Disparities in women’s referral to and enrollment in outpatient cardiac rehabilitation

Abstract

OBJECTIVE:The purpose of this study was to determine the predictors of referral and enrollment, including racial differences, in phase 2 cardiac rehabilitation programs among African-American and white women who are eligible for such programs. DESIGN: Prospective longitudinal design.SETTING: One large academic medical center and two large community hospitals. PATIENTS:A total of 253 women (108 African American, 145 white) were surveyed within the first month of discharge from the hospital for a percutaneous coronary intervention, coronary artery bypass surgery, or myocardial infarction without revascularization. A total of 234 (99 African American, 135 white) completed the 6-month follow-up. MAIN RESULTS:The rate of referral to outpatient phase 2 cardiac rehabilitation was significantly lower for AfricanAmerican women compared with white women, 12 (12%) versus 33 (24%) ( P = .03). Only 35 (15%) of women in the study reported enrollment in phase 2 cardiac rehabilitation programs, with fewer African-American women reporting enrollment compared with white women, 9 (9%) versus 26 (19%) ( P = .03). Controlling for age, education, angina class, and comorbidities, women with annual incomes <$20,000 were 66% less likely to be referred to cardiac rehabilitation ( P = .01) and 60% less likely to enroll compared to women with incomes >$20,000 ( P = .01). Although borderline significant, AfricanAmerican women were 55% less likely to be referred ( P = .059) and 58% less likely to enroll ( P = .059) than white women. CONCLUSIONS:We found disparities in cardiac rehabilitation program participation, with women with lower incomes less likely to be referred and to have lower enrollment rates in cardiac rehabilitation and a strong trend for African-American women to be less likely to be referred and enroll. Because almost all patients who have had an acute coronary event, with or without revascularization procedures, will benefit from cardiac rehabilitation, automatic referral systems should be considered to increase utilization and reduce disparities. Coronary heart disease (CHD) affects more than 50% of women, and is their major cause of disability and death.1 Cardiovascular disease accounts for more hospitalizations and health care costs than any other illness. Cardiac rehabilitation programs have been shown to reduce mortality, improve functional capacity, improve quality of life, and decrease the incidence of rehospitalization for cardiac complications and overall medical costs in both men and women. 2,3 Despite the preponderance of this evidence, less than 25% of patients eligible for cardiac rehabilitation services enroll in an early outpatient cardiac rehabilitation program. 4,5 The few studies that have reported genderspecific data show that women have lower attendance and higher dropout rates from outpatient cardiac rehabilitation compared with men. [4][5][6][7][8][9] Although the data are limited, the dropout rate is even higher for African-American women compared with white women (49% vs 36%, respectively), 10 and a n...

The Awareness of Physicians and Allied Health Professionals about Cardiopulmonary Rehabilitation: A Cross-Sectional Survey Study

“…The lack of cardiac rehabilitation can be attributed to physician indifference, lack of instruction about referral of the patients to specialized centers, and lack of motivation (3,4,8,15). In the United States, Australia, and Great Britain, in order to improve referral rates, medical personnel are attempting to implement automated patient referral mechanisms (8,17,19,22,23). Physician awareness of CPR in our study was similar to the results obtained in the USA and Europe.…”

“…However, even in the United States, where CPR is most commonly practiced, only 20%-30% of patients currently benefit from CPR (3,4,16,17). Patients who are female, elderly, unemployed, from the countryside, or high-risk or have minimal education or lack of transportation are less likely to have access to these programs (3,4,18,19). Survey studies of European countries showed that only 1/3 of eligible patients undergo any form of cardiac rehabilitation.…”

A Qualitative Exploration of Exercise Among Pulmonary Rehabilitation Participants: Insight From Multiple Sources of Social Influence

“…Research in clinical settings outside of PR (eg, cardiac rehabilitation) further highlights the usefulness of considering gender as socially constructed. In this regard, health-care workers' beliefs that men prefer exercise and women do not have shown that women may receive less support and/or exercise referrals 39 or that both sexes do not receive the type and quality of support needed. 40 Although themes related to the gendered (ie, socially constructed) ways in which men and women approach exercise have also been explored extensively in nonclinical populations, 38,41 this topic has not received research attention within the PR setting to date and is an important avenue for future research within the rehabilitation context.…”

Use of Cardiac Rehabilitation by Medicare Beneficiaries After Myocardial Infarction or Coronary Bypass Surgery

“…For example, striking increases in referrals, from 27% to 62%, were achieved by 1 Web-based referral opportunity. 33 A high overall referral rate, however, may not eliminate disparities reflecting lower use, for example, among women, 34,35 nonwhites, 36 or the very old.…”