Improving Veteran Referral to Cardiac Rehabilitation: A Hybrid Effectiveness-Implementation Trial

About This Grant

Background: Cardiac rehabilitation (CR), an outpatient program of supervised exercise and cardiac risk factor reduction, is part of the standard of care for cardiovascular disease. Unfortunately, less than 10% of eligible Veterans participate in CR programs. The first, necessary step for any Veteran to attend CR is to be referred to a CR program. CR referral is a quality measure, and referral rates have risen to over 80% of CR-eligible patients in non-VA hospitals. In contrast, preliminary data indicates that less than 30% of CR-eligible Veterans are referred to CR. In this proposal, a multidisciplinary team with expertise in CR, biomedical informatics, clinical trial design and implementation science will develop and test the Veteran Cardiac Rehabilitation Referral Program (VCR2P). VCR2P is a comprehensive intervention to improve CR referral for hospitalized Veterans including clinical decision support (CDS), Veteran educational materials, and a facility-based CR coordinator. We will evaluate VCR2P with a hybrid type 2 effectiveness-implementation trial at 3 VA hospitals. Significance: Low CR referral rates represent a major gap in quality between the VA and other hospital systems, thus improving CR referral will advance the HSR Quality and Safety of Health Care Priority. This proposal aligns with the HSR Health Care Informatics Priority as it will develop an innovative CDS tool to improve CR referral that is scalable and can be implemented at other VA hospitals. Innovation & Impact: CR referral has never been studied in the VA system, and prior work regarding CR referral interventions is limited to single centers. This will be the first trial to evaluate a CR referral intervention across multiple centers and CR-eligible conditions. Improving CR referral would significantly impact Veteran health as over 30,000 Veterans are hospitalized with CR-eligible conditions annually and CR is associated with a 30% decrease in readmissions, a 25% decrease in all-cause mortality and improved quality of life. Specific Aims: Aim 1 will characterize barriers to cardiac rehabilitation referral. The objective of this Aim is to conduct qualitative interviews and focus groups to obtain further information on CR referral processes from physicians, nurses, and Veterans at the 3 study sites. Aim 2 will develop and iteratively test the VCR2P. The objective of this Aim is to utilize an implementation-focused formative evaluation to develop 3 VCR2P components: (1) a CDS tool for automatic CR referral; (2) CR-related educational materials for Veterans; and (3) a role for a facility-based CR referral coordinator who will monitor CR referral processes. Aim 3 will evaluate VCR2P with a single arm, pre-post hybrid type 2 effectiveness-implementation trial. The objective of this Aim is to quantify the effects of a VCR2P on CR referral as well as CR initiation at the 3 study sites. We hypothesize that VCR2P will increase both CR referral rates and participation. Methodology: Population: Veterans with CR-eligible conditions, including myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting. Intervention: VCR2P, a comprehensive program to increase CR referral. Comparison: Veterans receiving current CR referral processes prior to VCR2P’s implementation. Outcome: Referral to CR (yes/no) is the primary outcome; CR initiation (yes/no) is the secondary outcome; implementation-related outcomes include reach, adoption, implementation, and maintenance. Time: CR referral will be evaluated during the Veteran’s hospitalization and CR initiation will be evaluated during a 6-month period after discharge; outcome data will be obtained from VA administrative files. Next Steps/Implementation: We will work with operational partners including the VA Cardiology National Program Office to disseminate the study results and implement VCR2P across the VA system. There is wide variation in CR referral rates at the facility level, ranging from 50% to <10% of CR-eligible Veterans. Depending on the study’s results, we anticipate a phased implementation of VCR2P focusing on facilities with the lowest CR referral rates to maximize improvements in Veteran cardiovascular outcomes.