Personalized cardiac rehabilitation as an object of organizational management: patient routing, control point system, and mechanisms for ensuring continuity (a cohort study)

BACKGROUND: Despite the regulatory establishment of a stage-based system of medical rehabilitation for patients with cardiovascular diseases, organizational gaps between inpatient and outpatient stages persist in real-world practice, reducing process controllability and reproducibility of outcomes. Personalized cardiac rehabilitation should therefore be considered not only as a clinical strategy but also as an object of organizational management.

AIM: This study aimed to provide scientific substantiation for a model of organizational management of personalized cardiac rehabilitation based on a formalized patient pathway, a system of control points, and mechanisms ensuring stage continuity.

METHODS: We conducted a prospective cohort organizational study that included 350 patients aged 40–75 years who had experienced cardiovascular events. A structured patient pathway model was developed and implemented, incorporating risk stratification, regulated inter-stage transitions, and a system of key performance indicators (KPIs). Model effectiveness was assessed by analyzing the dynamics of organizational and clinical-functional indicators before and after implementation using percentage change calculations.

RESULTS: Implementation of the model increased the proportion of patients transferred to the next rehabilitation stage within regulated timeframes from 62% to 89%, improved the completeness of individualized rehabilitation program documentation from 58% to 96%, and enhanced adherence to outpatient follow-up. We also observed improvements in functional exercise tolerance and a reduction in unplanned hospitalizations during the follow-up period.

CONCLUSION: Formalization of the patient pathway, implementation of structured control points, and digital recording of stage transitions allow personalized cardiac rehabilitation to be conceptualized as a controllable organizational technology. The proposed model improves continuity of care, ensures measurable outcomes, and creates a framework for scalability within practical healthcare settings.