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

Alline Beleigoli, Hila Ariela Dafny, Maria Alejandra Pinero de Plaza, Claire Hutchinson, Tania Marin, Joyce S. Ramos, Orathai Suebkinorn, Lemlem G. Gebremichael, Norma B. Bulamu, Wendy Keech, Marie Ludlow, Jeroen Hendriks, Vincent Versace, Robyn A. Clark

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1 Citation (Scopus)


Objective: To investigate cardiac rehabilitation utilisation and effectiveness, factors, needs and barriers associated with non-completion. Design: We used the mixed-methods design with concurrent triangulation of a retrospective cohort and a qualitative study. Setting: Economically disadvantaged areas in rural Australia. Participants: Patients (≥18 years) referred to cardiac rehabilitation through a central referral system and living in rural areas of low socioeconomic status. Main measures: A 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). Results: Among 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. Conclusions: Cardiac 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.

Original languageEnglish
JournalClinical Rehabilitation
Publication statusPublished or Issued - 17 Apr 2024
Externally publishedYes


  • cardiac rehabilitation
  • Cardiovascular disease
  • low socioeconomic status
  • morbidity and mortality
  • rural populations

ASJC Scopus subject areas

  • Physical Therapy, Sports Therapy and Rehabilitation
  • Rehabilitation

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