Best Practice in Cardiac Best Practice in Cardiac Rehabilitation ReferralRehabilitation Referral::

Integration across the Integration across the continuum of carecontinuum of care

Sherry L. Grace, PhDAssociate Professor, York University

Scientist TGRI & Adjunct Scientist TRI

CRCARE: Cardiac RehabCare Continuity through Automatic Referral Evaluation

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CR Use in the United StatesCR Use in the United States

Suaya et al., 2007. Circ.

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CR Use in OntarioCR Use in Ontario

CCN CR Pilot Project; Suskin, Arthur et al. CJC.

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The ProblemThe Problem• Under-utilization of CR• Due to a combination of factors:

1.Patients (preferences), 2.physicians (referral failure, encouragement,

time constraints),3.CR programs (distance, waits, hours)4.and the health care system (fragmentation, short

stays, funding)

5Pasquali, S. K., Alexander, K. P., Lytle, B. L., Coombs, L. P., & Peterson, E. D. (2001). Testing an intervention to increase cardiac rehabilitation enrollment after coronary artery bypass grafting. The American Journal of Cardiology, 88(12), 1415-1416, A6.

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CR Referral ProcessCR Referral Process

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Automatic ReferralAutomatic Referral

• DEF’N: –The implementation of standing

referral orders to CR based on eligible diagnoses supported by clinical practice guidelines

Fischer, 2008; JCN 23(6): 475

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The Cardiac Continuum of CareThe Cardiac Continuum of Care

In-pt. Cardiac

Unit

PrimaryCare

Cardiac Rehab

Patient

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CR Referral StrategiesCR Referral Strategies1. Liaison • Allied health professional talks to patients one-on-one

regarding CR (i.e., more interpersonal, less universal)2. Systematic Discharge Order Set/Pathway

a. Electronic • prompts to CR referral are electronically generated,

such as via electronic health records.b. Paper-based

• -Manual standard order, such as a discharge order set3. Usual care - referral to CR is at the discretion of the cardiac specialist

or other physician

Krepostman, Grace et al. 2005

“aut

omat

ic”

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Liaison Referral Strategy: PT, NP, RN, PeerLiaison Referral Strategy: PT, NP, RN, Peer

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eReferraleReferral StrategyStrategy

CR SITE

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Safer Healthcare Now! AMISafer Healthcare Now! AMI

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CRCARECRCARE: : CCardiac ardiac RRehab care ehab care CContinuity ontinuity through through AAutomatic utomatic RReferral eferral EEvaluationvaluation

• Study objective: to compare cardiac rehab enrollment following different referral strategies

• 5 yr study tracking pts from 11 hosps• Which referral strategy can optimize the number of

patients who enroll? – Automatic?

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11 Participating Ontario Sites11 Participating Ontario Sites

St. Mary’s (KW)

Windsor Regional

Hotel Dieu-Grace

Sudbury RegionalWilliam Osler

Ottawa Heart

York Central

Sunnybrook

UHN

Hamilton Health Sciences

Trillium

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MethodsMethods• Prospective, observational design

– Comparative effectiveness / quality improvement• ACS & revascularization inpatients recruited at all

participating sites• Clinical data extracted from charts• Patients completed baseline survey• Follow-up survey mailed 1 yr later

– Assesses self-reported CR utilization– We have data to show high concordance with CR site

report (Kayaniyil, Grace et al. CJC)

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CRCARE Flow DiagramCRCARE Flow Diagram5781 CAD in-

patients approached from 11 hospitals

1537 ineligible N =2636 participants

62% response rate

1608 declined

N =1803 participants

79% retention

446 declined401 ineligible

Chart Extraction

In-Hospital Survey

1 YR Follow-up Mailed Survey

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RESULTS: CR Utilization by Referral Strategy

•Pts referred to 1 of 52 CR programs•ps≤.001w GEE controlling for site

OR=12.8 OR=5.1 OR=3.1*86%

71%59%

32%

0%10%20%30%40%50%60%70%80%90%

100%

Automatic+ Liaison

Automaticonly

AlliedHealth /Liaison

Only

Usual

ReferralEnrolmt

So what is Best So what is Best Practice for integration Practice for integration across the cardiac care across the cardiac care

continuum?continuum?

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AHA/ACC/AACVPR Performance MeasuresAHA/ACC/AACVPR Performance Measures

AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J, Bonow RO, Estes NA 3rd, Goff DC, Grady KL, Hiniker AR, Masoudi FA, Radford MJ, Rumsfeld JS, Whitman GR; AACVPR; ACC; AHA; American College of Chest Physicians; American College of Sports Medicine; American Physical Therapy Association; Canadian Association of Cardiac Rehabilitation; European Association for Cardiovascular Prevention and Rehabilitation; Inter-American Heart Foundation; National Association of Clinical Nurse Specialists; Preventive Cardiovascular Nurses Association; Society of Thoracic Surgeons.J Am Coll Cardiol. 2007 Oct 2;50(14):1400-33.

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Safer Healthcare Now! AMISafer Healthcare Now! AMI

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CR Referral Policy In OntarioCR Referral Policy In Ontario

• GAP Tool / "Get with the Guidelines" - Best Practice for ACS

• Priority project for CCN for 2008/09 – Approved through the OMoHLTC– Rolled out at regional cardiac centres– Mandated to be implemented across province– Soon to be posted on CCN website

• All ACS patients ordered onto a clinical pathway – Discharge procedure and contract– Component of discharge care is an automatic referral to

cardiac rehab

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UOHI ACS Clinical Pathway Excerpt: UOHI ACS Clinical Pathway Excerpt: CR ReferralCR Referral

http://www.ccpnetwork.ca/GWG/resources/ACS_Clinical_Pathway.pdf

24Sherrard & Kearns, CICRP June 2007

Ottawa Model: Pt Tool

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ConclusionsConclusions• Automatic referral can result in significantly

greater CR enrollment– 3-13x greater– Can achieve 85% referral & 70% enrolment

• Gold standard = systematic + patient discussion• Presentation to participating sites has lead to

implementation of standard order sets and discussion on use of EPR to improve referral flow

• Discussions with CR programs re: handling increased pt volumes through evidence-based alternative program models

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Cardiac Inpatients Cardiac Rehab & Chronic Disease

Management

Primary Care

ACS Gap/SHN!CR Barriers ScaleGeographic IssuesContinuity of Care

CR2DoC

Research Program: Understanding & Optimizing Post-Acute Cardiac Care & Recovery

CR Program Models

CR4HER Healthy Living in Community

CRCARECR Wait TimesCCS Position Statement

CR Registries & Dashboards

HFStroke

DM

Psychosocial Well-being

DepressionPosttraumatic GrowthInsomniaSocial Support

Vulnerable GroupsWomenLow SESRuralSouth Asian

PATIENTPROVIDERHEALTH SYSTEM

YU: Central LHIN = YCH, SouthlakeUHN: Global Impact

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AcknowledgementsAcknowledgements• Co-PI: Donna E. Stewart MD, UHN• Co-Investigators: Alter D., Rush J., Anand S.,

Williamson K., Harvey P., Oh P., Gupta M…. • Co-Authors: Kelly Russell, Terry Fair, Gilbert

Wu & Paul Oh• Research Assistants & Graduate Students

• Funding:

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AHA GWTG ProgramAHA GWTG Program

GWTG is a national initiative of the AHA to improve guidelines adherence in patients hospitalized with cardiovascular disease.

GWTG uses collaborative learning sessions, conference calls, e-mail and staff support to assist hospital teams improve acute and secondary prevention care systems.

A web-based Patient Management Tool is used for point of care data collection and decision support, on-demand reporting, communication and patient education

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CR

Interactivelychecks patient’sdata with theAHA guidelines

SIMPLE, ONE PAGE, ON-LINE FORMSIMPLE, ONE PAGE, ON-LINE FORM

©2001 Outcome Sciences, Inc.

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• N=45,988 pts from 92 US hospitals

• Significant increase (12.7%) in referral to CR following GWTG pathway implementation (p<0.0001)

• No control grp

LaBresh, K. A., Fonarow, G. C., Smith, S. C.,Jr, Bonow, R. O., Smaha, L. C., Tyler, P. A., et al. (2007). Improved treatment of hospitalized coronary artery disease patients with the get with the guidelines program. Critical Pathways in Cardiology, 6(3), 98-105.

Impact of AHA GWTGImpact of AHA GWTG--CAD Program on CAD Program on Quality of CareQuality of Care

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AHA GWTG: CR Referral & EnrollmentAHA GWTG: CR Referral & Enrollment

n=2540%

n=46.1%

n=39255%

n=13934%

19% of total

GWTG PathwayN=714

CR Referral

CR Enrolment

Usual ReferralN=66

OR=2.3*

P=.08

Mazzini, M. J., Stevens, G. R., Whalen, D., Ozonoff, A., & Balady, G. J. (2008). Effect of an AHA GWTG program-based clinical pathway on referral and enrollment into CR after AMI. AJC, 101(8), 1084-1087.

•N = 780 AMI patients admitted to a single center during an 18-month period and discharged to home •Retrospective design

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How Many Cardiac Patients Should How Many Cardiac Patients Should we Aim to Reach?we Aim to Reach?

UK:

Bethell et al., JPH 2006

34JACC 50(7): e100

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Comparative Effectiveness of CR Comparative Effectiveness of CR Referral Strategies in OntarioReferral Strategies in Ontario

1. Automatic (paper or electronic) referral (n=3 wards)-prompts to CR referral are electronically generated, such as via

electronic health records.2. Liaison referral (n=7 wards)- Allied health professional talks to patients one-on-one

regarding CR (i.e., more interpersonal, less universal)3. Automatic referral + liaison (n=5 wards)- Manual standard order, such as a discharge order set4. Usual referral (n=2 wards)- referral to CR is at the discretion of the cardiologist or other

physician, signature required.