Background: The efficacy of cardiac rehabilitation programs (CRP) is well established, and completion of such programs after an event is standard-of-care in guidelines worldwide. Despite universal recommendations, participation in CRP is alarmingly low: estimated at 14%-35% in the US, and <15% of eligible patients in the Canadian province of Ontario. The inability to achieve even 50% participation in CRP represents a failure of health care systems (HCS) to deliver effective, high-quality services. Such a failure is particularly vexing in Canada, where the central tenet and legal requirement of the HC-S is universal access to all medically necessary services.
Objectives: A team of health care providers and administrators in Ontario used a systems integration approach to re-design the HCS in one health care region (HCR) to make an evidence-based CRP universally available. The key features of this HCS-integrated CRP (HCS-I-CRP), its adoption, and population health impact are reported here.
Methods: By design, the HCS-I-CRP included harmonized criteria that triggered automatic referral to a HCR-wide coordinating center, which then directed eligible patients to a CRP provided in local, community-based setting (LCB-CRP). Fourteen LCB-CRP, available within a 30-minute drive from most all locations in the HCR, were trained to provide a standardized CRP. Detailed patient outcomes were tracked in a centralized database. Using administrative data, within-HCR participation rates were monitored, and population level health impacts between the HCR implementing the HCS-I-CRP and all other HCRs in Ontario were compared for the 2 years prior and 1 year after the HCS-I-CRP implementation.
Results: More than 11,000 patients were referred through the HCS-I-CRP to a LCB-CRP. The estimated overall participation and completion rates were 31% and 67%, respectively. Population health impacts in the HCR implementing the HCS-I-CRP included (p<0.05): larger HCR-wide reduction in visits to family practitioners, cardiologists, and internists for any cardiac reason; larger HCR-wide reductions in hospitalizations, emergency department visits, and visits to cardiologist and internists for acute coronary syndrome; and larger HCR-wide reductions in visits to family practitioners and cardiologists for heart failure. Reductions in HCR-wide mortality for acute coronary syndrome approached significance (p=0.097).
Conclusions: The adoption of a HCS-I-CRP was extremely successful: referrals actually exceeded the capacity of LCB-CRPs and enrollment, unfortunately, had to be capped. Despite this, statistically significant, population level health benefits were observed. We anticipate that adoption of a province-wide HCS-I-CRP, initiated and buttressed by provincial policy, would achieve near universal access to CRP and population health benefits similar to or greater than those reported here.