Low disparity and high attendance rate to out-patient cardiac rehabilitation after systematic referral

Purpose: Outpatient Cardiac Rehabilitation (CR) improves prognosis in coronary heart disease (CHD) but remains underutilized, especially among women, ethnic minorities, and the elderly. We hypothesized that automatized early referral will increase attendance and reduce disparities. Methods: All consecutive patients discharged from our hospital with acute coronary syndrome (ACS) or stable CHD in a 24-months period from February 2011 were monitored for referral to and participation in CR after introduction of automatized early referral. Results: 817 patients were included in the study. Index event was STEMI (22%), NSTEMI (26%), unstable angina (18%) and stable CHD (34%). Mean age was 65 (inter quartile range 57-74), 246 (30%) were women and 138 (17%) belonged to an ethnic minority. Overall, 297 (36%) did not participate in CR: 248 (84%) were not referred and 49 declined to participate. Main reasons for non-referral were severe co-morbidity, living in a nursing home or recent participation in CR. The non-referred were older (mean age 69, p for difference compared to referred <0.001), 37% were women (p=0.002), and 16% belonged to an ethnic minority (p=0.81). In a logistic regression younger age (P<0.001) and STEMI versus other index events (OR 2.2, p=0.001) but not gender (p=0.12) or ethnicity (p=0.34) predicted referral after mutual adjustment. Of the 569 patients referred for CR, 49 (9%) declined participation. These non-attendees did not differ from attendees with regard to gender, ethnicity, age or index-event. In relation to traditional cardiovascular risk factors, smokers (p<0.001) and patients with diabetes (p=0.003) were less likely to attend whereas hypertension, hypercholesterolemia, family history of CHD, BMI and physical inactivity did not predict attendance. Conclusion: The study indicate that automatized referral results in very high rates of participation in cardiac rehabilitation with no gender or ethnic disparities. In this unselected sample of consecutive patients discharged with CHD, 74% participated in CR. Main reason for non-participation was non-referral: Among patients deemed eligible to CR only 9% declined participation.