Older, low-income female patients less likely to complete cardiac rehabilitation after bypass surgery

Bypass patients who are older, female and/or from lower-income neighbourhoods are more likely to face delays in beginning cardiac rehabilitation (CR), making them less likely to complete CR, which can lead to a higher mortality risk, suggests a new study.

The study, led by Dr. Susan Marzolini, exercise physiologist, Toronto Rehabilitation Institute (TR), UHN, examined nearly 6,500 coronary artery bypass graft surgery patients enrolled in the Cardiovascular Prevention and Rehabilitation program at Toronto Rehab over the course of 16 years.

Published in the November issue of Circulation: Cardiovascular Quality and Outcomes, the study found that bypass patients who waited longer than 60 days after their surgery to start CR were more likely to drop out of the program, attended fewer classes, and saw less improvement in their fat percentage and fitness, the Toronto study suggests.

"We know cardiac rehabilitation saves lives," says Dr. Paul Oh, Medical Director of the Cardiovascular Prevention and Rehabilitation Program at TR and co-author of the study. "Our past research has found that those who participate in cardiac rehabilitation after experiencing a major heart event cut the risk of dying from a subsequent heart event in half."

The study found that bypass patients are more likely to experience longer wait times, and subsequently poorer participation, if they are women, older, from a lower socioeconomic neighbourhood, employed, or had less social support. Any one of these factors is associated with longer wait times.

"We have now pinpointed a specific profile of bypass surgery patients most vulnerable to these delays and this study offers evidence that these wait times are problematic for the health of bypass patients," Dr. Marzolini notes.

In Ontario, cardiac rehabilitation services are reimbursed by the province's Ministry of Health. However, socioeconomic barriers exist that prevent some from accessing cardiac rehabilitation soon after bypass, she says.

"Women tend to experience heart events when they're older, and are more likely to be single," Dr. Marzolini explains. "With a lack of social support in place, they may have less access to transportation or be unable to overcome the cost associated with travel to the CR program, limiting their participation.

"Now that we've identified a gap with socially vulnerable bypass patients, this is a group we - as CR programs - can focus on and be equipped to reach out and help them."

Dr. Marzolini suggests the system could increase timely CR participation by ensuring surgical teams inform and refer patients to CR before hospital discharge. CR patients should be informed of the program options available in CR programs such as home program (off-site) models, evening classes, classes specifically for women; social support services; and help identifying transportation alternatives.

This study is specific to Toronto, ON, and similar research across Ontario and in the United States has also shown wait times to start CR after a heart event tend to exceed the suggested 60 days.

"While we cannot generalize the findings of this study yet, it gives us a great starting point to explore the impact of CR delays on a larger scale, find methods to integrate the socially vulnerable earlier, and continue to examine CR wait times for other cardiac patient populations," says Dr. Oh.