Sex and Racial Disparities in Cardiac Rehabilitation Referral at Hospital Discharge and Gaps in Long‐Term Mortality

Abstract

BackgroundCardiac rehabilitation (CR) referral is recommended for eligible patients, regardless of sex or race. It is unclear whether inequality in CR referral practices was associated with patients’ long‐term survival.Methods and ResultsWe linked the American Heart Association Get With The Guidelines Coronary Artery Disease registry with Medicare claims data for 48 993 coronary artery disease patients from 365 hospitals across the United States between 2003 and 2009. We used generalized estimation equations to estimate the association between CR referral and mortality accounting for clustering within hospitals. Between 2003 and 2009, only 40% of eligible patients received CR referrals. Females were 12% less likely to receive CR referral compared with males. Black, Hispanic, and Asian patients were 20%, 36%, and 50% less likely, respectively, to receive CR referral than white patients. CR referral was associated with 40% lower 3‐year all‐cause mortality. Women and minorities who received CR referral at hospital discharge had significantly lower mortality compared with those who did not (odds ratios=0.61 [95% confidence interval, 0.56–0.66] for women, 0.75 [95% confidence interval, 0.63–0.88] for black, 0.62 [95% confidence interval, 0.50–0.79] for Hispanic, and 0.63 [95% confidence interval, 0.46–0.85] for Asian patients). Seven percent of the black versus white mortality gap could potentially be reduced by equitable CR referral.Conclusions CR referral rates at hospital discharge remained low. Gaps in receiving CR referral at hospital discharge were large for women and minorities, and the mortality gap could potentially be reduced through elimination of inequality in CR referral.

Gender Difference in Secondary Prevention of Cardiovascular Disease and Outcomes Following the Survival of Acute Coronary Syndrome

“…These findings are supported by prior studies that women are less likely to utilise secondary preventive care. Although the fact that women are being referred to a cardiac rehabilitation program less often in the first place may contribute to the lower attendance rate compared to men, women were also reported to have greater dropout rates from the programs than men in past studies [12,[20][21][22]. Local and international studies have also found a sex difference in the use of secondary prevention medications [13,23,24].…”

Disparities in Health Care for Black Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review

“… 116 Likewise, they are less likely to be referred for and to receive cardiac rehabilitation 116,117 . One study noted that women and minorities that received cardiac rehabilitation had significantly lower mortality rates than those who did not, yet Black patients were still 20% less likely to be referred to cardiac rehabilitation than White participants 118 . The resultant 7% Black versus White mortality gap could potentially be reduced by equitable cardiac rehabilitation referrals 118 .…”

“…One study noted that women and minorities that received cardiac rehabilitation had significantly lower mortality rates than those who did not, yet Black patients were still 20% less likely to be referred to cardiac rehabilitation than White participants 118 . The resultant 7% Black versus White mortality gap could potentially be reduced by equitable cardiac rehabilitation referrals 118 . To date, there have been no reported racial disparities in outcomes of critical care rehabilitation, but it should be noted that critical care rehabilitation is most often the beginning of a long recovery.…”

“…Both cardiac and pulmonary rehabilitation have strong evidence showing improvement in functional, medical, and psychosocial outcomes for Black and White patients with cardiopulmonary diagnoses 119,120 . Relative differences in outcomes seem related to disparities in access, provider referral patterns, and biases that serve as barriers to cardiopulmonary rehabilitation for Black patients 118 . Current studies show that Black patients were 20%‐40% less likely to receive cardiac rehabilitation referrals, and increased mortality in Black patients after cardiac events may be because of lower rates of referral to cardiac rehab 112‐114 .…”

Diversity and Inclusion

“…Recent studies show that 91% of patients in contemporary coronary stent trials were White ( 5 ). Although there is a suggestion that the worse outcomes in Black patients treated with coronary stents is due partially to social determinants of health, which may be outside of the cardiologist’s control ( 6 ), the fact that minority groups are less likely to be treated with effective cardiac medications and to be referred for cardiac rehabilitation at hospital discharge likely plays a role as well ( 7 , 8 ). Patient race appears to play a role in clinician decision-making ( 9 ).…”