I remember it being early spring-- around 2015... I'm sitting with a group of patients, cardiac rehab staff including exercise physiologist, interns, nurses, the program director and the topic of "the challenge to increase referral rates and enrollment rates to cardiac rehab" surfaces.
I'm told how great we are doing at the University of Michigan and that our referral rate is something like 50 or 60% and our enrollment rate (i.e. the number of that 50-60 % referred enroll to start rehab) is over 70%... I'm actually caught off guard and ask this to be repeated as I'm not convinced this is all that "GREAT."
I'm certain there was some sort of mistake... you see... I had been referred automatically as part of my discharge plan from the cardiac ICU unit and knew that I was to follow-up with my cardiologist and then go to cardiac rehab... I simply didn't think this number was correct as I made the assumption that like PT for a broken leg-- this would be close to 100% referral and enrollment.... Why was it not?
I had presumed that, of course, if you've had a heart attack (or other cardiac event) where the evidence is crystal clear that it works, then all would be referred and we would do everything possible to assure you benefited from this wonderful treatment... no different that the assurance that I went to the pharmacy on the way home from the hospital to pick up and begin taking the 4 new medications prescribed.
Since this time, I have learned that U of M's program is much higher than the national average for referral and enrollment (likely due to number of reasons like income, education level, etc.).
That said, I continue to think about ways to help increase awareness and utilization and find ways to help U of M and other facilities from my perspective-- a patient who does not have any formal education in the healthcare disciplines.
I continue to wonder why all those eligible aren't referred to cardiac rehab (just as they are to be given meds)? I continue to wonder how to mobilize the powerful voices of the patients who are so grateful for the teams that help us put our lives back together after the frightening moments of seeing our mortality.
What are the barriers, what are the solutions, what have I learned since first hearing this news? Below you will find my attempt to think about these issues from a patient perspective.... some of these ideas have been championed by the national organization AACVPR known as the ROADMAP TO REFORM.
What I hope might be new is that by having a patient frame these ideas within the context of behavioral economics or behavioral science, including our inclination to be predictably irrational as human beings, that it provides yet another way to re-imagine and reinvent cardiac rehab in the future.
Cognitive Bias and "Tiny" Experiments- Are they worthy of rapid prototyping and implementing?
I purposely use the term experiment as although these certainly could (and maybe should) turn into Randomized Control Trials, my purpose here is that medicine tends to miss opportunity to just try something. I often hear: “Oh we try different things” but that is not the idea. The idea is to do controlled testing, make sure you collect the data, and you’re very rigorous about the whole thing. As an impatient patient, I'm trying to simply let folks know that we should at least be working frequently to innovate, rapidly prototype and work to inform the greater community about the power and benefits of cardiac rehab.
So try and implement these "tiny" experiments in your practice and see if a small change might have a big impact. If it does, then go back and do the rigorous study (RCT) and see if there is a cause/effect.
I will begin with the Referral process and stay tuned for the next 4 blogs where I will suggest ideas/innovations/experiments for Enrollment, Retention (persistence), Graduation (all sessions completed as prescribed) and Post-Graduation-- living a thriving life post cardiac event!
Referral- Experiment- Cognitive Bias Trying to Overcome
If at some of the best hospitals and health centers in the country the rate of referral for those eligible to attend cardiac rehab is 60%, then these kind of experiments seem easy and should be immediate.
All referrals by any physician should have only an opt out button and should be automatic. It should take doctors an active role to exclude a patient from this critical treatment.
Publish a list of docs who have the lowest percentage of patients referred who were eligible. Allow the natural competitive nature of colleagues to see where they lag behind their colleagues in referring for this important treatment.
Have a group of patients who are grateful for this treatment to meet with cardiologist and other docs in meetings and share their stories. This should be done in person (though video stories might be second best alternative). The point is use the power of story to help docs see how this affects their patients.
COGNITIVE BIASES THESE IDEAS WORK TO OVERCOME - Group Attribution Error, Authority Bias and Automation Bias. We fill in characteristics from stereotypes, generalities or prior histories--- If as my patient you appear fit already, you are too old and unlikely to attend or I just don't feel it's good for you, I don't think you can afford, then I don't refer you.
What are your ideas if you are a patient for increasing the referral rate? How might patient ideas unleash the most creative ways to assure all those who are eligible to attend cardiac rehab are referred? Let's hear your ideas!