Clinical effectiveness of cardiac rehabilitation and barriers to completion in patients of low socioeconomic status in rural areas: A mixed-methods study

ObjectiveTo investigate cardiac rehabilitation utilisation and effectiveness, factors, needs and barriers associated with non-completion.DesignWe used the mixed-methods design with concurrent triangulation of a retrospective cohort and a qualitative study.SettingEconomically disadvantaged areas in rural Australia.ParticipantsPatients (≥18 years) referred to cardiac rehabilitation through a central referral system and living in rural areas of low socioeconomic status.Main measuresA Cox survival model balanced by inverse probability weighting was used to assess the association between cardiac rehabilitation utilization and 12-month mortality/cardiovascular readmissions. Associations with non-completion were tested by logistic regression. Barriers and needs to cardiac rehabilitation completion were investigated through a thematic analysis of semi-structured interviews and focus groups (n = 28).ResultsAmong 16,159 eligible separations, 44.3% were referred, and 11.2% completed cardiac rehabilitation. Completing programme (HR 0.65; 95%CI 0.57–0.74; p < 0.001) led to a lower risk of cardiovascular readmission/death. Living alone (OR 1.38; 95%CI 1.00–1.89; p = 0.048), having diabetes (OR 1.48; 95%CI 1.02–2.13; p = 0.037), or having depression (OR 1.54; 95%CI 1.14–2.08; p = 0.005), were associated with a higher risk of non-completion whereas enrolment in a telehealth programme was associated with a lower risk of non-completion (OR 0.26; 95%CI 0.18–0.38; p < 0.001). Themes related to logistic issues, social support, transition of care challenges, lack of care integration, and of person-centeredness emerged as barriers to completion.ConclusionsCardiac rehabilitation completion was low but effective in reducing mortality/cardiovascular readmissions. Understanding and addressing barriers and needs through mixed methods can help tailor cardiac rehabilitation programmes to vulnerable populations and improve completion and outcomes.