New Data on Cardiac Rehab Highlight Geographic Discrepancies

This new investigation serves to update decades-old data on patient eligibility for and participation in cardiac rehabilitation programs.

New data highlight persistent disparities in eligibility for cardiac rehabilitation (CR) programs and access to the centers that provide them, according to new study findings published in JAMA Cardiology. This investigation focused on disparities related to Medicare patient geographic location of residence.

The study investigators noted that although geography “is highlighted as an important factor in rural area residents’ reduced CR use as travel distances to CR centers increase, CR use has yet to be described nationally across modern urbanization classifications.”

For their cross-sectional study, information was gathered from the CDC’s Interactive Atlas of Heart Disease and Stroke database on 4 types of rates and 1 additional measure:

  • County-level CR eligibility rates: per 1000 beneficiaries
  • Participation rates: percent eligible who completed at least 1 session
  • Adherence rates: mean completed sessions up to 365 days after a qualifying event
  • Completion rates: percent completing 36 or more sessions)
  • Hospitals per county offering center-based CR

In addition, their urban (n = 4) and rural (n = 2) classifications came from the National Center for Health Statistics. From most to least urban, these areas were large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan, and from least to most rural, micropolitan and noncore. Within their findings, a 2-tailed P less than .05 indicated statistical significance.

Eligibility rates for CR were highest in the rural areas, at 17.3% for micropolitan residents and 17.6% for noncore residents. These 2 areas also had the highest participation rates of 33.3% and 36.2%, respectively, and the highest completion rates of 38.6% and 41.2%, despite having scarce center access (1 and 0 centers).

The lowest eligibility, participation, and completion rates were seen for residents in large central metropolitan areas, and these were 13.6%, 25.5%, and 27.5%, respectively. This was seen despite having access to far more hospitals per county than all other location classifications: 4 vs 1 each for large fringe, medium, and small metropolitan areas and rural micropolitan and zero for rural noncore.

Adherence rates were equivalent across all geographic areas:

  • Large central metropolitan: 25.8%
  • Large fringe metropolitan: 25.5%
  • Medium metropolitan: 25.2%
  • Small metropolitan: 25.2%
  • Micropolitan: 25.8%
  • Noncore: 24.4%

However, when the impact of geographic region was considered—Midwest, Northeast, South, and West—significant interaction was seen nationwide for urban-rural association and CR eligibility (χ2 = 39.48; P < .001) and significant variations were seen in CR participation (χ2 = 162.44; P < .001).

“Unlike rural patterns in Midwestern, Northeastern, and Western regions,” the study authors wrote, “high CR eligibility rates among Southern rural area residents were contrasted by participation rates that were among the lowest observed nationally.”

Their findings, they added, deviate sharply from long-held misconceptions that residents who live in rural areas are less likely to initiate and complete CR.

Although no causal associations can be established from the findings, this study presented contemporary observations that may help shape future discussions on urban-rural health policies and practice-level interventions to increase CR use throughout the US,” they concluded.


Van Iterson EH, Laffin LJ, Bruemmer D, Cho L. Geographical and urban-rural disparities in cardiac rehabilitation eligibility and center-based use in the US. JAMA Cardiol. 2023;8(1):98-100. doi:10.1001/jamacardio.2022.4273

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