The present study is the first published national evaluation of the timeliness of access to CR, based on perceptions of patients, providers, and CR programs compared with national guidelines. Our study provides insight regarding the views and perceptions of different stakeholders on a topic that is, both in daily practice and in national policies, often determined by non-empirical assessment among a small number of individuals. There is no objective standard for acceptable wait times, other than participation rates [3, 4, 18, 19] and some emerging evidence of a relationship between wait time and peak oxygen consumption achieved [20, 21] at this time, but our analysis of the subjective views of these stakeholders has provided important information regarding the appropriateness of the consensus recommendations.
Patient perceptions of CR waits
The current study found that, overall, the median wait for patients to access CR was 42 days, which exceeds the 30-day CCS benchmark  by 40%. Registry data suggests that almost half of this time was spent waiting for the referral documentation to be generated and transmitted by a healthcare provider, and just over half was spent waiting for their intake appointment to be scheduled and assessments completed to commence the individually-tailored exercise program. This finding suggests that, to reduce wait times, strategies need to be targeted to both the pre-referral process, as well as the post-referral process.
However, over 90% of patients considered their wait acceptable. Their ideal wait was 28 days, which is highly congruent with the consensus-derived CCS benchmark . The most common reasons reported for delays in access were the patient’s health status, followed by physician delays in transmitting clinical information to CR. In contrast, CR programs perceived that the most common reasons for delays in access were patient unavailability for personal reasons, capacity and funding limitations, as well as delayed physician referral.
Healthcare providers and CR waits
Overall, cardiac specialists in Canada perceived that only approximately 1/3 of their indicated patients were accessing CR within the 30-day recommended wait time overall. This varied by CR indication, with physicians perceiving that a median of 10-30% of patients meet the “preferable” benchmarks, and 21-60% of patients meet the “acceptable” benchmarks. In particular, they perceived that only 10% of percutaneous coronary intervention patients meet the preferable wait times, and 1/5-1/3 of arrhythmia, transplant and heart failure patients meet the acceptable wait times.
CR programs and specialists generally perceived that the same degree of patients were meeting the preferable CR wait times, but CR programs tended to perceive that more patients were meeting the acceptable benchmarks than the specialists. Specialist perceptions of the appropriate number of days’ of wait by CR indication were all at the high end or exceeded the CCS preferable wait time benchmarks, and were at the low end of the acceptable benchmarks. With the exception of percutaneous coronary intervention patients, it was notable that the specialists’ views on appropriate waiting times largely matched the CR programs’ views of feasible waiting times. This suggests that what is considered appropriate according to specialists could be feasible within current funding policies. CR program perceptions of the feasible number of days’ wait were significantly higher than what was considered appropriate. These findings allude to the limited capacity in the health system to deliver the highest quality care.
Overall, a patient’s median wait time from referral receipt to the start of CR in Canada is 64 days. Considering that this does not reflect the time waiting from the referral event, this exceeds the 30-day recommendation. However, the overall consensus based on patient, specialist and CR program perceptions, as well as registry data, suggests that patients generally access CR around the acceptable wait time range of 60 days in Canada.
Strategies to reduce CR wait times
Our overall findings suggest that some patients perceive that they are experiencing prolonged CR waits, and in particular, wait times for percutaneous coronary intervention patients need to be addressed. There are 2 specific approaches that are successful in mitigating CR wait times. First, interprofessional education classes can be offered to patients shortly after hospital discharge. Provision of these sessions may encourage earlier adoption of heart health-promoting behavior, provide reassurance to patients and family members, enable verification of discharge instructions, ensure identification of any clinical issues, which may have arisen, such as infection, and mitigate some causes of wait time delays . Second, other programs have liaised with inpatient cardiac wards within their institutions to facilitate initiation of CR referral before patient discharge, rather than at a post-discharge visit weeks or months later. Such referral strategies are shown to cut CR wait times in half . Indeed, a recent CCS-CACR policy position recommends that all indicated patients be referred to CR systematically prior to discharge via a standard order .
In response to perceived access delays for patients, some CR programs have instituted innovative practices. Indeed, quality management strategies have been successfully implemented to significantly reduce wait times to access chronic disease management programming , such as process mapping, and performance data collection and evaluation . For example, in response to delays in booking intake exercise stress tests required to initiate an exercise program, some CR programs no longer require a stress test prior to CR initiation in low-risk patients or use a six-minute walk test. Clearly, all quality management strategies need to take into consideration, not only the patient experience, but also safety and patient outcome.
Caution is warranted when interpreting results from the current study, mostly because of generalizability and measurement issues. There was a considerably low response to the cardiac specialist survey. Therefore, it cannot be determined whether our results are representative of cardiac specialists across the country. Respondents were primarily Ontario cardiologists in urban settings. In a review of physician response to surveys, demographic characteristics of late respondents (considered to be a proxy for non-respondents) were similar to the characteristics of respondents to the first mailing . Moreover, physicians as a group are more homogeneous with regard to knowledge, training, attitudes, and behaviour than the general population, suggesting that nonresponse bias may not be as crucial in physician surveys as in surveys of the general population . In addition, the response rate of patients is unknown, although CR participant response rates are usually high.
Second, respondents were mainly providing perceptions of wait times, and therefore, there might have been some error associated with the wait time estimates. Wait times were also reported from a registry in an attempt to compensate for this limitation. However, it remains unknown whether different stakeholders may be over or under-estimating waits. Third, the multiple comparisons made between cardiac specialist and CR program perceptions may have resulted in inflated error rates. A more conservative approach was not adopted given the lack of information known in this domain; therefore, further study is warranted. Finally, the cross-sectional design precludes causal conclusions.