Why are women missing from outpatient cardiac rehabilitation programs? A review of multilevel factors affecting referral, enrollment, and completion

The effects of a cardiac rehabilitation program tailored for women on their perceptions of health: a randomized clinical trial

PURPOSE

The aim of this study was to compare the effects of a cardiac rehabilitation (CR) program tailored for women with a traditional program on perceptions of health among women with coronary heart disease.

METHODS

This 2-group randomized clinical trial compared the perceptions of health among 92 women completing a traditional 12-week CR program with those of 133 women completing a tailored program that included motivational interviewing guided by the transtheoretical model of behavior change. Perceptions of health were measured using the SF-36 Health Survey at baseline, postintervention, and at 6-month follow-up. Analysis of variance was used to compare changes in SF-36 Health Survey subscale scores over time.

RESULTS

The group-by-time interaction was significant for the general health (F2,446 = 3.80, P = .023), social functioning (F2,446 = 4.85, P = .008), vitality (F2,446 = 5.85, P = .003), and mental health (F2,446 = 3.61, P = .028) subscales, indicating that the pattern of change was different between the 2 groups. Of the 4 subscales on which there were significant group-by-time interactions, the tailored group demonstrated improved scores over time on all 4 subscales, while the traditional group improved on only the emotional role limitations and vitality subscales.

CONCLUSIONS

A tailored CR program improved general health perceptions, mental health, vitality, and social functioning in women when compared with traditional CR. To the extent that perceptions of health contribute to healthy behaviors fostered in CR programs, tailoring CR programs to alter perceptions of health may improve adherence.

The effects of a cardiac rehabilitation program tailored for women on global quality of life: a randomized clinical trial

BACKGROUND

Women with heart disease have adverse psychosocial profiles and poor attendance in cardiac rehabilitation (CR) programs. Few studies examine CR programs tailored for women for improving their quality of life (QOL).

METHODS

This randomized clinical trial (RCT) compared QOL among women in a traditional CR program with that of women completing a tailored program that included motivational interviewing guided by the Transtheoretical Model (TTM) of behavior change. Two measures of QOL, the Multiple Discrepancies Theory questionnaire (MDT) and the Self-Anchoring Striving Scale (SASS), were administered to 225 women at baseline, postintervention, and 6-month follow-up. Analysis of Variance (ANOVA) was used to compare changes in QOL scores over time.

RESULTS

Baseline MDT and SASS scores were 35.1 and 35.5 and 7.1 and 7.0 for the tailored and traditional CR groups, respectively. Postintervention, MDT and SASS scores increased to 37.9 and 7.9, respectively, for the tailored group compared with 35.9 and 7.1 for the traditional group. Follow-up scores were 37.7 and 7.6 for the tailored group and 35.7 and 7.1 for the traditional group. Significant group by time interactions were found. Subsequent tests revealed that MDT and SASS scores for the traditional group did not differ over time. The tailored group showed significantly increased MDT and SASS scores from baseline to posttest, and despite slight attenuation from posttest to 6-month follow-up, MDT and SASS scores remained higher than baseline.

CONCLUSIONS

The CR program tailored for women significantly improved global QOL compared with traditional CR. Future studies should explore the mechanisms by which such programs affect QOL.

Predicting cardiac rehabilitation attendance in a gender-tailored randomized clinical trial

PURPOSE

This study compared attendance of women participating in a motivationally enhanced, gender-tailored cardiac rehabilitation (CR) program with that of women attending a traditional outpatient CR program. We also sought to determine the significant baseline predictors of attendance of the exercise and education components of the interventions.

METHODS

Data from 252 women with CHD in the randomized clinical trial, the Women's-Only Cardiac Rehabilitation Program, were used in this study. The experimental design used 2 treatment groups: both receiving a comprehensive, 12-week, CR program, with 1 group receiving a gender-tailored, stage-of-change matched, behavioral enhancement using individualized motivational interviewing.

RESULTS

Compared with women in the traditional CR program, women in the gender-tailored program attended significantly more of the prescribed exercise (90% vs 77%) and education sessions (87% vs 56%). Group assignment accounted for about 5% of the variance in exercise attendance (F1,250 = 12.755, P < .001) and about 24% of the variance in education attendance (F1,250 = 77.942, P < .001). After controlling for group assignment, the baseline characteristics of smoking status, marital status, and anxiety accounted for about 17% of the variance in exercise attendance (F5,245 = 10.494, P < .001). Smoking status and marital status were significant baseline predictors of education attendance (F5,245 = 6.115, P < .001) after controlling for group assignment.

CONCLUSIONS

The long-standing, poor attendance of women in CR continues to be an unresolved international challenge. Gender-tailored, stage-matched, CR programs hold promise for enhancing attendance to prescribed protocols. Additional research examining the efficacy of gender-sensitive, motivationally enhanced CR for women compared with generic CR programs is warranted.

The effects of a tailored cardiac rehabilitation program on depressive symptoms in women: A randomized clinical trial

BACKGROUND

Depression is known to co-occur with coronary heart disease (CHD). Depression may also inhibit the effectiveness of cardiac rehabilitation (CR) programs by decreasing adherence. Higher prevalence of depression in women may place them at increased risk for non-adherence.

OBJECTIVE

To assess the impact of a modified, stage-of-change-matched, gender-tailored CR program for reducing depressive symptoms among women with CHD.

METHODS

A two-group randomized clinical trial compared depressive symptoms of women in a traditional 12-week CR program to those completing a tailored program that included motivational interviewing guided by the Transtheoretical Model of behavior change. Women in the experimental group also participated in a gender-tailored exercise protocol that excluded men. The Center for Epidemiological Studies Depression (CES-D) Scale was administered to 225 women at baseline, post-intervention, and at 6-month follow-up. Analysis of Variance was used to compare changes in depression scores over time.

RESULTS

Baseline CES-D scores were 17.3 and 16.5 for the tailored and traditional groups, respectively. Post-intervention mean scores were 11.0 and 14.3; 6-month follow-up scores were 13.0 and 15.2, respectively. A significant group by time interaction was found for CES-D scores (F(2, 446)=4.42, p=.013). Follow-up tests revealed that the CES-D scores for the traditional group did not differ over time (F(2, 446)=2.00, p=.137). By contrast, the tailored group showed significantly decreased CES-D scores from baseline to post-test (F(1, 223)=50.34, p<.001); despite the slight rise from post-test to 6-month follow-up, CES-D scores remained lower than baseline (F(1, 223)=19.25, p<.001).

CONCLUSION

This study demonstrated that a modified, gender-tailored CR program reduced depressive symptoms in women when compared to a traditional program. To the extent that depression hinders CR adherence, such tailored programs have potential to improve outcomes for women by maximizing adherence. Future studies should explore the mechanism by which such programs produce benefits.

The development of an internet-based outpatient cardiac rehabilitation intervention: a Delphi study

Background

Face-to-face outpatient cardiac rehabilitation (OCR) programs are an important and effective component in the management of cardiovascular disease. However, these programs have low participation rates, especially among patients who live rural or remote. Hence, there is a need to develop OCR programs that provide an alternative to face-to-face contact such as by using the Internet. Only a very limited number of Internet-based OCR programs have been developed and evaluated. Therefore, the purpose of this study was to identify issues that are relevant to the development of an Internet-based OCR intervention.

Methods

A three-round Delphi study among cardiac rehabilitation experts was conducted. In the first round, 43 experts outlined opinions they had on the development of an online ORC platform into an open-ended electronic questionnaire. In the second round, 42 experts completed a structured (five-point scale) electronic questionnaire based on first round results, in which they scored items on their relevance. In the third round, the same experts were asked to re-rate the same items after feedback was given about the group median relevance score to establish a level of consensus.

Results

After the third round, high consensus was reached in 120 of 162 (74%) questionnaire items, of which 93 (57% of 162 items) also had high relevance according to the experts. The results indicate that experts strongly agreed on desired website content, data obtained from the patient, and level of interaction with patients that should be part of an Internet-based OCR intervention.

Conclusion

The high rates of consensus and relevance observed among cardiac rehabilitation experts are an indication that they perceived the development and implementation of an Internet-based ORC intervention as feasible, and as a valuable alternative to face-to-face programs. In many ways the experts indicated that an Internet-based ORC program should mimic a traditional face-to-face program, and emphasize the crucial role of the cardiac rehabilitation manager who interacts with patients from a distance. The present study revealed practical insights into how Internet OCR interventions should be designed and opens the door for the development of such an intervention to be subsequently examined in a longitudinal and experimental study.

Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review

Poor adherence to treatment can have negative effects on outcomes and healthcare cost. However, little is known about the barriers to treatment adherence within physiotherapy. The aim of this systematic review was to identify barriers to treatment adherence in patients typically managed in musculoskeletal physiotherapy outpatient settings and suggest strategies for reducing their impact. The review included twenty high quality studies investigating barriers to treatment adherence in musculoskeletal populations. There was strong evidence that poor treatment adherence was associated with low levels of physical activity at baseline or in previous weeks, low in-treatment adherence with exercise, low self-efficacy, depression, anxiety, helplessness, poor social support/activity, greater perceived number of barriers to exercise and increased pain levels during exercise. Strategies to overcome these barriers and improve adherence are considered. We found limited evidence for many factors and further high quality research is required to investigate the predictive validity of these potential barriers. Much of the available research has focussed on patient factors and additional research is required to investigate the barriers introduced by health professionals or health organisations, since these factors are also likely to influence patient adherence with treatment.

A multisite examination of sex differences in cardiac rehabilitation barriers by participation status

BACKGROUND

Despite its proven benefits and need, women are significantly less likely than men to participate in and complete cardiac rehabilitation (CR). The purpose of this study was to quantitatively investigate sex differences in CR barriers by participation status.

METHODS

Cardiac outpatients (1496, 430 female, 28.7%) of 97 cardiologists completed a mailed survey to discern CR participation. Respondents were asked to rate 19 CR barriers on a 5-point Likert scale.

RESULTS

Five hundred twenty-nine (43%) respondents self-reported participating in CR, with men being more likely to participate (p < 0.05). There was no significant sex difference in total number of CR barriers, but differences in individual barriers were found. For CR participants, t tests revealed significant sex differences in the perception of exercise as tiring or painful (p = 0.042) and work responsibilities (p = 0.013). For CR nonparticipants, women rated the following barriers as greater than men: transportation (p = 0.025), family responsibilities (p = 0.039), lack of CR awareness (p = 0.036), experiencing exercise as tiring or painful (p = 0.002), and comorbidities (p = 0.009).

CONCLUSIONS

Overall, women do not perceive greater barriers to CR participation than men, but the nature of their barriers differs, particularly among nonparticipants. Beliefs about the value of CR, awareness, and exercise parameters are all modifiable barriers that should be addressed among women.

Examining the challenges of recruiting women into a cardiac rehabilitation clinical trial

PURPOSE

To examine the challenges of recruiting women for a 5-year cardiac rehabilitation randomized clinical trial; the aims of the study were to describe the range of recruitment sources, examine the myriad of factors contributing to ineligibility and nonparticipation of women during protocol screening, and discuss the challenges of enrolling women in the trial.

METHODS

The Women's-Only Phase II Cardiac Rehabilitation program used an experimental design with 2 treatment groups. Eligible participants included women who were (1) diagnosed with a myocardial infarction or stable angina or had undergone coronary revascularization within the last 12 months; (2) able to read, write, and speak English; and (3) older than 21 years. Responses to multiple recruitment strategies including automatic hospital referrals, physician office referrals, mass mailings, media advertisements, and community outreach are described. Reasons for ineligibility and nonparticipation in the trial are explored.

RESULTS

Automatic hospital order was the largest source of referral (n = 1,367, 81%) accounting for the highest enrollment rate of women (n = 184, 73%). The barriers to enrollment into the cardiac rehabilitation clinical trial included patient-oriented, provider-oriented, and programmatic factors. Of the referral sources, 52% were screened ineligible for provider-oriented reasons, 31% were ineligible due to patient-oriented factors, and 17.4% were linked to the study protocol. Study nonparticipation of those eligible (73.8%) was largely associated with patient-oriented factors (65.2%), with far less due to provider-related factors (4%) or study-related factors (3.4%).

CONCLUSION

Standing hospital orders facilitated enrollment to the cardiac rehabilitation clinical trial, yet women failed to participate predominantly due to significant patient-oriented biopsychosocial barriers.

Contribution of patient and physician factors to cardiac rehabilitation enrollment: a prospective multilevel study

BACKGROUND

Cardiac rehabilitation (CR) is an established means of reducing mortality, yet is grossly underutilized. This is due to both health system and patient-level factors; issues that have yet to be investigated concurrently. This study utilized a hierarchical design to examine physician and patient-level factors affecting verified CR enrollment.

DESIGN

A prospective multisite study, using a multilevel design of 1490 coronary artery disease outpatients nested within 97 Ontario cardiology practices (mean 15 per cardiologist).

METHODS

Cardiologists completed a survey regarding CR attitudes. Outpatients were surveyed prospectively to assess factors affecting CR enrollment. Patients were mailed a follow-up survey 9 months later to self-report CR enrollment. This was verified with 40 CR sites.

RESULTS

Five hundred and fifty (43.4%) outpatients were referred, and 469 (37.0%) enrolled in CR. In mixed logistic regression analyses, factors affecting verified CR enrollment were greater strength of physician endorsement (P=0.005), shorter distance to CR (P=0.001), being married (P=0.01), and fewer perceived CR barriers (P=0.03).

CONCLUSION

Both physician and patient factors play a part in CR enrollment. Patient CR barriers should be addressed during referral discussions, and reasons why physicians fail to uniformly endorse CR exploration. Although distance to CR was related to patient enrollment patterns, greater access to home-based CR services should be provided.

Stress and Coping with Women’s Health Issues

The goals of this review are: (1) to present the Leventhal common-sense model (CSM) of self-regulation of stress and coping with health threats as well as new directions and questions arising from this model, and (2) to apply this theoretical perspective to women’s health issues in order to highlight concerns that are unique to women. Examples from research on women’s health are reviewed to show: (a) how women apply decision rules to the internal and external information available to them in order to interpret their symptoms, in an attempt to reach a coherent representation of the health threat; (b) how these representations are related to women’s choices of coping strategies and why they are often unrelated to actual coping; and (c) how women appraise their situation and in what ways this internal appraisal could differ from objective outcomes. Viewing coping with women’s health issues through the lens of the CSM highlights the ways in which biological and social gender differences in the experience of illness and the interactions between them affect each stage of the self-regulation process (i.e., women’s experience of the stressor and the representations they form, how these representations guide coping, and women’s appraisal of their situation). This review helps identify principles and general conclusions derived from the CSM and generalizes them across various threats to women’s health, which should be taken into account when planning theoretically-based interventions to support women coping with health threats, as well as questions that should be investigated in future research.

Cost-effectiveness of cardiac rehabilitation program delivery models in patients at varying cardiac risk, reason for referral, and sex

BACKGROUND

Little is known about the relative cost-effectiveness of different secondary prevention cardiac rehabilitation (CR) program designs or how cost-effectiveness is influenced by patient clinical and demographic characteristics. The purpose of the study was (i) to evaluate the incremental cost-effectiveness of a standard 3-month CR program (SCR) versus a program distributed over 12 months (distributed CR, DCR); and (ii) to determine the effect of patient demographic characteristics (cardiac risk, cardiac diagnosis, sex) on incremental cost-effectiveness.

METHODS

A two group cost-effectiveness analysis was conducted alongside a randomized controlled trial. Patients with coronary artery disease (mean age=58 years, SD+/-10) were randomized to either SCR (n=196) or DCR (n=196) and followed for 24 months. Program delivery costs, cardiac healthcare use, morbidity, mortality, and quality-adjusted life years were assessed. Cost-effectiveness was evaluated with incremental cost-utility analysis.

RESULTS

In the pooled analysis, we found the probability of SCR being more cost-effective than DCR was 63-67%. The subanalysis found SCR to be the more cost-effective intervention for patients at high risk, patients with previous coronary artery bypass graft and for male patients. The DCR program was more cost-effective for patients with lower risk of disease progression and for female patients.

CONCLUSION

Differences were noted in the cost-effectiveness of CR models based on cardiac risk level, reason for referral, and demographic characteristics. Our results suggest improved cost-effectiveness may be gained by triaging patients to different CR intervention models, however, further investigation is required.

Contribution of patient and physician factors to cardiac rehabilitation referral: a prospective multilevel study

BACKGROUND

Cardiac rehabilitation (CR), in most developed countries, is a proven means of reducing mortality but it is grossly underutilized owing to factors involving both the health system and patients. These issues have not been investigated concurrently. To this end, we employed a hierarchical design to investigate physician and patient factors that affect verified CR referral.

METHODS

This study was prospective with a multilevel design. We assessed 1,490 outpatients with coronary artery disease attending 97 cardiology practices. Cardiologists completed a survey about attitudes to CR referral. Outpatients were surveyed prospectively to assess sociodemographic, clinical, behavioral, psychosocial and health system factors that affected CR referral. Responses were analyzed by mixed logistic regression analyses. After 9 months, CR referral was verified at 40 centers.

RESULTS

Health-care providers referred 550 (43.4%) outpatients to CR. Factors affecting verified referral included positive physician perceptions of CR (P = 0.03), short distance to the closest CR site (P = 0.003), the perception of fewer barriers to CR (P < 0.001) and a sense of personal control over their condition by the patient (P = 0.001).

CONCLUSIONS

Physician-related and patient-related factors both contribute to CR referral. The most relevant physician perceptions of such programs are program quality and perceived benefit. For patients, the most relevant factors are perceived barriers to CR, which might be conveyed during prereferral discussions. Work to improve physicians' perceptions and patients' understanding might improve use of rehabilitation services.

Exercise, quality of life, and symptoms in men and women five to six years after coronary artery bypass graft surgery

BACKGROUND

Coronary artery bypass graft (CABG) surgery is commonly performed to treat symptoms of heart disease and improve function and quality of life (QL). Health-related behavior including exercise after surgery may promote optimal recovery; however, relationships among exercise behavior, functional status, symptoms, and QL 5 to 6 years after CABG have not been examined in a representative patient sample.

METHODS

Telephone interviews and postal surveys were used to examine long-term (5-6 year) recovery after CABG of 163 men and women of the Minnesota participants enrolled in the Post-CABG Biobehavioral Study.

RESULTS

Regular exercise and better functional status were related to reports of less shortness of breath and fatigue and better subjective health perception, satisfaction, and QL.

RECOMMENDATIONS

Positive relationships between regular exercise and more favorable QL and symptom relief 5 to 6 years after CABG in this observational cohort study warrant prospective study trials to determine the potential long-term benefits of regular exercise after CABG.

The contribution of changes in diet, exercise, and stress management to changes in coronary risk in women and men in the Multisite Cardiac Lifestyle Intervention Program

BACKGROUND

The relative contribution of health behaviors to coronary risk factors in multicomponent secondary coronary heart disease (CHD) prevention programs is largely unknown.

PURPOSE

Our purpose is to evaluate the additive and interactive effects of 3-month changes in health behaviors (dietary fat intake, exercise, and stress management) on 3-month changes in coronary risk and psychosocial factors among 869 nonsmoking CHD patients (34% female) enrolled in the health insurance-based Multisite Cardiac Lifestyle Intervention Program.

METHODS

Analyses of variance for repeated measures were used to analyze health behaviors, coronary risk factors, and psychosocial factors at baseline and 3 months. Multiple regression analyses evaluated changes in dietary fat intake and hours per week of exercise and stress management as predictors of changes in coronary risk and psychosocial factors.

RESULTS

Significant overall improvement in coronary risk was observed. Reductions in dietary fat intake predicted reductions in weight, total cholesterol, low-density lipoprotein cholesterol, and interacted with increased exercise to predict reductions in perceived stress. Increases in exercise predicted improvements in total cholesterol and exercise capacity (for women). Increased stress management was related to reductions in weight, total cholesterol/high-density lipoprotein cholesterol (for men), triglycerides, hemoglobin A1c (in patients with diabetes), and hostility.

CONCLUSIONS

Improvements in dietary fat intake, exercise, and stress management were individually, additively and interactively related to coronary risk and psychosocial factors, suggesting that multicomponent programs focusing on diet, exercise, and stress management may benefit patients with CHD.

Five-year Changes in North Carolina Outpatient Cardiac Rehabilitation

PURPOSE

The purpose of this study was to describe cardiac rehabilitation programming, barriers to participation, and reasons for dropout in North Carolina from a program director's perspective and to compare those results with those of a similar statewide survey conducted 5 years earlier.

METHODS

In 1999 and 2004, a survey was mailed to all North Carolina program directors of outpatient cardiac rehabilitation programs. The response rate was 85% (61/72) in 1999 and 79% (61/77) in 2004.

RESULTS

More than 85% of North Carolinians older than 40 years lived within a 15-mile buffer of an outpatient cardiac rehabilitation program in 2004. Most programs were staffed with personnel trained in nursing, exercise physiology, and nutrition in 1999 and 2004. Women and African Americans remained disproportionately underrepresented as participants in the program for both years. In 2004, approximately one third of cardiac rehabilitation programs reported having a referral to rehabilitation on the hospital discharge plan for myocardial infarction and coronary artery bypass surgery. In 1999 and 2004, the most frequently reported barrier to participation remained financial, followed by lack of interest or motivation and workplace conflicts. Work conflicts, lack of interest, and comorbidities were the most frequently reported reasons for dropping out from cardiac rehabilitation programs in both 1999 and 2004.

CONCLUSIONS

Increasing participation in cardiac rehabilitation programs by addressing barriers at multiple levels may facilitate greater patient participation. This statewide survey could be used in other states as a surveillance tool, to track changes in rehabilitation over time from a program director's perspective.

Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review

BACKGROUND

Despite the documented efficacy of cardiac rehabilitation (CR), a minority of patients with diagnosed coronary artery disease are referred. Although referral is a necessary step in the promotion of CR uptake, little is known about its determinants.

PURPOSE

The objective of this paper was to systematically review the available literature on factors predicting referral of patients to CR to appraise both their relative impact and consistency across studies.

METHODS

Studies were identified by searching MEDLINE (1966-2003), CINAHL (1982-2003), HealthSTAR (1975-2003), EMBASE (1966-2003), and The Cochrane Library Controlled Trials. Search terms were "myocardial infarction," "acute myocardial infarction," "coronary artery disease," combined with "rehabilitation," "cardiac rehabilitation," "secondary prevention," "exercise training," "referral," and/or "consultation." Forty-five studies were identified and independently assessed by 2 reviewers using predetermined eligibility criteria.

RESULTS

Ten published observational studies (1999-2004) including 30,333 coronary artery disease patients were selected. Determinants of referral to CR were grouped as sociodemographic, health status, and health care system factors. Major predictors were English speaking (RR 9.56, 95% CI 2.18-41.93), prior myocardial infarction (RR 2.73, 95% CI 1.69-4.42), being admitted to hospitals providing CR (RR 5.35, 95% CI 4.04-7.10), and having insurance coverage (RR 2.94, 95% CI 1.13-7.66).

CONCLUSION

This review highlights disparities in referral to CR and reveals a treatment gap in the secondary prevention of cardiovascular disease. Precise estimates of the impact of all factors on referral are not possible, but some hierarchies and potential priorities for action are evident.

Ethnic Differences in Barriers and Referral to Cardiac Rehabilitation Among Women Hospitalized With Coronary Heart Disease

Important gender differences in cardiac rehabilitation utilization are well established, yet few studies have documented whether reported barriers and referrals vary by ethnicity. This is a cross-sectional study to determine whether barriers and referrals to participation in cardiac rehabilitation differed by race/ethnicity in 304 women (52% ethnic minorities) hospitalized with coronary heart disease. Nearly all subjects (92%) strongly agreed that physician referral was important to participation in rehab, but only 22% of subjects reported physician instruction to attend. Whites were more likely than minorities to report instruction to attend cardiac rehabilitation, and minorities were more likely to report financial barriers when compared with whites. These disparities need to be addressed because minority women have a worse prognosis following hospitalization for coronary heart disease, and cardiac rehabilitation has been shown to improve survival.

Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors

Comprehensive cardiac rehabilitation reduces mortality and morbidity but is utilised by only a fraction of eligible cardiac patients, with the participation rate of women being only about half that of men. This quantitative review assesses 32 studies meeting inclusion criteria, describing 16,804 patients, 5882 of whom were female. It was found that the main predictor of referral to a cardiac rehabilitation programme was the physician's endorsement of the effectiveness of such a programme. Patients were more likely to participate in rehabilitation programmes when they were actively referred, educated, married, possessed high self efficacy, and when the programmes were easily accessible. Patients were less likely to participate when they had to travel long distances to participate in a cardiac rehabilitation programme, or experienced guilt over family obligations. Women were less often referred and participated less often even after referral. In conclusion, many of the observed predictors, including those particular to women, are potentially modifiable with the help of health professionals.

Gender, Ethnicity, and Cardiovascular Disease

Although the influence of gender and ethnicity on cardiovascular disease has been understudied, cardiovascular nurse researchers have contributed significantly to the existing body of knowledge. This article distinguishes between the constructs of "gender versus sex'' and "ethnicity versus race,'' acknowledging that the terms are often used interchangeably in research. A sampling of the substantial contributions of cardiovascular nurse researchers related to gender and ethnicity in the areas of symptoms of cardiovascular disease; risk factors and prevention; delay in seeking care, diagnosis, and treatment; recovery and outcomes; and cardiac rehabilitation is highlighted. Recommendations for future research include publishing research data by gender and ethnicity subgroups even though statistical comparisons may not be feasible, and increasing cardiovascular disease research in minority populations such as Asian Americans, Pacific Islanders, Native Americans, and Hispanics. Finally, we challenge cardiovascular nurse researchers to shift from the documentation of disparities toward designing and testing of interventions to eliminate health disparities.

Disparities in women's referral to and enrollment in outpatient cardiac rehabilitation

OBJECTIVE

The purpose of this study was to determine the predictors of referral and enrollment, including racial differences, in phase 2 cardiac rehabilitation programs among African-American and white women who are eligible for such programs.

DESIGN

Prospective longitudinal design.

SETTING

One large academic medical center and two large community hospitals.

PATIENTS

A total of 253 women (108 African American, 145 white) were surveyed within the first month of discharge from the hospital for a percutaneous coronary intervention, coronary artery bypass surgery, or myocardial infarction without revascularization. A total of 234 (99 African American, 135 white) completed the 6-month follow-up.

MAIN RESULTS

The rate of referral to outpatient phase 2 cardiac rehabilitation was significantly lower for African-American women compared with white women, 12 (12%) versus 33 (24%) (P=.03). Only 35 (15%) of women in the study reported enrollment in phase 2 cardiac rehabilitation programs, with fewer African-American women reporting enrollment compared with white women, 9 (9%) versus 26 (19%) (P=.03). Controlling for age, education, angina class, and comorbidities, women with annual incomes <20,000 dollars were 66% less likely to be referred to cardiac rehabilitation (P=.01) and 60% less likely to enroll compared to women with incomes >20,000 dollars (P=.01). Although borderline significant, African-American women were 55% less likely to be referred (P=.059) and 58% less likely to enroll (P=.059) than white women.

CONCLUSIONS

We found disparities in cardiac rehabilitation program participation, with women with lower incomes less likely to be referred and to have lower enrollment rates in cardiac rehabilitation and a strong trend for African-American women to be less likely to be referred and enroll. Because almost all patients who have had an acute coronary event, with or without revascularization procedures, will benefit from cardiac rehabilitation, automatic referral systems should be considered to increase utilization and reduce disparities.

Coronary heart disease: the female heart is vulnerable

During the past decade, an overall theme has emerged, validating the exploration of gender-based differences in coronary heart disease (CHD) as a basis for clinical strategies to improve outcomes for women. Underrepresentation of women in most of CHD and lack of gender-specific reporting in many clinical trials continue to limit the available knowledge and evidence-based medicine needed to devise optimal managements for women with CHD. Control of conventional coronary risk factors provides comparable cardioprotection for men and women. Current evidence fails to show cardiac protection from menopausal hormone therapy. Clinical presentations of coronary heart disease (CHD) and management strategies differ between the sexes. Underutilization of proven beneficial therapies is a contributor to less-favorable outcomes in women. The contemporary increased application of appropriate diagnostic, therapeutic, and interventional managements has favorably altered the prognosis for women, particularly when the data are adjusted for baseline characteristics. Better education of women during office visits, earlier and more aggressive control of coronary risk factors, and a greater index of suspicion regarding chest pain and its appropriate evaluation may help to reverse the trend of late referral and late intervention. Research indicates that behavioral changes on the part of women and reshaping of practice patterns by their health care providers may dramatically reduce the number of women disabled and killed by CHD each year.