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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 2.

Articles Examining Distance/Travel Time as Geographic Indicators of Cardiac Rehabilitation Utilization, N = 10

Study, Country Design Sample Geographic Indicator CR Utilization Covariate Adjustment Results
Ades et al., 1992, United States Prospective cohort. Assessments at 2 time-points: prior to hospital discharge and 2–4 weeks post-discharge, single-site. N=226 patients hospitalized for an MI or CABG surgery. Age range = 62–92 years. Mean age 70±6, 57% male. Self-reported travel time from home to the CR program in Vermont in minutes. No definition of CR use was provided. 47 (21%) self-reported participated. Age; Sex; Education; Occupation; Marital Status; Primary care physician recommendation for participation; patient “denial” of severity of illness; history of depression; psychosocial characteristics; cardiac diagnosis; comorbidities; own and drive a car. CR attendees had a significantly shorter mean travel time of 17±11 minutes, compared to 25±15 minutes among non-attendees (p=.003).
Melville et al., 1999, United Kingdom 2 Retrospective cohorts: 1992 and 1996, multi-centre. 1992: N=617, AMI patients from 2 large teaching hospitals, mean age 65±11, 65% male. 1996: N=261, AMI patients, mean age 66±12, 67% male. GIS-calculated distance from home to hospital in km using “MapInfo” software. Attending at least 1 CR session. 323 (52.4%) participated in the 1992 cohort. 131 (50.2%) participated in the 1996 cohort. Age; Sex; Outpatient Admitted to one of the 2 hospitals in Nottingham) with appointment to Thrombolysis; Length of stay; Cardiac history; Complicated MI; Killip class; NHAR classification; Diuretic on discharge; Townsend (deprivation) score. In the 1992 cohort, the mean distance from home was 6.2±3.6 km ranging from 0–24 km. Among the 1996 cohort, the mean distance from home was 6.4±4.1 ranging from 0–20.9 km. Distance was not a significant predictor in CR attendance in both cohorts.
Missik et al., 2001, United States Cross-sectional comparative design between April 1, 1995 and September 30, 1995, single-site. N=370 females treated and discharged with MI, PCI, angina, and/or CABG. Mean age 66±10, 88% with access to transportation. Self-reported distance from home to nearest CR facility in miles. Distance as binary variable (< or ≥20 miles [or 32 km]). Attending at least 1 CR session. 91 (24.6%) self-reported participated. Education; history of CHD; cardiac diagnosis; physician referral; & insurance coverage. Of those referred, 75 (21%) participants lived further than 20 miles or 32 km from the nearest CR site.
17 (19%) attendees lived farther than 20 miles or 32 km away, compared to 58 (22%) of non-attendees (p=n.s.).
Yates et al., 2003, United States Cross-sectional, comparative design, single-site. N=222 CAD in-patients. Mean age 67, age range = 41–92 years; 73% male, 97% Caucasian. All rural sample as defined as population <50,000 in one city or <100,000 in one metropolitan statistical area. Self-reported distance from home to the nearest CR site in miles. No definition of attendance available. 154 (69%) self-reported participated. Education; physician explanation of CR; & being informed about CR during hospitalization. The mean distance from CR for attendees was 10.7±14.1 miles or 17.1 km, compared to non-attendees who had a mean distance of 27.3±26.6 miles or 43.7 km (p<0.05). For every 10 miles that a patient lived closer to a CR site, they were 1.05 times more likely to attend (OR=1.05; 95%CI [1.02–1.07]).
Suaya et al., 2007, United States Retrospective design using Medicare claims files from 1997, multi-centre. N=267,427 MI and CABG outpatient Medicare beneficiaries aged ≥ 65 years at time of qualifying hospital admission. 56% male, 92% white. Distance from patient’s residence operationalized as zip code centroid to the nearest available CR facility within the state (located by its exact latitude and longitude). Five quintiles (Q) were used to classify distance from closest CR site, with Q1 being closest and Q5 being farthest. Attending at least 1 CR session. 18.7% (n=49,877) attended at least 1 session of outpatient CR, and attended an average of 24 of 36 sessions. Patient sociodemographics; comorbid conditions; characteristics of the index hospitalization and inpatient facility; socioeconomic and disability characteristics associated with the patient’s zip code; state indicators; clustering of patients within their index hospital. Patients living in the farthest quintile were 71% less likely to participate in CR than those living in the quintile closest to a CR facility (OR=0.29; 95%CI [0.27–0.31]).
De Angelis et al., 2008, Australia Prospective cohort between July and December 2005, multi-centre. N=97 rural patients with a principal discharge diagnosis of PCI, CABG, AMI, or UA; mean age=66.5±10.8; age range 42–90; 72% male; One community-based and 5 hospital-based CR programs located within the Greater Green Triangle region in south-west Victoria were chosen as sites for this study. Self-report distance from home to closest CR site in km No definition of attendance available. 81 (84%) self-reported participated in the CR program. None Attendees lived an average of 15.4±20.6 km from the CR program whereas, non-attendees lived an average of 40.4± 37.5 km from the CR program (p=0.019).
Grace et al., 2008, Canada Prospective cohort recruited from 97 cardiologists in Ontario, multi-centre. N=1268 CAD patients, mean age=67.3±11.2; 71.8% male, 86.3% white. Distance (km) and travel time (minutes) from home to closest CR were computed using GIS. Attending at least one CR session. Overall, 469 (37%) self-reported enrolled in CR. Physician referral intentions; physician perceptions of CR; Work status; income; Marital status; Education; Strength of provider CR endorsement; comorbidities; Age; Depressive symptoms; Exercise benefit perceptions; Illness perceptions; Functional status; Type of referring physician; CR barriers The mean CR travel time and distance of CR attendees were 16.14 ± 23.91 km, 21.12 ± 23.03 minutes, for non-attendees were 27.91±87.34 km, 31.39 ± 79.23 minutes. Only distance was entered to the logistic regression model. Shorter distance to CR was a factor associated with enrollment (p<.001).
*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. Drive time (minutes) and distance (km) between the home and the CR site referred were calculated using GIS software: www.Whereis.com Attending at least 1 CR session. 123 (72%) attended CR. Most patients (90/123, 73%) who attended one session completed the full program. Self-report data was confirmed by CR programs. Whether patients being referred to the program at Royal Melbourne Hospital or elsewhere. Mean travel time to CR for attendees was 11±10.1; for non-attendees was 16.4±8.2 (p=0.02). Travel time was significantly negatively related to CR utilization (OR=0.86; 95%CI (0.75–0.99)).
Dunlay et al, 2009, U.S. Prospective cohort between June 2004 and May 2006, single-site. N=179 patients with suspected MI, mean age=64.8 no SD or range was stated. 65.9% male. Self-report driving distance from home to the CR site, with a cut-off <5 miles living from home to the CR site. No definition of attendance available. 115 (64.2%) attended. The mean number of sessions attended within 90 days of MI was 13.5±8.2 of 36 sessions. Data obtained through electronic medical records. None Driving distance from a CR center was not significantly associated with CR utilization (p=0.11).
Brual et al., 2010, Canada Prospective cohort recruited from 97 cardiologists in Ontario, multi-centre. N=1268 CAD out-patients; mean age=67.2±11.2, 71.8% male, 86.3% white. Drive time (minutes) and distance (km) between the home and the nearest CR site were calculated using GIS Enrollment rate was reported as in Grace et al., 2008. Self-reported degree of participation was defined by the percentage of prescribed sessions attended. Enrollees attended a mean of 84.6±25.7% of prescribed sessions. Data was verified by CR programs. None Patients with 50–60 minutes drive time were less likely to enroll CR (OR=.51 [95% CI .26–.98]). Degree of participation among enrollees was not significantly related to drive time (p=0.63).

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.