Background: Cardiac rehabilitation programs (CRP) after a cardiovascular event are standard-of-care worldwide, though participation remains very low (estimated at 14%-35% in the US and <15% in Ontario). Removing health care system (HCS) barriers to accessing CRPs is essential to realize patient and population level health benefits, and to understand patient barriers to completion of CRP.
Objectives: To develop a regional delivery system for CRP that removes HCS barriers to CRP so that patient factors affecting CRP participation and completion can be ascertained.
Methods: One health care region (HCR) in Ontario implemented a regional CRP that was fully integrated into the HCS. The integrated CRP (HCS-I-CRP) automated referrals to an HCR-wide coordinating center which directed patients to a to a CRP in a local, community-based setting (LCB-CRP) within a 30-minute drive. The CRP was standardized across all LCB-CRPs. Information related to the referral, initiation, and completion of the CRP was collected and analyzed.
Results: Referral and eligibility criteria were intentionally broad and included any cardiovascular admission within 1 year, or any cardiovascular intervention, procedure, or diagnosis. Automated inpatient and community referrals were received for cardiac or non-cardiac related hospitalizations (62% and 29%, respectively), or ambulatory health care visits (9%). The age distribution of patients referred from hospital and community sources was similar, though community referred patients were less complex (lower Johns Hopkins Adjusted Clinical Group (JH-ACG) category). In comparing the patient characteristics of those who completed vs. those who started but did not complete the CRP, the following patterns were observed: (1) completion rates were nearly identical across hospital and community all referral sources; (2) older patients were more likely to compete the CRP (72% for 70-89 years old vs. 57% for 40-49 years old); (3) while there were more referrals for men (61.5%) than women, the completion rates for men and women were nearly identical; (4) neighborhood income quintile of patients was not associated with completion of the CRP; (5) sicker patients were less likely to complete the CRP (higher resource utilization band, JH-ACG, and Charlson index); and (6) patients with heart failure were least likely to complete the CRP (58.8% vs. 66.8% for all other diagnoses).
Conclusions: Our results suggest that an HCS-I-CRP with automatic referral to a LCB-CRP within a 30-minute drive removed traditional barriers to completing CRP: there were no socioeconomic or gender differences in CRP completion, and elderly patients had higher completion rates. Sicker patients were least likely to complete CRP. Mechanisms to identify these patients earlier and / or support their completion of these programs to reduce disease morbidity should be developed.