Barriers to Cardiac Rehabilitation Participation: Predicting Enrollment in an Urban, Safety-Net Hospital

Abstract

The Centers for Disease Control and Prevention (CDC) suggest that cardiovascular disease (CVD) is the leading cause of death in the United States. It is estimated that approximately 600,000 people die each year from CVD-related causes (Kochanek, Xu, Murphy, Minino, & Kung, 2011). However, these mortality rates vary among socioeconomic classes. There are more risk factors associated with CVD-related mortality in individuals of lower socioeconomic status (SES) compared to those of middle or high SES, such as less access to effective health care services, increased likelihood of sedentary lifestyles, greater exposure to tobacco, and lack of health insurance (Mead, Andres, Ramos, Siegal, & Regenstein, 2010). Although these risk factors are present, some of these are modifiable by secondary prevention efforts such as cardiac rehabilitation (CR). CR has been shown to be effective in improving clinical outcomes of patients with CVD (Dunlay et al., 2009). Specifically, CR is associated with decreased risk of subsequent cardiac events as well as cardiac-related mortality. Although CR is associated with beneficial outcomes following CVD, referral to and participation rates in CR are low (Grace et al., 2009). Among eligible CR patients, it is estimated that approximately 14% to 55% of those referred actually participate, with even lower participation rates reported among women, elderly, minorities, and economically disadvantaged populations (Dunlay et al., 2009). Previous research has examined psychosocial, demographic, and clinical predictors of participation in CR predominantly with patients of middle to high-income status, most of whom had health insurance. For example, Lane, Carroll, Ring, Beevers, and Lip (2001) examined predictors of attendance after myocardial infarction (MI). Among 263 eligible participants, 108 (41%) attended CR. Results showed that those who did not attend CR were more likely to be female, live alone, lack employment, live in economicallydeprived areas, show more symptoms of depression and anxiety, and exercise infrequently prior to MI. Additionally, Dunlay et al. (2009) investigated perceived barriers to participation in CR. Among 179 survey respondents, 115 (64.2%) attended CR. Patient and clinical characteristics associated with CR participation included younger age, male sex, lack of diabetes, more severe myocardial infarctions (MI), no prior MI, and no prior CR attendance. The psychosocial factors associated with participation included placing a high importance on CR, feeling that CR was necessary, better perceived health prior to MI, the ability to drive, and post-secondary education. Results showed that the most commonly endorsed barriers to participating in CR were the associated costs and lack of insurance coverage (27.9%), and perceived inconvenience (20.1%). Although these findings are significant in discovering factors associated with participation in CR, their sample included middle and high SES participants, and was predominantly (90%) European American. More information regarding perceived barriers to participation in CR is necessary to understand how social and psychological factors impact outcomes following a CVD diagnosis. The purpose of the current study was to examine rates of enrollment, demographic characteristics, and perceived barriers to participation in CR within a diverse sample of patients eligible for CR at a safety-net hospital. Further, I sought to investigate the relationship of demographic characteristics and perceived barriers in predicting enrollment in CR within this sample.