Social Inequality in the Comprehensive Cardiac Rehabilitation Pathway: A NATIONWIDE COHORT STUDY ACROSS HOSPITALS AND PRIMARY HEALTH CARE CENTERS

Abstract

Purpose: To examine socioeconomic differences in the nonpharmacological cardiac rehabilitation (CR) pathway from hospital discharge to CR completion in hospital and primary care settings.

Methods: This nationwide cohort study included patients hospitalized with ischemic heart disease between April 1, 2019, and March 31, 2022. Follow-up continued through December 31, 2022, focusing on nonutilization of 11 CR components, including: delayed CR needs assessment (>14 days) and physical exercise training (>29 days); lack of patient education, physical exercise training, test of cardiorespiratory fitness (CRF), depression screening, improvement in CRF (<10% increase), smoking cessation, and finalizing CR meeting; and completion of <75% of planned exercise sessions and dropout. Socioeconomic differences were analyzed by educational attainment, income, occupation, and cohabitant status.

Results: Among 45 497 hospitalized patients with ischemic heart disease, 43% (n = 19 573) participated in CR. Only 25% received a CR needs assessment within 14 days of discharge. Socioeconomic differences were demonstrated throughout the CR pathway, except for the finalizing meeting, improvement in CRF, and smoking cessation. The odds of nonutilization among patients with lower educational attainment ranged between 8% higher odds of delayed CR needs assessment (adjusted OR = 1.08: 95% CI, 1.01-1.15) and 31% higher odds of no CRF test (adjusted OR = 1.31: 95% CI, 1.18-1.45).

Conclusions: The observed socioeconomic differences throughout the CR pathway underscore the need for targeted interventions to ensure early assessment of CR needs and participation in specific CR activities among patients with lower socioeconomic positions. This study identifies specific patient characteristics and CR activities as key markers for reducing these inequalities.

Keywords: cardiac rehabilitation; myocardial ischemia; socioeconomic disparities in health.