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Effectiveness of inpatient and outpatient strategies in increasing referral and utilization of cardiac rehabilitation: a prospective, multi-site study

Sherry L Grace12345*, Kelly L Angevaare2, Robert D Reid6, Paul Oh35, Sonia Anand7, Milan Gupta8, Stephanie Brister2, Donna E Stewart2 and and On behalf of the CRCARE Investigators

Author Affiliations

1 School of Kinesiology and Health Science, York University, 4700 Keele St, Toronto, Canada

2 Toronto General Hospital, University Health Network, 200 Elizabeth St, Toronto, Canada

3 Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, Canada

4 Mackenzie Health, 10 Trench Street, Richmond Hill, Canada

5 Cardiac Program, Toronto Rehabilitation Institute, University Health Network, 347 Rumsey Road, Toronto, Canada

6 Minto Prevention and Rehabilitation Centre, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Canada

7 Clinical Epidemiology and Biostatistics, McMaster University, 237 Barton St. E, Hamilton, Canada

8 William Osler Health Centre, 2100 Bovaird Drive East, Brampton, Canada

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Implementation Science 2012, 7:120  doi:10.1186/1748-5908-7-120

Published: 13 December 2012



Despite the evidence of benefit, cardiac rehabilitation (CR) remains highly underutilized. The present study examined the effect of two inpatient and one outpatient strategy on CR utilization: allied healthcare provider completion of referral (a policy that had been endorsed and approved by the cardiac program leadership in advance; PRE-APPROVED); CR intake appointment booked before hospital discharge (PRE-BOOKED); and early outpatient education provided at the CR program shortly after inpatient discharge (EARLY ED).

In this prospective observational study, 2,635 stable cardiac inpatients from 11 Ontario hospitals completed a sociodemographic survey, and clinical data were extracted from charts. One year later, participants were a mailed survey that assessed CR use. Participating inpatient units and CR programs to which patients were referred were coded to reflect whether each of the strategies was used (yes/no). The effect of each strategy on participants’ CR referral and enrollment was examined using generalized estimating equations.


A total of 1,809 participants completed the post-test survey. Adjusted analyses revealed that the implementation of one of the inpatient strategies was significantly related to greater referral and enrollment (PRE-APPROVED: OR = 1.96, 95%CI = 1.26 to 3.05, and OR = 2.91, 95%CI = 2.20 to 3.85, respectively). EARLY ED also resulted in significantly greater enrollment (OR = 4.85, 95%CI = 2.96 to 7.95).


These readily-implementable strategies could significantly increase access to and enrollment in CR for the cardiac population. The impact of these strategies on wait times warrants exploration.

Cardiac rehabilitation; Patient care management; Cardiovascular diseases