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Barriers to Cardiac Rehabilitation in Women With Cardiovascular Disease: An Integrative Review

McCarthy, Margaret M. MS, RN, FNP-BC; Vaughan Dickson, Victoria PhD, CRNP; Chyun, Deborah PhD, RN

The Journal of Cardiovascular Nursing: September-October 2011 - Volume 26 - Issue 5 - p E1-E10
doi: 10.1097/JCN.0b013e3181f877e9
ARTICLES: ONLINE ONLY
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Although death rates from cardiovascular disease (CVD) have declined in recent years, it continues to be the leading cause of death for women in the United States. The risk factors for CVD are well established and include physical inactivity. According to the Centers for Disease Control, in 2008, 38% of women reported no physical activity. For many women who experience a cardiac event, their first opportunity to become physically active is through a formal cardiac rehabilitation (CR) program. Unfortunately, women often underutilize CR programs. The purpose of this integrative review was to examine the barriers to participation in a CR program among women with CVD.

Although death rates from cardiovascular disease (CVD) have declined in recent years, it continues to be the leading cause of death for women in the United States. The risk factors for CVD are well established and include physical inactivity. According to the Centers for Disease Control, in 2008, 38% of women reported no physical activity. For many women who experience a cardiac event, their first opportunity to become physically active is through a formal cardiac rehabilitation (CR) program. Unfortunately, women often underutilize CR programs. The purpose of this integrative review was to examine the barriers to participation in a CR program among women with CVD.

Margaret M. McCarthy, MS, RN, FNP-BC Doctoral Student, College of Nursing, New York University.

Victoria Vaughan Dickson, PhD, CRNP Assistant Professor, College of Nursing, New York University.

Deborah Chyun, PhD, RN Associate Professor, College of Nursing, New York University.

The authors have no funding or conflicts of interest to disclose.

Correspondence Margaret M. McCarthy, MS, RN, FNP-BC, College of Nursing, New York University, 726 Broadway, New York, NY 10003 (mmm529@nyu.edu).

Although death rates from cardiovascular disease (CVD) have declined in recent years, CVD continues to be the leading cause of death for women in the United States. In the years between 1996 and 2006, the overall death rate from CVD declined 29.2%; however, in 2006, approximately 433 000 women died of CVD, which represents more deaths than from cancer, chronic lower respiratory diseases, Alzheimer disease, and accidents collectively.1

The risk factors for CVD are well established and include age, male sex, postmenopausal female, heredity, obesity, smoking, hypertension, hyperlipidemia, diabetes, and sedentary lifestyle. This is of particular significance because the prevalence of CVD increases as women age, and outcomes are very poor in women including higher mortality among women with heart failure.2 In women aged 40 to 59 years, the prevalence of CVD is 39.6%; this increases to more than 73% in women aged 60 to 79 years.1 Additionally, in 2008, 38% of women reported no leisure-time physical activity, an important risk factor for CVD, compared with 34% for men.3 The consequences of physical inactivity take a toll on health. According to an analysis of data from the National Center of Health Statistics, physical inactivity accounts for nearly 1 in 10 deaths in the United States.1

Lack of physical activity is a modifiable risk factor, and for many women who experience a cardiac event, their first opportunity to become physically active is through a structured cardiac rehabilitation (CR) program. Cardiac rehabilitation programs, considered secondary prevention programs, aim to improve functional capacity and quality of life, reduce cardiac risk factors, and prevent future events among individuals with CVD. In addition to a structured exercise program, components of a CR program often include medical history and physical examination; nutrition counseling; weight, blood pressure, and lipid management; diabetes evaluation and education; psychosocial evaluation and treatment; and tobacco cessation programs.4 The benefits of participation in CR program include improved exercise capacity, improvement in lipid profile, reduction of obesity indices, improvement in depression and anxiety, and improvement in overall quality of life.5

Cardiac rehabilitation is indicated for individuals with myocardial infarction (MI), acute coronary syndrome, coronary artery bypass graft (CABG), percutaneous intervention, stable angina, valve replacement/repair, heart or heart/lung transplant, advanced heart failure, or asymptomatic coronary heart disease (CHD) and patients at high risk of CHD.5 However, CR is grossly underutilized, especially by women. In a study of 267 427 Medicare beneficiaries, of whom 44% were women, and 92% were white, claims were analyzed to determine the use of CR after hospitalization for acute MI or CABG. The authors found that only 13.9% of patients after acute MI and 31% of patients after bypass surgery attended CR. In women overall, the use of CR was 14.3%.6

The reason for low participation in CR among women is unclear. Given the well-documented benefits of CR that include improved quality of life, understanding the barriers to CR that women with CVD face will guide the development of effective clinical strategies to increase participation in this high-risk population-women with CVD. The purpose of this integrative review was to examine the barriers to participation in a CR program among women with CVD.

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Methods

In this review, guidelines from Whittemore and Knafl7 and Ganong8 were followed. As such, a thorough review will summarize the state of the science, contribute to the development of theory, and apply both to practice and policy.7 It also should be held to the same standards of rigor as primary research.8 The electronic databases that were used for this review included PubMed, CINAHL, MEDLINE, Web of Science, EMBASE, and PsycINFO. A hand search of the retained articles was also conducted. Key words included women, cardiovascular disease (CVD), heart disease, barriers, cardiac rehabilitation (CR), and physical activity.

The inclusion criteria for this review were primary qualitative and quantitative studies published in English from 1998 to 2009. The limited period was chosen because of the changing nature of treatment of CVD and of the more recent studies indicating the need for women to be studied separately from men. For example, in a 2001 systematic review of exercise-based rehabilitation for CHD, Jolliffe et al9 found that the majority of the population studied was male. One study10 from 1992 was added to this review as it became apparent that it was consistently referenced in many of the current studies. Only studies that provided separate data for women in regard to barriers to CR were retained. International studies (n = 6) were included.

Exclusion criteria for this review included literature reviews or summaries and unpublished dissertations. However, original studies cited were included if they met our inclusion criteria. Studies that examined barriers, but did not separate results by sex, were excluded because the purpose of this review was to examine the barriers to participation by women in CR. A total of 61 studies were retrieved. During the data evaluation stage, 19 primary studies were retained based on the inclusion and exclusion criteria; 13 were quantitative, 4 were qualitative, and 2 studies were a mixed methodology. The Figure illustrates the inclusion/exclusion strategy. A summary of the results can be found in the Table. As a result, the following integrative review presents the state of science as it applies to the barriers to participation in CR for women with CVD.

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Results

As a result of this review of the literature, we identified provider-level barriers, system-level factors, and individual-level variables that were associated with participation in CR by women.

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Provider-Level Barriers

Referral

Participation in a CR program requires a referral from a healthcare provider because eligibility criteria must be evaluated. However, lack of a physician referral was the most frequently described barrier to CR for women, discussed in 12 of the 19 studies.

In this review, we found that sex bias was noted in referral to CR by healthcare providers. Bongard et al11 found sex bias in referral after an acute coronary event in a sample of almost 2000 men and 700 women; being a woman was independently associated with lower probability of being referred (female-to-male adjusted odds ratio [OR], 0.44; confidence interval [CI], 0.31-0.64; P < .0001). In a much smaller sample (n = 40 women and 40 men), Caulin-Glaser et al12 found that women were less likely than men to receive a referral to CR after revascularization procedure (P < .001). Halm et al13 noted that although women had a significantly higher eligibility rate (P ≤ .001) for CR than men (in a small sample of 46 women and 41 men), they were referred at a lower rate (P ≤ .01). In a qualitative study of 40 women who had experienced an MI, 18 women reported not being offered CR.14 Ades et al10 found that the most powerful predictor of attendance was the strength of the physician referral. In a sample of 226 patients, physicians referred older men with a similar medical profile more strongly than older women (P < .05). In a study of 304 women with a diagnosis of heart disease, more than 90% rated the importance of their physician's referral to a CR program as a 3, 4, or 5 on a Likert scale of 1 to 5, indicating strong agreement.15

Missik16 in a study of 370 women found that referral was a significant predictor of CR participation (overall percentage prediction, 99.68%). In addition, when referral was removed as an independent predictor variable, insurance specific to CR was a significant predictor of a referral; a patient without CR insurance had low odds of being referred (OR, 0.06; P = .000).

One study had contrasting results regarding sex bias in referral to CR. Heid and Schmelzer,17 in a study comparing referral and enrollment rates between men and women, found no significant difference in referral rates between the sexes (χ2 = 0.12; P = .7). Although this study lacked a power analysis (n = 202; women = 42%), almost 600 patients' charts were randomly selected for review, and 202 met the inclusion criteria: subjects older than 21 years and having a diagnosis indicating a potential need for CR. Importantly, the hospital that served as the site of the study had a robust 3-phase CR program, which typically includes both inpatient and outpatient long-term maintenance components. These results suggest that a well-established CR program that develops structured referral processes for inpatients may result in higher utilization than typically seen when providers must orchestrate the referral process.

We also found evidence of disparities in referral of women to CR by ethnicity and socioeconomic status. Mochari et al15 found only 17% of minority women were instructed to attend CR, as compared with 27% of white women (P = .02). Allen et al18 included both white (n = 145) and African American women (n = 108) in a study to determine predictors of referral and enrollment in CR. Results indicated that African American women were less likely to receive a referral than white women (P = .03) and that women with an annual income of less than $20 000 were also less likely to be referred (P = .01), suggesting the presence of a health disparity.

Referral to CR is standard practice for patients following medical cardiac events (eg, MI) as well as surgical procedures (eg, CABG, valve repair, etc.). However, this literature review found differences in referral practices among these populations. Plach19 compared women with CABG (n = 106) with those who had valve surgery (n = 31) and found that those with CABG were more likely to receive a referral (χ2 = 12.48; P < .001). Correspondingly, Gallagher et al20 found that in a total sample of 196 women, those with a CABG were almost 7 times more likely to attend CR than women with MI (OR, 6.82; 95% CI, 1.84-25.21; P = .0002). When analyzing the process of referral in participating hospitals, they noted that CABG patients were more likely to be referred than MI patients.

Similarly, in a large secondary data analysis of the American Heart Association's Get With the Guidelines Program, Brown et al21 identified factors associated with CR referral in patients discharged after acute MI, percutaneous intervention, or CABG (n = 72 817; 32% women). In this sample, 56% were referred to CR, and older age, non-ST-segment elevation MI, and the presence of most comorbidities were associated with a decreased likelihood of referral. Although female sex did not reach statistical significance as a predictor in the regression analysis, the data demonstrate that significantly more women were not referred to CR than were referred (33.7% vs 30.8% respectively; P < .0001).

The reason for disparate referral rates by providers remains unclear. However, in a qualitative, exploratory study, Scott and Allen22 provide insight by identifying factors that physicians felt affected women's referral to CR. This small convenience sample of physicians (n = 13) who were in a position to refer patients to CR identified the following factors: inability to determine if a woman was an appropriate candidate, need for a clear communication among inpatient and outpatient providers during the referral process, and the perception among providers that women are not interested in attending CR.

Although a provider may give a CR referral, this may not be enough to ensure participation. In a study of women referred to CR (n = 131), subjects were asked to rate the perceived importance of potential barriers and facilitators to CR. The only barrier that was rated significantly more important in women who chose not to enroll in CR was the statement: "My doctor does not really think I need it" (P = .04).23 This underscores the need for not only referral, but also education and support to facilitate enrollment.

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System-Level Factors

A typical CR program entails 36 sessions over 12 weeks. Although many health insurers cover CR, including Medicare for most cardiac diagnoses, there is often an insurance deductible or copay associated with CR as well as other out-of-pocket expenses such as transportation or loss time from work to attend.

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Insurance and Financial Issues

Lack of insurance coverage or financial concerns was identified in this review as a system-level barrier to participation in CR. In the study of 370 women with CHD, Missik16 found insurance specific to CR to be a significant predictor of referral (OR, 0.06; P < .001). Mochari et al15 reported that minority women were significantly more likely to report finances as a barrier than white women (P < .008). Four other studies, qualitative and mixed methods, found insurance or financial reasons to be a barrier to enrollment, 13,14,17,24 although all had small sample sizes (n = 6-27). Given the small sample sizes of these studies, it is difficult to generalize the extent to which lack of insurance is a factor in CR participation. Interestingly, all of the studies that cited insurance or cost as an issue were done in the United States. Lack of insurance or financial concerns were not cited as barriers in studies that took place outside the United States, where health insurance programs differ.

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Transportation

For many women, transportation acted as a significant barrier to attending CR. In 7 of the studies (2 quantitative, 3 qualitative, and 2 mixed method), when women were asked why they did not participate, transportation problems were frequently cited as a reason.13,14,17,20,24-26 Missik,16 in a cross-sectional comparative study, examined accessibility factors in women who did and did not participate in CR, finding significant differences with nonparticipants having less access to transportation than participants (P < .001). Ades et al,10 in a study assessing sex-related differences in CR participation (n = 226; 43% women), found more women noting transportation problems than men (32% vs 16% respectively; P = .01).

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Individual-Level Factors

Individual level factors including poor perceived health, comorbid conditions, and perceptions about CR were identified as barriers to CR in much of the literature.

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Health Perceptions

Poor perceived general health was frequently cited as a barrier to CR participation13,17-20,26-28 and was usually associated with the presence of a comorbid condition. In a study,17 10 women who did not participate in CR were interviewed regarding their decision, and 6 women cited poor health as one of the reasons. In a small comparative study (n = 87; 53% women), Halm et al13 interviewed women who never enrolled in CR. Having a comorbid condition, such as arthritis and peripheral vascular disease that inhibited one's ability to engage in physical activity, was cited as one of the most common reasons they did not participate.

Similarly, self-reported poor health or "feeling too sick" was cited frequently as a reason for not participating in CR by women.18-20,26 Among female nonparticipants, comorbid conditions were rated as significant barriers when compared with male counterparts (Lieberman et al,28P < .02; Grace et al,27P < .01). However, the sample size of female nonparticipants in the quantitative studies varied widely: ranging from n = 10 (Plach19) to n = 226 (Grace et al27), and 4 studies had 60 or fewer female subjects. Findings from studies with small samples limit the generalizability of the results to the larger population of women with CVD. In addition, the lack of power of the study may result in nonsignificant findings.

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Personal Perceptions of CR

Lack of awareness and misperceptions of CR programs and its benefits may be another important factor in the decision to participate for women who are eligible for CR. In addition to finding a significant difference between referral of men and women to CR, Caulin-Glaser et al12 found that after revascularization procedures, men (n = 40), as compared with women (n = 40), were more likely to receive in-hospital teaching about CR (P < .001). Grace et al27 found female nonparticipants rated 2 barriers (using a 5-point Likert-type scale) significantly higher than men: lack of CR awareness (P < .05) and perception of exercise as tiring or painful (P < .01). In-hospital teaching that provides education about the benefits of CR may raise awareness and dispel misperceptions about exercise.

Personal beliefs about CR participation coupled with lack of awareness were significant barriers that emerged both from the qualitative and quantitative literature reviewed. For example, themes that included a "dislike of exercise," "feeling uncomfortable," and fear of becoming ill (eg, short of breath) emerged across several studies.19,25 Although these were relatively small samples, they provide important insight into the reasons why women may be reluctant to participate in a CR program. Similarly, Farley et al26 reported that women (n = 51) identified personal preferences for lack of participation in CR that included not wanting to dwell on or be reminded of cardiac problems, wanting to deal with it by themselves, and feeling uncomfortable in groups. Additionally, lack of perceived need for CR was also identified by women (n = 8) as a reason for not attending CR in a qualitative study by McSweeney and Crane.14

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Summary of Findings

Despite the methodological limitations of each study, the results of this integrative review represent the major themes that have emerged as barriers to CR participation among women with CVD. Our findings suggest that there are multilevel barriers including provider-level (disparities in referral process by providers), system-level (insurance, financial issues, and access barriers), and individual-level factors, primarily perceptions about personal health and CR that influence participation in CR by women.

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Discussion

Although the lack of sample size calculations and subsequent small sample sizes make the findings of many studies in this review difficult to generalize, our critical analysis indicates several implications for further study to understand the barriers to CR experienced by women. In several of these studies, identifying the barriers to participation in CR for women was not the primary focus of the study,21,24-26 resulting in smaller sample sizes due to subgroup analysis and underpowered studies. Additionally, the lack of probability sampling for all but two of the studies17,24 limits the generalizability of the results. A larger study using appropriate sample size calculations, probability sampling, and exclusively addressing the issues of barriers to participation in CR by women is needed.

In addition, findings of studies that were conducted outside the United States11,20,25-28 cannot be generalized to the United States for many reasons, including the dissimilarities in the structure of the healthcare systems and health insurance. More research needs to be conducted within the confines of the US healthcare system on the system-level barriers identified in this review. Access to comprehensive healthcare that includes CR is a critical area that requires further inquiry.

Disparities in CR utilization require further investigation. Only 2 studies compared different ethnicities and their ensuing referral rates.15,18 Because there are known disparities in the prevalence of CVD in different ethnicities,1 access and participation in secondary prevention measures need to be studied in these different populations. In many of these studies, the highest percentage of female participants was white,12-15,17-19,21,23,27 and results may not generalize to other ethnicities. In the remainder of the studies, data were not provided regarding the race or ethnicity of the female participants.

Of particular interest in this review was the disparity in provider referrals for women compared with men. Sex bias in the treatment of CVD has been recognized as contributing to health disparities among women with CVD. For example, in a study of individuals (n = 2620; 47% women) following acute MI, it was found that although women received similar pharmacological treatment to men, they were 46% less likely to be referred for diagnostic coronary angiography (OR, 0.54; CI, 0.45-0.64). Even after adjusting for confounders, women were still 27% less likely to be referred (OR, 0.73; CI, 0.57-0.94).29

Our finding that sex bias may extend to CR is of particular concern and suggests the need for examining how standards of care are applied across populations. Efforts to address the multifactorial provider- and system-level barriers are clearly needed. That is, when women do not receive adequate referral and advisement about CR from healthcare providers, it may be more difficult for them to overcome access barriers such as transportation or financial concerns or even personal beliefs. Ades et al10 found that the lower CR participation rate in older women was essentially due to a weaker physician recommendation score, which suggests that endorsement by a healthcare provider is the most effective way to promote participation.

This literature review identified several key gaps in the literature that warrant investigation. Although we found interesting data regarding the influence of perceived health and personal beliefs on CR participation, notably missing from these studies was the role that depression or anxiety may play. The prevalence of depression and anxiety in patients with CVD is well documented in the literature, but grossly missing in the CR literature. It is estimated that one-third of women after an MI experience anxiety and depression.30 In the study of 204 women by Marcuccio et al,24 38% reported clinical depression, and 17% reported increased anxiety. Although several studies suggest apprehension about CR,19,25,27 none of the studies reviewed utilized depression and anxiety as an independent predictor of participation in CR. The presence of depression and anxiety as a factor in CR participation needs to be explored.

Table

Table

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Nursing Implications

The findings of this review have implications for nursing practice and research. As part of clinical practice, nurses are responsible for identifying appropriate secondary prevention measures for their patients that include facilitating the referral to CR. Advanced practice nurses need to identify and refer all appropriate patients. Educating both providers and patients about eligibility, components, and benefits of CR may improve the rate of participation by women. The results from this review also suggest the need to establish policy and procedures for automatic referral for patients who meet the specified enrollment criteria. Activating supportive resources such as social services and family members to overcome logistics of attending CR for women (eg, transportation) is also indicated. Finally, research is needed to develop and test strategies that remove barriers from the system, address personal health beliefs, and facilitate CR participation among women.

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REFERENCES

1. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics-2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119(3):e21-e181.
2. Jessup M, Pina IL. Is it important to examine gender differences in the epidemiology and outcome of severe heart failure? J Thorac Cardiovasc Surg. 2004;127(5):1247-1252.
3. Center for Disease Control. The healthy people 2010 database. January, 2010 edition. http://wonder.cdc.gov/scripts/broker.exe. Accessed June 2, 2010.
4. Balady GJ, Williams MA, Ades PA,et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007;115(20):2675-2682.
5. Lavie CJ, FAU - Thomas RJ, Thomas RJ, et al. Exercise training and cardiac rehabilitation in primary and secondary prevention of coronary heart disease. Mayo Clin Proc. 2009;84(4):373-83. (1942-5546 [electronic]).
6. Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2007;116(15):1653-1662.
7. Whittemore RPRN, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546-553.
8. Ganong LH. Integrative reviews of nursing research. Res Nurs Health. 1987;10(1):1-11.
9. Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2000;4(4):CD001800.
10. Ades PA, Waldmann ML, Polk DM, Coflesky JT. Referral patterns and exercise response in the rehabilitation of female coronary patients aged greater than or equal to 62 years. Am J Cardiol. 1992;69(17):1422-1425.
11. Bongard V, Grenier O, Ferrieres J, et al. Drug prescriptions and referral to cardiac rehabilitation after acute coronary events: comparison between men and women in the French PREVENIR Survey. Int J Cardiol. 2004;93(2-3):217-223.
12. Caulin-Glaser T, Blum M, Schmeizl R, Prigerson HG, Zaret B, Mazure CM. Gender differences in referral to cardiac rehabilitation programs after revascularization. J Cardiopulm Rehabil. 2001;21(1):24-30.
13. Halm M, Penque S, Doll N, Beahrs M. Women and cardiac rehabilitation: referral and compliance patterns. J Cardiovasc Nurs. 1999;13(3):83-92.
14. McSweeney JC, Crane PB. An act of courage: women's decision-making processes regarding outpatient cardiac rehabilitation attendance… including commentary by Bach CA. Rehabil Nurs. 2001;26(4):132.
15. Mochari HY, Lee JWR, Kligfield P, Linfante AH, Smith S, Mosca L. Ethnic differences in barriers to cardiac rehabilitation among women hospitalized with coronary heart disease. Circulation. 2002;106(19):3514.
16. Missik E. Women and cardiac rehabilitation: accessibility issues and policy recommendations. Rehabil Nurs. 2001;26(4):141-147.
17. Heid HG, Schmelzer M. Influences on women's participation in cardiac rehabilitation. Rehabil Nurs. 2004;29(4):116-121.
18. Allen JK, Scott LB, Stewart KJ, Young DR. Disparities in women's referral to and enrollment in outpatient cardiac rehabilitation. J Gen Intern Med. 2004;19(7):747-753.
19. Plach SK. Women and cardiac rehabilitation after heart surgery: patterns of referral and adherence. Rehabil Nurs. 2002;27(3):104.
20. Gallagher R, McKinley S, Dracup K. Predictors of women's attendance at cardiac rehabilitation programs. Prog Cardiovasc Nurs. 2003;18(3):121-126.
21. Brown TM, Hernandez AF, Bittner V, et al. Predictors of cardiac rehabilitation referral in coronary artery disease patients: findings from the American Heart Association's Get With the Guidelines Program. J Am Coll Cardiol. 2009;54(6):515-521.
22. Scott LB, Allen JK. Providers' perceptions of factors affecting women's referral to outpatient cardiac rehabilitation programs: an exploratory study. J Cardiopulm Rehabil. 2004;24(6):387-391.
23. Sanderson B, Shewchuk R, Bittner V. Cardiac rehabilitation and women: what keeps them away? J Cardiopulm Rehabil Prev. 2010;30(1):12-21.
24. Marcuccio E, Loving N, Bennett SK, Hayes SN. A survey of attitudes and experiences of women with heart disease. Womens Health Issues. 2003;13(1):23-31.
25. Cooper AF, Jackson G, Weinman J, Horne R. A qualitative study investigating patients' beliefs about cardiac rehabilitation. Clin Rehabil. 2005;19(1):87-96.
26. Farley RL, Wade TD, Birchmore L. Factors influencing attendance at cardiac rehabilitation among coronary heart disease patients. Eur J Cardiovasc Nurs. 2003;2(3):205-212.
27. Grace SL, Gravely-Witte S, Kayaniyil S, Brual J, Suskin N, Stewart DE. A multisite examination of sex differences in cardiac rehabilitation barriers by participation status. J Womens Health (Larchmt). 2009;18(2):209-216.
28. Lieberman L, Meana M, Stewart D. Cardiac rehabilitation: gender differences in factors influencing participation. J Womens Health. 1998;7(6):717-723.
29. Nguyen JT, Berger AK, Duval S, Luepker RV. Gender disparity in cardiac procedures and medication use for acute myocardial infarction. Am Heart J. 2008;155(5):862-868.
30. Schweikert B, Hunger M, Meisinger C, Konig HH, Gapp O, Holle R. Quality of life several years after myocardial infarction: comparing the MONICA/KORA registry to the general population. Eur Heart J. 2009;30(4):436-443.
Keywords:

barriers; cardiovascular disease; cardiac rehabilitation; review; women

© 2011 Lippincott Williams & Wilkins, Inc.