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. Author manuscript; available in PMC: 2015 Jun 19.
Published in final edited form as: Health Place. 2010 Aug 10;16(6):1196–1205. doi: 10.1016/j.healthplace.2010.08.004

Table 1.

Articles Examining Rurality as a Geographic Indicator of Cardiac Rehabilitation Utilization, N = 9

Study, Country Design Sample Geographic Indicator CR Utilization Covariate Adjustment Results
Johnson et al., 1998, United States Prospective cohort. 3 assessment points: i) time of hospital discharge, ii) two weeks post-discharge, iii) one week after estimated completion of a 12-week with 3 sessions/week CR program, multi-centre. N=254 rural residents hospitalized for MI, CABG, or PCI in four hospitals. Mean age 64, no SD or range available, 67% male, 98% white. Degree of rurality based on location of residence. using the MSU Rurality Index. Grouped into 3 categories: 35% (N=89) of participants were classified as living on a farm/ranch or rural area; 34% (N=86) were classified as living in small towns, and 31% (N=79) were living in a city or suburban area. Attended at least 1 of 36 sessions in a formal CR program. 72 (28%) self-report CR participation. 14 (19%) self-reported completing 1–18 sessions, 15 (21%) completed 19–35 sessions, 43 (60%) completed all 36 available sessions. Model of Participation (N=254): Age, social support, intention to attend, & education. Model of Session Attended (N=74): Emotional health, social support, employment status, locus of control, functional abilities, economic adequacy, & health beliefs Degree of rurality was significantly associated with utilization (β=−.649, p=0.005; N=254), but not associated with number of sessions attended.
King et al., 1999, Canada Retrospective cohort of patients identified using health records between September 1, 1996 and August 31, 1997, multi-centre. N=1245 outpatients following MI, PCI and/or CABG. Age range = 27–93 years Mean age: 63±11, 76.7% male, 98% English-speaking, 81% European origin Location of residence: i) city (N=595; 47.8%), ii) metro area (N=133; 10.7%), iii) within 1 h of the tertiary care city (N=192; 15.4%), iv) within province (N=266; 21.4%), v) out of province (N=55; 4.4%), vi) out of country (N=4; 0.3%). Data was obtained via health records. Attending at least 1 CR session, which was ascertained through health records. Program reported attendance rate was 28% (N=354). English speaking; current smoker; sex; history of COPD/Asthma; age; PCI; Neurological/Cognitive impairment Living in the city of the tertiary care centre was associated with a greater likelihood of attending CR (OR=3.97, 95%CI= [2.97 – 5.31]).
King et al., 2001, Canada Prospective cohort. Telephone interview at two time points: 2 weeks and approx. 6 months after hospital discharge, multi-centre. N=304 outpatients following acute MI and/or CABG. 69.1% < 70 years of age, 76% male. Location of residence: i) city or metropolitan (N=192; 53%), ii) within 1 hour of the closest CR program (N=50; 16.4%), iii) within the province (N=70, 23%) e, iv) out of province or country (N=22, 7.2%). Data was obtained via health records. Attending at least 1 CR session. 96 (32%) self-reported CR attendance. Age; sex; hypertension; diabetes; dyslipidemia; family history; smoking status; body mass index; number of risk cardiac? factors; NYHA class; previous cardiac event; self-efficacy; motivation; depression; social support; behavioural performance-health maintenance & role resumption Participants living in the city were 4.5 times more likely to attend CR (OR=4.48, p<0.001).
Smith et al., 2005, Canada Retrospective study of patients between 1 April 1996 and 31 March 2000, multi-centre. N=3536 patients who underwent CABG, mean age=64.4±9.87; 79.1% male. Geographic proximity was defined as to CR site was defined as living within Greater city region which was confirmed by postal code. 43.4% living within the city area. Data was obtained via health records. Attending at least 1 CR service. 2121 (60%) patients attended the CR intake appointment. Of those who attended their intake appointment, 1466 (69.1%) enrolled in at least one session. Preoperative CR; Sex; Hyperlipidemia; English Speaking; Previous CABG; Living with spouse; Age; Urgent surgery; Obesity; Diabetes. Geographic proximity was a significant correlate of CR utilization (OR=2.85; 95%CI [2.44–3.33]).
*Suaya et al., 2007, United States Retrospective design using Medicare claims files. Medicare beneficiaries hospitalized in 1997 with “a qualifying coronary discharge diagnosis” and aged ≥ 65 years at time of admission, multi-centre. N=267,427 AMI and CABG outpatient Medicare beneficiaries aged ≥ 65 years at time of qualifying hospital admission. 56% male, 92% white. Patient’s zip codes were linked with the US 2000 Census data to determine levels of urbanization. Five quintiles were used to classify levels of urbanization, with Q1 being high and Q5 being low level of urbanization. 18.7% (n=49,877) attended at least 1 session of outpatient CR, and attended an average of 24 of 36 sessions. Data obtained via database linkage. sociodemographic; comorbid conditions; characteristics of the index hospitalization and inpatient facility; socioeconomic and disability characteristics of the patient’s zip code; state indicators; clustering of patients within their index hospital Patients with the highest levels of urbanization were 36% less likely to utilize CR than those living in the most rural quintile (p<0.001).
Sundararajan et al., 2004, Australia Retrospective cohort study from January to December 1998, multi-centre. N=12,821 MI, CABG or PCI patients, age range 40–90 or up; 70.1% male. Accessible geographic place of residence (yes/no) was indicated by Accessibility/Remoteness Index of Australia. N=2,477 (19.3%) living in inaccessible geographic place of residence; N=10,344 (80.7%) living in accessible geographic place of residence. Attending at least 1 CR session. 23.7% participated in the CR program. 75% of these attendees completed a full 6–8-week program. Data was reported by 66 CR programs. Age; Sex; Marital status; Cardiac diagnosis/procedure; Number of comorbid conditions; heart failure; Index admission to intensive care unit; Index admission classified as emergency; Type of hospital; quartile of economic resources N=2552 (25%) patients living in accessible vs. N=489 (20%) living in inaccessible geographic place of residence were more likely to attend CR (OR=1.28; 95%CI [1.13–1.45]).
Brady et al., 2005, Canada Prospective cohort. Two assessment time points: 1–2 weeks prior to surgery and 10–12 weeks post surgery, multi-centre. N=78 patients undergoing CABG surgery in 1 of 2 tertiary hospitals in the same city. Age range = 43–79 years; Mean age 62±9, 95% male, 60% urban, 90% able to drive self. Location of residence: urban (as defined as < 30 minutes from emergency care, N=46; 60%) or rural (≥ 30 minutes from emergency care, N=31; 40%). Data obtained via self-report survey. No definition for enrollment. Self-report CR enrollment rate was 46%. Exercise capacity, self-efficacy, depressive symptoms, stage of change N=26 (57%) of urban participants enrolled in CR, compared to only N=9 (29%) of rural participants (p<0.02). Location of residence was a significant predictor of CR enrollment.
Harrison et al., 2005, United Kingdom Retrospective cohort between January 2000 and December 2001, multi-centre. N=236 patients w/diagnoses included angina pectoris, MI, Subsequent MI, chronic ischemic heart disease, MI with heart failure, CABG, & Angioplasty of coronary artery. Mean age 67±1. 69% male, 83% rural. Patients’ location of residence was classified as rural (n=196, 84.1%) or urban (n=37, 15.9%) using the Oxford-Countryside classification of rural wards. No definition for attendance. Overall, self-report CR utilization rate was 39%, with 23% completing the program. Age; sex; deprivation; attended one of the three local main CR providers. N=10 (27%) urban participants and N=80 (40.8%) rural participants participated in CR.
N=7 (18.9%) urban participants and N=46 (23.5%) rural participants completed the program. Urban/rural locality was not associated with program completion.
Higgins et al., 2008, Australia Prospective cohort between July 2001 and April 2004, single-site. N=184 patients undergoing CABG, mean age=66±10; range, 42–88, 79.4% male. 170 patients were tracked. Patient’s residence was classified as rural/remote (n=80, 47.1%) or metropolitan (n=90, 52.9%) using the Australian Institute of Health and Welfare guide. Attending at least one CR session. 123 (72%) attended. Most patients (90/123, 73%) of these patients completed the full program. Data obtained via self-report & confirmed by CR programs. None 66 (54%) urban participants and 24 (51%) rural participants attended CR. Location of residence was not related to utilization.

2MWT, Two Minute Walk Test, CABG, CAD, Coronary Artery Disease, coronary artery bypass graft, CHD, Coronary Heart Disease, COPD, Chronic Obstructive Pulmonary Disease, CR, cardiac rehabilitation, GIS, geographic information system, GPS, Global Positioning System, Km, Kilometers, CESEI, Cardiac Exercise Self-Efficacy Instrument, HADS-D, Hospital Anxiety and Depression scale-Depression subscale, MI, Myocardial Infarction, MSU, Montana State University, NYHA, New York Heart Association, NHAR, Nottingham heart attack register, PCI, Percutaneous Coronary Intervention, UA, Unstable Angina.

*

study measured both rurality and distance/time.