Referral, Participation and Completion Rates in the Birjand Cardiac Rehabilitation Cohort after Coronary Revascularization

Abstract

Introduction: Cardiac rehabilitation (CR) is a cornerstone of secondary prevention following coronary revascularization; however, its utilization remains suboptimal in underserved regions. This study aimed to evaluate referral, participation, and completion rates of CR and their associated factors in Birjand, Iran.

Materials and Methods: This retrospective cohort study included 758 consecutive patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) between April 2022 and May 2023. Data on demographics, insurance status, education level, and physician CR familiarity were collected using a structured checklist and phone follow-up. The CR program was defined as 36 supervised sessions. Multivariate logistic regression models were used to identify factors associated with referral, participation, and completion. All reported odds ratios were derived from fully adjusted models.

Results: Among 749 eligible patients, 19(26.3%) were referred to CR, 103(52.3% of referred) participated, and 69(67.0% of participants) completed the program. Multivariate analysis showed that higher education was the strongest predictor of referral (odds ratio [OR]=9.50, 95% confidence interval [CI], 4.9%, 18.27%, P<0.001), followed by male gender (OR=2.12, 95% CI, 1%, 4.49%, P=0.005). Furthermore, physicians familiar with CR had approximately a 3-fold higher referral rate compared to less-familiar colleagues. Insurance coverage was significantly associated with program completion (78% of insured vs 59% of uninsured completers; P=0.018).

Conclusion: Referral is the main systemic barrier to CR utilization in this underprivileged region. Participation and completion among referred patients reflect a selected group with adequate access, highlighting the need for system level interventions focused on physician referral practices—particularly for women and less educated patients—and improved insurance coverage to enhance equitable access to CR.