Elsevier

American Heart Journal

Volume 151, Issue 2, February 2006, Pages 249-256
American Heart Journal

Curriculum in Cardiology
Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: A systematic review

https://doi.org/10.1016/j.ahj.2005.03.034Get rights and content

Background

Despite the documented efficacy of cardiac rehabilitation (CR), a minority of patients with diagnosed coronary artery disease are referred. Although referral is a necessary step in the promotion of CR uptake, little is known about its determinants.

Purpose

The objective of this paper was to systematically review the available literature on factors predicting referral of patients to CR to appraise both their relative impact and consistency across studies.

Methods

Studies were identified by searching MEDLINE (1966-2003), CINAHL (1982-2003), HealthSTAR (1975-2003), EMBASE (1966-2003), and The Cochrane Library Controlled Trials. Search terms were “myocardial infarction,” “acute myocardial infarction,” “coronary artery disease,” combined with “rehabilitation,” “cardiac rehabilitation,” “secondary prevention,” “exercise training,” “referral,” and/or “consultation.” Forty-five studies were identified and independently assessed by 2 reviewers using predetermined eligibility criteria.

Results

Ten published observational studies (1999-2004) including 30 333 coronary artery disease patients were selected. Determinants of referral to CR were grouped as sociodemographic, health status, and health care system factors. Major predictors were English speaking (RR 9.56, 95% CI 2.18-41.93), prior myocardial infarction (RR 2.73, 95% CI 1.69-4.42), being admitted to hospitals providing CR (RR 5.35, 95% CI 4.04-7.10), and having insurance coverage (RR 2.94, 95% CI 1.13-7.66).

Conclusion

This review highlights disparities in referral to CR and reveals a treatment gap in the secondary prevention of cardiovascular disease. Precise estimates of the impact of all factors on referral are not possible, but some hierarchies and potential priorities for action are evident.

Section snippets

Identification of relevant studies

Studies were identified by searching the following electronic databases: MEDLINE (1966-2003), CINAHL (1982-2003), HealthSTAR (1975-2003), EMBASE (1966-2003), and The Cochrane Library Controlled Trials Registry. For studies on referral of patients with CAD, the search terms combined were “myocardial infarction,” “acute myocardial infarction,” “coronary artery disease,” with “rehabilitation,” “cardiac rehabilitation,” “referral,” or “consultation.” Search terms such as “secondary prevention” and

General characteristics of the studies

All 10 included studies were observational (Table I), including 10 487 referrals among 30 333 patients with CAD. Nine cohort studies (6 prospective and 3 retrospective) and one cross-sectional study, published between 1999 and 2004, were assessed. Five studies were conducted in the United States, 3 in Canada, and 2 in Australia. Most studies sought to answer questions on determinants of referral to CR after acute MI.15, 26, 27, 28, 29, 30

Quality assessment of studies on referral

The quality of the studies was assessed according to the

Discussion

This systematic review suggests that referral to CR is an example of a treatment gap in the secondary prevention of CAD. Furthermore, the review identified 3 domains in which referral disparities can be found; these are sociodemographic factors, health status factors, and health care system factors. Although the data did not allow the advantages of statistical pooling, there was sufficient consistency across studies to permit clustering of the individual factors. Because of study design

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