Clinical Effectiveness of cardiac rehabilitation utilisation and the barriers to its completion among patients of low socioeconomic status living in rural areas: a mixed methods study

Background Low socioeconomic status (LSES) and rurality are associated with poor cardiovascular outcomes and reduced cardiac rehabilitation (CR) participation. Aim To investigate CR utilization and effectiveness, factors, needs and barriers associated with non-completion among patients of LSES in rural Australia. Methods Through a concurrent triangulation mixed methods design we converged the results of a retrospective cohort and a qualitative study. A Cox survival model applied to a population balanced by inverse probability weighting assessed the association between CR utilization and 12-month mortality/cardiovascular readmissions. Associations with non-completion were tested by logistic regression. Barriers and needs to CR completion were evaluated by thematic analysis of semi-structured interviews and focus groups with 28 participants. Results Among 16,159 eligible separations, 44.3% were referred and 11.2% completed CR. Completing CR (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 program 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 CR completion. Conclusions CR completion was low but effective in reducing mortality/cardiovascular readmissions. Understanding and addressing barriers and needs through mixed methods can help tailor CR programs to vulnerable populations and improve completion and outcomes.