Improving Cardiac Rehabilitation Referral Patterns Using Computerized Physician Order Entry Systems

Much of the immense burden of cardiovascular disease is ultimately a consequence of unhealthy lifestyle choices, such as physical inactivity, caloric over-consumption, and tobacco use. Unfortunately, clinicians rarely have sufficient time or resources to meaningfully address these issues. Cardiac rehabilitation is a comprehensive program for the secondary prevention of cardiovascular events for a wide spectrum of patients and is designed to address the lifestyle factors related to cardiovascular disease. While cardiac rehabilitation initially focused on exercise training, it has expanded over time to include cardiovascular education, nutritional counseling, behavioral interventions, and pharmacologic therapy. A large body of literature on cardiac rehabilitation has accrued demonstrating its robust health benefits, 1,2 including a survival benefit among patients with coronary artery disease, 2 and now it is advocated by professional clinical organizations for several cardiovascular conditions. 1 Despite its clinical need, cardiac rehabilitation remains vastly underutilized in the US, with 30% of eligible patients enrolling nationwide. 2 While several reasons exist for this poor utilization, the most critical and potentially most correctable reason is widely acknowledged to be the referral process, as only 1 in 2 patients eligible for cardiac rehabilitation are currently being referred. 3 Opportunities for referral often present themselves during the chaotic hospital discharge process or the first outpatient clinic visit after hospitalization, when busy practitioners are in the midst of dealing with symptoms, further testing, medication titration, and other clinical issues. As a result, cardiac rehabilitation generally lies at the bottom of practitioners’ priority lists for ongoing therapy. Also, it is oftentimes unclear which provider should take responsibility for the referral. Further complicating the referral process, many insurance companies require preauthorization. Finally, even if a referral is eventually made, they are often ineffective, being delayed weeks to months after a cardiovascular event, well past the point when patients may be motivated, willing, or able to attend cardiac rehabilitation.