However, as new referral strategies become adopted into clinical practice, it will be important for clinicians to remain active in the referral process because physician advocacy remains a strong factor in determining whether patients will enroll in CR programs.341 Beyond the challenges in the referral process, many patient and health system factors negatively affect CR use patterns. Referral to CR is particularly low among specific populations such as patients of low socioeconomic status, women, older adults, and ethnic minorities.323 In addition, CR program loca- tions and hours of operation prohibit the use of this service by some patients, and CR programs may not even be available in some rural or medically underserved areas. Finally, the finan- cial costs, related to copays, transportation, and time off from work, over the course of an entire CR program dissuade some patients from using this service. To address all these barriers to CR use, multiple strategies will need to be undertaken. First, greater attention will need to be paid in the referral process to identify and address an indi- vidual s unique barriers to CR use. This will require greater communication with patients and better coordination between the referring center (hospitals or office-based practices) and CR programs. Second, healthcare reform efforts will need to provide further incentives to patients and healthcare sys- tems to use CR programs. Third, new paradigms for deliv- ering comprehensive CR programs such as home-based CR programs will need to be further developed. Although these challenges are daunting, they are of central importance to improving clinical outcomes after CABG. CR Recommendations 1. CR is recommended for all patients after CABG, with the referral ideally performed early postopera- tively during the surgical hospital stay (Class I; Level of Evidence A). 