Heart, Lung and Circulation
Original Article| Volume 24, ISSUE 8, P806-816, August 2015

Education of Physicians and Implementation of a Formal Referral System Can Improve Cardiac Rehabilitation Referral and Participation Rates after Percutaneous Coronary Intervention

Published:February 20, 2015DOI:


      Cardiac rehabilitation (CR) is an effective preventive measure that remains underutilised in the United States. The study aimed to determine the CR referral rate (RR) after percutaneous coronary intervention (PCI) at an academic tertiary care centre, identify barriers to referral, and evaluate awareness of CR benefits and indications (CRBI) among cardiologists. Subsequently, it aimed to evaluate if an intervention consisting of physicians’ education about CRBI and implementation of a formal CR referral system could improve RR and consequently participation rate (PR).


      Data were retrospectively collected for all consecutive patients who underwent PCI over 12 months. Referral rate was determined and variables were compared for differences between referred and non-referred patients. A questionnaire was distributed among the physicians in the Division of Cardiology to assess awareness of CRBI and referral practice patterns.
      After implementation of the intervention, data were collected retrospectively for consecutive patients who underwent PCI in the following six months. Referral rate and changes in PRs were determined.


      Prior to the intervention, RR was 17.6%. Different barriers were identified, but the questionnaire revealed lack of physicians’ awareness of CRBI and inconsistent referral patterns. After the intervention, RR increased to 88.96% (Odds Ratio 37.73, 95% CI 21.34-66.70, p<0.0001) and PR increased by 32.8% to reach 26%. Personal endorsement of CRBI by cardiologists known to patients increased CR program graduation rate by 35%.


      Cardiologists’ awareness of CRBI increases CR RR and their personal endorsement improves PR and compliance. Education of providers and implementation of a formal referral system can improve RR and PR.


      CABG (Coronary artery bypass graft), CR (Cardiac rehabilitation), DM (Diabetes mellitus), GRMC (Georgia Regents Medical Center), MI (Myocardial infarction), PCI (Percutaneous coronary intervention)


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        • Roger V.L.
        • Go A.S.
        • Lloyd-Jones D.M.
        • Benjamin E.J.
        • Berry J.D.
        • Borden W.B.
        • et al.
        Executive summary: Heart disease and stroke statistics--2012 update: A report from the American Heart Association.
        Circulation. 2012; 125: 188-197
        • Jolliffe J.A.
        • Rees K.
        • Taylor R.S.
        • Thompson D.
        • Oldridge N.
        • Ebrahim S.
        Exercise-based rehabilitation for coronary heart disease.
        Cochrane Database Syst Rev. 2001; : CD001800
        • Taylor R.S.
        • Brown A.
        • Ebrahim S.
        • Jolliffe J.
        • Noorani H.
        • Rees K.
        • et al.
        Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials.
        Am J Med. 2004; 116: 682-692
      1. Brown A, Taylor R, Noorani H, Stone J, Skidmore B. Exercise-based cardiac rehabilitation programs for coronary artery disease: a systematic clinical and economic review. Ottawa: Canadian Coordinating Office for Health Technology Assessment; 2003. Technology report no 34.

        • Goel K.
        • Lennon R.J.
        • Tilbury R.T.
        • Squires R.W.
        • Thomas R.J.
        Impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary intervention in the community.
        Circulation. 2011; 123 (Epub 2011 May 16): 2344-2352
      2. King SB 3rd, Smith SC Jr, Hirshfeld JW Jr, Jacobs AK, Morrison DA, Williams DO; 2005 WRITING COMMITTEE MEMBERS, Feldman TE, Kern MJ, O’Neill WW, Schaff HV, Whitlow PL, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW. 2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: 2007 Writing Group to Review New Evidence and Update the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention, Writing on Behalf of the 2005 Writing Committee. Circulation. 2008 Jan 15;117(2):261–95. Epub 2007 Dec 13.

      3. American Association of Cardiovascular and Pulmonary Rehabilitation; American College of Cardiology Foundation; American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation), Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J. AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services Endorsed by the American College of Chest Physicians, the American College of Sports Medicine, the American Physical Therapy Association, the Canadian Association of Cardiac Rehabilitation, the Clinical Exercise Physiology Association, the European Association for Cardiovascular Prevention and Rehabilitation, the Inter-American Heart Foundation, the National Association of Clinical Nurse Specialists, the Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2010 Sep 28;56(14):1159–67.

      4. Decision Memo for Cardiac Rehabilitation Programs (CAG-00089R). Baltimore, MD; Centers for Medicare and Medicaid Services; 2006.

        • Walther C.
        • Gielen S.
        • Hambrecht R.
        The effect of exercise training on endothelial function in cardiovascular disease in humans.
        Exerc Sport Sci Rev. 2004; 32: 129-134
        • Dunlay S.M.
        • Pack Q.R.
        • Thomas R.J.
        • Killian J.M.
        • Roger V.L.
        Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction.
        Am J Med. 2014; 127 (Epub 2014 Feb 18): 538-546
        • Belardinelli R.
        • Paolini I.
        • Cianci G.
        • Piva R.
        • Georgiou D.
        • Purcaro A.
        Exercise training intervention after coronary angioplasty: the ETICA trial.
        J Am Coll Cardiol. 2001; 37: 1891-1900
        • Lan C.
        • Chen S.Y.
        • Chiu S.F.
        • Hsu C.J.
        • Lai J.S.
        • Kuan P.L.
        Poor functional recovery may indicate restenosis in patients after coronary angioplasty.
        Arch Phys Med Rehabil. 2003; 84: 1023-1027
        • Briffa T.G.
        • Eckermann S.D.
        • Griffiths A.D.
        • Harris P.J.
        • Heath M.R.
        • Freedman S.B.
        • Donaldson L.T.
        • Briffa N.K.
        • Keech A.C.
        Cost-effectiveness of rehabilitation after an acute coronary event: a randomised controlled trial.
        Med J Aust. 2005; 183: 450-455
        • Papadakis S.
        • Reid R.D.
        • Coyle D.
        • Beaton L.
        • Angus D.
        • Oldridge N.
        Cost-effectiveness of cardiac rehabilitation program delivery models in patients at varying cardiac risk, reason for referral, and sex.
        Eur J Cardiovasc Prev Rehabil. 2008; 15: 347-353
        • Brown T.M.
        • Hernandez A.F.
        • Bittner V.
        • Cannon C.P.
        • Ellrodt G.
        • Liang L.
        • Peterson E.D.
        • Piña I.L.
        • Safford M.M.
        • Fonarow G.C.
        American Heart Association Get With The Guidelines Investigators.
        Predictors of cardiac rehabilitation referral in coronary artery disease patients: findings from the American Heart Association's Get With The Guidelines Program. J Am Coll Cardiol. 2009; 54: 515-521
        • Bittner V.
        • Sanderson B.
        • Breland J.
        • Green D.
        Referral patterns to a University-based cardiac rehabilitation program.
        Am J Cardiol. 1999; 83 (A5): 252-255
        • Ades P.A.
        • Waldmann M.L.
        • Polk D.M.
        • Coflesky J.T.
        Referral patterns and exercise response in the rehabilitation of female coronary patients aged greater than or equal to 62 years.
        Am J Cardiol. 1992; 69: 1422-1425
        • Roblin D.
        • Diseker 3rd, R.A.
        • Orenstein D.
        • Wilder M.
        • Eley M.
        Delivery of outpatient cardiac rehabilitation in a managed care organization.
        J Cardiopulm Rehabil. 2004; 24: 157-164
        • Suaya J.A.
        • Shepard D.S.
        • Normand S.L.
        • Ades P.A.
        • Prottas J.
        • Stason W.B.
        Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery.
        Circulation. 2007; 116 (Epub 2007 Sep 24): 1653-1662
        • Mochari H.
        • Lee J.R.
        • Kligfield P.
        • Mosca L.
        Ethnic differences in barriers and referral to cardiac rehabilitation among women hospitalized with coronary heart disease.
        Prev Cardiol. 2006; 9: 8-13
        • Jackson L.
        • Leclerc J.
        • Erskine Y.
        • Linden W.
        Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors.
        Heart. 2005; 91: 10-14
        • Cortés O.
        • Arthur H.M.
        Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review.
        Am Heart J. 2006; 151: 249-256
        • Blackburn G.G.
        • Foody J.M.
        • Sprecher D.L.
        • Park E.
        • Apperson-Hansen C.
        • Pashkow F.J.
        Cardiac rehabilitation participation patterns in a large, tertiary care center: evidence for selection bias.
        J Cardiopulm Rehabil. 2000; 20: 189-195
        • Grace S.L.
        • Evindar A.
        • Kung T.
        • Scholey P.
        • Stewart D.E.
        Increasing access to cardiac rehabilitation: automatic referral to the program nearest home.
        J Cardiopulm Rehabil. 2004; 24: 171-174
        • Grace S.L.
        • Scholey P.
        • Suskin N.
        • Arthur H.M.
        • Brooks D.
        • Jaglal S.
        • Abramson B.L.
        • Stewart D.E.
        A prospective comparison of cardiac rehabilitation enrollment following automatic vs usual referral.
        J Rehabil Med. 2007; 39: 239-245
        • Thomas R.J.
        • Miller N.H.
        • Lamendola C.
        • Berra K.
        • Hedbäck B.
        • Durstine J.L.
        • Haskell W.
        National Survey on Gender Differences in Cardiac Rehabilitation Programs.
        Patient characteristics and enrollment patterns. J Cardiopulm Rehabil. 1996; 16: 402-412
        • Centers for Disease Control and Prevention (CDC)
        Receipt of cardiac rehabilitation services among heart attack survivors--19 states and the District of Columbia, 2001.
        MMWR Morb Mortal Wkly Rep. 2003; 52: 1072-1075
        • Aragam K.G.
        • Moscucci M.
        • Smith D.E.
        • Riba A.L.
        • Zainea M.
        • Chambers J.L.
        • Share D.
        • Gurm H.S.
        Trends and disparities in referral to cardiac rehabilitation after percutaneous coronary intervention.
        Am Heart J. 2011; 161: 544-55100
        • Leung Y.W.
        • Brual J.
        • Macpherson A.
        • Grace S.L.
        Geographic issues in cardiac rehabilitation utilization: a narrative review.
        Health Place. 2010; 16 (Epub 2010 Aug 10): 1196-1205
        • Arena R.
        • Williams M.
        • Forman D.E.
        • Cahalin L.P.
        • Coke L.
        • Myers J.
        • Hamm L.
        • Kris-Etherton P.
        • Humphrey R.
        • Bittner V.
        • Lavie C.J.
        American Heart Association Exercise, Cardiac Rehabilitation and Prevention Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity and Metabolism. Increasing referral and participation rates to outpatient cardiac rehabilitation: The valuable role of healthcare professionals in the inpatient and home health settings: A science advisory from the American Heart Association.
        Circulation. 2012; 125 (Epub 2012 Jan 30): 1321-1329
        • Moradi B.
        • Maleki M.
        • Esmaeilzadeh M.
        • Abkenar H.B.
        Physician-related factors affecting cardiac rehabilitation referral.
        J Tehran Heart Cent. 2011; 6 (Epub 2011 Nov 30): 187-192
        • Barber K.
        • Stommel M.
        • Kroll J.
        • Holmes-Rovner M.
        • McIntosh B.
        Cardiac rehabilitation for community-based patients with myocardial infarction: factors predicting discharge recommendation and participation.
        J Clin Epidemiol. 2001; 54: 1025-1030
        • Wenger N.K.
        Current status of cardiac rehabilitation.
        J Am Coll Cardiol. 2008; 51: 1619-1631
        • Kraal J.J.
        • Peek N.
        • van den Akker-Van Marle M.E.
        • Kemps H.M.
        Effects and costs of home-based training with telemonitoring guidance in low to moderate risk patients entering cardiac rehabilitation: The [email protected] study.
        BMC Cardiovasc Disord. 2013; 13: 82
        • Lee Y.H.
        • Hur S.H.
        • Sohn J.
        • Lee H.M.
        • Park N.H.
        • Cho Y.K.
        • et al.
        Impact of home-based exercise training with wireless monitoring on patients with acute coronary syndrome undergoing percutaneous coronary intervention.
        J Korean Med Sci. 2013; 28 (Epub 2013 Mar 27): 564-568
        • Scalvini S.
        • Zanelli E.
        • Comini L.
        • Dalla Tomba M.
        • Troise G.
        • Febo O.
        • Giordano A.
        Home-based versus in-hospital cardiac rehabilitation after cardiac surgery: a nonrandomized controlled study.
        Phys Ther. 2013; 93 (Epub 2013 Apr 18): 1073-1083
        • Grace S.L.
        • Gravely-Witte S.
        • Brual J.
        • Suskin N.
        • Higginson L.
        • Alter D.
        • Stewart D.E.
        Contribution of patient and physician factors to cardiac rehabilitation referral: a prospective multilevel study.
        Nat Clin Pract Cardiovasc Med. 2008; 5 (Epub 2008 Jun 10): 653-662
        • Grace S.L.
        • Angevaare K.L.
        • Reid R.D.
        • Oh P.
        • Anand S.
        • Gupta M.
        • Brister S.
        • Stewart D.E.
        • CRCARE Investigators
        Effectiveness of inpatient and outpatient strategies in increasing referral and utilization of cardiac rehabilitation: a prospective, multi-site study.
        Implement Sci. 2012; 7: 120
        • Boyden T.
        • Rubenfire M.
        • Franklin B.
        Will increasing referral to cardiac rehabilitation improve participation?.
        Prev Cardiol. 2010; 13: 192-201
        • Dunlay S.M.
        • Witt B.J.
        • Allison T.G.
        • Hayes S.N.
        • Weston S.A.
        • Koepsell E.
        • Roger V.L.
        Barriers to participation in cardiac rehabilitation.
        Am Heart J. 2009; 158 (Epub 2009 Sep 29): 852-859
        • Higgins R.O.
        • Murphy B.M.
        • Goble A.J.
        • Le Grande M.R.
        • Elliott P.C.
        • Worcester M.U.
        Cardiac rehabilitation program attendance after coronary artery bypass surgery: overcoming the barriers.
        Med J Aust. 2008; 188: 712-714
        • Russell K.L.
        • Holloway T.M.
        • Brum M.
        • Caruso V.
        • Chessex C.
        • Grace S.L.
        Cardiac rehabilitation wait times: effect on enrollment.
        J Cardiopulm Rehabil Prev. 2011; 31: 373-377
        • Gregory P.C.
        • LaVeist T.A.
        • Simpson C.
        Racial disparities in access to cardiac rehabilitation.
        Am J Phys Med Rehabil. 2006; 85: 705-710
        • Weingarten M.N.
        • Salz K.A.
        • Thomas R.J.
        • Squires R.W.
        Rates of enrollment for men and women referred to outpatient cardiac rehabilitation.
        J Cardiopulm Rehabil Prev. 2011; 31: 217-222
        • Smith K.M.
        • Harkness K.
        • Arthur H.M.
        Predicting cardiac rehabilitation enrollment: the role of automatic physician referral.
        Eur J Cardiovasc Prev Rehabil. 2006; 13: 60-66
        • Ghisi G.L.
        • Polyzotis P.
        • Oh P.
        • Pakosh M.
        • Grace S.L.
        Physician factors affecting cardiac rehabilitation referral and patient enrollment: a systematic review.
        Clin Cardiol. 2013; 36 (Epub 2013 May 3): 323-335
        • Grace S.L.
        • Evindar A.
        • Kung T.N.
        • Scholey P.E.
        • Stewart D.E.
        Automatic referral to cardiac rehabilitation.
        Med Care. 2004; 42: 661-669
        • Grace S.L.
        • Leung Y.W.
        • Reid R.
        • Oh P.
        • Wu G.
        • Alter D.A.
        CRCARE Investigators. The role of systematic inpatient cardiac rehabilitation referral in increasing equitable access and utilization.
        J Cardiopulm Rehabil Prev. 2012; 32: 41-47