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Cardiac rehabilitation participation patterns in a large, tertiary care center: evidence for selection bias
G G Blackburn1, J M Foody, D L Sprecher
1Department of Cardiology, Cleveland Clinic Foundation, Ohio, USA. Blackbg@ccf.org
Insights
Overall cardiac rehabilitation participation remains low, with younger patients and those with better heart function preferentially enrolling. Traditional risk factors do not appear to influence referral, and women are more likely to join community-based programs.
Area of Science:
- Cardiology
- Public Health
- Rehabilitation Medicine
Background:
- Clinical practice guidelines recommend cardiac rehabilitation for secondary risk reduction.
- The influence of patient risk factor profiles on referral to cardiac rehabilitation has not been previously evaluated.
Purpose of the Study:
- To evaluate the role of risk factor profiles in patient referral to cardiac rehabilitation programs.
- To assess participation rates and characteristics in hospital-based versus community-based cardiac rehabilitation.
Main Methods:
- Compared patients in a hospital-based cardiac rehabilitation program (n=371) with non-participants (n=2960) using demographic and cardiovascular disease risk factor data.
- Interviewed a subset of non-participants (n=100) to determine participation in other rehabilitation programs.
Main Results:
- Only 11% of eligible patients participated in the hospital-based program; standard risk factors were similar between participants and non-participants.
- Rehabilitation participants were younger, had better left ventricular function, and women were underrepresented compared to non-participants.
- Women were more represented in community-based programs (42.8%) than the hospital-based program (19.7%).
Conclusions:
- Institution-specific data likely underestimate overall cardiac rehabilitation participation.
- Traditional cardiovascular disease risk factors do not appear to be primary drivers for referral.
- Younger patients with lower mortality risk and women in community settings show higher participation in cardiac rehabilitation.
Background:
Clinical practice guidelines have been published for cardiac rehabilitation, directing programs to address secondary risk-reduction issues. The role of risk factor profiles in the referral of patients to cardiac rehabilitation programs has not been evaluated.
Methods:
Patients from the Cardiovascular Information Registry at the Cleveland Clinic Foundation (CCF) who entered the CCF hospital-based cardiac rehabilitation program (n = 371) were compared with those who did not participate in the CCF program (n = 2960) with respect to gender, demographics, and risk factor profile for CAD. A random subset of those who did not participate in the CCF program (n = 100) was interviewed by phone to determine participation patterns in other rehabilitation programs.
Results:
Only 11% of patients participated in CCF-based program. Standard risk factors were similar between participants and nonparticipants. Rehabilitation patients were younger (63 +/- 10 versus 66 +/- 10, P < 0.01) and as a group had better left ventricular function (moderate-severe left ventricle: 16% versus 23%, P < 0.01) than nonparticipants. Women were underrepresented in the CCF rehabilitation population (20% versus 30%, P < 0.01). Of the phone survey sample, 21% of patients entered other community-based rehabilitation programs. Similar trends with respect to risk factors, younger age, and better left ventricular function were noted for the community subset. However, women accounted for a greater percentage of the participants in the community programs than the CCF-based program (42.8% versus 19.7%, P < 0.03).
Conclusions:
Conclusions based on institution-specific programs likely underestimate overall participation in cardiac rehabilitation. Traditional risk factors apparently are not considered when referring patients to cardiac rehabilitation programs. Younger patients with lower mortality risks preferentially participate in rehabilitation programs. Women are more likely to participate in community-based programs. Overall use of cardiac rehabilitation programs remains low.