Cardiac Rehabilitation Rates Lower for Minority Patients, Regardless of Income Level

Jared W. Magnani, MD, MSc

New research indicates minority patients had lower participation in cardiac rehabilitation than their non-Hispanic White counterparts, regardless of their socioeconomic status.

An analysis of health insurance claims data from more than 107,000 people across the US, results of the study indicated the probability of attending cardiac rehabilitation was 31% lower among Asian individuals, 19% lower among Black individuals, and 43% lower among Hispanic individuals compared to their White counterparts in models adjusted for age, sex, hypertension, diabetes, depression, ischemic stroke, income, and education.

“Clinicians should promote cardiac rehabilitation for all eligible patients after a major cardiac event or diagnosis and be aware of the factors that may make it more challenging for some people to participate,” Jared W. Magnani, MD, MSc, an associate professor of cardiology at the University of Pittsburgh’s Center for Research on Health Care, in a statement.

Mountains of data dating back decades have demonstrated the association between cardiac rehabilitation participation and improved cardiovascular outcomes. However, a considerable amount of data has also outlined disparities in participation among patients based on racial/ethnic background as well as socioeconomic status. With an interest in further exploring whether income levels may attenuate disparities in participation based on racial/ethnic background, Magnani and colleagues designed their study as a retrospective analysis of patients with a cardiac rehabilitation-qualifying diagnosis from Optum’s Clinformatics database from 2016-2018.

Limiting their population of interest to those aged 18 years or older, those with continuous enrollment for 6 months or longer prior to enrollment and enrollment for at least 90 days after discharge, and those with full data on income, race, and sex, investigators identified 107,199 individuals for inclusion in their final analytic sample. For the purpose of analysis, a cardiac rehabilitation-eligible event included an acute myocardial infarction listed as first or second diagnosis, CABG, valve repair or replacement, and PCI. Annual household income level was broken down into 5 categories defined as less than $40,000, $40,000-$59,999, $60,000-$74,999, $75,000-$99,999, and $100,000 or more.

The primary outcome of interest for the study was defined as participation in cardiac rehabilitation in the 1-year period following a qualifying event, with participation defined as attendance to at least 1 session. Secondary outcomes included the number of sessions attended by those who attended at least 1 session and time to initiation of rehabilitation, which was defined as the number of days from discharge to initial session.

The final analytic cohort had a mean age of 70.4±11.6 years, 37.4% were female, 76% were White, 11.8% were Black, 9.8% were Hispanic, and 2.5% were Asian. Investigators pointed out 34.2% of the study population had a high school degree or lower and 31.% had an annual household income of less than $40,000. Among the 107,199, a total of 28,443 attended at least 1 cardiac rehabilitation session, with a mean time to initiation of 45.8±46.5 days among participants. After adjustment, time to initiation was time to initiation 9.4 (95% CI, 5.2 to 13.7), 10.4 (95% CI, 8.1 to 12.8), and 8.5 (95% CI, 5.8 to 11.2) days longer for Asian, Black, and Hispanic individuals, respectively, compared to their White counterparts.

When examining participation and race, investigators found 22.5% of Asian patients, 17.6% of Black patients, 14.4% of Hispanic patients, and 29.6% of White patients participated in at least 1 session. The overall mean number of sessions attended among those who participated was 15.3±13.7, which investigators noted varied significantly based on race and ethnicity (P <.0001). After adjustment for demographic, clinical, and social factors, investigators found Black patients attended a mean of 1.4 (95% CI, 0.8 to 2.0; P <.0001) more sessions than White patients, but an opposite trend was observed with Hispanic individuals, who attended a mean of 0.8 (95% CI, −1.5 to −0.1, P=.02) fewer sessions.

In fully adjusted analyses, Asian patients were 31% (95% CI, 27 to 36%) less likely to participate in rehabilitation, Black patients were 19% (95% CI, 16 to 22%) less likely to participate in rehabilitation, and Hispanic patients were 43% (95% CI, 40 to 45%) less likely to participate in rehabilitation compared to White individuals (all P <.0001). Investigators pointed out these disparities became more apparent when examining associations among those aged 65 years and older, particularly among Asian and Hispanic patients. Additionally, investigators pointed out associations between race or ethnicity and attendance differed significantly across household income categories (P for interaction=.0005), but Asian, Black, and Hispanic individuals were less likely to attend across all income categories.

“Future studies should evaluate how other social variables—such as the ability to understand health information, the number of people in a household or employment status—may contribute to disparities in cardiac rehabilitation participation,” Magnani added. “In addition, addressing these disparities will require continued research into new initiatives that may help to increase participation in cardiac rehabilitation programs. Several options include automatic referral, virtual delivery options, development of rehabilitation facilities in underserved or rural areas, community-based cardiac rehabilitation, evening programs and home-based programs.”

This study, “Racial and Ethnic Differences in Cardiac Rehabilitation Participation: Effect Modification by Household Income,” was published in the Journal of the American Heart Association.