Importance of Baseline Functional and Socioeconomic Factors for Participation in Cardiac Rehabilitation

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Enrollment in cardiac rehabilitation has been reported to improve exercise capacity, psychological well-being, and survival. However, participation rates are low and the reasons for nonparticipation have not been adequately defined. The purpose of this study was to evaluate the major correlates of nonparticipation and to examine the level of participation of patients who stand to benefit most on the basis of preenrollment functional status and health behaviors. Three hundred ninety-three patients undergoing coronary artery bypass surgery (1) had baseline functional status and quality-of-life data collected, and (2) were recruited for participation in the Duke Center for Living comprehensive 3-week posh-coronary bypass surgery rehabilitation program. Baseline demographic, clinical, calheterization, functional status, psychological status, and health behavior descriptors were analyzed to identify univariate and multivariable correlates of a patient's decision to participate in the program. At baseline, most clinical factors were similar in participants (n = 52) and nonparticipanls (n = 341), but the nonparricipants were more often women (26% vs 12%, p = 0.02). Participants were also more likely to be employed (63% vs 45%, p = 0.02) and had a higher education and income distribution than nonparricipants (both p = 0.001). On 2 separate scales, nonparricipants had significantly more baseline functional impairment than participants (both p = 0.001). In multivariable analysis, the independent correlates of higher participation rates were: higher education (college graduates 71% more likely to participate than high school graduates) and better baseline Duke Activity Status Index (patients with mild functional impairment were at least 42% more likely to participate than patients with moderate impairment). Thus, patients with greater functional impairment and with lower socioeconomic status were disproportionately underrepresented in our cardiac rehabilitation program despite active recruitment and a waiver of direct costs offered to patients who could not afford the program. New methods must be devised to provide rehabilitation services to patients who stand to benefit significantly from them but who are unable or unwilling to participate in conventional structured programs.

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Methods

Study population: Potential candidates for rehabilitation after CABG were identified from daily listings of the cardiac surgical inpatient census by Center for Living (CFL) staff members. For logistic reasons, only patients living within a 60-mile radius of Duke Medical Center were actively recruited to participate in rehabilitation. Persons living beyond this distance were encouraged to enroll in a rehabilitation program closer to home and were given appropriate referral information, but were

Results

Rehabilitation participants and nonparticipants were similar in age and race, but nonparticipants were more often women (26% vs 12%, p = 0.02) (Table I). Diabetes tended to be more prevalent in the nonparticipants (p = 0.09). Participants were more likely to be employed at the time of their bypass surgery (p = 0.02) (Table I). They were also more educated (p = 0.001) and had a significantly higher income than nonparticipants (p = 0.001).

On 2 separate scales (the Duke Activity Status Index and the Health

Discussion

Cardiac rehabilitation programs are often recommended for patients who have had a myocardial infarction, coronary bypass surgery, or coronary angioplasty, and typically include a central component of exercise training along with education about risk factors, dietary counseling, and vocational rehabilitation.1 Although the cost-effectiveness of these programs remains controversial, there is evidence that they improve exercise capacity and psychological well-being, and some evidence that they

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This study was supported by Research Grants HL-36587, HL-45702, HL-57302, and HL-17670 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland; Research Grants HS-05636 and HS-06503 from the Agency for Health Core Policy and Research, Rockville, Maryland; and a grant from the Robert Wood Johnson Foundation, Princeton, New jersey.

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