CI: 0.56-0.92), depression (OR, 0.56; 95% CI: 0.36-0.88), or current smoking (OR, 0.59; 95% CI: 0.44-0.78) were less likely to enroll. ■ CONCLUSIONS: Predictors of patient enrollment in CR following referral included both organizational and personal factors. Modifiable organizational factors that were associated either positively or negatively with enrollment in CR may help directors of CR programs improve enrollment.
Cardiac rehabilitation (CR) is considered an integral component of the continuum of care for patients with coronary heart disease (CHD).1 Many major meta-analyses have shown participation in CR promotes a healthy lifestyle, reduces risk factors, improves health-related quality of life, and decreases mortality and morbidity.2-9 Despite the documentation of substantial morbidity and
K E Y
W O R D S
cardiac rehabilitation coronary heart disease enrollment organizational factors patient factors
Author Affiliations: Brandeis University, Waltham, Massachusetts (Drs Turk-Adawi, Stason, and Shepard); Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin (Dr Oldridge); and Division of Biostatistics, Medical College of Wisconsin, Milwaukee (Dr Tarima). The authors declare no conflicts of interest. Correspondence: Karam I. Turk-Adawi, PhD, c/o Donald Shepard, Brandeis University, 415 S St, MS 035, Waltham, MA 02454 ([email protected]). DOI: 10.1097/HCR.0000000000000017
mortality benefits, fewer than 30% of eligible patients utilize CR services.10-12 However, there is increasing evidence on improving CR enrollment by implementation of referral strategies.13-17 A recent systematic review by Grace et al13 reported enrollment rates of 44% to 73% in patients referred to CR, using various recently identified, but still underutilized, referral strategies. Higgins et al14
114 / Journal of Cardiopulmonary Rehabilitation and Prevention 2014;34:114-122
www.jcrpjournal.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-13-00016.indd 114
07/02/14 5:57 PM
and Mueller et al15 have also reported relatively high enrollment rates of 72% and 53%, respectively, in patients who were referred to CR. Several studies have examined extensively patientand provider-related factors11,18,19 contributing to low enrollment rates. However, organization level–related factors have been studied only recently and to a lesser extent than patient- or provider-related factors.20-23 Notably, most studies that investigated organizational factors are qualitative in nature and based on patients’ and health care professional perceptions and beliefs,20-23 without demonstration of statistical inferences on the role of these organizational factors in CR enrollment. Therefore, the aim of this study was to examine concurrently the role of patient and CR organizational factors in CR enrollment in a multisite sample of 38 CR facilities and their patients.
T a b l e 1 • Patient Characteristics and Rates of CR Enrollment
Characteristic Entire cohort
67.6 .42
Male
69.3
67.8
Female
30.7
67.0 .22
Whites Nonwhites
94.1
68.4
5.9
54.3
Age group, y
Cardiac Rehabilitation Enrollment Among Referred Patients PATIENT AND ORGANIZATIONAL FACTORS
Karam I. Turk-Adawi, PhD; Neil B. Oldridge, PhD; Sergey S. Tarima, PhD; William B. Stason, MD; Donald S. Shepard, PhD
■ PURPOSE: Cardiac rehabilitation (CR) is underutilized despite welldocumented benefits for patients with coronary heart disease. The purpose of this study was to identify organizational and patient factors associated with CR enrollment. ■ METHODS: Facilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry (N = 38) were surveyed, and the records of referred patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities. ■ RESULTS: Of the 6874 patients referred to the 38 facilities, 67.6% (n = 4,644) enrolled in CR. Patients receiving coronary artery bypass grafting (adjusted odds ratio [OR], 1.72; 95% CI: 1.36-2.19) and those who possessed health insurance (OR, 3.04; 95% CI: 2.00-4.63) were more likely to enroll. Enrollment was also positively impacted by organizational factors, including promotion of CR program (OR, 2.35; 95% CI: 1.39-4.00), certification by the American Association of Cardiovascular Pulmonary Rehabilitation (OR, 2.63; 95% CI: 1.325.35), and a rural location (OR, 3.30; 95% CI: 2.35-4.64). Patients aged ≥65 years (OR, 0.81; 95% CI: 0.74-0.90) and patients with heart failure (OR, 0.40; 95% CI: 0.22-0.72), diabetes (OR, 0.58; 95% CI: 0.370.89), myocardial infarction without a cardiac procedure (OR, 0.78; 95% CI: 0.67-0.90), previous coronary artery bypass grafting (OR, 0.72; 95% CI: 0.56-0.92), depression (OR, 0.56; 95% CI: 0.36-0.88), or current smoking (OR, 0.59; 95% CI: 0.44-0.78) were less likely to enroll. ■ CONCLUSIONS: Predictors of patient enrollment in CR following referral included both organizational and personal factors. Modifiable organizational factors that were associated either positively or negatively with enrollment in CR may help directors of CR programs improve enrollment.
Cardiac rehabilitation (CR) is considered an integral component of the continuum of care for patients with coronary heart disease (CHD).1 Many major meta-analyses have shown participation in CR promotes a healthy lifestyle, reduces risk factors, improves health-related quality of life, and decreases mortality and morbidity.2-9 Despite the documentation of substantial morbidity and
K E Y
W O R D S
cardiac rehabilitation coronary heart disease enrollment organizational factors patient factors
Author Affiliations: Brandeis University, Waltham, Massachusetts (Drs Turk-Adawi, Stason, and Shepard); Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin (Dr Oldridge); and Division of Biostatistics, Medical College of Wisconsin, Milwaukee (Dr Tarima). The authors declare no conflicts of interest. Correspondence: Karam I. Turk-Adawi, PhD, c/o Donald Shepard, Brandeis University, 415 S St, MS 035, Waltham, MA 02454 ([email protected]). DOI: 10.1097/HCR.0000000000000017
mortality benefits, fewer than 30% of eligible patients utilize CR services.10-12 However, there is increasing evidence on improving CR enrollment by implementation of referral strategies.13-17 A recent systematic review by Grace et al13 reported enrollment rates of 44% to 73% in patients referred to CR, using various recently identified, but still underutilized, referral strategies. Higgins et al14
114 / Journal of Cardiopulmonary Rehabilitation and Prevention 2014;34:114-122
www.jcrpjournal.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-13-00016.indd 114
07/02/14 5:57 PM
and Mueller et al15 have also reported relatively high enrollment rates of 72% and 53%, respectively, in patients who were referred to CR. Several studies have examined extensively patientand provider-related factors11,18,19 contributing to low enrollment rates. However, organization level–related factors have been studied only recently and to a lesser extent than patient- or provider-related factors.20-23 Notably, most studies that investigated organizational factors are qualitative in nature and based on patients’ and health care professional perceptions and beliefs,20-23 without demonstration of statistical inferences on the role of these organizational factors in CR enrollment. Therefore, the aim of this study was to examine concurrently the role of patient and CR organizational factors in CR enrollment in a multisite sample of 38 CR facilities and their patients.
T a b l e 1 • Patient Characteristics and Rates of CR Enrollment
Characteristic Entire cohort
67.6 .42
Male
69.3
67.8
Female
30.7
67.0 .22
Whites Nonwhites
94.1
68.4
5.9
54.3
Age group, y
