Advertisement
Canadian Journal of Cardiology

Sex Differences in Cardiac Rehabilitation Adherence: A Meta-analysis

Published:April 26, 2016DOI:https://doi.org/10.1016/j.cjca.2016.01.036

      Abstract

      Background

      Cardiac rehabilitation (CR) participation is associated with significantly lower mortality, and this benefit has been established as dose-dependent. Because it has been suggested that women are adherent to CR programs less than men, the objective of this study was to review CR adherence among women and men, and to determine whether a sex difference exists.

      Methods

      MedLine, CINAHL, EMBASE, PsycINFO, and the Cochrane databases were systematically searched. Titles and abstracts were screened, and selected full-text articles were independently considered on the basis of predefined inclusion/exclusion criteria. Data from included articles were extracted by 2 authors independently and assessed for quality. The meta-analysis was undertaken with predefined subgroup analyses.

      Results

      The search identified 5148 articles, of which 149 were fully examined for inclusion consideration. Fourteen studies reporting data on 8176 participants (2234 [27.3%] women) were included. Overall, CR adherence ranged from 36.7% to 84.6% of sessions, with a mean of 66.5 ± 18.2% (median, 72.5%). Men and women enrolled in CR adhered to 68.6% and 64.2% of prescribed sessions, respectively (mean difference = −3.6; 95% confidence interval, −6.9 to −0.3). The sex difference persisted in studies of high quality, that were undertaken in Canada, published since 2010, and where programs were longer than 12 weeks' duration and offered fewer than 3 sessions per week.

      Conclusions

      To our knowledge, this is the first meta-analysis to systematically report CR adherence rates, and results suggest that patients adhere to more than two-thirds of prescribed sessions. CR adherence is significantly lower among women than men. Identified strategies to promote adherence need to be tested among women.

      Résumé

      Introduction

      On sait que la réadaptation cardiaque (RC) est associée à une réduction significative de la mortalité et que ce bienfait est proportionnel au nombre de séances de RC. Puisqu’il a été dit que le taux de participation des femmes aux programmes de RC est inférieur à celui des hommes, cette étude avait pour objectif de comparer l’observance de ces programmes chez les hommes et les femmes afin de déterminer s’il y avait un écart à ce chapitre entre les 2 sexes.

      Méthodes

      Nous avons procédé au dépouillement systématique des bases de données MEDLINE, CINAHL, EMBASE, PsycINFO et Cochrane. Les titres et les résumés ont été passés en revue et des articles de plein texte ont été passés au crible à l’aide de critères d’inclusion et d’exclusion prédéfinis. Les données tirées des articles retenus ont été revues par 2 auteurs indépendants et évalués en vue de déterminer leur qualité. Une métaanalyse a ensuite été menée par l’intermédiaire d’analyses par sous-groupes prédéfinis.

      Résultats

      La recherche a permis de sélectionner 5148 articles dont 149 ont fait l’objet d’une analyse détaillée en vue de leur inclusion à cette métaanalyse. Au total, 14 études cliniques portant sur 8176 participants (dont 2234 [27,3 %] étaient des femmes) ont été retenues. De manière globale, la participation aux séances de RC allait de 36,7 à 84,6 %, soit une moyenne de 66,5 ± 18,2 % (médiane de 72,5 %). Les hommes et les femmes inscrits à un programme de RC participaient à 68,6 % et 64,2 % des séances prévues, respectivement (écart moyen = -3,6; intervalle de confiance à 95 %; de -6,9 à -0,3). L’écart entre les sexes a persisté lors des études de grande qualité menées au Canada et publiées depuis 2010; les programmes en question duraient plus de 12 semaines et comportaient moins de 3 séances de RC par semaine.

      Conclusions

      Il s’agit, à notre connaissance, de la première métaanalyse ayant porté sur l’analyse systématique de l’observance des programmes de RC. Les résultats obtenus portent à croire que les patients prennent part à plus des deux tiers des séances offertes dans le cadre de ces programmes. Le taux de participation est significativement inférieur chez les femmes comparativement aux hommes. Il y a donc lieu d’évaluer auprès de la clientèle féminine les stratégies déjà établies visant à promouvoir l’observance des programmes de RC.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • World Health Organization
        Global Status Report on Noncommunicable Diseases 2014.
        World Health Organization, Geneva2014
        • Vaccarino V.
        • Badimon L.
        • Corti R.
        • et al.
        Presentation, management, and outcomes of ischaemic heart disease in women.
        Nat Rev Cardiol. 2013; 10: 508-518
        • Mosca L.
        • Benjamin E.J.
        • Berra K.
        • et al.
        Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: a guideline from the American Heart Association.
        Circulation. 2011; 123: 1243-1262
        • Anderson L.
        • Taylor R.S.
        Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews.
        Cochrane Database Syst Rev. 2014; 12: CD011273
        • Alter D.A.
        • Oh P.I.
        • Chong A.
        Relationship between cardiac rehabilitation and survival after acute cardiac hospitalization within a universal health care system.
        Eur J Cardiovasc Prev Rehabil. 2009; 16: 102-113
        • Stone J.
        • Suskin N.
        • Arthur M.
        Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention: Translating Knowledge Into Action.
        3rd ed. Canadian Association of Cardiovascular Prevention and Rehabilitation, Winnipeg2009
        • Smith S.C.
        • Benjamin E.J.
        • Bonow R.O.
        • et al.
        AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation.
        Circulation. 2011; 124: 2458-2473
        • Samayoa L.
        • Grace S.L.
        • Gravely S.
        • et al.
        Sex differences in cardiac rehabilitation enrollment: a meta-analysis.
        Can J Cardiol. 2014; 30: 793-800
        • Colella T.J.
        • Gravely S.
        • Marzolini S.
        • et al.
        Sex bias in referral of women to outpatient cardiac rehabilitation? A meta-analysis.
        Eur J Prev Cardiol. 2015; 22: 423-441
        • Scott L.A.
        • Ben-Or K.
        • Allen J.K.
        • et al.
        Why are women missing from outpatient cardiac rehabilitation programs? A review of multilevel factors affecting referral, enrollment, and completion.
        J Womens Health. 2002; 11: 773-791
        • Martin B.J.
        • Hauer T.
        • Arena R.
        • et al.
        Cardiac rehabilitation attendance and outcomes in coronary artery disease patients.
        Circulation. 2012; 126: 677-687
        • Colbert J.D.
        • Martin B.J.
        • Haykowsky M.J.
        • et al.
        Cardiac rehabilitation referral, attendance and mortality in women.
        Eur J Prev Cardiol. 2015; 22: 979-986
        • Turk-Adawi K.I.
        • Oldridge N.B.
        • Tarima S.S.
        • Stason W.B.
        • Shepard D.S.
        Cardiac rehabilitation patient and organizational factors: what keeps patients in programs?.
        J Am Heart Assoc. 2013; 2: e000418
        • Mikkelsen T.
        • Korsgaard Thomsen K.
        • Tchijevitch O.
        Non-attendance and drop-out in cardiac rehabilitation among patients with ischaemic heart disease.
        Dan Med J. 2014; 61: A4919
        • Turk-Adawi K.I.
        • Grace S.L.
        Narrative review comparing the benefits of and participation in cardiac rehabilitation in high-, middle- and low-income countries.
        Heart Lung Circ. 2015; 24: 510-520
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
        BMJ. 2009; 339: b2700
        • Downs S.H.
        • Black N.
        The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions.
        J Epidemiol Community Health. 1998; 52: 377-384
      1. Review Manager (RevMan). Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011.

        • Egger M.
        • Smith G.D.
        • Schneider M.
        • Minder C.
        Bias in meta-analysis detected by a simple, graphical test.
        BMJ. 1997; 315: 629-634
        • Duval S.
        • Tweedie R.
        Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis.
        Biometrics. 2000; 56: 455-463
      2. Comprehensive Meta-Analysis. Available at: https://www.meta-analysis.com/index.php. Accessed March 8, 2016.

        • Kowal T.P.
        • Chessex C.
        • Lee D.S.
        • Grace S.L.
        Integrated cardiovascular rehabilitation: how do noncardiac and polyvascular disease patients fare?.
        J Cardiopulm Rehabil Prev. 2015; 35: 114-123
        • Dunlay S.M.
        • Witt B.J.
        • Allison T.G.
        • et al.
        Barriers to participation in cardiac rehabilitation.
        Am Heart J. 2009; 158: 852-859
        • Banerjee A.T.
        • Gupta M.
        • Singh N.
        Patient characteristics, compliance, and exercise outcomes of South Asians enrolled in cardiac rehabilitation.
        J Cardiopulm Rehabil Prev. 2007; 27: 212-218
        • Pack Q.R.
        • Mansour M.
        • Barboza J.S.
        • et al.
        An early appointment to outpatient cardiac rehabilitation at hospital discharge improves attendance at orientation: a randomized, single-blind, controlled trial.
        Circulation. 2013; 127: 349-355
        • Oldridge N.B.
        • Ragowski B.
        • Gottlieb M.
        Use of outpatient cardiac rehabilitation services: factors associated with attendance.
        J Cardiopulm Rehabil. 1992; 12: 25-31
        • Grace S.L.
        • Gravely-Witte S.
        • Kayaniyil S.
        • et al.
        A multisite examination of sex differences in cardiac rehabilitation barriers by participation status.
        J Womens Health. 2009; 18: 209-216
        • Casey E.
        • Hughes J.W.
        • Waechter D.
        • Josephson R.
        • Rosneck J.
        Depression predicts failure to complete phase-II cardiac rehabilitation.
        J Behav Med. 2008; 31: 421-431
        • Grace S.L.
        • Scholey P.
        • Suskin N.
        • et al.
        A prospective comparison of cardiac rehabilitation enrollment following automatic vs usual referral.
        J Rehabil Med. 2007; 39: 239-245
        • Cannistra L.B.
        • Balady G.J.
        • O’Malley C.J.
        • Weiner D.A.
        • Ryan T.J.
        Comparison of the clinical profile and outcome of women and men in cardiac rehabilitation.
        Am J Cardiol. 1992; 69: 1274-1279
        • Tsui K.Y.
        • Segaram S.S.
        • Jamnik V.
        • Wu G.
        • Grace S.L.
        Variation in patient perceptions of healthcare provider endorsement of cardiac rehabilitation courtney.
        J Cardiopulm Rehabil Prev. 2012; 32: 192-197
        • Sarrafzadegan N.
        • Rabiei K.
        • Shirani S.
        • et al.
        Drop-out predictors in cardiac rehabilitation programmes and the impact of sex differences among coronary heart disease patients in an Iranian sample: a cohort study.
        Clin Rehabil. 2007; 21: 362-372
        • Dunlay S.M.
        • Pack Q.R.
        • Thomas R.J.
        • Killian J.M.
        • Roger V.L.
        Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction.
        Am J Med. 2014; 127: 538-546
        • Swardfager W.
        • Herrmann N.
        • Marzolini S.
        • et al.
        Major depressive disorder predicts completion, adherence, and outcomes in cardiac rehabilitation: a prospective cohort study of 195 patients with coronary artery disease.
        J Clin Psychiatry. 2011; 72: 1181-1188
        • Grace S.L.
        • Evindar A.
        • Kung T.
        • Scholey P.
        • Stewart D.E.
        Increasing access to cardiac rehabilitation: automatic referral to the program nearest home.
        J Cardiopulm Rehabil. 2004; 24: 171-174
        • Clark A.M.
        • King-Shier K.M.
        • Spaling M.A.
        • et al.
        Factors influencing participation in cardiac rehabilitation programmes after referral and initial attendance: qualitative systematic review and meta-synthesis.
        Clin Rehabil. 2013; 27: 948-959
      3. The Canadian Cardiovascular Society. Bridge. Available at: http://bridge.ccs.ca/index.php/en. Accessed May 1, 2015.

      4. Canadian Association of Cardiac Prevention and Rehabilitation. Canadian Cardiac Rehab Registry. Available at: http://www.cacpr.ca/resources/registry.cfm. Accessed May 1, 2015.

        • Karmali K.N.
        • Davies P.
        • Taylor F.
        • et al.
        Promoting patient uptake and adherence in cardiac rehabilitation.
        Cochrane Database Syst Rev. 2014; 6: CD007131
        • Beckie T.M.
        • Beckstead J.W.
        The effects of a cardiac rehabilitation program tailored for women on global quality of life: a randomized clinical trial.
        J Womens Health (Larchmt). 2010; 19: 1977-1985

      Linked Article

      • Cardiac Rehabilitation Adherence: Another Gender-Treatment Paradox
        Canadian Journal of CardiologyVol. 32Issue 11
        • Preview
          Cardiovascular disease remains the leading cause of death in North America with a higher rate of morbidity and mortality in women than in men.1 After an acute coronary syndrome (ACS), women are more likely than men to die, particularly women younger than the age of 55 years who present with an ST-elevation myocardial infarction.2,3 Further, women with an ACS suffer from delays in diagnosis and treatment,4 undergo less invasive management,5,6 receive less medical therapy,7 and have higher complication rates such as bleeding, than do men.
        • Full-Text
        • PDF