More education about cardiac rehab needed

Black and poor women referred less often

Despite ample evidence that cardiac rehabilitation services provide health benefits to people who have suffered from a heart attack or other cardiac trouble, clinicians still do not make automatic referrals to cardiac rehab programs, a recent study shows.

Several medical organizations have published guidelines recommending that anyone who has had a myocardial infarction be referred to cardiac rehabilitation, says Jerilyn K. Allen, RN, ScD, FAAN, an associate dean for research and a professor at the Johns Hopkins University School of Nursing in Baltimore. "Patients who have undergone revascularization and, in particular, coronary artery bypass surgery also qualify for cardiac rehab in terms of guidelines," she says. "And people who’ve had angioplasty or coronary interventions also should be referred."

However, research by Allen and colleagues shows that too few women who suffer from heart attacks are referred to cardiac rehabilitation services. Specifically, the study found the rate of referral to outpatient cardiac rehabilitation was significantly lower for African American women than for white women, and women with annual incomes of less than $20,000 per year were less likely to be referred to such services, even if they had access to insurance that would cover the services.1

African American women were 58% less likely to enroll in cardiac rehab services than white women, and when the results were controlled for income, there was borderline significance, Allen notes. "It’s always dangerous to conjecture, but we do know there are health disparities out there based on socioeconomic status, as well as ethnicity, and this is another potential piece of evidence that there may be some bias in terms of referral based, really, on socioeconomic status," she says. "Referral should not be based on people’s ability to pay because a majority of the women surveyed were covered under Medicare, which covers cardiac rehab," Allen notes.

Of 253 women surveyed, only 19% reported receiving a referral to outpatient cardiac rehabilitation, and more than half the women said they had no knowledge of cardiac rehabilitation, the survey found. Women who had incomes of less than $20,000 a year were 66% less likely to be referred to cardiac rehab, Allen explains. "A high percentage of the women surveyed said they were very interested in rehab and stated cardiac rehabilitation was something they would have liked to have taken advantage of," she says.

Although the study relied on the memories and reporting of patients, it’s unlikely patients would say they had not received cardiac referrals if they had, or if they had forgotten about a referral, then that would mean it wasn’t communicated in an effective way, Allen notes.

Increase outreach efforts

The study highlights the need for rehabilitation facilities to increase outreach and educational efforts regarding cardiac rehab services. "Frequently, what happens is a cardiac surgeon may not see a rehab referral as within his scope of practice, that it’s not his responsibility to recommend cardiac rehab or to help a patient with follow-up through cardiac rehab," Allen says. "The primary care provider might see it as the cardiologist’s responsibility, so it could be that people may think rehab’s important, but see it as within someone else’s purview to do the referring and discussion; and as a result, it gets lost," she points out.

The solution would be an automatic referral system in which cardiac patients leave the hospital with some type of outpatient cardiac rehabilitation referral, Allen suggests. "For example, there are discharge prescriptions," she says. "When a patient is discharged it’s part of discharge planning, and so rehab would have to be integrated into discharge planning and not just into patient education."

When a physician writes a rehab referral order, it sends a strong message to patients that they think this is important, she adds.

The rehab referral bias that meant poor and, perhaps, black women received cardiac rehab referrals less frequently than white and affluent women is difficult to explain, although Allen and co-investigators have been studying potential explanations for these findings. "We did some focus groups with providers, cardiologists, primary care physicians, and cardiac surgeons to determine their perspective on why this is happening," she says. "We received some hints that relate to actual biases and some concerns about whose responsibility it is and who should be doing it."

Not conscious biases

The biases did not appear to be conscious biases and not racism, Allen points out. "We’re talking about biases in terms of saying, Well, they’re not going to go to rehab anyway,’ and that kind of thing," she notes. "And that has evolved from many years of getting negative feedback about people not staying in cardiac rehab or not ever going."

Also, physicians expressed some concerns about the benefits of cardiac rehab and whether it really is necessary when people could exercise on their own at home, Allen adds. "I think it’s going to take more than just education, but maybe in the form of providing feedback to physicians about their patients and how their patients have gone to cardiac rehab and how well they’ve done, and so forth and so on," she says. "Maybe that’s the way to change an attitude, by making it more real as opposed to quoting guidelines and studies," Allen continues.

The rehab industry would make faster progress in marketing cardiac rehab services to physicians if it would get patients to provide positive reports to doctors, she says. "Patients are wonderful about giving messages back to physicians and changing their attitudes," Allen notes. "So activate the patient to motivate the physician to use rehab, and it could work in this situation to change attitudes."


1. Allen JK, Scott LB, Stewart KJ, et al. Disparities in women’s referral to and enrollment in outpatient cardiac rehabilitation. J Gen Intern Med 2004; 19:747-753.