099 Lack of Impact of Automated Referral on Attendance At Cardiac Rehabilitation Among Coronary Artery Bypass Grafting Patients: The Calgary Experience

Abstract

Cardiac Rehabilitation (CR) is a guideline indicated modality for reducing residual cardiovascular risk among patients after they undergo Coronary Artery Bypass Grafting (CABG). However, many patients do not attend - further, some patients are not given the opportunity to attend as they are never referred. The objective of this study was to assess rates of referral to CR and the impact of an automated referral system. All subjects who underwent CABG surgery in Calgary, Canada between 1996 and 2010 were included. Data was obtained from the Alberta Provincial Project for Outcome Assessment in Coronary Heart disease (APPROACH) and CR databases. Automated referral to CR was instituted in July 2007. Baseline characteristics were compared between those who were referred to CR and those who were not pre- and post-automated referral. Predictors of referral and attendance rates were also assessed pre- and post-automation. A total of 5256 subjects (mean age 65.6 (+/− 10.1) years, 80.7% male) underwent CABG during the study period; 4700 prior to automation, 556 post. Subjects pre- and post- automation were similar in terms of mean age, proportion female, heart failure, and diabetes (all p>0.05). Rates of referral increased from 41.9% prior to automated referral to 75.7% post-automation (p<0.0001). Of the 2390 subjects referred to CR, 1497 (62.6%) attended - however, attendance rates were significantly lower after automation than before, 48.2 vs 65.7% (p<0.0001). Referral to CR, regardless of attendance status, was associated with reduced mortality (unadjusted hazard ratio, 0.54, 95%CI 0.48, 0.61; adjusted for all clinical comorbidities, 0.74, 95% CI 0.66, 0.84). Automated referral to CR in CABG patients results in higher rates of referral. However, there is a commensurate decline in CR attendance. Automated referral to CR is insufficient to increase attendance; when CR referral is automated, care must still be made to emphasize the benefits of CR to patients.