Changing the referral process for cardiac rehabilitation to opt-out rather than opt-in caused referral rates to jump from 12 percent to 75 percent in nine months at the Hospital of the University of Pennsylvania, according to data presented at the American College of Cardiology’s Cardiovascular Summit and the ACC’s National Cardiovascular Data Registry annual meeting.

Cardiac rehab—a combination of exercise training, risk factor modification and psychosocial counseling—is generally recognized to improve outcomes for patients with cardiovascular disease. Yet it remains underutilized across the United States, with participation varying widely from state to state and region to region.

Recognizing this problem, the Penn researchers established a system of alerts based on electronic medical records to identify patients who qualify for cardiac rehab. All members of the cardiac care team—including bedside nurses, advanced practice providers, physicians and case managers—were educated on the benefits of cardiac rehab and encouraged to discuss them with eligible patients prior to discharge.

In the 21 months before the implementation of the program, the hospital’s average referral rate was 12 percent. It increased to 75 percent in the following three quarters.

"If a provider thought a patient would benefit from cardiac rehab, they would hand the patient a handwritten prescription but didn't have the tools to get them there," Elizabeth Jolly, MBA, the hospital’s interventional cardiology transitions coordinator, said in a press release. "At a big institution like ours, we have so many patients that it's not always evident who qualifies for cardiac rehab. Now we know in real time. We started bringing cardiac rehab into our conversations with patients and adding it to discharge documentation and conversations following discharge as well. Now this is part of our daily workflow."

The project was part of the Penn Medicine Nudge Unit, the first of its kind created in the healthcare setting. Borrowed from governments in the United Kingdom and other countries, a “nudge unit” is designed to use behavioral science to influence behavior in a predictable way without restricting choices.

Lest this sound sinister or manipulative, Srinath Adusumalli, MD—who presented the cardiac rehab referral data at the ACC’s Cardiovascular Summit—told Cardiovascular Business these nudges are only done to encourage the use of evidence-based practices. They also should be transparent and align with the welfare of the person being nudged.

“The ideal candidate for a nudge in terms of an intervention is something that has a strong evidence base that most would not argue with but for one reason or another is underutilized,” Adusumalli said.

At Penn, they’ve used this reasoning to change defaults around flu vaccinations and medications—for example, bumping cheaper generic drugs to the top of ordering lists. But the cardiac rehab process is different, Adusumalli said, because the default leads to an entirely different pathway of care, not just an option of X versus Y.

Adusumalli’s team eventually plans to follow up and see how their increase in cardiac rehab referrals affects actual participation rates—both in terms of whether patients attend any sessions at all and the proportion of prescribed sessions they complete. But the researchers are pleased they’ve at least improved the first step of the process.

“If you’re not referred, you don’t even have the opportunity to go so I think that was the first problem we wanted to attack,” Adusamalli said.

Adusamalli believes leveraging default options within the electronic medical record could lead to better utilization of other interventions. Sometimes all it takes is a nudge.

“Despite the fact that we have lots of advanced technology ranging from medical technologies to computer technologies like AI (artificial intelligence) and all that, we still haven’t solved the basic problems in delivering evidence-based healthcare, in translating our robust evidence base into actual care that reaches our patients,” he said. “I think this is a way that’s generally a low-cost approach that for certain interventions—cardiac rehab is one of them—works really well in trying to crack that nut which has been a difficult one for years.”