Elsevier

Canadian Journal of Cardiology

Volume 27, Issue 2, March–April 2011, Pages 192-199
Canadian Journal of Cardiology

Society position statement
Systematizing Inpatient Referral to Cardiac Rehabilitation 2010: Canadian Association of Cardiac Rehabilitation and Canadian Cardiovascular Society Joint Position Paper: Endorsed by the Cardiac Care Network of Ontario

https://doi.org/10.1016/j.cjca.2010.12.007Get rights and content

Abstract

Despite recommendations in clinical practice guidelines, evidence suggests cardiac rehabilitation (CR) referral and use following indicated cardiac events is low. Referral strategies such as systematic referral have been advocated to improve CR use. The objective of this policy position is to synthesize evidence and make recommendations on strategies to increase patient enrollment in CR. A systematic review of 6 databases from inception to January 2009 was conducted. Only primary, published, English-language studies were included. A meta-analysis was undertaken to synthesize the enrollment rates by referral strategy. In all, 14 studies met inclusion criteria. Referral strategies were categorized as systematic on the basis of use of systematic discharge order sets, as liaison on the basis of discussions with allied health care providers, or as other on the basis of patient letters. Overall, there were 7 positive studies, 5 without comparison groups, and 2 studies that reported null findings. The combined effect sizes of the meta-analysis were as follows: 73% (95% CI, 39%-92%) for the patient letters (“other”), 66% (95% CI, 54%-77%) for the combined systematic and liaison strategy, 45% (95% CI, 33%-57%) for the systematic strategy alone, and 44% (95% CI, 35%-53%) for the liaison strategy alone. In conclusion, the results suggest that innovative referral strategies increase CR use. Although patient letters look promising, evidence for this strategy is sparse and inconsistent at present. Therefore we suggest that inpatient units adopt systematic referral strategies, including a discussion at the bedside, for eligible patient groups in order to increase CR enrollment and participation. This approach should be considered best practice for further investigation.

Résumé

Malgré les recommandations énoncées dans les lignes directrices de pratique clinique, les données nous montrent que l'orientation des patients en réadaptation cardiaque et l'utilisation de cette réadaptation suite aux accidents cardiaques qui suivent sont faibles. Les stratégies d'orientation comme l'orientation systématique ont été préconisées pour améliorer l'utilisation de la réadaptation cardiaque. L'objectif de cette politique est de faire la synthèse des données et d'émettre des recommandations sur les stratégies en vue d'augmenter le nombre de patients en réadaptation cardiaque. On a réalisé une analyse systématique de 6 bases de données depuis leur création jusqu'en janvier 2009. Seules les plus importantes études publiées en anglais ont été citées. Une méta-analyse a été réalisée afin de synthétiser le nombre de patients pour la stratégie d'orientation. Au total, 14 études répondaient aux critères d'inclusion. Il y a eu classement des stratégies d'orientation sous les rubriques systématiques en fonction de l'utilisation de l'ensemble des prescriptions liées au congé systématique, sous liaison en fonction des discussions avec les dispensateurs de soins apparente's et sous autres en fonction des lettres aux patients. Dans l'ensemble, 7 études se sont avérées positives, 5 étaient sans groupes de comparaison et les résultats ont été nuls pour 2 études. Voici quelles étaient les tailles d'effet combinées de la méta-analyse : 73 % (95 % insuffisance coronarienne, 39 % à 92 %) pour les lettres aux patients (autres), 66 % (95 % insuffisance coronarienne, 54 % à 77 %) pour les stratégies systématiques et de liaison combinées, 45 % (95 % insuffisance coronarienne, 33 % à 57 %) pour la stratégie systématique seule et 44 % (95 % insuffisance coronarienne, 35 % à 53 %) pour la stratégie de liaison seule. En conclusion, les résultats indiquent que les stratégies d'orientation innovatrices augmentent l'utilisation de la réadaptation cardiaque. Même si les lettres aux patients semblent prometteuses, les données concernant cette stratégie sont peu abondantes et variables pour l'instant. Par conséquent, il y a lieu de suggérer que les unités de malades hospitalisés adoptent des stratégies d'orientation systématiques, citons entre autres les discussions au chevet du patient, pour les groupes de patient admissibles afin d'augmenter le nombre de patients en réadaptation et leur participation. On devra tenir compte de cette ligne de conduite thérapeutique en tant que meilleure pratique pour investigation future.

Section snippets

Objectives and Methods

The objective of this policy position is to synthesize evidence and make recommendations on strategies to increase patient enrollment in CR. Comprehensive literature searches of Scopus, MEDLINE, CINAHL, PsycINFO, PubMed, and the Cochrane Library databases were conducted to identify eligible peer-reviewed articles. The search strategy for each database consisted of 4 themes: (1) CVDs, (2) rehabilitation, (3) referral, and (4) enrollment. Articles were included in the review if they met the

Conclusions

Despite the proven benefits of CR,3 only an average of 34% of eligible patients are referred,55 and 20% ultimately enroll.21 This trend runs counter to evidence-based clinical practice guidelines, which recommend CR as the standard of care in the management of CVD.27 Based on the evidence synthesized through the development of this policy position, we strongly suggest that to increase CR enrollment, a combination of systematic and liaison referral strategies be implemented for all inpatient

Acknowledgements

We gratefully acknowledge Shannon Gravely-Witte, MSc, who performed the systematic review of the literature and undertook quality assessment in accordance with the grading of recommendations assessment, development, and evaluation (GRADE) system, and Yvonne Leung, MA, who undertook the meta-analysis. The authors are grateful to Marilyn Thomas, Carolyn Pullen, Michelle Graham, MD, and Michael McDonald, MD, for their support in the preparation of this document. We also acknowledge the Secondary

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    The disclosure information of the authors and reviewers is available from the CCS on the following Web sites: www.ccs.ca and www.ccsguidelineprograms.ca.

    This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgment in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available, and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.

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