The Association of Patient Educational Attainment With Cardiac Rehabilitation Adherence and Health Outcomes

Patients with lower levels of educational attainment (one measure of socioeconomic status) have higher rates of cardiac risk factors, complete fewer sessions of cardiac rehabilitation, and improve less on fitness measures, even when controlling for other variables. Programs must improve engagement with these high-risk patients. Purpose: Participating in cardiac rehabilitation (CR) after a cardiac event provides many clinical benefits. Patients of lower socioeconomic status (SES) are less likely to attend CR. It is unclear whether they attain similar clinical benefits as patients with higher SES. This study examines how educational attainment (one measure of SES) predicts both adherence to and improvements during CR. Methods: This was a prospective observational study of 1407 patients enrolled between January 2016 and December 2019 in a CR program located in Burlington, VT. Years of education, smoking status (self-reported and objectively measured), depression symptom level (Patient Health Questionnaire), self-reported physical function (Medical Outcomes Survey), level of fitness (peak metabolic equivalent, peak oxygen uptake, and handgrip strength), and body composition (body mass index and waist circumference) were obtained at entry to, and for a subset (n = 917), at exit from CR. Associations of educational attainment with baseline characteristics were examined using Kruskal-Wallis or Pearson's χ2 tests as appropriate. Associations of educational attainment with improvements during CR were examined using analysis of covariance or logistic regression as appropriate. Results: Educational attainment was significantly associated with most patient characteristics examined at intake and was a significant predictor of the number of CR sessions completed. Lower educational attainment was associated with less improvement in cardiorespiratory fitness, even when controlling for other variables. Conclusions: Patients with lower SES attend fewer sessions of CR than their higher SES counterparts and may not attain the same level of benefit from attending. Programs need to increase attendance within this population and consider program modifications that further support behavioral changes during CR.

[1]  S. Higgins,et al.  Current smoking as a marker of a high-risk behavioral profile after myocardial infarction. , 2020, Preventive medicine.

[2]  A. Jackson,et al.  Health Literacy of Patients Attending Cardiac Rehabilitation. , 2020, Journal of cardiopulmonary rehabilitation and prevention.

[3]  R. Júarez-Vela,et al.  Relationship between Determinants of Health, Equity, and Dimensions of Health Literacy in Patients with Cardiovascular Disease , 2020, International journal of environmental research and public health.

[4]  Janet S. Wright,et al.  Tracking Cardiac Rehabilitation Participation and Completion Among Medicare Beneficiaries to Inform the Efforts of a National Initiative , 2020, Circulation. Cardiovascular quality and outcomes.

[5]  T. Lagu,et al.  Association Between Patient Cost Sharing and Cardiac Rehabilitation Adherence. , 2019, Mayo Clinic proceedings.

[6]  N. Mikkelsen,et al.  Depression, Socioeconomic Factors, and Ethnicity as Predictors of Cardiorespiratory Fitness Before and After Cardiac Rehabilitation. , 2019, Journal of cardiopulmonary rehabilitation and prevention.

[7]  D. Shepard,et al.  Financial Incentives to Increase Cardiac Rehabilitation Participation Among Low-Socioeconomic Status Patients: A Randomized Clinical Trial. , 2019, JACC. Heart failure.

[8]  Nader N Kabboul,et al.  The Effect of Cardiac Rehabilitation on Health-Related Quality of Life in Patients With Coronary Artery Disease: A Meta-analysis. , 2019, The Canadian journal of cardiology.

[9]  A. Kurti,et al.  Tobacco use in cardiac patients: Perceptions, use, and changes after a recent myocardial infarction among US adults in the PATH study (2013-2015). , 2018, Preventive medicine.

[10]  S. van den Broucke,et al.  Does health literacy mediate the relationship between socioeconomic status and health disparities? Integrative review. , 2018, Health promotion international.

[11]  S. Scholes,et al.  Education-related disparities in reported physical activity during leisure-time, active transportation, and work among US adults: repeated cross-sectional analysis from the National Health and Nutrition Examination Surveys, 2007 to 2016 , 2018, BMC Public Health.

[12]  M. Paasche-Orlow,et al.  Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association. , 2018, Circulation.

[13]  M. Gulati,et al.  Socioeconomic Status and Cardiovascular Outcomes: Challenges and Interventions , 2018, Circulation.

[14]  A. V. Pedersen,et al.  Are Differences in Physical Activity across Socioeconomic Groups Associated with Choice of Physical Activity Variables to Report? , 2018, International journal of environmental research and public health.

[15]  Greet Cardon,et al.  Socio-economic determinants of physical activity across the life course: A "DEterminants of DIet and Physical ACtivity" (DEDIPAC) umbrella literature review , 2018, PloS one.

[16]  M. Ritchey,et al.  Use of Outpatient Cardiac Rehabilitation Among Heart Attack Survivors — 20 States and the District of Columbia, 2013 and Four States, 2015 , 2017, MMWR. Morbidity and mortality weekly report.

[17]  S. Higgins,et al.  Effect of Socioeconomic Status on Propensity to Change Risk Behaviors Following Myocardial Infarction: Implications for Healthy Lifestyle Medicine. , 2017, Progress in cardiovascular diseases.

[18]  J. Attia,et al.  Effects of education and income on cardiovascular outcomes: A systematic review and meta-analysis , 2017, European journal of preventive cardiology.

[19]  S. Higgins,et al.  Patient Characteristics Predictive of Cardiac Rehabilitation Adherence , 2017, Journal of cardiopulmonary rehabilitation and prevention.

[20]  Janet S. Wright,et al.  Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative , 2017, Mayo Clinic proceedings.

[21]  Y. Jadotte,et al.  Disparities in Cardiac Rehabilitation Participation in the United States: A SYSTEMATIC REVIEW AND META-ANALYSIS , 2017, Journal of cardiopulmonary rehabilitation and prevention.

[22]  Alberto Ruano-Ravina,et al.  Participation and adherence to cardiac rehabilitation programs. A systematic review. , 2016, International journal of cardiology.

[23]  S. Higgins,et al.  Financial incentives to promote cardiac rehabilitation participation and adherence among Medicaid patients. , 2016, Preventive medicine.

[24]  Hae-Ra Han,et al.  Health Literacy and Heart Failure: A Systematic Review , 2016, The Journal of cardiovascular nursing.

[25]  A. Jemal,et al.  Elimination of cost‐sharing and receipt of screening for colorectal and breast cancer , 2015, Cancer.

[26]  D. Shepard,et al.  State-by-State Variations in Cardiac Rehabilitation Participation Are Associated With Educational Attainment, Income, and Program Availability , 2014, Journal of cardiopulmonary rehabilitation and prevention.

[27]  O. Lundberg,et al.  Trends in inequalities in premature mortality: a study of 3.2 million deaths in 13 European countries , 2014, Journal of Epidemiology & Community Health.

[28]  M. Redaélli,et al.  Efficacy of a long-term secondary prevention programme following inpatient cardiovascular rehabilitation on risk and health-related quality of life in a low-education cohort: a randomized controlled study , 2014, European journal of preventive cardiology.

[29]  M. L. Larsen,et al.  Extended cardiac rehabilitation for socially vulnerable patients improves attendance and outcome. , 2013, Danish medical journal.

[30]  Megan E. Piper,et al.  Long-term effects of smoking and smoking cessation on exercise stress testing: three-year outcomes from a randomized clinical trial. , 2012, American heart journal.

[31]  M. Whooley,et al.  Accuracy and Prognostic Value of American Heart Association–Recommended Depression Screening in Patients With Coronary Heart Disease: Data From the Heart and Soul Study , 2011, Circulation. Cardiovascular quality and outcomes.

[32]  S. Ebrahim,et al.  Exercise-based cardiac rehabilitation for coronary heart disease. , 2016, The Cochrane database of systematic reviews.

[33]  Rajiv Nariani,et al.  Effects of cardiac rehabilitation referral strategies on referral and enrollment rates , 2010, Nature Reviews Cardiology.

[34]  K. Schulman,et al.  Relationship Between Cardiac Rehabilitation and Long-Term Risks of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries , 2010, Circulation.

[35]  S. Yusuf,et al.  Education and risk for acute myocardial infarction in 52 high, middle and low-income countries: INTERHEART case-control study , 2009, Heart.

[36]  A. Clark,et al.  Cardiac rehabilitation: into the future , 2009, Heart.

[37]  S. Normand,et al.  Cardiac rehabilitation and survival in older coronary patients. , 2009, Journal of the American College of Cardiology.

[38]  R. Chan,et al.  Influence of socioeconomic status on lifestyle behavior modifications among survivors of acute myocardial infarction. , 2008, The American journal of cardiology.

[39]  C. Torp‐Pedersen,et al.  Mortality after acute myocardial infarction according to income and education , 2006, Journal of Epidemiology and Community Health.

[40]  A. Leppin,et al.  Social inequality in patients’ physical and psychological state and participation in rehabilitation after myocardial infarction in Germany , 2005, International journal of rehabilitation research. Internationale Zeitschrift fur Rehabilitationsforschung. Revue internationale de recherches de readaptation.

[41]  Snehamay Khasnabis,et al.  Access to Health Care and Nonemergency Medical Transportation , 2005 .

[42]  P. Ades.  Cardiac rehabilitation and secondary prevention of coronary heart disease. , 2001, The New England journal of medicine.

[43]  MarkkuMähönen,et al.  Relationship of Socioeconomic Status to the Incidence and Prehospital, 28-Day, and 1-Year Mortality Rates of Acute Coronary Events in the FINMONICA Myocardial Infarction Register Study , 2000 .

[44]  P. Savage,et al.  Determinants of physical functioning in coronary patients: response to cardiac rehabilitation. , 1999, Archives of internal medicine.

[45]  J. Pell,et al.  Retrospective study of influence of deprivation on uptake of cardiac rehabilitation , 1996, BMJ.

[46]  C. Sherbourne,et al.  The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. , 1994 .

[47]  J O Prochaska,et al.  Stages of change in the modification of problem behaviors. , 1992, Progress in behavior modification.

[48]  R. Levy,et al.  Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. , 1972, Clinical chemistry.