News Release

Automatic referrals, plus a patient discussion, may increase use of cardiac rehab

Peer-Reviewed Publication

JAMA Network

Automatically referring patients with heart disease to cardiac rehabilitation—when followed by a discussion between patient and clinician—was associated with an increased rate at which patients use this beneficial service, according to a report in the February 14 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

"Cardiovascular disease remains the leading cause of mortality worldwide, and this is chiefly attributable to modifiable risk factors such as hypertension, dyslipidemia, obesity, smoking, unhealthy diet and a sedentary lifestyle," the authors write as background information in the article. "Cardiac rehabilitation offers a comprehensive approach to chronic disease management, by addressing these risk factors." Evidence demonstrates that, compared with usual care, cardiac rehabilitation reduces illness and death by about one-fourth over one to two years. However, an estimated 70 percent to 80 percent of eligible patients being treated for cardiac disease in the United States, Canada and the United Kingdom do not receive cardiac rehabilitation after being discharged from the hospital.

Sherry L. Grace, Ph.D., of York University, Toronto, and colleagues in the Cardiac Rehabilitation Care Continuity Through Automatic Referral Evaluation (CRCARE) Investigators group studied 2,635 patients with coronary artery disease at 11 Canadian hospitals. Patients completed a survey with sociodemographic information while in the hospital, their clinical data were extracted from medical charts and 1,809 participants completed a follow-up survey one year later.

Each hospital used one of four referral strategies for cardiac rehabilitation: an automatic referral using electronic patient records or standard discharge orders; liaison referral, whereby the referral is facilitated by a personal discussion with a clinician; a combination of both automatic and liaison strategies; or "usual" referral, in which select patients are referred at the discretion of clinicians.

Overall, patients who were referred to cardiac rehabilitation had attended 82.8 percent of sessions during the year following hospitalization. The strategy used by the hospital was significantly associated with cardiac rehabilitation referral and enrollment. Combined automatic and liaison referral resulted in an eight-fold increase in the likelihood that patients would be referred to cardiac rehabilitation, and more than 70 percent of patients enrolled in a rehabilitation program.

In comparison, at hospitals using only automatic referrals, 70.2 percent of patients received referrals and 60 percent enrolled in cardiac rehabilitation. Among patients at hospitals using only a liaison referral strategy, 59 percent received a referral and 50.6 percent enrolled. Usual care resulted in a 32.2 percent referral rate and 29 percent enrollment rate.

The combined strategy may be most effective because it targets both clinicians and patients, the authors note: "the order set or electronic record prompts the referral, and the patient discussion ensures health care provider endorsement and clarifies any misconceptions or barriers patients may have about cardiac rehabilitation," they write. "Implementation could potentially raise cardiac rehabilitation use 45 percent, suggesting that major public health gains could be achieved in the population being treated for cardiac disease."


(Arch Intern Med. 2011;171[3]:235-241. Available pre-embargo to the media at

Editor's Note: The CRCARE study was funded by the Canadian Institutes of Health Research (CIHR) Institute of Gender and Health and a Heart and Stroke Foundation of Canada grant. Dr. Grace is supported by the CIHR Institute of Health Services and Policy Research New Investigator Award. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

To contact Sherry L. Grace, Ph.D., call Nicole Bodnar at 416-340-4800, ext. 3417, or e-mail

For more information, contact JAMA/Archives Media Relations at 312/464-JAMA (5262) or e-mail

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