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Cardiac rehabilitation aims to facilitate physical, psychological, and emotional recovery for patients following coronary revascularisation, and evidence suggests that it improves short and long term prognosis.1 Recently theNational service framework for coronary heart disease has stated that by April 2002, 85% of eligible patients should be offered cardiac rehabilitation.1 However, service provision for coronary artery bypass surgery (CABG) is far from optimal. Male sex and socioeconomic deprivation are associated with risk of cardiovascular disease and are also important factors in use of cardiac investigations, referral and waiting times for CABG itself.2 ,3 More recently this has been reconfirmed with the take up of cardiac rehabilitation among patients following myocardial infarction,4 but not in patients following CABG. We therefore examined determinants of uptake of cardiac rehabilitation in patients following CABG.
Between 1 November 1998 and 31 October 1999 we conducted an evaluation of patients' referrals for cardiac rehabilitation following CABG alone at one centre. Patients referred fell into the hospital catchment area which is not covered by a cardiac liaison service. All patients were invited by post or telephone to attend a seven week cardiac rehabilitation programme based at the hospital site. Patients are first invited to a pre-assessment clinic two weeks after discharge and a six week course on health education including supervised exercise and relaxation classes one month later. Patients who failed to attend were followed up by telephone. Data were abstracted on demographic details, cardiovascular risk factors, attendance, and reasons for non-attendance. Since the hospital site is centrally located with easy access, data on the mode of transport for patients invited for cardiac rehabilitation was not collected. The Carstairs index, derived from patients' post codes was used to measure socioeconomic deprivation,5 and was divided into three groups where category 1 denotes least deprived and 3 most deprived. Differences in patient characteristics between those attending and not attending were tested using t test and chi square (χ2). Logistic regression was used to determine effects of independent variables on attendance and was reported as odds ratios and 95% confidence intervals (CI).
The referrals of 187 patients were reviewed and of these 111 (59%) attended at least one cardiac rehabilitation sessions. There were no significant differences in age, sex, previous myocardial infarction or CABG between patients attending or never attending cardiac rehabilitation (table 1). Non-attendance was associated with socioeconomic deprivation (p = 0.01) and smoking (p = 0.005). Using logistic regression to adjust for age, sex, and other risk factors, deprivation and smoking were both independently associated with non-attendance with odds ratios of 0.38 (95% CI 0.16 to 0.90) and 0.39 (95% CI 0.17 to 0.93), respectively. There was a significant trend to suggest that patients with more risk factors were less likely to attend cardiac rehabilitation (p < 0.001). Of the patients who did not attend 11/76 (15%) stated they were not interested, 7/76 (10%) felt fine, and 22/76 (29%) gave no reason. Of this patient group, 23/40 (58%) were least deprived and 10/40 (25%) most deprived. Of the remaining non-attenders, 12/76 (17%) had multiple health problems, 6/76 (8%) work pressures, 3/76 (3%) had died, 3/76 (3%) could not speak English, and 12/76 (15%) could not be reached.
These results show a strong association between socioeconomic deprivation, smoking, and non-attendance of cardiac rehabilitation for patients following CABG. Forty one per cent of patients did not attend cardiac rehabilitation. Non-attendance was two thirds more likely if the patient smoked or lived in a deprived area and was significantly associated with having more cardiovascular risk factors than those attending. One third of patients invited for cardiac rehabilitation had previous myocardial infarction or CABG but the referral letters did not record whether this patient group had ever attended previous programmes. Recent evidence indicates that understanding and perceptions of patients having undergone coronary revascularisation of their disease may also affect attendance of cardiac rehabilitation.6 These factors require further investigation. Cardiac rehabilitation programmes may need to consider addressing the specific requirements for patients following CABG with greater risk factors and low socioeconomic status. These may include programmes which encourage the disinterested, and address issues of language barriers and work pressures. This is vital if the aims of theNational service framework for coronary heart disease 1 are to be realised.