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Gender, Race and Cardiac Rehabilitation in the United States: Is There a Difference in Care?

  • Arthur R. Menezes
    Affiliations
    From the Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana
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  • Carl J. Lavie
    Correspondence
    Correspondence: Carl j. Lavie, MD, Cardiac Rehabilitation and Prevention, Exercise Laboratories, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA 70121–2483
    Affiliations
    From the Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana
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  • Alban DeSchutter
    Affiliations
    From the Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana
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  • Richard V. Milani
    Affiliations
    From the Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana
    Department of Preventive Cardiology, Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana
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      Abstract

      Coronary heart disease is the leading cause of death within the United States, involving both genders and among all races and ethnic populations. Cardiac rehabilitation (CR) has been shown to significantly improve morbidity and mortality, and these benefits extend to individuals of both genders and all ages with coronary heart disease. Despite this, referral and participation rates remain surprisingly low. Furthermore, women and minorities have even lower referral rates than do their male and white counterparts. over the course of this article, we will review CR referral and participation among women, as well as racial and ethnic minorities in the United States. We will also examine barriers to CR participation among these subgroups.

      Key Indexing Terms

      Coronary heart disease (CHD) is the leading cause of death worldwide. Approximately, 2200 Americans die of cardiovascular disease (CVD) each day, which accounts for 32.8% of all deaths in the United States.
      • Go A.S.
      • Mozaffarian D.
      • Roger V.L.
      • et al.
      Heart disease and stroke statistics—2013 update: a report from the American Heart Association.
      Cardiac rehabilitation (CR) programs are medically supervised exercise programs that have been shown to improve physical function, exercise capacity, quality of life, psychosocial well-being, as well as morbidity and mortality.
      • Leon A.S.
      • Franklin B.A.
      • Costa F.
      • et al.
      Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation.
      These benefits have been shown to extend to both genders and to all age groups.
      • Williams M.A.
      • Ades P.A.
      • Hamm L.F.
      • et al.
      Clinical evidence for a health benefit from cardiac rehabilitation: an update.
      Yet, despite the beneficial effects of CR programs on outcomes among patients with CHD,
      • Witt B.J.
      • Jacobsen S.J.
      • Weston S.A.
      • et al.
      Cardiac rehabilitation after myocardial infarction in the community.
      participation rates in the United States are dismally low, with probably well less than 30% of eligible patients participating in these programs.
      • Thomas R.J.
      • King M.
      • Lui K.
      • et al.
      AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services endorsed by the American College of Chest Physicians, American College of Sports Medicine, American Physical Therapy Association, Canadian Association of Cardiac Rehabilitation, European Association for Cardiovascular Prevention and Rehabilitation, Inter-American Heart Foundation, National Association of Clinical Nurse Specialists. Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons.
      The leading cause of death among women in the United States is CVD. Despite this, there is compelling evidence to suggest that female patients with CVD are under-referred to CR programs when compared with male patients. Furthermore, there is evidence to suggest that even after referral, the CR participation rates and the completion rates are lower among female patients.
      • Menezes A.R.
      • Lavie C.J.
      • Milani R.V.
      • et al.
      Cardiac rehabilitation in the United States.
      Currently, racial and ethnic minorities constitute approximately 28% of the U.S. population, with this number projected to increase to 40% in the next 15 years.
      • Cruz-Flores S.
      • Rabinstein A.
      • Biller J.
      • et al.
      Racial-ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
      Fifteen percent of the Hispanic Americans population are currently the fastest growing group in the United States, followed by blacks/African Americans at 12% and Asian Americans, American Indian and Alaska Natives representing approximately 7%.
      • Day J.C.
      According to the 2011 Heart Disease and Stroke Statistics update, 44.8% of black men and 47.3% of black women older than 20 years have CVD compared with 37.4% of white men and 33.8% of white women in the same age group, whereas 30.7% of Mexican American men and 30.9% of Mexican American women older than 20 years have CVD.
      • Roger V.L.
      • Go A.S.
      • Lloyd-Jones D.M.
      • et al.
      Heart disease and stroke statistics—2011 update: a report from the American Heart Association.
      Over the last 4 decades, there has been an overall decrease in the mortality rates from CHD and acute myocardial infarction (MI) in the United States.
      • Cardiovascular Health Branch, Division ofChronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, CDC
      Trends in ischemic heart disease mortality—United States, 1980–1988.
      • Levy R.I.
      The decline in cardiovascular disease mortality.
      However, there is evidence to suggest that there has been steeper decline in CHD mortality among whites compared with blacks,
      • Rosamond W.D.
      • Chambless L.E.
      • Heiss G.
      • et al.
      Twenty-two-year trends in incidence of myocardial infarction, coronary heart disease mortality, and case fatality in 4 US communities, 1987–2008.
      as well as decreased hospitalization among whites for acute MI’s when compared with their black counterparts.
      • Yeh R.W.
      • Sidney S.
      • Chandra M.
      • et al.
      Population trends in the incidence and outcomes of acute myocardial infarction.
      In fact, this increased risk of fatal incident CHD among blacks is almost twice the age-standardized rate compared with white men and white women. This increased risk has been attributed to racial differences in CHD risk factors, which were more prevalent among blacks compared with white men and women.
      • Safford M.M.
      • Brown T.M.
      • Muntner P.M.
      • et al.
      Association of race and sex with risk of incident acute coronary heart disease events.
      This can be explained by the fact that racial minorities tend to receive lower quality health care,
      fewer referrals
      • Dunlay S.M.
      • Witt B.J.
      • Allison T.G.
      • et al.
      Barriers to participation in cardiac rehabilitation.
      or less accessibility to health care
      • Shippee T.P.
      • Ferraro K.F.
      • Thorpe R.J.
      Racial disparity in access to cardiac intensive care over 20 years.
      when compared with nonminorities. In addition to this, CR utilization and participation rates among racial and ethnic minorities are also low in the United States.
      • Valencia H.E.
      • Savage P.D.
      • Ades P.A.
      Cardiac rehabilitation participation in underserved populations. Minorities, low socioeconomic, and rural residents.
      Over the course of this review, we will access the CR referral and participation among women, as well as racial minorities in the United States. We will also examine barriers to CR participation in these subgroup populations.

      BENEFITS OF CR

      Over the years, CR has been shown to provide a multitude of physiological, psychological and cognitive benefits (Table 1). One of the fundamental merits of CR is the mortality benefit even among those individuals who have undergone revascularization therapy and/or medical and device therapy. Suaya et al
      • Suaya J.A.
      • Stason W.B.
      • Ades P.A.
      • et al.
      Cardiac rehabilitation and survival in older coronary patients.
      demonstrated marked reductions in mortality among those who attended CR (21%–34%) compared with those who did not. This benefit was observed among both men and women. Furthermore, a dose effect of CR was demonstrated with better outcomes among those who attended more sessions. This dose effect of CR was seen in another study by Hammill et al.
      • Hammill B.G.
      • Curtis L.H.
      • Schulman K.A.
      • et al.
      Relationship between cardiac rehabilitation and long-term risks ofdeath and myocardial infarction among elderly Medicare beneficiaries.
      Here, patients who attended all 36 CR sessions had a 14% lower risk of mortality and 12% lower risk of MI compared with those who attended just 24 sessions, a 22% lower risk of mortality and 23% lower risk of MI compared with those who attended just 12 sessions, and a 47% lower risk of mortality and 31% lower risk of MI compared with those who attended just 1 session.
      Table 1Benefits of cardiac rehabilitation
      Adapted from Menezes et al.
      • Menezes A.R.
      • Lavie C.J.
      • Milani R.V.
      • et al.
      Cardiac rehabilitation and exercise therapy in the elderly: should we invest in the aged?.
      Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.
      Improvements in exercise capacity
       Estimated METs
       Maximal oxygen consumption (peak V˙o2)
      Improvements in lipids
       Total cholesterol
       HDL-C
       LDL-C
       Triglycerides
       Total cholesterol/HDL-C
       LDL-C/HDL-C
      Reduction in obesity indices
       Weight
       % Body fat
       Body mass index
      Major morbidity and mortality
       Reduction in overall mortality
       Reduction in congestive heart failure
       Reduction in hospital costs
       Reduction in nonfatal myocardial infarction
      Improvement in psychological factors
       Depression score
       Anxiety score
      METs, metabolic equivalent of tasks; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol.
      Because of the beneficial effects of estrogen, younger women tend to have an extra level of protection from CVD than men partly due to higher levels of high-density lipoprotein cholesterol (HDL-C)
      • Medina R.A.
      • Aranda E.
      • Verdugo C.
      • et al.
      The action of ovarian hormones in cardiovascular disease.
      and through the reduction of atherogenic lipoproteins such as low-density lipoprotein levels (LDL-C) and lipoprotein A.
      • Lamon-Fava S.
      Complete and selective estrogenic effects on lipids and cardiovascular disease.
      • Shwaery G.T.
      • Vita J.A.
      • Keaney Jr., J.F.
      Antioxidant protection of LDL by physiologic concentrations of estrogens is specific for 17-beta-estradiol.
      However, this benefit disappears with menopause, and the risk of CV events rises in postmenopausal women to eventually equal to that of men.
      • Rich-Edwards J.W.
      • Manson J.E.
      • Hennekens C.H.
      • et al.
      The primary prevention of coronary heart disease in women.
      In addition to its benefit on mortality, CR may provide improvements in HDL-C and/or triglycerides (TGs), which may average +6% and –15% for HDL-C and TGs, respectively.
      • Menezes A.R.
      • Lavie C.J.
      • Milani R.V.
      • et al.
      Cardiac rehabilitation in the United States.
      In fact, there is evidence to suggest that with CR, women may experience greater improvements in HDL-C, despite similar changes in fitness and body composition after these outpatient programs.
      • Savage P.D.
      • Brochu M.
      • Ades P.A.
      Gender alters the high-density lipoprotein cholesterol response to cardiac rehabilitation.
      Furthermore, these improvements in lipid profile have been observed in both younger and older female patients.
      • Lavie C.J.
      • Milani R.V.
      Benefits of cardiac rehabilitation and exercise training in elderly women.
      In general, most CHD patients with elevated LDL-C are already on statin therapy, which provides effective LDL-C reduction. As a result, in clinical practice, smaller demonstrable benefits regarding isolated LDL-C are seen with CR.
      • Lavie C.J.
      • Milani R.V.
      High-dose atorvastatin in acute coronary and cerebrovascular syndromes.
      • Lavie C.J.
      • Milani R.V.
      • O’Keefe J.H.
      Statinwars: Emphasis on potency vs event reduction and safety?.
      Regardless, women seem to demonstrate greater decreases in LDL-C compared with men after CR programs.
      • Warner Jr., J.G.
      • Brubaker P.H.
      • Zhu Y.
      • et al.
      Long-term (5-year) changes in HDL cholesterol in cardiac rehabilitation patients. Do sex differences exist?.
      The rates of obesity and metabolic syndrome are increasing rapidly in the United States.
      • Artham S.M.
      • Lavie C.J.
      • Milani R.V.
      Value of weight reduction in patients with cardiovascular disease.
      Numerous studies have demonstrated that obese individuals are more likely to be predisposed to hypertension, insulin resistance and dyslipidemia in addition to other medical conditions.
      • Menezes A.R.
      • Lavie C.J.
      • Milani R.V.
      • et al.
      Cardiac rehabilitation and exercise therapy in the elderly: should we invest in the aged?.
      A potential benefit of formal CR is weight reduction among the large number of patients with CHD who are overweight or obese.
      • Bader D.S.
      • Maguire T.E.
      • Spahn C.M.
      • et al.
      Clinical profile and outcomes of obese patients in cardiac rehabilitation stratified according to National Heart, Lung, and Blood Institute criteria.
      Furthermore, among the 45 obese patients in a small study from the Ochsner CR program who achieved 5% or greater weight loss, greater improvements in exercise capacity and plasma lipids were observed when compared with the 81 obese individuals who did not lose weight.
      • Lavie C.J.
      • Milani R.V.
      Effects of cardiac rehabilitation, exercise training, and weight reduction on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in obese coronary patients.
      In addition to improvements in plasma lipid profiles, a more recent study demonstrated that overweight/obese individuals who lost weight showed significantly greater improvements in many of their CHD risk factors including insulin resistance, blood pressure, clotting profiles, peak exercise capacity and inflammation.
      • Lavie C.J.
      • Milani R.V.
      • Artham S.M.
      • et al.
      The obesity paradox, weight loss, and coronary disease.
      • Ades P.A.
      • Savage P.D.
      • Harvey-Berino J.
      The treatment of obesity in cardiac rehabilitation.
      • Lavie C.J.
      • Morshedi-Meibodi A.
      • Milani R.V.
      Impact of cardiac rehabilitation on coronary risk factors, inflammation, and the metabolic syndrome in obese coronary patients.
      There also seems to be a mortality benefit present with successful weight loss after CR.
      • Sierra-Johnson J.
      • Romero-Corral A.
      • Somers V.K.
      • et al.
      Prognostic importance of weight loss in patients with coronary heart disease regardless of initial body mass index.
      Inflammation is regarded as a possible mechanism in both initiation and progression of atherosclerosis, which in turn propagates CV events.
      • Pearson T.A.
      • Mensah G.A.
      • Alexander R.W.
      • Centers for Disease Control and Prevention
      • Association American Heart
      • et al.
      Markers of inflammation and cardiovascular disease: application to clinical and public health practice: a statement for healthcare professionals from the Center for Disease Control and Prevention and the American Heart Association.
      • Zebrack J.S.
      • Anderson J.L.
      • Maycock C.A.
      • Intermountain Heart Collaborative (IHC) Study Group
      • et al.
      Usefulness of high-sensitivity C-reactive protein in predicting long-term risk of death or acute myocardial infarction in patients with unstable or stable angina pectoris or acute myocardial infarction.
      Inflammatory markers such as high sensitivity C-reactive protein have been associated as a CHD risk factor and are a potent independent predictor of CHD events. CR has been shown to reduce levels of high sensitivity C-reactive protein in patients regardless of the percutaneous intervention status.
      • Milani R.V.
      • Lavie C.J.
      • Mehra M.R.
      Reduction in C-reactive protein through cardiac rehabilitation and exercise training.
      • Kim Y.J.
      • Shin Y.O.
      • Bae J.S.
      • et al.
      Beneficial effects of cardiac rehabilitation and exercise after percutaneous coronary intervention on hsCRP and inflammatory cytokines in CAD patients.
      • Caulin-Glaser T.
      • Falko J.
      • Hindman L.
      • et al.
      Cardiac rehabilitation is associated with an improvement in C-reactive protein levels in both men and women with cardiovascular disease.
      In addition to the physiological benefits of CR, non-mortality benefits have been observed as well. CR improves the quality of life for patients with CHD, which has been translated to increased physical activity and vocational status.
      • Shepherd C.W.
      • While A.E.
      Cardiac rehabilitation and quality of life: a systematic review.
      There is also evidence to suggest that CR participation significantly enhances the older patients’ ability to live independently by improving their ability to perform common household tasks.
      • Johnston M.
      • MacDonald K.
      • Manns P.
      • et al.
      Impact of cardiac rehabilitation on the ability of elderly cardiac patients to perform common household tasks.
      Psychological stress (PS) is generally underemphasized in medical practice and has been demonstrated among the 9 major modifiable CVD risk factors. PS was ranked only below lipids and smoking in overall pathogenicity of CVD and is comparable in risk with hypertension and abdominal obesity.
      • Yusuf S.
      • Hawken S.
      • Ounpuu S.
      • et al.
      Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.
      Recent data demonstrates a high prevalence of PS among patients with CHD, which is markedly improved after CR programs.
      • Menezes A.R.
      • Lavie C.J.
      • Milani R.V.
      • et al.
      Psychological risk factors and cardiovascular disease: is it all in your head?.
      • Lavie C.J.
      • Milani R.V.
      Adverse psychological and coronary risk profiles in young patients with coronary artery disease and benefits of formal cardiac rehabilitation.
      In fact, although PS makes completion of CR difficult, those individuals who completed CR programs had statistically significant improvements in depression and anxiety compared with dropouts.
      • McGrady A.
      • McGinnis R.
      • Badenhop D.
      • et al.
      Effects of depression and anxiety on adherence to cardiac rehabilitation.
      Finally, this improvement in PS has been observed among men and women.
      • Hazelton G.
      • Williams J.W.
      • Wakefield J.
      • et al.
      Psychosocial benefits of cardiac rehabilitation among women compared with men.
      Among the patients who did not participate in any formal CR program (n = 522), there was a 30% mortality in depressed subjects during follow-up compared with only 8% in those who chose to participate in CR.
      • Milani R.V.
      • Lavie C.J.
      Impact of cardiac rehabilitation on depression and its associated mortality.
      However, among those patients who remained depressed after CR, there was a 4-fold increase in mortality during 3-year follow-up (22% versus 5%; P < 0.001) compared with those who were not depressed after CR. Furthermore, those patients who did not improve their exercise capacity after CR (assessed by peak oxygen consumption V˙o2) maintained a high prevalence of depression and high mortality risk, whereas those who achieved either mild (<10%) or marked (>10%) improvement in peak V˙o2 after CR significantly reduced both prevalence of depression and mortality risk. This suggests that only small improvements in exercise capacity are needed to gain dramatic improvements in depression-related increased mortality risk. These findings were also seen among heart failure (HF) patients, where depressed patients who completed CR had 59% lower mortality compared with HF-depressed patients who did not complete CR.
      • Milani R.V.
      • Lavie C.J.
      • Mehra M.R.
      • et al.
      Impact of exercise training and depression on survival in heart failure due to coronary heart disease.
      More importantly, those HF patients who remained depressed after CR had a nearly 4-fold higher mortality compared with patients whose depression resolved after CR (P = 0.005). Furthermore, among 269 patients with acute MI or after elective percutaneous coronary intervention, participants who underwent CR were less anxious and depressed and were found to be more relaxed and content.
      • Yu C.M.
      • Lau C.P.
      • Chau J.
      • et al.
      A short course of cardiac rehabilitation program is highly cost effective in improving long-term quality of life in patients with recent myocardial infarction or percutaneous coronary intervention.
      Lavie et al
      • Lavie C.J.
      • Milani R.V.
      Prevalence of hostility in young coronary artery disease patients and effects of cardiac rehabilitation and exercise training.
      demonstrated that younger patients (<50 years) had hostility scores that were 2.5 times higher than the older patients (≥65 years), and these patients with hostility symptoms had more adverse CHD risk profiles, including higher levels of total cholesterol, TG, total cholesterol/ HDL-C, fasting glucose and glycosylated hemoglobin compared with younger patients with low hostility scores. Furthermore, after CR, there was a significant improvement in behavioral characteristics (including hostility) and CHD risk factors, especially among this younger population.

      CR AND WOMEN

      As mentioned earlier, at every age group, female patients are under-referred to outpatient CR compared with their male counterparts. Although the exact reason for this is unknown, it is apparent that many physicians fail to understand the CVD risks in women and that more women die from CVD each year than men.
      • Kochanek K.D.
      • Xu J.
      • Murphy S.L.
      • et al.
      Deaths: final data for 2009.
      • Christian A.
      • Mills T.
      • Simpson S.
      • et al.
      Quality of cardiovascular disease preventive care and physician/practice characteristics.
      In fact, compared with men, women are more likely to be assigned a lower-risk category, despite a similar calculated risk.
      • Mosca L.
      • Linfante A.H.
      • Benjamin E.J.
      • et al.
      National study of physician awareness and adherence to cardiovascular disease prevention guidelines.
      This, in turn, leads to suboptimal cardiac care for this population subset, which includes under-referral to CR.
      In a study consisting of 87 patients admitted for angina, MI and coronary artery bypass grafting (CABG) (46 women and 41 men), Halm et al
      • Halm M.
      • Penque S.
      • Doll N.
      • et al.
      Women and cardiac rehabilitation: referral and compliance patterns.
      demonstrated that although women participants had higher eligibility rates for phase 2 CR, more men received referrals from their physicians than women. Furthermore, the male patients had higher completion rates.
      Ades et al
      • Ades P.A.
      • Waldmann M.L.
      • Polk D.M.
      • et al.
      Referral patterns and exercise response in the rehabilitation of female coronary patients aged greater than or equal to 62 years.
      demonstrated that older women were less likely to enroll in CR compared with older men (15% versus 25%; P = 0.06), despite similar clinical profiles. The authors attributed this difference to an increased likelihood of primary care physicians recommending CR to men compared with women. The women who did participate in outpatient CR showed a similar improvement in aerobic capacity (P = 0.02) compared with men as demonstrated in peak V˙o2 increasing by 17% in women and by 19% in men.
      Furthermore, there is evidence to suggest that even among women, those of African American descent are less likely to get referred to CR programs compared with their white counterparts. In fact, in a study of 253 women, referral to phase 2 CR was significantly lower for African American women compared with white women (12 [12%] versus 33 [24%]; P = 0.03).
      • Allen J.K.
      • Scott L.B.
      • Stewart K.J.
      • et al.
      Disparities in women’s referral to and enrollment in outpatient cardiac rehabilitation.
      Finally, there is evidence to suggest that the strength of physician recommendations is one of the most significant factors affecting patient CR participation.
      • Ghisi G.L.
      • Polyzotis P.
      • Oh P.
      • et al.
      Physician factors affecting cardiac rehabilitation referral and patient enrollment: a systematic review.
      In addition to lower referral rates, women have lower enrollment and participation rates in CR programs. This is partly due to the fact that many women have incorrect beliefs about their risk for CHD.
      • Covello V.T.
      • Peters R.G.
      Women’s perceptions of the risks of age-related diseases, including breast cancer: reports from a 3-year research study.
      A 1995 study of Stanford University graduates demonstrated that most women between 40 and 50 years grossly underestimated their lifetime risk of having CHD.
      • Pilote L.
      • Hlatky M.A.
      Attitudes ofwomen toward hormone therapy and prevention of heart disease.
      In fact, women tend to overestimate their risk of breast cancer and underestimate their risk of deadlier diseases such as heart disease. African American and Hispanic women were significantly less aware of their CHD risk compared with white women, although the gap has narrowed since 1997.
      • Mosca L.
      • Mochari-Greenberger H.
      • Dolor R.J.
      • et al.
      Twelve-year follow-up of American women’s awareness of cardiovascular disease risk and barriers to heart health.
      One of the reasons accounting for decreased enrollment and lower participation rates in CR programs is lower education levels among nonenrollees.
      • Sanderson B.K.
      • Shewchuk R.M.
      • Bittner V.
      Cardiac rehabilitation and women: what keeps them away?.
      Another factor that seems to affect female participation is encouragement from family members. Compared with men, encouragement from adult children seems to be significantly more influential for female participation.
      • Lieberman L.
      • Meana M.
      • Stewart D.
      Cardiac rehabilitation: gender differences in factors influencing participation.
      As a result, permission should be sought to discuss the benefits of CR with adult family members. Women, particularly older women, also tended to have less social support, which compromised their ability to attend these programs.
      • King K.M.
      • Humen D.P.
      • Smith H.L.
      • et al.
      Psychosocial components of cardiac recovery and rehabilitation attendance.
      Furthermore, women tend to have higher depressive scores after a CVD event when compared with men,
      • Norrman S.
      • Stegmayr B.
      • Eriksson M.
      • et al.
      Depressive mood after a cardiac event: gender inequality and participation in rehabilitation programme.
      and depressed patients were twice as likely to dropout from these programs than nondepressed patients.
      • Turner S.C.
      • Bethell H.J.
      • Evans J.A.
      • et al.
      Patient characteristics and outcomes of cardiac rehabilitation.
      In fact, a survey of 204 women with heart disease demonstrated that PS, such as anxiety or clinical depression, was reported by almost 57% of the women in the study.
      • Marcuccio E.
      • Loving N.
      • Bennet S.
      • Hayes S.
      A survey of attitudes and experiences of women with heart disease.
      Similarly, uninsured patients or patients with economic burden were less likely to enroll in outpatient CR.
      • Parashar S.
      • Spertus J.A.
      • Tang F.
      • et al.
      Predictors of early and late enrollment in cardiac rehabilitation, among those referred, after acute myocardial infarction.
      Finally, there is evidence to suggest that lower enrollment and participation among women in CR programs may also be because of increased age and greater comorbidities.
      • Barber K.
      • Stommel M.
      • Kroll J.
      • et al.
      Cardiac rehabilitation for community-based patients with myocardial infarction: factors predicting discharge recommendation and participation.
      • Jones C.A.
      • Valle M.
      • Manring S.
      Using survival analysis to explore female cardiac rehabilitation programme adherence.
      Discomfort at participating in a program dominated by men and previous lack of physical activity experience may also deter some women from enrolling in these programs.
      • Conn V.S.
      • Taylor S.G.
      • Abele P.B.
      Myocardial infarction survivors: age and gender differences in physical health, psychosocial state and regimen adherence.

      CR AND RACE

      The population in the United States is getting progressively more heterogeneous, potentially providing greater challenges in providing unprejudiced health care. White patients are more likely to be referred to outpatient CR than black patients. In fact, even after controlling for age, education, socioeconomic status and insurance, race is still independently associated with reduced referral to CR
      • Gregory P.C.
      • LaVeist T.A.
      • Simpson C.
      Racial disparities in access to cardiac rehabilitation.
      • Valencia H.E.
      • Savage P.D.
      • Ades P.A.
      Cardiac rehabilitation participation in underserved populations. Minorities, low socioeconomic, and rural residents.
      (Table 2).
      Table 2Barriers to cardiac rehabilitation among women and minorities
      Barriers to cardiac rehabilitation
      Low physician referral rates
      Lack of awareness among women about their coronary heart disease risk
      Low education
      Low social support
      Psychological stress
       Depression
       Anxiety
      Financial barriers
       High co-pays
       Obtaining time off from work
       Lack of insurance
      Language barriers
      Cultural differences
       Belief that one’s fate is controlled by God
       Family dynamics in decision-making process
      Geographic inaccessibility
      Lack of transportation
      Physical deconditioning
      Lack of previous physical activity experience
      A study of 145,661 consecutive patients, who underwent percutaneous coronary intervention across 31 hospitals in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium between 2003 and 2008, evaluated the referral rates to outpatient CR. Overall, approximately one third of eligible patients were not referred to these programs. Furthermore, race-specific referral rates differed significantly among whites and minorities in the lowest referring hospitals (P < 0.0001) but not in the highest referring hospitals (P = 0.16).
      • Aragam K.G.
      • Moscucci M.
      • Smith D.E.
      • et al.
      Trends and disparities in referral to cardiac rehabilitation after percutaneous coronary intervention.
      This suggests that quality of care measures, such as CR referral, vary measurably by location and site.
      Minority status also predicts lower participation rates in CR programs. In a study of 601,000 Medicare patients, CR participation rates among whites were significantly greater than nonwhites (19.6% versus 7.8%) after MI or CABG. Furthermore, nonwhites began CR on average of 1 week later than whites.
      • Valencia H.E.
      • Savage P.D.
      • Ades P.A.
      Cardiac rehabilitation participation in underserved populations. Minorities, low socioeconomic, and rural residents.
      Another survey of 500 randomly picked CR programs in the United States also demonstrated that after MI or CABG, enrollment was generally lowest for nonwhites.
      • Thomas R.J.
      • Miller N.H.
      • Lamendola C.
      • et al.
      National Survey on Gender Differences in Cardiac Rehabilitation Programs. Patient characteristics and enrollment patterns.
      In a study of 822 patients who were referred to outpatient CR, 59.4% enrolled. Nonwhites were found to initiate CR less often than whites (54.4% versus 65.2%, P = 0.003). In fact, the authors observed that whites were 77.5% more likely to initiate CR (odds ratio [OR], 1.78). Furthermore, they found that gender and referral patterns did not influence initiation among nonwhites.
      • Prince D.Z.
      • Sobolev M.
      • Gao J.
      • et al.
      Racial disparities in cardiac rehabilitation initiation and the effect on survival.
      The impact of the American Heart Association “Get With the Guidelines” program on referral and enrollment into CR was recently evaluated. Contrary to the previously mentioned studies, ethnicity did not affect referral to CR. However, ethnicity was associated with lower enrollment. Hispanic patients had 92% (OR, 0.08; P = 0.02) lower odds of enrolling in CR compared with white patients, whereas black patients had 57% (OR, 0.43; P = 0.06) lower odds of enrolling compared with white patients.
      • Mazzini M.J.
      • Stevens G.R.
      • Whalen D.
      • et al.
      Effect of an American Heart Association Get With the Guidelines program-based clinical pathway on referral and enrollment into cardiac rehabilitation after acute myocardial infarction.
      Among patients referred to CR programs, including ethnic minorities, speaking English was a strong determinant in being referred to phase 2 CR,
      • Cortés O.
      • Arthur H.M.
      Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review.
      suggesting that ineffective communication is a strong barrier to CR referral. Cultural differences also play a role and influence patient’s decision-making process. For instance, black patients identified additional factors such as perceptions of health care discrimination, perceptions of undesirable physician behavior, faith in God to control one’s destiny and patient-physician camaraderie that influenced their decision-making process.
      • Ferguson J.A.
      • Weinberger M.
      • Westmoreland G.R.
      • et al.
      Racial disparity in cardiac decision making: results from patient focus groups.
      Another study demonstrated that among less acculturated Latina women, 49% would prefer family members to determine the final treatment decision compared with less than 4% of African Americans and whites (P < 0.001).
      • Maly R.C.
      • Umezawa Y.
      • Ratliff C.T.
      • et al.
      Racial/ethnic group differences in treatment decision-making and treatment received among older breast carcinoma patients.
      There is also evidence to suggest that PS levels were substantially higher for Mexican American men compared with white men. Furthermore, initial PS did seem more predictive of participation in CR among Mexican American men than white men. Interestingly, Mexican American women with high PS were less likely to attend CR programs compared with Mexican American men with high PS.
      • Wilkinson-Lee A.
      • Rohrbaugh M.J.
      • Schoenfeld J.
      • et al.
      Mexican- and Anglo-Americans in Cardio Rehabilitation: Do Cultural Differences Make a Difference?.
      Finally, minorities were more likely to quote financial difficulties as a barrier to participate in CR compared with whites.
      • Mochari H.
      • Lee J.R.
      • Kligfield P.
      • et al.
      Ethnic differences in barriers and referral to cardiac rehabilitation among women hospitalized with coronary heart disease.

      CONCLUSIONS AND RECOMMENDATIONS

      CHD is the leading cause of death worldwide. Despite the multitude of proven benefits of CR on morbidity and mortality, referral and participation rates are dismally low, particularly among women and minorities.
      Because of the beneficial effects of CR on patients with CHD, more emphasis should be placed on referring all appropriate patients to these programs. Furthermore, efforts should be made to minimize racial and ethnic disparities in referral to CR.
      First and foremost, physicians should refer all eligible patients to CR and take an active role in stressing and explaining the importance of such programs before hospital discharge. Automatic referrals to CR before discharge seems to be effective in increasing referral rates
      • Gravely-Witte S.
      • Leung Y.W.
      • Nariani R.
      • et al.
      Effects of cardiac rehabilitation referral strategies on referral and enrollment rates.
      and may increase enrollment by as much as 50% compared with “usual” referral.
      • Grace S.L.
      • Scholey P.
      • Suskin N.
      • et al.
      A prospective comparison of cardiac rehabilitation enrollment following automatic vs usual referral.
      However, automatic referral plus patient discussions about the benefits of these programs may result in greater CR participation.
      • Grace S.L.
      • Russell K.L.
      • Reid R.D.
      • et al.
      Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study.
      Liaison referral was perceived to be the most suitable referral method for improved participation.
      • Grewal K.
      • Leung Y.W.
      • Safai P.
      • et al.
      Access to cardiac rehabilitation among South-Asian patients by referral method: a qualitative study.
      Using nurses before discharge to help explain the disease process and treatment plan to the patient, with additional follow-up after discharge may also increase enrollment rates in CR.
      • Cossette S.
      • Frasure-Smith N.
      • Dupuis J.
      • et al.
      Randomized controlled trial of tailored nursing interventions to improve cardiac rehabilitation enrollment.
      Special efforts need to be made by physicians and hospital staff to identify individuals who are less likely to enter CR programs, such as women and underserved minorities. This is especially important because this population exhibits higher mortality within first 5 years after a 1st MI compared with whites and males.
      • Balady G.J.
      • Ades P.A.
      • Bittner V.A.
      • et al.
      Referral, enrollment, and delivery ofcardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association.
      If possible, alternative delivery measures should be attempted to increase participation in CR. Internet-based programs or virtual CR has shown promise and may be a suitable alternative among eligible patients.
      • Zutz A.
      • Ignaszewski A.
      • Bates J.
      • et al.
      Utilization of the internet to deliver cardiac rehabilitation at a distance: a pilot study.
      This approach may bypass 2 common barriers to CR participation, namely accessibility and cost. However, there are limited data regarding the effectiveness among culturally and linguistically diverse populations.
      • Clark R.A.
      • Conway A.
      • Poulsen V.
      • et al.
      Alternative models of cardiac rehabilitation: a systematic review.
      Home-based CR has shown some benefit and may be another alternative among patients who are unable or unwilling to attend traditional CR programs because of geographic isolation or transport issues.
      • Poortaghi S.
      • Baghernia A.
      • Golzari S.E.
      • et al.
      The effect of home-based cardiac rehabilitation program on self efficacy of patients referred to cardiac rehabilitation center.
      • Scalvini S.
      • Zanelli E.
      • Comini L.
      • et al.
      Home-based versus in-hospital cardiac rehabilitation after cardiac surgery: a nonrandomized controlled study.
      Tailoring CR programs to meet the needs of women may also improve enrollment and adherence.
      • Budnick K.
      • Campbell J.
      • Esau L.
      • et al.
      Cardiac rehabilitation for women: a systematic review.
      • Rolfe D.E.
      • Sutton E.J.
      • Landry M.
      • et al.
      Women’s experiences accessing a women-centered cardiac rehabilitation program: a qualitative study.
      There is some evidence to suggest that women attending CR orientation had a greater chance of enrolling; however, it is unclear as to which component of the orientation is most effective (motivational interviewing, individualized attention or the clarity with which expectations were communicated).
      • Beckie T.M.
      • Mendonca M.A.
      • Fletcher G.F.
      • et al.
      Examining the challenges of recruiting women into a cardiac rehabilitation clinical trial.
      Finally, culturally sensitive patient care may help develop and strengthen the physician-patient relationship. Identifying barriers such as family dynamics, religion, cultural beliefs and language barriers may help physicians better understand their patients and subsequently customize health care plans to better suit the patient’s needs.

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