Abstract
Cardiac rehabilitation (CR) services improve various clinical outcomes in patients with cardiovascular disease, but such services are underutilized, particularly in women. The aim of this study was to identify evidence-based barriers and solutions for CR participation in women. A literature search was carried out using PubMed, EMBASE, Cochrane, OVID/Medline, and CINAHL to identify studies that have assessed barriers and/or solutions to CR participation. Titles and abstracts were screened, and then the full-text of articles that met study criteria were reviewed. We identified 24 studies that studied barriers to CR participation in women and 31 studies that assessed the impact of various interventions to improve CR referral, enrollment, and/or completion of CR in women. Patient-level barriers included lower education level, multiple comorbid conditions, non-English native language, lack of social support, and high burden of family responsibilities. We found support for the use of automatic referral and assisted enrollment to improve CR participation. A small number of studies suggest that incentive-based strategies, as well as home-based programs, may contribute to improving CR attendance and completion rates. A systematic approach to CR referral, including automatic CR referral, may help overcome barriers to CR referral in women and should be implemented in clinical practice. However, more studies are needed to help identify the best methods to improve CR attendance and completion of CR rates in women.
Cardiac rehabilitation (CR) is a cost-effective, class 1 recommended component of the continuum of care for patients with cardiovascular disease1, 2 that has been shown to improve various important patient outcomes, including exercise capacity, cardiovascular risk factor control, social functioning, and psychological well-being, hospital readmission rates, and mortality rates.1, 3–9
Despite this, however, CR utilization remains low,6, 10–13 particularly among women.14–16 Women are substantially less likely to be referred to a CR program (odds ratio [OR], 0.68),15 to enroll in CR once referred (OR, 0.64),14 and to complete a full course of CR (OR, 0.73), as compared with men17 (OR, 0.89).18 The negative impact of this treatment gap is accentuated by the fact that clinical outcome improvements after CR are at least as great in women as in men.17–24
Although some studies have identified gender-related barriers to CR14, 25, 26 and others have assessed efforts to reduce those barriers,27–29 uncertainty exists regarding the relative strength of various strategies to improve CR utilization by women. With the objective to provide clinicians and policymakers with specific evidence-based strategies to improve CR participation in women, we carried out a systematic literature review to (1) identify gender-related barriers to CR participation, and (2) enable us to rate solutions to the gender-related gap in CR participation, according to the level of published evidence that supports them.
METHODS
To identify studies on barriers and their potential solutions to CR participation, we carried out a systematic and comprehensive search in PubMed, EMBASE, Cochrane, OVID/Medline, and CINAHL databases. An expert librarian designed the search with input from the lead investigator (M.S.P.) using key search terms (see Supplemental Appendix 1, available online at http://www.mayoclinicproceedings.org). We supplemented the search by reviewing references in the selected articles, structured reviews, and meta-analyses. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations in performing our systematic review.30
To identify studies of barriers and solutions to CR participation that are pertinent to recent gender-related health care delivery gaps, we selected randomized clinical trials, controlled clinical trials, and observational studies that had been published before October 20, 2016, without language restrictions. Studies were restricted to those whose sample included adults older than 18 years who had CR-eligible diagnoses, such as myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft surgery, heart failure, heart valve surgery (replacement or repair), heart transplantation, and stable angina. International studies were included.
We excluded studies that lacked gender-specific results, although for studies on potential solutions to low CR referral, enrollment, and completion rates, we included all studies in which the percentage of women in the sample was specified, even if the results were not specified by gender, given the low number of studies in this category. Although qualitative studies can help clarify the underlying issues surrounding the delivery of health care services, we excluded them from our analysis to focus on the highest level of published evidence from clinical trials and observational studies that have studied the most common barriers to and most effective solutions for CR participation in women.
Two reviewers (M.S. and J.R.M.-I.) working independently and in duplicate analyzed the eligible studies to assess the risk of bias using a modified Ottawa classification for observational studies and the Cochrane assessment tool for randomized clinical trials (RCTs).31, 32 Disagreement between reviewers was resolved by consensus.
The search results were uploaded using systematic review software (Covidence). Two reviewers (M.S. and J.R.M.-I.) independently reviewed all abstracts and titles for inclusion. After abstract screening and retrieval of potentially eligible studies, the full-text publications were assessed for eligibility with excellent chance-adjusted interreviewer agreement (K statistic, 0.831169). Duplicate studies were excluded. Disagreements were resolved by group consensus. The senior author (R.J.T.) reviewed results for accuracy.
All coauthors reviewed the solutions identified from the literature search and scored each solution by the American College of Cardiology/American Heart Association guidelines for level of evidence (level A = 1 or more high-quality RCTs or meta-analyses; level B-R = 1 or more moderate quality RCTs or meta-analyses; level B-NR = 1 or more moderate quality nonrandomized studies; level C = 1 or more studies with significant limitations; level E = based on expert opinion, published evidence lacking or unclear) and strength of recommendation (class 1 = strong, benefit much greater than risk; class 2a = moderate, benefit greater than risk; class 2b = weak, benefit greater than or equal to risk; class 3 = no benefit [moderate], benefit equal to risk; class 3: harm [strong], risk greater than benefit) for each solution.33 Coauthor responses were summarized and any items that lacked a clear majority agreement were resolved by additional discussion. Because the barriers identified did not represent the same constructs, authors agreed to not pool estimates and rather focus on summarizing the available evidence.
RESULTS
A total of 3988 articles were screened, from which we identified 54 studies that met our inclusion criteria. Of these, 24 studies18, 27, 34–55 were studies of CR barriers and 31 studies27–29, 56–83 were studies of potential solutions to improve CR participation. One study addressed both CR barriers and potential CR solutions. Of the included studies addressing CR barriers one was an RCT27 and 23 were observational cohort studies.18, 34–55 The studies addressing potential CR solutions included 15 RCTs27–29, 56, 58, 59, 62, 71, 72, 74–76, 78, 82, 83 and 16 observational studies.57, 60, 61, 63–70, 73, 77, 79–81 The study selection process is described in more detail in Supplemental Figure 1, available online at http://www.mayoclinicproceedings.org.
Overall, studies included in our review had moderate risk of bias mainly driven by unclear allocation concealment and blinding for RCTs and/or inappropriate patient selection and follow-up for observational studies. A summary of the risk of bias of the included studies is presented in Supplemental Appendix 2 and Supplemental Figure 2, available online at http://www.mayoclinicproceedings.org.
Barriers to CR Referral, Enrollment, and Completion
We identified 24 studies related to barriers on CR participation in women.18, 27, 34–55 Table 1 lists the patient-, provider-, and social/ environmental-level factors that were identified, including those that are nonmodifiable (eg, age and diagnosis) and potentially modifiable (eg, transportation barriers). It is worth noting that the studies in our analysis reported barriers that were pertinent to the patient groups unique to their study cohort and local factors (eg, the ethnicity/racial mixture of the study cohort, transportation challenges, or number of available CR centers). Care should be taken in applying in one location or setting, the results of studies from different locations or settings.
TABLE 1.
Factors Associated With Lower CR Participation for Women
CR participation steps | Levels of barriers | Factor |
---|---|---|
Referral | Patient | Coronary artery bypass graft,40 percutaneous coronary intervention,40, 43 and valve surgery50 as reason for CR referral |
Older age34 | ||
Health care provider | Lack of written referral necessary for participation from physicians38 | |
Social/environment | Individuals from underrepresented minority groups, particularly those with financial barriers35, 49 | |
Lack of CR insurance48 | ||
| ||
Enrollment | Patient | Perception of exercise as being tiring or painful18 |
Lack of CR awareness18 | ||
Multiple comorbidities18, 44 | ||
PCI43 as reason for CR admission | ||
Higher exercise barriers as measured by the EBBS score43 | ||
History of myocardial infarction39 | ||
Older than 70 y or younger than 55 y55 | ||
Health care provider | Lack of strong endorsement to attend to CR38, 52 | |
Lack of health care provider support54 | ||
Social/environment | Education level <12 y52 | |
Transportation issues18 | ||
Numerous family responsibilities18 or home- related stress42 | ||
Lack of support system (friends, family)54 | ||
Individuals from underrepresented minority groups, particularly those with financial barriers35 | ||
Unemployed42 | ||
| ||
Completion/adherence | Patient | Multiple comorbidities45 |
<55 y of age45 | ||
Obesity51 | ||
Depression as measured by the BDI-II score51 | ||
Diabetes36 | ||
Previous myocardial infarction39 | ||
High level of anxiety as measured by STAI-S score27 | ||
Current smoker27 | ||
Physically inactive previous CR55 | ||
Lack of history of CHD48 | ||
Health care provider | None reported | |
Social/environment | Divorced/separated27 | |
Transportation problems45, 46 | ||
Long distance between CR program and place of residence46 | ||
Numerous family responsebilities45 | ||
Lack of CR insurance48 |
BDI-II = Beck Depression Inventory-ii; CHD = coronary heart disease; EBBS = Exercise Benefits and Barriers Scale; CR = cardiac rehabilitation; MI = myocardial infarction; STAI-S = State-Trait Anxiety Inventory.
Patient-level Factors
Age and34, 55 comorbidities,18 including musculoskeletal,45 depression,51 diabetes,36 and obesity51 among others factors, have been shown to limit participation in and completion of CR by women. A patient’s lack of information on or familiarity with CR can serve as a barrier to participation.18 Likewise, negative beliefs or perceptions about CR are associated with lower CR participation.18, 43
Of note, we found discrepant results regarding the association between CR participation and a history of either percutaneous coronary intervention or coronary artery bypass graft, with 2 studies40, 43 reporting lower rates of CR participation in these groups and another study suggesting the opposite.53 A similar discrepancy was noted with a history of depression, with one study51 reporting that depression was associated with lower rates of CR completion, whereas another study showed no significant association between depression and CR participation, for men or for women.37 Of interest, obesity was found to be associated with higher CR participation rates41 but lower completion rates, as compared with nonobese patients.51
Provider-level Factors
A strong, supportive endorsement of CR by a health care professional has been shown to improve CR participation rates for women and for men.54
Social/Environmental-level Factors
Transportation problems,18, 45 family obligations at home, lack of CR insurance, and financial concerns35, 49 are all associated with lower CR participation by women. In addition, a lack of social support from family and friends has been reported to be a barrier to CR enrollment.54
Solutions to CR Referral, Enrollment, and Completion
A total of 31 studies were identified that assessed the impact of various interventions that were aimed at improving CR participation.27–29, 56–83 The percentage of participants who were women in these studies was 37.37%, with 27 of the 31 studies including less than 50% of female participants. Six studies listed results separately for women and men,57, 62, 68, 72, 78, 79 whereas only 3 studies assessed interventions to improve CR participation exclusively in women.27–29
Interventions that have been reported to improve CR participation are listed in Table 2, along with the ratings for their level of evidence and strength of recommendation. Systematic approaches to CR referral (eg, automatic referral and “liaison” coaching interventions) have been found to improve CR referral in women and in men, but their impact on CR enrollment is variable.67, 68 Interventions aimed to help patients enroll in CR promptly after hospital discharge have been found to improve CR referral, enrollment, and completion rates.65, 79 In addition, interventions that increase CR awareness among patients and health providers have been shown to increase referral and enrollment rates.60, 62
TABLE 2.
Summary of Evidence and Recommendations for Improving CR Referral, Enrollment, and Completion, Regardless of Gender
A. CR Referral evidence-based solutions | |||||||
---|---|---|---|---|---|---|---|
| |||||||
Intervention | Description | Articles | Proportion of women |
Location | Level addressed |
Level of evidence |
Strength of recommendation |
Early access | Integration of early cardiac access clinic increased referral rates to 8 times compared with the comparison group | Parker et al,79 2011 CCT | 41% | Canada | Health care provider | B-Nonrandomized | IIa |
| |||||||
Automatic referral | Use of the American Heart Association GWTG pathway was associated with 0.5 times higher referral rates | Mazzini et al,73 2008 observational study | 33% | USA | Health care provider | B-Nonrandomized | I |
Systematic referral methods improved CR referral by 2-7 times compared with usual care | Gravely et al,68 2014 observational study | 25% | Canada | Health care provider | |||
Grace et al,67 2007 observational study | 30.84% | Canada | |||||
Grace et al,65 2012 observational study | 26.8% | Canada | |||||
Grace et al,66 2011 observational study | 26.8% | Canada | |||||
Preapproved strategy (cardiac program leadership endorsement of a policy for referral by an allied health professional of all indicated patients) increased referral rates by 2 times that in the comparison group | Grace et al,63 2012 CCT | 25% | Canada | Health care provider | |||
| |||||||
Liaison referral | Liaison intervention increased referral rates 3 times that of usual care | Gravely et al,68 2014 observational study | 25% | Canada | Health care provider | B-Randomized | I |
Grace et al,66 2011 observational study | 26.8% | Canada | |||||
Jolly et al,71 1998 RCT | 29% | UK | |||||
| |||||||
Peer navigation | Bedside visit, education material, and encouragement to obtain CR referral before discharge did not have any effect on referral rates | Ali-Faisal et al,56 2016 RCT | 17% | USA | Health care provider | B-Randomized | IIb |
| |||||||
Automatic + liaison referral | Combined automatic and liaison referral resulted in increasing CR referral rates by 8 to 10 times compared with usual care | Grace et al,66 2011 observational study | 26.8% | Canada | Patient + Health care provider | B-Nonrandomized | I |
Gravely et al,68 2014 observational study | 25% | Canada | |||||
| |||||||
Increase awareness | Increase awareness of CR among health care providers through education combined with a formal referral system increased referral rates by 38 times compared with usual care | Dahhan et al,60 2015 observational study | 41.3% | USA | Patient | B-Nonrandomized | I |
| |||||||
B. CR enrollment/participation evidence-based solutions | |||||||
| |||||||
Intervention | Description | Articles | Proportion of women | Location | Level addressed | Level of evidence | Strength of recommendation |
| |||||||
Increase awareness | Increased awareness by patients and health care providers increased CR participation by 2 to 32 times, respectively, compared with usual care | Dankner et al,62 2015 CCT | 23.83% | Israel | Patient | B-Nonrandomized | I |
Dahhan et al,60 2015 observational study | 41.3% | USA | |||||
| |||||||
Patient navigation | Education about CR and support by phone and mail by navigator increased awareness and CR enrollment by 9 times compared with usual care | Scott et al,82 2013 RCT | 33.7% | USA | Health care provider | B-Randomized | IIa |
Information about benefits of CR and then providing referral process assistance increased enrollment by 1.8 times | Pasquali et al,80 2001 observational study | 38% | USA | ||||
| |||||||
Referred to site closer to home | Participants rereferred to a CR program closer to their home were significantly more likely to enroll than those who were not | Ali-Faisal et al,56 2016 RCT | 17% | USA | Social + Environment | B-Randomized | IIa |
| |||||||
Physician recommendation | Strong CR endorsement by a nurse or a physician increased attendance by 3 and 14 times, respectively | Johnson et al,70 2010 observational study | 37.81% | Australia | Health care provider | 7C | IIa |
| |||||||
Early access | Early appointment increased participation rates from 1.6 to 4 times higher than in the comparison group | Parker et al,79 2011 CCT | 41% | Canada | Health care provider | B-Nonrandomized | I |
Pack et al,78 2013 RCT | 25% | USA | |||||
Grace et al,63 2012 CCT | 25% | Canada | |||||
| |||||||
Automatic referral | Automatic referral was associated with an increase in participation 2 to 5 times higher than in the comparison group | Gravely et al,68 2014 observational study | 25% | Canada | Health care provider | B-Nonrandomized | I |
Grace et al,67 2007 observational study | 30.84% | Canada | |||||
Grace et al,65 2012 observational study | 26.8% | Canada | |||||
Grace et al,66 2011 observational study | 26.8% | Canada | |||||
Grace et al,63 2012 CCT | 25% | Canada | |||||
Mueller et al,76 2009 CCT | 31% | USA | |||||
Grace et al,64 2004 observational study | 39.3% | Canada | |||||
| |||||||
Liaison referral | Liaison assistance increased enrollment rate compared with usual care | Grace et al,66 2011 observational study | 26.8% | Canada | Health care provider | B-Nonrandomized | I |
Gravely et al,68 2014 observational study | 25% | Canada | |||||
| |||||||
Automatic referral + liaison | Combined systematic referral and liaison strategy resulted in 4 to 6.5 times greater enrollment | Grace et al,66 2011 observational study | 26.8% | Canada | Patient + Health care provider | B-Nonrandomized | I |
Gravely et al,68 2014 observational study | 25% | Canada | |||||
| |||||||
Letter | Theory-based invitation letter improved attendance by 3-fold | Mosleh et al,75 2014 RCT | 31% | Jordan | Health care provider | B-Randomized | IIa |
| |||||||
Gender-tailored intervention | Gender-tailored behavioral intervention increased attendance by 4 to 5 sessions | Beckie and Beckstead,27 2010 RCT | 100% | USA | Patient | B-Randomized | IIa |
| |||||||
Alternative programs models | No difference in CR attendance between supervised mixed-sex, supervised women-only, or home-based CR | Grace et al,28 2016 RCT | 100% | Canada | Patient + Social/ Environment | B-Randomized | IIb or C |
Midence et al,29 2016 RCT | 100% | Canada | |||||
| |||||||
Community program | CR participation by women increased by 1.2 times vs hospital-based CR | Blackburn et al,57 2000 observational study | 29% | USA | Social/ Environment | B-Nonrandomized | IIa |
| |||||||
Home visit | Peer advisor/advanced practice nurse intervention increased participation rates at 3 mo by 3 times | Carroll et al,58 2007 RCT | 66% | USA | Health care provider | B-Randomized | IIb |
| |||||||
Nursing phone call | Nursing assessment and encouragement by phone call 2 wk before CR increased participation by 3.4 times | Harkness et al,69 2005 observational study | 24.66% | Canada | Health care provider | C | IIa |
| |||||||
One inpatient visit and 2 outpatient calls | Nursing inpatient visit and 2 additional contacts during the 10 d after hospital discharge increased CR participation rates by 2.6 times | Cossette et al,59 2012 RCT | 16.9% | Canada | Health care provider | B-Randomized | IIa |
| |||||||
Motivational interviewing | Personalized motivational interviewing increased CR participation by 2 sessions compared with the comparison group | McGrady et al,74 2014 RCT | 34% | USA | Patient | B-Randomized | IIa |
| |||||||
Home-based | Uptake was higher in home-based program compared with center-based program | Jolly et al,72 2007 RCT | 23.42% | UK | Patient + Social/Environment | A | I |
Varnfield et al,83 2014 RCT | 16.5% | Australia | |||||
| |||||||
C. CR completion/adherence evidence-based solutions | |||||||
| |||||||
Intervention | Description | Articles | Proportion of women | Location | Level addressed | Level of evidence | Strength of recommendation |
| |||||||
Early access | Integration of early cardiac access clinic increased CR completion rates by 1.4 times above the comparison group | Parker et al, observational study | 41% | Canada | Health care provider | B –Nonrandomized | Ia |
| |||||||
Automatic referral | No significant differences in completion rates with systematic inpatient referral compared with usual care | Grace et al,65 observational study | 26.8% | Canada | Health care provider | B-Nonrandomized | I |
| |||||||
Incentive/ motivational programs | Incentive/motivational programs increased completion rates by 1.8 times | Pack et al,77 observational study | 30% | USA | Patient | B-Nonrandomized | IIa |
| |||||||
Home based | Telephone consultation and education by webcast program did not show significant difference vs traditional program | Scane et al,81 observational study | 20.5% | Canada | Patient + Social/ Environment | B- Randomized | IIa |
| |||||||
Telemedicine supported | Telemedicine-delivered CR in a rural setting had similar adherence to conventional CR | Dalleck et al,61 observational study | 42% | New Zealand | Patient + Social/ Environment | B-Nonrandomized | IIb |
| |||||||
Smartphone/Web-based model | Smartphone-based/Web-based model improved completion rates by 1/3 compared with the traditional program83 | Varnfield et al,83 RCT | 16.5% | Australia | Patient + Social/ Environment | A | I |
CCT = controlled clinical trial; CR = cardiac rehabilitation; GWTG = get with the guidelines; RCT = randomized clinical trial.
Interventions with a letter describing a strong support for CR participation by a health care provider, posthospital home-based visits, and/or telephone calls have also been found to help improve CR participation.58, 59, 69, 75 Home-based CR delivery may contribute to improving participation and completion rates72 for men and for women, based on the results of a meta-analysis.84, 85 Tele-health delivery models may also help increase CR enrollment and completion rates, particularly in women, who appear to be greater adopters of tele-health health care delivery tools and interventions.86, 87
DISCUSSION
This is the first study to our knowledge to have systematically reviewed CR participation barriers for women and provide a practical summary of specific and effective evidencebased interventions to facilitate their participation with the last goal of decreasing the high burden of cardiovascular disease among women.
We identified 24 studies18, 27, 34–55 that ascertained significant and unique barriers for women associated with reduced referral, enrollment, and participation in women. The barriers identified reflect a complex array of demographic, socioeconomic, medical, and societal challenges that impede the delivery of CR services for all patients, but particularly for women. Many of the barriers appear to be either nonmodifiable (eg, age and gender) or are not easily modifiable (eg, socioeconomic status, financial constraints, and education level). Others, such as a low awareness of CR or a lack of strong physician recommendation or referral to CR, appear to be more amenable to corrective action.
We also identified 31 published studies27–29, 56–83 that analyzed the impact of various interventions on CR referral, enrollment, and completion. Several types of interventionsdprimarily systematic approaches to CR referral, enrollment, and completiond were considered to be of highest strength of recommendation and level of evidence, as noted in Table 2. It is worth noting that these highly rated, systematic approaches to improving CR delivery can help to reduce most, if not all, types of barriers to CR participation, including both modifiable and nonmodifiable barriers. Systematic approaches, such as automated CR referral systems,64–68, 73, 76 liaison/nurse-to-patient contact,56, 66, 68, 80, 82 and early posthospital enrollment,63, 78, 79 are feasible and effective ways to overcome referral bias, improve awareness of CR, and address other barriers that are particularly challenging for women in need of CR. The use of systematic approaches to CR enrollment would help to address the current common problem of delayed enrollment,78 an important issue since each day of enrollment delay translates into a 1% decrement in the likelihood of CR enrollment.88 At the same time, such approaches may play an essential role in addressing the lack of support or endorsement that have been reported as barriers to CR participation among women.
Furthermore, incentive programs,74, 77 flexible hours, and the use of alternative delivery CR models are additional strategies that can help women once they enroll in CR to avoid “dropping out,” and instead receive a “full dose” of CR services. The impact of such interventions can have a considerable impact, potentially tripling the level of CR participation and the related health benefits for women (and for men) in need of CR services.89 Alternative models of CR delivery that offer more flexible and personalized treatment options, including the use of home-based and/or smartphone-based CR models, may be even more ideally suited for women than for men.86, 87 Women-only CR programs have been tested in a relatively small number of studies, and may play a role in helping to provide more flexible options to women in need of effective CR services. Further research is warranted in exploring the impact of these alternative delivery models on CR outcomes in both women and men. In addition, further studies are needed that explore the barriers and potential solutions to CR participation for women, related to their specific psychosocial and health perception parameters.27, 51 Additional work is also needed to explore the impact of larger-scale, public awareness campaigns, such as the Go Red For Women campaign from the American Heart Association on CR awareness and participation among women.90 Finally, the interplay between gender and ethnicity warrants further investigation, particularly because women in underrepresented minority groups experience various health care disparities, including the underutilization of CR services.91
Study Limitations
Our review of barriers to CR participation for women was admittedly focused on quantitative research studies and could be enhanced by the addition of qualitative studies that may further elucidate some CR barriers, such as the lack of peer support.92 Our assessment of interventions aimed at improving CR participation is limited by the relatively low availability of published studies on gender-based solutions to CR referral, enrollment, and participation. However, the studies in our analysis did include a significant number of women, sufficient to provide evidence for the impact of various interventions on CR participation in women.
CONCLUSION
A wide, complex variety of modifiable and nonmodifiable barriers exist that limit CR participation in women. High-quality systematic approaches to improving CR participation can help to overcome these barriers and are strongly recommended. New delivery models for CR, such as home-based and/or smartphone-based CR, appear to be promising approaches to help improve CR delivery to women, but further research is needed in this important area.
Supplementary Material
ARTICLE HIGHLIGHTS.
Fewer women than men participate in cardiac rehabilitation because of a complex and unique array of demographic, socioeconomic, medical, and societal challenges faced by women.
Systematic approaches to cardiac rehabilitation referral, enrollment, and participation have been shown to improve cardiac rehabilitation participation and are recommended to help overcome the gender gap in cardiac rehabilitation participation.
Further research is warranted on the impact of novel cardiac rehabilitation delivery models, such as home-based cardiac rehabilitation, on the gender gap in cardiac rehabilitation participation.
Acknowledgments
We are grateful to Patricia Erwin, librarian, for assistance with the literature search. We also acknowledge the helpful critiques and suggestions from Begoña Martínez Jarreta, MD, PhD, and Marina Gimeno González, MD.
Grant Support: The work was supported in part by grant Z.1.05/1.1.00/02.0123 (F.L.-J. and M.S.) from the European Regional Development Fund-Project of The International Clinical Research Center of St. Anne’s University Hospital Brno (FNUSA-ICRC).
Abbreviations and Acronyms
- CR
cardiac rehabilitation
- OR
odds ratio
- RCT
randomized clinical trial
Footnotes
SUPPLEMENTAL ONLINE MATERIAL
Supplemental material can be found online at http://www.mayoclinicproceedings.org. Supplemental material attached to journal articles has not been edited, and the authors take responsibility for the accuracy of all data.
Potential Competing Interests: Dr Lopez-Jimenez reports an unrelated financial disclosure (speaker’s honorarium, Amg
References
- 1.Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011;(7):CD001800. doi: 10.1002/14651858.CD001800.pub2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Wenger NK. Current status of cardiac rehabilitation. J Am Coll Cardiol. 2008;51(17):1619–1631. doi: 10.1016/j.jacc.2008.01.030. [DOI] [PubMed] [Google Scholar]
- 3.Goel K, Pack QR, Lahr B, et al. Cardiac rehabilitation is associated with reduced long-term mortality in patients undergoing combined heart valve and CABG surgery. Eur J Prev Cardiol. 2015;22(2):159–168. doi: 10.1177/2047487313512219. [DOI] [PubMed] [Google Scholar]
- 4.Armstrong MJ, Sigal RJ, Arena R, et al. Cardiac rehabilitation completion is associated with reduced mortality in patients with diabetes and coronary artery disease. Diabetologia. 2015;58(4):691–698. doi: 10.1007/s00125-015-3491-1. [DOI] [PubMed] [Google Scholar]
- 5.Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation. 2010;121(1):63–70. doi: 10.1161/CIRCULATIONAHA.109.876383. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Balady GJ, Ades PA, Bittner VA, et al. American Heart Association Science Advisory and Coordinating Committee. Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation. 2011;124(25):2951–2960. doi: 10.1161/CIR.0b013e31823b21e2. [DOI] [PubMed] [Google Scholar]
- 7.Dobson LE, Lewin RJ, Doherty P, Batin PD, Megarry S, Gale CP. Is cardiac rehabilitation still relevant in the new millennium? J Cardiovasc Med (Hagerstown) 2012;13(1):32–37. doi: 10.2459/JCM.0b013e32834d4571. [DOI] [PubMed] [Google Scholar]
- 8.Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J. 2011;162(4):571–584e2. doi: 10.1016/j.ahj.2011.07.017. [DOI] [PubMed] [Google Scholar]
- 9.Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women-2011 update: a guideline from the American Heart Association. J Am Coll Cardiol. 2011;2011;123(11):1243–1262. doi: 10.1161/CIR.0b013e31820faaf8. Erratum in Circulation. 2011; 123(22):e624. Circulation.;2011 124(16):pe427. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Aragam KG, Dai D, Neely ML, et al. Gaps in referral to cardiac rehabilitation of patients undergoing percutaneous coronary intervention in the United States. J Am Coll Cardiol. 2015;65(19):2079–2088. doi: 10.1016/j.jacc.2015.02.063. [DOI] [PubMed] [Google Scholar]
- 11.Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2007;116(15):1653–1662. doi: 10.1161/CIRCULATIONAHA.107.701466. [DOI] [PubMed] [Google Scholar]
- 12.Thomas RJ. The gap in cardiac rehabilitation referral: a system-based problem with system-based solutions. J Am Coll Cardiol. 2015;65(19):2089–2090. doi: 10.1016/j.jacc.2015.03.521. [DOI] [PubMed] [Google Scholar]
- 13.Witt BJ, Jacobsen SJ, Weston SA, et al. Cardiac rehabilitation after myocardial infarction in the community. J Am Coll Cardiol. 2004;44(5):988–996. doi: 10.1016/j.jacc.2004.05.062. [DOI] [PubMed] [Google Scholar]
- 14.Samayoa L, Grace SL, Gravely S, Scott LB, Marzolini S, Colella TJ. Sex differences in cardiac rehabilitation enrollment: a meta-analysis. Can J Cardiol. 2014;30(7):793–800. doi: 10.1016/j.cjca.2013.11.007. [DOI] [PubMed] [Google Scholar]
- 15.Colella TJ, Gravely S, Marzolini S, et al. Sex bias in referral of women to outpatient cardiac rehabilitation? A meta-analysis. Eur J Prev Cardiol. 2015;22(4):423–441. doi: 10.1177/2047487314520783. [DOI] [PubMed] [Google Scholar]
- 16.Scott LA, Ben-Or K, Allen JK. Why are women missing from outpatient cardiac rehabilitation programs? A review of multilevel factors affecting referral, enrollment, and completion. J Womens Health (Larchmt) 2002;11(9):773–791. doi: 10.1089/15409990260430927. [DOI] [PubMed] [Google Scholar]
- 17.Feola M, Garnero S, Daniele B, et al. Gender differences in the efficacy of cardiovascular rehabilitation in patients after cardiac surgery procedures. J Geriatr Cardiol. 2015;12(5):575–579. doi: 10.11909/j.issn.1671-5411.2015.05.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Grace SL, Gravely-Witte S, Kayaniyil S, Brual J, Suskin N, Stewart DE. A multisite examination of sex differences in cardiac rehabilitation barriers by participation status. J Womens Health (Larchmt) 2009;18(2):209–216. doi: 10.1089/jwh.2007.0753. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Anjo D, Santos M, Rodrigues P, et al. The benefits of cardiac rehabilitation in coronary heart disease: a gender issue? [Article in English, Portuguese] Rev Port Cardiol. 2014;33(2):79–87. doi: 10.1016/j.repc.2013.06.014. [DOI] [PubMed] [Google Scholar]
- 20.Hazelton G, Williams JW, Wakefield J, Perlman A, Kraus WE, Wolever RQ. Psychosocial benefits of cardiac rehabilitation among women compared with men. J Cardiopulm Rehabil Prev. 2014;34(1):21–28. doi: 10.1097/HCR.0000000000000034. [DOI] [PubMed] [Google Scholar]
- 21.Josephson EA, Casey EC, Waechter D, Rosneck J, Hughes JW. Gender and depression symptoms in cardiac rehabilitation: women initially exhibit higher depression scores but experience more improvement. J Cardiopulm Rehabil. 2006;26(3):160–163. doi: 10.1097/00008483-200605000-00008. [DOI] [PubMed] [Google Scholar]
- 22.Barth J, Volz A, Schmid JP, et al. Gender differences in cardiac rehabilitation outcomes: do women benefit equally in psychological health? J Womens Health (Larchmt) 2009;18(12):2033–2039. doi: 10.1089/jwh.2008.1058. [DOI] [PubMed] [Google Scholar]
- 23.Sarrafzadegan N, Rabiei K, Kabir A, et al. Gender differences in risk factors and outcomes after cardiac rehabilitation. Acta Cardiol. 2008;63(6):763–770. doi: 10.2143/AC.63.6.2033395. [DOI] [PubMed] [Google Scholar]
- 24.Colbert JD, Martin BJ, Haykowsky MJ, et al. Cardiac rehabilitation referral, attendance and mortality in women. Eur J Prev Cardiol. 2015;22(8):979–986. doi: 10.1177/2047487314545279. [DOI] [PubMed] [Google Scholar]
- 25.McCarthy MM, Vaughan Dickson V, Chyun D. Barriers to cardiac rehabilitation in women with cardiovascular disease: an integrative review. J Cardiovasc Nurs. 2011;26(5):E1–E10. doi: 10.1097/JCN.0b013e3181f877e9. [DOI] [PubMed] [Google Scholar]
- 26.Oosenbrug E, Marinho RP, Zhang J, et al. Sex differences in cardiac rehabilitation adherence: a meta-analysis. Can J Cardiol. 2016;32(11):1316–1324. doi: 10.1016/j.cjca.2016.01.036. [DOI] [PubMed] [Google Scholar]
- 27.Beckie TM, Beckstead JW. Predicting cardiac rehabilitation attendance in a gender-tailored randomized clinical trial. J Cardiopulm Rehabil Prev. 2010;30(3):147–156. doi: 10.1097/HCR.0b013e3181d0c2ce. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Grace SL, Midence L, Oh P, et al. Cardiac rehabilitation program adherence and functional capacity among women: a randomized controlled trial. Mayo Clin Proc. 2016;91(2):140–148. doi: 10.1016/j.mayocp.2015.10.021. [DOI] [PubMed] [Google Scholar]
- 29.Midence L, Arthur HM, Oh P, Stewart DE, Grace SL. Women’s health behaviours and psychosocial well-being by cardiac rehabilitation program model: a randomized controlled trial. Can J Cardiol. 2016;32(8):956–962. doi: 10.1016/j.cjca.2015.10.007. [DOI] [PubMed] [Google Scholar]
- 30.Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336–341. doi: 10.1016/j.ijsu.2010.02.007. [DOI] [PubMed] [Google Scholar]
- 31.Higgins RO, Murphy BM, Goble AJ, Le Grande MR, Elliott PC, Worcester MU. Cardiac rehabilitation program attendance after coronary artery bypass surgery: overcoming the barriers. Med J Aust. 2008;188(12):712–714. doi: 10.5694/j.1326-5377.2008.tb01852.x. [DOI] [PubMed] [Google Scholar]
- 32.Wells GA, Shea B, O’Connell D, et al. [Accessed November 1, 2016];The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.htm.
- 33.Jacobs AK, Anderson JL, Halperin JL. The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(13):1373–1384. doi: 10.1016/j.jacc.2014.06.001. [DOI] [PubMed] [Google Scholar]
- 34.Ades PA, Waldmann ML, Polk DM, Coflesky JT. Referral patterns and exercise response in the rehabilitation of female coronary patients aged greater than or equal to 62 years. Am J Cardiol. 1992;69(17):1422–1425. doi: 10.1016/0002-9149(92)90894-5. [DOI] [PubMed] [Google Scholar]
- 35.Allen JK, Scott LB, Stewart KJ, Young DR. Disparities in women’s referral to and enrollment in outpatient cardiac rehabilitation. J Gen Intern Med. 2004;19(7):747–753. doi: 10.1111/j.1525-1497.2004.30300.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Armstrong MJ, Martin B-J, Arena R, et al. Patients with diabetes in cardiac rehabilitation: attendance and exercise capacity. Med Sci Sports Exerc. 2014;46(5):845–850. doi: 10.1249/MSS.0000000000000189. [DOI] [PubMed] [Google Scholar]
- 37.Casey E, Hughes JW, Waechter D, Josephson R, Rosneck J. Depression predicts failure to complete phase-II cardiac rehabilitation. J Behav Med. 2008;31(5):421–431. doi: 10.1007/s10865-008-9168-1. [DOI] [PubMed] [Google Scholar]
- 38.Caulin-Glaser T, Blum M, Schmeizl R, Prigerson HG, Zaret B, Mazure CM. Gender differences in referral to cardiac rehabilitation programs after revascularization. J Cardiopulm Rehabil. 2001;21(1):24–30. doi: 10.1097/00008483-200101000-00006. [DOI] [PubMed] [Google Scholar]
- 39.Chamosa S, Alarcon JA, Dorronsoro M, et al. Predictors of enrollment in cardiac rehabilitation programs in Spain. J Cardiopulm Rehabil Prev. 2015;35(4):255–262. doi: 10.1097/HCR.0000000000000126. [DOI] [PubMed] [Google Scholar]
- 40.De Feo S, Tramarin R, Ambrosetti M, et al. Gender differences in cardiac rehabilitation programs from the Italian survey on cardiac rehabilitation (ISYDE-2008) Int J Cardiol. 2012;160(2):133–139. doi: 10.1016/j.ijcard.2011.04.011. [DOI] [PubMed] [Google Scholar]
- 41.Dunlay SM, Witt BJ, Allison TG, et al. Barriers to participation in cardiac rehabilitation. Am Heart J. 2009;158(5):852–859. doi: 10.1016/j.ahj.2009.08.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Gallagher R, McKinley S, Dracup K. Predictors of women’s attendance at cardiac rehabilitation programs. Prog Cardiovasc Nurs. 2003;18(3):121–126. doi: 10.1111/j.0889-7204.2003.02129.x. [DOI] [PubMed] [Google Scholar]
- 43.Grace SL, Grewal K, Arthur HM, Abramson BL, Stewart DE. A prospective, controlled multisite study of psychosocial and behavioral change following women’s cardiac rehabilitation participation. J Womens Health (Larchmt) 2008;17(2):241–248. doi: 10.1089/jwh.2007.0519. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Lieberman L, Meana M, Stewart D. Cardiac rehabilitation: gender differences in factors influencing participation. J Womens Health (Larchmt) 1998;7(6):717–723. doi: 10.1089/jwh.1998.7.717. [DOI] [PubMed] [Google Scholar]
- 45.Marzolini S, Brooks D, Oh PI. Sex differences in completion of a 12-month cardiac rehabilitation programme: an analysis of 5922 women and men. Eur J Cardiovasc Prev Rehabil. 2008;15(6):698–703. doi: 10.1097/HJR.0b013e32830c1ce3. [DOI] [PubMed] [Google Scholar]
- 46.Mikkelsen T, Korsgaard Thomsen K, Tchijevitch O. Non-attendance and drop-out in cardiac rehabilitation among patients with ischaemic heart disease. Dan Med J. 2014;61(10):A4919. [PubMed] [Google Scholar]
- 47.Missik E. Personal perceptions and women’s participation in cardiac rehabilitation. Rehabil Nurs. 1999;24(4):158–165. doi: 10.1002/j.2048-7940.1999.tb02164.x. [DOI] [PubMed] [Google Scholar]
- 48.Missik E. Women and cardiac rehabilitation: accessibility issues and policy recommendations. Rehabil Nurs. 2001;26(4):141–147. doi: 10.1002/j.2048-7940.2001.tb01937.x. [DOI] [PubMed] [Google Scholar]
- 49.Mochari H, Lee JR, Kligfield P, Mosca L. Ethnic differences in barriers and referral to cardiac rehabilitation among women hospitalized with coronary heart disease. Prev Cardiol. 2006 Winter;9(1):8–13. doi: 10.1111/j.1520-037x.2005.3703.x. [DOI] [PubMed] [Google Scholar]
- 50.Plach SK. Women and cardiac rehabilitation after heart surgery: patterns of referral and adherence. Rehabil Nurs. 2002;27(3):104–109. doi: 10.1002/j.2048-7940.2002.tb01998.x. [DOI] [PubMed] [Google Scholar]
- 51.Sanderson BK, Bittner V. Women in cardiac rehabilitation: outcomes and identifying risk for dropout. Am Heart J. 2005;150(5):1052–1058. doi: 10.1016/j.ahj.2004.12.027. [DOI] [PubMed] [Google Scholar]
- 52.Sanderson BK, Shewchuk RM, Bittner V. Cardiac rehabilitation and women: what keeps them away? J Cardiopulm Rehabil Prev. 2010;30(1):12–21. doi: 10.1097/HCR.0b013e3181c85859. [DOI] [PubMed] [Google Scholar]
- 53.Stewart Williams JA. Using non-linear decomposition to explain the discriminatory effects of male-female differentials in access to care: a cardiac rehabilitation case study. Soc Sci Med. 2009;69(7):1072–1079. doi: 10.1016/j.socscimed.2009.07.012. [DOI] [PubMed] [Google Scholar]
- 54.Wieslander I, Baigi A, Turesson C, Fridlund B. Women’s social support and social network after their first myocardial infarction: a 4-year follow-up with focus on cardiac rehabilitation. Eur J Cardiovasc Nurs. 2005;4(4):278–285. doi: 10.1016/j.ejcnurse.2005.06.004. [DOI] [PubMed] [Google Scholar]
- 55.Worcester MU, Murphy BM, Mee VK, Roberts SB, Goble AJ. Cardiac rehabilitation programmes: predictors of non-attendance and dropout. Eur J Cardiovasc Prev Rehabil. 2004;11(4):328–335. doi: 10.1097/01.hjr.0000137083.20844.54. [DOI] [PubMed] [Google Scholar]
- 56.Ali-Faisal SF, Scott L, Johnston L, Grace SL. Cardiac rehabilitation referral and enrolment across an academic health sciences centre with eReferral and peer navigation: a randomised controlled pilot trial. BMJ Open. 2016;6(3):e010214. doi: 10.1136/bmjopen-2015-010214. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 57.Blackburn GG, Foody JM, Sprecher DL, Park E, Apperson-Hansen C, Pashkow FJ. Cardiac rehabilitation participation patterns in a large, tertiary care center: evidence for selection bias. J Cardiopulm Rehabil Prev. 2000;20(3):189–195. doi: 10.1097/00008483-200005000-00007. [DOI] [PubMed] [Google Scholar]
- 58.Carroll DL, Rankin SH, Cooper BA. The effects of a collaborative peer advisor/advanced practice nurse intervention: cardiac rehabilitation participation and rehospitalization in older adults after a cardiac event. J Cardiovasc Nurs. 2007;22(4):313–319. doi: 10.1097/01.JCN.0000278955.44759.73. [DOI] [PubMed] [Google Scholar]
- 59.Cossette S, Frasure-Smith N, Dupuis J, Juneau M, Guertin MC. Randomized controlled trial of tailored nursing interventions to improve cardiac rehabilitation enrollment. Nurs Res. 2012;61(2):111–120. doi: 10.1097/NNR.0b013e318240dc6b. [DOI] [PubMed] [Google Scholar]
- 60.Dahhan A, Maddox WR, Krothapalli S, et al. Education of physicians and implementation of a formal referral system can improve cardiac rehabilitation referral and participation rates after percuta-neouscoronary intervention. Heart Lung Circ. 2015;24(8):806–816. doi: 10.1016/j.hlc.2015.02.006. [DOI] [PubMed] [Google Scholar]
- 61.Dalleck LC, Schmidt LK, Lueker R. Cardiac rehabilitation outcomes in a conventional versus telemedicine-based programme. J Telemed Telecare. 2011;17(5):217–221. doi: 10.1258/jtt.2010.100407. [DOI] [PubMed] [Google Scholar]
- 62.Dankner R, Drory Y, Geulayov G, et al. A controlled intervention to increase participation in cardiac rehabilitation. Eur J Prev Cardiol. 2015;22(9):1121–1128. doi: 10.1177/2047487314548815. [DOI] [PubMed] [Google Scholar]
- 63.Grace SL, Angevaare KL, Reid RD, et al. CRCARE Investigators. Effectiveness of inpatient and outpatient strategies in increasing referral and utilization of cardiac rehabilitation: a prospective, multi-site study. Implement Sci. 2012;7:120. doi: 10.1186/1748-5908-7-120. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 64.Grace SL, Evindar A, Kung TN, Scholey PE, Stewart DE. Automatic referral to cardiac rehabilitation. Med Care. 2004;42(7):661–669. doi: 10.1097/01.mlr.0000129901.05299.aa. [DOI] [PubMed] [Google Scholar]
- 65.Grace SL, Leung YW, Reid R, Oh P, Wu G, Alter DA. CRCARE Investigators. The role of systematic inpatient cardiac rehabilitation referral in increasing equitable access and utilization. J Cardiopulm Rehabil Prev. 2012;32(1):41–47. doi: 10.1097/HCR.0b013e31823be13b. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 66.Grace SL, Russell KL, Reid RD, et al. Cardiac Rehabilitation Care Continuity Through Automatic Referral Evaluation (CRCARE) Investigators. Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study. Arch Intern Med. 2011;171(3):235–241. doi: 10.1001/archinternmed.2010.501. [DOI] [PubMed] [Google Scholar]
- 67.Grace SL, Scholey P, Suskin N, et al. A prospective comparison of cardiac rehabilitation enrollment following automatic vs usual referral. J Rehabil Med. 2007;39(3):239–245. doi: 10.2340/16501977-0046. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 68.Gravely S, Anand SS, Stewart DE, Grace SL. CRCARE Investigators. Effect of referral strategies on access to cardiac rehabilitation among women. Eur J Prev Cardiol. 2014;21(8):1018–1025. doi: 10.1177/2047487313482280. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 69.Harkness K, Smith KM, Taraba L, Mackenzie CL, Gunn E, Arthur HM. Effect of a postoperative telephone intervention on attendance at intake for cardiac rehabilitation after coronary artery bypass graft surgery. Heart Lung. 2005;34(3):179–186. doi: 10.1016/j.hrtlng.2004.07.010. [DOI] [PubMed] [Google Scholar]
- 70.Johnson NAIK, Nagle AL, Wiggers JH. Attendance at outpatient cardiac rehabilitation: is it enhanced by specialist nurse referral? Aust J Adv Nurs. 2010;27(4):31–37. [Google Scholar]
- 71.Jolly K, Bradley F, Sharp S, Smith H, Mant D. Follow-up care in general practice of patients with myocardial infarction or angina pectoris: initial results of the SHIP trial. Southampton Heart Integrated Care Project. Fam Pract. 1998;15(6):548–555. doi: 10.1093/fampra/15.6.548. [DOI] [PubMed] [Google Scholar]
- 72.Jolly K, Taylor R, Lip GY, et al. The Birmingham Rehabilitation Uptake Maximisation Study (BRUM). Home-based compared with hospital-based cardiac rehabilitation in a multi-ethnic population: cost-effectiveness and patient adherence. Health Technol Assess. 2007;11(35):1–118. doi: 10.3310/hta11350. [DOI] [PubMed] [Google Scholar]
- 73.Mazzini MJ, Stevens GR, Whalen D, Ozonoff A, Balady GJ. 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. Am J Cardiol. 2008;101(8):1084–1087. doi: 10.1016/j.amjcard.2007.11.063. [DOI] [PubMed] [Google Scholar]
- 74.McGrady A, Burkes R, Badenhop D, McGinnis R. Effects of a brief intervention on retention of patients in a cardiac rehabilitation program. Appl Psychophysiol Biofeedback. 2014;39(3–4):163–170. doi: 10.1007/s10484-014-9252-y. [DOI] [PubMed] [Google Scholar]
- 75.Mosleh SM, Bond CM, Lee AJ, Kiger A, Campbell NC. Effectiveness of theory-based invitations to improve attendance at cardiac rehabilitation: a randomized controlled trial. Eur J Cardiovasc Nurs. 2014;13(3):201–210. doi: 10.1177/1474515113491348. [DOI] [PubMed] [Google Scholar]
- 76.Mueller E, Savage PD, Schneider DJ, Howland LL, Ades PA. Effect of a computerized referral at hospital discharge on cardiac rehabilitation participation rates. J Cardiopulm Rehabil Prev. 2009;29(6):365–369. doi: 10.1097/HCR.0b013e3181b4ca75. [DOI] [PubMed] [Google Scholar]
- 77.Pack QR, Johnson LL, Barr LM, et al. Improving cardiac rehabilitation attendance and completion through quality improvement activities and a motivational program. J Cardiopulm Rehabil Prev. 2013;33(3):153–159. doi: 10.1097/HCR.0b013e31828db386. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 78.Pack QR, Mansour M, Barboza JS, et al. An early appointment to outpatient cardiac rehabilitation at hospital discharge improves attendance at orientation: a randomized, single-blind, controlled trial. Circulation. 2013;127(3):349–355. doi: 10.1161/CIRCULATIONAHA.112.121996. [DOI] [PubMed] [Google Scholar]
- 79.Parker K, Stone JA, Arena R, et al. An early cardiac access clinic significantly improves cardiac rehabilitation participation and completion rates in low-risk ST-elevation myocardial infarction patients. Can J Cardiol. 2011;27(5):619–627. doi: 10.1016/j.cjca.2010.12.076. [DOI] [PubMed] [Google Scholar]
- 80.Pasquali SK, Alexander KP, Lytle BL, Coombs LP, Peterson ED. Testing an intervention to increase cardiac rehabilitation enrollment after coronary artery bypass grafting. Am J Cardiol. 2001;88(12):1415–1416. doi: 10.1016/s0002-9149(01)02123-3. A6. [DOI] [PubMed] [Google Scholar]
- 81.Scane K, Alter D, Oh P, Brooks D. Adherence to a cardiac rehabilitation home program model of care: a comparison to a well-established traditional on-site supervised program. Appl Physiol Nutr Metab. 2012;37(2):206–213. doi: 10.1139/h11-151. [DOI] [PubMed] [Google Scholar]
- 82.Scott LB, Gravely S, Sexton TR, Brzostek S, Brown DL. Examining the effect of a patient navigation intervention on outpatient cardiac rehabilitation awareness and enrollment. J Cardiopulm Rehabil Prev. 2013;33(5):281–291. doi: 10.1097/HCR.0b013e3182972dd6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 83.Varnfield M, Karunanithi M, Lee CK, et al. Smartphone-based home care model improved use of cardiac rehabilitation in postmyocardial infarction patients: results from a randomised controlled trial. Heart. 2014;100(22):1770–1779. doi: 10.1136/heartjnl-2014-305783. [DOI] [PubMed] [Google Scholar]
- 84.Taylor RS, Dalal H, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2015;(8):CD007130. doi: 10.1002/14651858.CD007130.pub3. [DOI] [PubMed] [Google Scholar]
- 85.Huang K, Liu W, He D, et al. Telehealth interventions versus center-based cardiac rehabilitation of coronary artery disease: a systematic review and meta-analysis. Eur J Prev Cardiol. 2015;22(8):959–971. doi: 10.1177/2047487314561168. [DOI] [PubMed] [Google Scholar]
- 86.Kontos E, Blake KD, Chou WY, Prestin A. Predictors of eHealth usage: insights on the digital divide from the Health Information National Trends Survey 2012. J Med Internet Res. 2014;16(7):e172. doi: 10.2196/jmir.3117. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 87.Tennant B, Stellefson M, Dodd V, et al. eHealth literacy and Web 2.0 health information seeking behaviors among baby boomers and older adults. J Med Internet Res. 2015;17(3):e70. doi: 10.2196/jmir.3992. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 88.Russell KL, Holloway TM, Brum M, Caruso V, Chessex C, Grace SL. Cardiac rehabilitation wait times: effect on enrollment. J Cardiopulm Rehabil Prev. 2011;31(6):373–377. doi: 10.1097/HCR.0b013e318228a32f. [DOI] [PubMed] [Google Scholar]
- 89.Ades PA, Keteyian SJ, Wright JS, et al. Increasing cardiac rehabilitation participation from 20% to 70%: a road map from the Million Hearts Cardiac Rehabilitation Collaborative [published online ahead of print November 14, 2016] Mayo Clin Proc. doi: 10.1016/j.mayocp.2016.10.014. pii: S0025-6196(16)30648-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 90.Kling JM, Miller VM, Mankad R, et al. Go Red for Women cardiovascular health-screening evaluation: the dichotomy between awareness and perception of cardiovascular risk in the community. J Womens Health (Larchmt) 2013;22(3):210–218. doi: 10.1089/jwh.2012.3744. [DOI] [PubMed] [Google Scholar]
- 91.Mead H, Ramos C, Grantham SC. Drivers of racial and ethnic disparities in cardiac rehabilitation use: patient and provider perspectives. Med Care Res Rev. 2016;73(3):251–282. doi: 10.1177/1077558715606261. [DOI] [PubMed] [Google Scholar]
- 92.Rolfe DE, Sutton EJ, Landry M, Sternberg L, Price JA. Women’s experiences accessing a women-centered cardiac rehabilitation program: a qualitative study. J Cardiovasc Nurs. 2010;25(4):332–341. doi: 10.1097/JCN.0b013e3181c83f6b. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.