Cardiac Rehabilitation Adherence: Another Gender-Treatment Paradox

Scoping 'sex' and 'gender' in rehabilitation: (mis)representations and effects

BACKGROUND

Researchers have highlighted a large-scale global unmet need for rehabilitation. While sex and gender have been shown to interact with each other and with other social and structural factors to influence health and wellbeing, less is known about how sex and gender shape rehabilitation participation and outcomes within health systems.

METHODS

Using an intersectional approach, we examine literature that explores the relationship between sex and/or gender and rehabilitation access, use, adherence, outcomes, and caregiving. Following a comprehensive search, 65 documents met the inclusion criteria for this scoping review of published literature. Articles were coded for rehabilitation-related themes and categorized by type of rehabilitation, setting, and age of participants, to explore how existing literature aligned with documented global rehabilitation needs. Responding to a common conflation of sex and gender in the existing literature and a frequent misrepresentation of sex and gender as binary, the researchers also developed a schema to determine whether existing literature accurately represented sex and gender.

RESULTS

The literature generally described worse rehabilitation access, use, adherence, and outcomes and a higher caregiving burden for conditions with rehabilitation needs among women than men. It also highlighted the interacting effects of social and structural factors like socioeconomic status, racial or ethnic identity, lack of referral, and inadequate insurance on rehabilitation participation and outcomes. However, existing literature on gender and rehabilitation has focused disproportionately on a few types of rehabilitation among adults in high-income country contexts and does not correspond with global geographic or condition-based rehabilitation needs. Furthermore, no articles were determined to have provided an apt depiction of sex and gender.

CONCLUSION

This review highlights a gap in global knowledge about the relationship between sex and/or gender and rehabilitation participation and outcomes within health systems. Future research should rely on social science and intersectional approaches to elucidate how gender and other social norms, roles, and structures influence a gender disparity in rehabilitation participation and outcomes. Health systems should prioritize person-centered, gender-responsive care, which involves delivering services that are responsive to the complex social norms, roles, and structures that intersect to shape gender inequitable rehabilitation participation and outcomes in diverse contexts.

Benchmarking Depressive Symptoms in Cardiac Rehabilitation

PURPOSE

Depression affects cardiac health and is important to track within cardiac rehabilitation (CR). Using two depression screeners within one sample, we calculated prevalence of baseline depressive symptomology, improvements during CR, and predictors of both.

METHODS

Data were drawn from the University of Vermont Medical Center CR program prospectively collected database. A total of 1781 patients who attended between January 2011 and July 2019 were included. Two depression screeners (Geriatric Depression Scale-Short Form [GDS-SF] and Patient Health Questionnaire-9 [PHQ-9]) were compared on proportion of the sample categorized with ≥ mild or moderate levels of depressive symptoms (PHQ-9 ≥5, ≥10; GDS-SF ≥6, ≥10). Changes in depressive symptoms by screener were examined within patients who had completed ≥9 sessions of CR. Patient characteristics associated with depressive symptoms at entry, and changes in symptoms were identified.

RESULTS

Within those who completed ≥9 sessions of CR with exit scores on both screeners (n = 1201), entrance prevalence of ≥ mild and ≥ moderate depressive symptoms differed by screener (32% and 9% PHQ-9; 12% and 3% GDS-SF; both P< .001). Patients who were younger, female, with lower cardiorespiratory fitness (CRF) scores were more likely to have ≥ mild depressive symptoms at entry. Most patients with ≥ mild symptoms decreased severity by ≥1 category by exit (PHQ-9 = 73%; GDS-SF = 77%). Nonsurgical diagnosis and lower CRF were associated with less improvement in symptoms on the PHQ-9 (both P< .05).

CONCLUSION

Our results provide initial benchmarks of depressive symptoms in CR. They identify younger patients, women, patients with lower CRF, and those with nonsurgical diagnosis as higher risk groups for having depressive symptoms or lack of improvement in symptoms.

Health Care Use and Associated Time and Out of Pocket Expenditures for Patients With Cardiovascular Disease in a Publicly Funded Health Care System

BACKGROUND

The objectives of this study were to describe (1) health care use and associated patient time and out of pocket (OOP) costs over 2 years after a cardiac diagnosis, (2) the sociodemographic and clinical drivers of these costs, and (3) patient costs related to cardiac rehabilitation (CR) participation.

METHODS

Secondary analysis was conducted in an observational prospective CR program evaluation cohort in Ontario, which has a publicly funded health care system. A convenience sample of patients from 1 of 3 CR programs was approached at the first visit, and consenting participants completed a survey. Participants were e-mailed surveys again 6 months and 1 and 2 years later; these later surveys assessed their cardiac care and medications and the time and OOP costs associated with care visits. Patient time was valued based on average wages in Ontario.

RESULTS

Of 411 consenting patients, 240 (58.3%) completed CR, and 192 (46.7%) were retained at 2 years. Patients most often visited a general practitioner and had electrocardiography and treatment for angina. The total cost to patients over 2 years was CAD$73.70 ± $275.84 for time and $377.01 ± $321.72 for OOP costs ($525.93 ± $467.08 overall). With adjustment, there were significantly higher OOP costs for women (P < 0.001) and less educated (P < 0.001) patients. Participants spent considerable money that was relatively OOP on CR visits alone ($384.78 ± $269.67), with time costs at $379.07 ± $1035.49 ($939.43 ± $1333.29 overall; 1.6% share of 1 year's income).

CONCLUSIONS

In conclusion, time and OOP costs are modest for patients with cardiac conditions, except for CR. Alternative delivery models are needed, in particular for low-income patients.