An Evidence-Based Health Services Evaluation of Informational and Management Continuity in Heart Patients

Key Implications for Decision Makers

  • Cardiovascular disease is the leading cause of death and disability for Canadian men and women. Substantial health risks continue following a cardiac event, and cardiac rehabilitation is a proven means of secondary prevention and risk reduction.
  • Cardiac patients frequently move from one system of care to another. Hence, informational and management continuity among cardiac specialists in acute care, primary healthcare providers, and cardiac rehabilitation sites is needed to ensure access to cardiac rehabilitation services and ongoing risk reduction.
  • Some healthcare providers are skeptical about the benefits of cardiac rehabilitation despite evidence and clinical practice guidelines endorsing these cardiac programs. Many physicians are unaware of cardiac rehabilitation site locations which may be closest to home for their patients.
  • A cardiac continuity model involving electronic discharge orders for referral to the closest cardiac rehabilitation program for all eligible patients and post-cardiac rehabilitation discharge summaries to primary healthcare providers can provide cardiac patients with greater access to cardiac rehabilitation and can assist primary healthcare providers in giving their patients efficient continuing care for optimal disease management.
  • E-referral mechanisms are recommended, as our study showed they increased overall cardiac rehabilitation utilization by more than two times and significantly reduced service waiting times.
  • Electronic health records were strongly endorsed by physicians to ensure standardization in cardiac continuity, increase the efficiency of data transfer, enable a multidisciplinary summary to be generated, decrease time for referral and discharge, reduce redundancy in documentation, enhance and prompt communication between care agencies, concentrate efforts on specific clinical content, and improve primary care physician satisfaction.
  • Primary care physicians want a standardized cardiac rehabilitation discharge summary to ensure they receive needed management information in a timely manner to enable ongoing risk reduction for their cardiac patients.

Executive Summary

Substantial health risks continue following coronary events and procedures. Secondary prevention such as cardiac rehabilitation improves subsequent prognosis through the modification of cardiac risk factors in patients with cardiovascular disease. Optimal cardiac care as suggested in international clinical practice guidelines involves care pathways including systematic referral to cardiac rehabilitation from acute care and ongoing communication with healthcare providers to ensure ongoing evidence-based care for optimal risk reduction.

However, most research demonstrates low cardiac rehabilitation referral and enrollment. Cardiac patients often move from one system of care to another for required services. Therefore, continuity between acute, primary, and community care is often fragmented. Automatic prompts and processes may reduce such discrepancies and minimize patient- and physician-related care gaps.

A cardiac continuity model involving electronic discharge orders for referral to the closest cardiac rehabilitation program for all eligible patients was compared to usual cardiac care. Results revealed that two times more patients enroll in cardiac rehabilitation where referral processes are automated. In addition, the number of days between acute care discharge and cardiac rehabilitation intake was cut in half.

Primary healthcare providers need to receive cardiac rehabilitation discharge summaries regarding care provided to enable ongoing risk factor reduction and to ensure appropriate long-term care and follow-up. A chart audit of cardiac rehabilitation discharge summaries was conducted and revealed great variability in clinical and service data reported. Semi-structured telephone interviews with a subsample of the healthcare providers who received these cardiac rehabilitation discharge summaries identified four main issues of concern: a need for the standardization of a discharge summary to reduce variability in the data that are provided; a need for effective communication of cardiac rehabilitation discharge data in a timely manner using electronic health records to increase data transfer efficiency; a desire for more communication with cardiac rehabilitation programs; and a concern that cardiac care is highly variable among their patients, including the unnecessary duplication of tests. Overall, information regarding cardiac rehabilitation services and patients' status is currently being inadequately conveyed to primary care physicians, and these healthcare providers require such information promptly to ensure proper follow-up of their patients.

Primary care physicians identified electronic health records as a potential means of improving cardiac continuity. Physicians suggested electronic health records may improve continuity of care by standardizing referral and discharge documents, enabling a multi-factorial summary to be generated, decreasing time required for referral and discharge, reducing redundancy in documentation, increasing patient satisfaction, enhancing communication between care agencies, and concentrating efforts on specific clinical content.

Semi-structured interviews with key informants identified modifiable barriers to cardiac continuity: improving communication among physicians and cardiac rehabilitation programs; automating processes to ensure equitable referral; minimizing territoriality; and increasing physician awareness of cardiac rehabilitation sites.

As the Heart and Stroke Foundation and national government agencies are exploring the potential of a Canadian cardiovascular strategy, the results of this study shed light on cardiac care processes from acute care to secondary prevention (cardiac rehabilitation) to primary healthcare. Moreover, Canada's Health Infoway and Ontario's Smart Systems for Health Agency will be interested in our results as they advance the implementation of electronic health records. Through the realization of automatic referral processes and the standardization of discharge summaries using electronic health records, the resulting efficient data transfer will minimize the current gaps in cardiac care and will be highly welcomed by primary healthcare providers.