Simple EHR Switch Could Dramatically Improve Referral Rates for Cardiac Rehabilitation

January 15, 2021
Patrick Campbell

A quality improvement study conducted at a trio of Penn Medicine hospitals suggests changing cardiac rehabilitation referrals from an opt-in to an opt-out decision in their EHR could drastically improve referral rates.

A simple switch in electronic health records could lead to fewer deaths and rehospitalizations among patients with cardiovascular conditions.

A new study from the Perelman School of Medicine at the University of Pennsylvania found making clinicians opt-out of cardiac rehabilitation instead of opt-in led to a 47-percentage point increase in referrals to cardiac rehabilitation.

"Referral for cardiac rehab has traditionally been a manual process that involved many stakeholders," said lead investigator Mitesh Patel, MD, director of Penn Medicine's Nudge Unit, in a statement. "By restructuring the pathway as an opt-out decision, we were able to leverage technology to automate the process and significantly reduce the burden on clinicians and patients."

With an interest in evaluating how changes in the cardiac rehabilitation referral decision pathways could influencereferral rates, Patel and a team of colleagues designed and conducted the current study at a trio of Penn Medicine hospital in Philadelphia, Pennsylvania. Beginning in January 2017, an opt-out referral decision pathway was implemented into the electronic health record to automatically identify eligible patients and notify staff through secure messaging at 1 of the 3 hospitals.

Check out this related study from Penn Medicine examining how an EHR ‘nudge’ might effect statin prescribing rates

All cardiac rehabilitation referrals were manually verified. Additionally, all patients received educational material on the importance and relevance of rehabilitation. For the purpose of analysis, investigators obtained data for 1 year before and 2 years after the intervention was implemented for comparison.

A linear probability model was used to perform a difference-in-differences analysis to evaluate changes in referral rates at the intervention site compared to the 2 control sites during the preintervention and post-intervention periods. Of note, all models were adjusted for age, sex, race/ethnicity, insurance, annual household income, body mass index, and history of myocardial infarction, congestive heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, hypertension, diabetes, and smoking.

During the study period, a sample of 2832 patients with ischemic heart disease were identified for inclusion at the 3 Penn Medicine hospitals. This cohort had a mean age of 66.7 (SD, 11.4) years, 812 were female, 1870 were White, and 564 were Black. Initial analysis indicated trends in referral rates for cardiac rehabilitation did not differ between the intervention and control sites during the preintervention period.

At the completion of the study, the investigator’s comparison indicated the percentage of referrals at the intervention site reached 85.7% compared to 31.6% at the study’s control sites, which resulted in a 47-percentage point difference (95% CI, 39.2-55.1; P <.001).

"When we surveyed our providers prior to launching the intervention, we learned they were largely interested in having their patients participate in a cardiac rehab program after discharge, but they were not properly equipped to make that happen," said Elizabeth Jolly, RN, an interventional cardiology transitions coordinator at the Hospital of the University of Pennsylvania, in the aforementioned statement. "With our interventions, we saw that the opt-out pathway coupled with the list of facilities made the referral process effortless."

This study, “Referral Rates for Cardiac Rehabilitation Among Eligible Inpatients After Implementation of a Default Opt-Out Decision Pathway in the Electronic Medical Record,” was published in JAMA Network Open.