Angina Heart Disease
Author Interviews

Effect of Patient Navigation on Enrollment in Cardiac Rehabilitation Author Interview:
Lisa A. Benz Scott, Ph.D.

Director, Graduate Program in Public Health
Associate Professor, Health Care Policy & Management; Medicine
Stony Brook University Medical Center

Lisa A. Benz Scott, Ph.D.
Lisa A. Benz Scott, Ph.D. What do we know about Cardiac Rehabilitation Enrollment?

Dr. Benz Scott: Secondary prevention measures, such as outpatient cardiac rehabilitation (OCR) can effectively reduce the burden of heart disease, which is the global leading cause of death and disability. Despite this, enrollment of patients that could benefit from OCR is low. The largest US study to date reported that the national OCR participation rate is 19%, with New York State being significantly lower at 12%. Furthermore, there is little research that has examined innovative ways to improve enrollment in the U.S. How was your study designed and conducted?

The study was designed to test the effect of a Cardiac Patient Navigation (PN) intervention on rates of OCR enrollment to programs located in Suffolk County (Long Island, New York) compared to usual care (UC). Patients were recruited from Stony Brook University Hospital on Long Island, New York between May, 2009 to June 2011.

A total of 178 patients were eligible and consented to participate. Patients were interviewed about their care up to 12 weeks post-hospitalization. How did you intervene to improve OCR enrollment: Patient Navigation.

The intervention was a Patient Navigation (PN) program called “Your Health, Your Way” that was designed, implemented, and evaluated within the context of a randomized trial (patients were assigned to either usual/standard care or navigation “just by chance”).

Consistent with prior research on the use of lay health advisors in cancer care coordination, two individuals with no prior clinical knowledge were trained as navigators to provide basic education and support (informational, social) about OCR and to educate patients to effectively navigate the inpatient to outpatient cardiac care system, with a particular focus on enrolling in a local OCR program. The intervention group had a patient navigator meet with them briefly prior to hospital discharge.

Navigated patients were given information about OCR (i.e. the likely benefits of participation, the location of local programs and details on how to access it) as well as facilitating enrollment into a program of their choice. Individuals discharged prior to face-to-face navigation were mailed information to their home which was reviewed by telephone with a navigator within 1 week. Approximately 10 days after hospital discharge, PN patients received a follow-up telephone call to encourage them to discuss OCR with a physician (primary care, internist, cardiologist, surgeon) and to encourage enrollment into the program. Those assigned to the UC group received the standard discharge instructions that a nurse routinely provides to all patients. Both the intervention and UC groups had in-depth telephone interviews at 4 and 12 weeks post-hospitalization.

During the telephone interview, participants were questioned about their OCR knowledge, awareness and referral and participation in the program. What are the main findings of the study?

What we found: Patient Navivigation improves rates of OCR enrollment. Of the 178 study participants, 21 (23.6%) of the 89 randomized to PN and 6 (6.7%) of the 89 randomized to UC enrolled in an OCR program.

Thus, significantly more PN intervention participants enrolled in OCR compared to UC participants. Enrollment rates differed between groups, with more than 3-fold more navigated patients having enrolled into a program. Were any of the findings unexpected?

We had expected that the rate of OCR enrollment in the Navigated group would be higher than what was found, but it was still significant compared to the dismal rates among usual care patients.

The findings show great promise for the potential of lay health advisors as navigators integrated into care coordination services in real world practice settings, though more strategies are needed to reduce barriers to enrollment among eligible cardiac patients. What do the results mean?

Although still suboptimal, OCR enrollment rates within 3 months of hospitalization were significantly higher among patients assigned to navigation by trained lay advisors compared to UC. Nearly 24% of PN patients enrolled in OCR compared to only 7% of UC patients, thus nearly 20% more intervention patients were able to take advantage of the benefits that can be realized through participation in an OCR program. What should clinicians and patients take away from this study?

Clinicians should be aware of the importance of educating patients about OCR, and hospitals should consider including lay health educators to help cardiac patients navigate from inpatient to outpatient services as a part of a comprehensive approach to health and the care continuum. Moreover, inpatient and outpatient cardiac service providers are encouraged to partner with researchers to test initiatives for quality improvement purposes, using established techniques to promote rigorous methods, analysis, and implementation of new strategies.

While wider adoption of interventions to improve rates of OCR enrollment would potentially improve the health of many cardiac patients, new funding and service delivery models should be explored due to differences across settings. While we continue to look for ways for patients to make an informed decision to enroll, CR programs might not have sufficient staff or funding to handle such increases in patient volumes, increasing waiting times for patients to access CR, thus this should be further explored. Fundamentally, communication between tertiary care and secondary prevention / rehabilitation programs is a key component to improve care transitions for patients from the inpatient to outpatient settings.

Finally, patients should ask questions about the options that are available to them after they leave the hospital. Seeking information about programs that would benefit their health is important to a healthy recovery. Patients should engage in conversations with clinicians and peers about the opportunities that are available to them after a cardiac hospitalization — and take advantage of cardiac rehabilitation, which would provide them with the tools to live healthier and longer lives. : What further research do you recommend as a result of your study?

Although US-based interventions aimed at improving enrollment have shown promise, it is unknown if nurses, peers or trained PN lay advisors are most effective.  Navigation involving lay health advisors is understudied but has great potential based on studies in cancer services. It is currently unknown if a PN intervention is cost-effective and what elements maximize patient use of healthcare services. Ideally, more research is needed to assess which components of navigation alone or in combination (face to face at bedside, phone support post-discharge, mailed information, or a combination of methods) achieve significant improvements. The goal should be to integrate the least intensive intervention to achieve the greatest return on investment for the healthcare system and patient alike.


Effect of Patient Navigation on Enrollment in Cardiac Rehabilitation.

Benz Scott L, Gravely S, Sexton TR, Brzostek S, Brown DL. Arch Intern Med. 2012;():1-2. doi:10.1001/2013.jamainternmed.1042.

For more information:
State Heart Disease and Stroke Prevention Program Addresses Cardiac Rehabilitation Cardiac Rehabilitation Facts from the CDC
(Centers for Disease Control and Prevention)

Cardiac Rehabilitation Facts

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Updated 12/28/2012