Disclosures: Adusumalli reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
January 21, 2021
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Default interventions spurred rise in cardiac rehabilitation referrals

Disclosures: Adusumalli reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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Default option interventions were associated with a significant increase in cardiac rehabilitation referrals for patients with ischemic heart disease, according to findings published in JAMA Network Open.

“At our institution as well as around the country, we noted a long-standing problem that patients eligible for a highly evidence-based therapy, cardiac rehabilitation, were not being referred for that therapy,” Srinath Adusumalli, MD, MSHP, assistant professor of medicine in the division of cardiovascular medicine at Perelman School of Medicine at the University of Pennsylvania, told Healio. “We did some qualitative investigations locally and within the existing medical literature and found one of the largest barriers was the lack of a defaulted, structured and easy-to-use pathway for cardiac rehabilitation referral that the entire care team could use.”

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Researchers redesigned defaults in the decision pathway at one of three Penn Medicine hospitals in Philadelphia to assess changes in cardiac rehabilitation referral from 2016 to 2018; clinicians had to opt their patients out of cardiac rehabilitation referral instead of opting them in. The other two hospitals served as controls. The quality improvement study included 2,832 patients with ischemic heart disease (mean age, 67 years; 29% women).

In January 2017, an opt-out cardiac rehabilitation referral decision pathway was implemented using the electronic health record to identify eligible patients and notify staff through secure text messages. Patients were also provided educational material on the importance and relevance of cardiac rehabilitation.

There were no differences between the intervention and control groups for pre-intervention trends.

At intervention sites, the percentage of cardiac rehabilitation referrals was 85.7% compared with 31.6% for the control sites. Intervention sites demonstrated a 47-percentage-point increase (95% CI, 39.2-55.1; P < .001) in cardiac rehabilitation referrals compared with control sites over time.

According to Adusumalli, the implication of completing a referral that includes closing the loop between a patient and a cardiac rehabilitation center is that it lays a foundation for patients to understand morbidity and mortality reduction benefits associated with cardiac rehabilitation completion.

“One of the largest challenges is that referral is only the first step to completion of cardiac rehabilitation therapy. Even after referral, patients need to be able to access cardiac rehabilitation in a way that is convenient within their daily lives,” Adusumalli said. “This particular challenge is exacerbated during the COVID-19 pandemic, during which time many in-person cardiac rehabilitation facilities are unavailable. This is why we are now focusing on developing approaches to virtual, more convenient ways to participate in cardiac rehabilitation that also utilize patient and providers behavioral change strategies.”

For more information:

Srinath Adusumalli, MD, MSHP, can be reached sri.adu@uphs.upenn.edu.