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.
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.
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.
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.
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).
Individual level factors including poor perceived health, comorbid conditions, and perceptions about CR were identified as barriers to CR in much of the literature.
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.
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
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.
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.
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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Keywords:© 2011 Lippincott Williams & Wilkins, Inc.
barriers; cardiovascular disease; cardiac rehabilitation; review; women