Underutilization of Hospital-based Cardiac Rehabilitation after Acute Myocardial Infarction in Korea

Sun-Hyung Kim; Jun-soo Ro; Yoon Kim; Ja-Ho Leigh; Won-Seok Kim

doi:10.3346/jkms.2020.35.e262

Journal List > J Korean Med Sci > v.35(30) > 1146108

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Kim, Ro, Kim, Leigh, and Kim: Underutilization of Hospital-based Cardiac Rehabilitation after Acute Myocardial Infarction in Korea

Original Article

Musculoskeletal Disorders, Rehabilitation & Sports Medicine

Journal of Korean Medical Science 2020; 35(30): e262.

Published online: 8 July 2020

DOI: https://doi.org/10.3346/jkms.2020.35.e262

Underutilization of Hospital-based Cardiac Rehabilitation after Acute Myocardial Infarction in Korea

Sun-Hyung Kim^1,^*

, Jun-soo Ro^2,^*

, Yoon Kim^3,⁴

, Ja-Ho Leigh²

, Won-Seok Kim¹

¹Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.

²Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.

³Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea.

⁴Institute of Health Policy and Management, Medical Research Center, Seoul National University, Seoul, Korea.

Address for Correspondence: Ja-Ho Leigh, MD. Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea. jaho.leigh@gmail.com

Address for Correspondence: Won-Seok Kim, MD, PhD. Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173-beon-gil, Bundang-gu, Seongnam 13620, Republic of Korea. wondol77@gmail.com

Equal contributor:

^*Sun-Hyung Kim and Jun-soo Ro contributed equally to this work.

Received 4 March 2020 Accepted 27 May 2020

The Korean Academy of Medical Sciences

(open-access, https://creativecommons.org/licenses/by-nc/4.0/):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Cardiac rehabilitation (CR) after acute myocardial infarction (AMI) is recommended as a mandatory intervention in several national clinical practice guidelines published in America, Europe, and Korea to reduce recurrence and mortality. However, underutilization of CR is an established worldwide issue. In Korea, the promotion of CR is expected due to coverage by National Health Insurance. Nevertheless, the national status of CR use has not been reported. This retrospective cohort study aimed to investigate the current status of CR use in patients with AMI using nationwide data from the National Health Insurance Service of Korea.

Methods

Patients with AMI admitted with the diagnosis of ‘I21’ code (from International Classification of Diseases, 10th revision, Clinical Modification) from July 1st, 2017 to June 30th, 2018 were included. CR use was defined as CR treatment or evaluation being performed during an outpatient follow-up period within 6 months after discharge. Participation rate and density were calculated nationally and by administrative division. Logistic regression analysis was performed to identify the influencing factors of CR participation.

Results

Nationally, 1.5% of AMI patients (960/64,982) underwent CR during outpatient treatment after discharge. CR density was approximately 10. Logistic regression analysis revealed that influencing factors included old age, female sex, rural residence, and low Charlson comorbidity index.

Conclusion

Hospital-based CR after AMI is underutilized despite its coverage by the National Health Insurance. More CR facilities have to be installed according to the needs of CR in various regions.

Graphical Abstract

Keywords: Acute Myocardial Infarction, Cardiac Rehabilitation, Patient Participation Rates, Density, Barrier, Health Services Underutilization

INTRODUCTION

Ischemic heart disease (IHD) is one of the most burdensome chronic diseases in Korea.1 With an improvement in survival after IHD,2 more efforts are being channeled towards secondary prevention.3 Cardiac rehabilitation (CR), an aspect of secondary prevention program, is highly recommended after IHD in national clinical practice guidelines,4 5 6 (based on the evidence of CR) for improving clinical outcomes.7 8 9 Nevertheless, CR participation rate after IHD has been low and shows disparities between countries10 and individuals on account of various barriers.11 According to a global report based on the responses of experts in CR from countries in 2017, and IHD burdens report from the Institute for Health Metrics and Evaluation, CR was available in only half of all countries, and the number of CR facilities for patients with IHD was insufficient in Korea.12 13 The number of incident IHD cases per year per CR facility in Korea was 22, higher than the median value among countries worldwide (n = 21) and the mean of the Organization for Economic Cooperation and Development countries (n = 17).12

In Korea, CR was primarily introduced around the late 1990s. There has been expert- and government-led efforts to promote CR. Regional cardiocerebrovascular centers have been established since 2009, and a total of 14 centers are being operated to improve the quality of cardiovascular treatment, including CR. CR services after IHD have been reimbursed as medical treatment benefits since February 2017. Despite these efforts, the rate of CR participation remains low in the hospitals actively delivering CR (14%–35%).11 Nationwide CR participation rates are expected to be lower, considering the insufficient number of CR facilities12; however, this has not been estimated in Korea. Understanding the current status of nationwide CR use may be an important first step to establish an effective strategy towards the promotion of CR in Korea.

Therefore, this study was designed to measure the nationwide hospital-based CR participation rate, the current numbers of hospitals delivering CR services among patients after acute myocardial infarction (AMI), and the insufficiency in the number of CR facilities in Korea compared to those of other high-income countries. The Korean National Health Insurance Service (NHIS) database from 2017 was used, because only claim codes starting from February 2017 could be identified. Similarly, the risk factors for CR nonparticipation after AMI were identified in hospitals considered as actively delivering CR.

METHODS

Data source

The NHIS, the only insurer operated by the Korean government, covers 97.0% of the Korean population.14 The NHIS database contains eligibility information (income-based insurance contributions, demographic variables, date of death), healthcare utilization information (diagnosis, length of stay, treatment costs, services received), and healthcare provider information (types of institutions, human resources, equipment).15 With permission to access the database, one can collect information about demographics, inpatient and outpatient medical service claim data, and disorders diagnosed per the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) codes.

Operational definitions of AMI patients and CR participation

Patients were diagnosed with AMI if they were 1) aged between 40 and 80 years, and 2) hospitalized according to the ICD-10-CM based diagnosis of AMI (I21). In a previous study, this definition had a range between 71.4%–73.1% accuracy and fair-to-good reliability.16 The index admission occurred between July 1, 2017 and June 30, 2018 (Fig. 1). This period was selected with consideration for National Health Insurance coverage of CR starting in February 2017.

Fig. 1

Study flow.

AMI, acute myocardial infarction.

The CR participation was defined as the presence of at least one outpatient-based claim code for ‘MM452 (cardiac rehabilitation evaluation)’ or ‘MM453 (cardiac rehabilitation therapy)’. To avoid irrelevant claims, the claim code had to be presented within 6 months after the diagnosis of AMI until December 31st, 2018 (Fig. 1). During the analysis period, the medical costs of CR were fully insured by the NHIS.

Other variables

Age, sex, and the amount of health insurance premium were identified from the NHIS database. Age was categorized as follows: 40–60, 61–70, and 71–80. Based on the amount of health insurance premium per patient, the income status among all Korean citizens was estimated as quartile. All subjects were classified into urban and rural residents according to their place of registration, which was Si-Gun-Gu (administrative districts in Korea). Urban residents were defined as people living in ‘Si’ or ‘Gu’, whereas rural residents were those who live in ‘Gun’.

The classification variable in the NHIS database was used in the identification of hospital types. The hospitals were classified into three divisions according to the Korean medical law as follows: tertiary hospital, general hospital, and hospital.

For the identification of underlying comorbidities of patients, Charlson comorbidity index (CCI) was obtained by reviewing ICD-10-CM diagnoses.17 In this study, CCI was categorized as 0–4, 5–6, and ≥ 7.

Data analysis and outcomes

Based on the definition, as mentioned earlier, the number of AMI patients and CR participants were estimated. The crude CR participation rate was calculated using the formula below:

C R p a r t i c i p a t i o n r a t e (%) = \frac{Number of CR participants}{Number of AMI patients} \times 100

CR density, which was first suggested by Turk-Adawi et al.,12 means the number of AMI cases per year per CR facility. Higher numbers represent less sufficient capacity of CR services.

C R d e n s i t y = \frac{AMI incidence}{Number of CR facilities × Median annual capacity per facility ( = 250)}

The numbers below the decimal point were rounded off. In addition, the number of CR facilities could be identified from the administrative data. Median annual capacity per facility was adapted from the report from Turk-Adawi et al.12 It was estimated by surveying the average number of annual patients-per-center to CR experts in each country. In Korea, this number was 250. CR participation rate and density was calculated both nationally and by administrative division.

Statistical analysis

Baseline characteristics of the study participants according to CR participation were expressed as the number and percentage, and each variable was categorized. Values were compared using χ² tests. Logistic regression analyses were conducted to identify the influencing factors of CR only in hospitals with more than 10 CR participants per year, considering the volume threshold for the supply pattern of CR. The SAS software (version 7.1; SAS Institute, Cary, NC, USA) was used, and a 2-sided P value of < 0.05 was considered statistically significant.

Ethics statement

This study was approved by the Institutional Review Board (IRB) of Seoul National University Bundang Hospital, Korea (IRB No. X-1901/514-901), the need to obtain informed consent was waived due to the retrospective nature of the study. Data in the Korean NHIS were fully anonymized for analyses.

RESULTS

Baseline characteristics

During the index period, 64,982 patients were hospitalized following the clinical diagnosis of AMI in Korea, including 43,160 (66.4%) males and 21,822 (33.6%) females. Table 1 shows the characteristics of the study population according to CR participation. Significant differences were observed between the participants and the nonparticipants following classification by age, sex, residential area, hospital type, and CCI. High ratios of older age, female, rural resident, hospital (non-tertiary, non-general), and low CCI were observed in the nonparticipant group.

Table 1

Baseline characteristics of study participants

Characteristics		Total	CR participants	CR nonparticipants	P value
Number		64,982	960 (1.5)	64,022 (98.5)
Age, yr					< 0.001^a
	40–60	25,508	513 (2.0)	24,995 (98.0)
	61–70	19,496	307 (1.6)	19,189 (98.4)
	71–80	19,978	140 (0.7)	19,838 (99.3)
Sex					< 0.001^a
	Male	43,160	824 (1.9)	42,336 (98.1)
	Female	21,822	136 (0.6)	21,686 (99.4)
Insurance premium					0.347
	1st quantile	11,868	171 (1.4)	11,697 (98.6)
	2nd quantile	11,236	164 (1.5)	11,072 (98.5)
	3rd quantile	14,731	226 (1.5)	14,505 (98.5)
	4th quantile	21,237	353 (1.7)	20,884 (98.3)
	Medical aid recipients	5,008	35 (0.7)	4,973 (99.3)
Urban/rural					< 0.001^a
	Urban resident	55,997	887 (1.6)	55,110 (98.4)
	Rural resident	8,981	73 (0.8)	8,908 (99.2)
Hospital type					< 0.001^a
	Tertiary hospital	19,790	634 (3.2)	19,156 (96.8)
	General hospital	27,274	306 (1.1)	26,968 (98.9)
	Hospital	10,190	10 (0.1)	10,180 (99.9)
CCI, preoperative					< 0.001^a
	0–4	7,843	9 (0.1)	7,834 (99.9)
	5–6	34,302	594 (1.7)	33,708 (98.3)
	≥ 7	23,797	357 (1.5)	23,440 (98.5)

Data are presented as number (%).

CR = cardiac rehabilitation, CCI = Charlson comorbidity index.

^aSignificance below 0.05.

CR participation rate and density

In the 64,982 study subjects, the national CR participation rate was 1.5% (960/64,982). There were 26 CR-providing facilities (15 tertiary hospitals and 11 general hospitals). In the calculation of the CR density, the number of study subjects was treated as annual AMI incidence. According to this parameter, the national CR density was approximately 10 AMI incidence/capacity/year, which means 10 times more CR facilities are needed to accommodate the incidence of AMI.

The CR use, according to the administrative divisions, is presented in Table 2. The CR participation rate widely varied across the nation, ranging from 0.0% to 6.4%. Similarly, variation was observed in CR density, with values ranging from 3 to 18.

Table 2

Hospital-based CR utilization by administrative division

Administrative division	AMI incidence	No. of CR-providing facilities	CR capacity^a	CR density^b	CR participation rate, %
Seoul	14,015	7	1,750	8	1.3
Busan	5,672	2	500	11	2.3
Daegu	4,549	1	250	18	1.7
Incheon	2,845	1	250	11	2.1
Gwangju	2,561	1	250	10	1.1
Daejeon	1,627	1	250	7	0.9
Ulsan	1,522	0	0	-	0
Gyeongi-do	12,409	5	1,250	10	1.9
Gangwon-do	2,491	2	500	5	1.0
Chungcheongbuk-do	1,996	1	250	8	0.2
Chungcheongnam-do	2,598	0	0	-	0.1
Jeollabuk-do	2,637	1	250	11	4.8
Jeollanam-do	2,319	0	0	-	0.1
Gyeongsangbuk-do	2,936	1	250	12	0.3
Gyeongsangnam-do	4,004	2	500	8	0.4
Jeju-do	801	1	250	3	6.4
Total	64,982	26	6,500	10	1.5

AMI = acute myocardial infarction, CR = cardiac rehabilitation.

^aCR capacity calculated as the median number of patients that each facility could serve per year (= 250) multiplied by the number of facilities; ^bCR density calculated as the AMI incidence divided by CR capacity.

Among 8,855 patients who were treated in hospitals with more than 10 participants per year, the participation rate increased to 9.5% (843/8,855).

Factors associated with CR participation

Factors associated with the CR participation are shown in Table 3. The younger age group demonstrated a higher odds ratio of CR participation than did the older age group. Male patients participated more in CR than female patients did. In addition, urban residents seemed to participate more in CR than rural residents. Patients with the lowest CCI ranging from 0–4 participated less in CR than those with CCI ≥ 7. No significant difference was observed in CR participation between the groups classified based on insurance premium quantile.

Table 3

Logistic regression analysis for CR participation

Variables		OR (95% CI)	P value
Age, yr			< 0.001^a,b
	40–60	2.804 (2.259–3.479)
	61–70	2.272 (1.811–2.849)
	71–80	Ref.
Sex
	Male	2.026 (1.675–2.539)	< 0.001^a
	Female	Ref.
Insurance premium
	1st quantile	0.853 (0.432–1.053)	0.953
	2nd quantile	0.912 (0.691–1.145)	0.274
	3rd quantile	0.987 (0.752–1.110)	0.315
	4th quantile	Ref.
Urban/rural
	Urban resident	1.382 (1.062–1.797)	0.016^a
	Rural resident	Ref.
CCI			0.001^a,b
	0–4	0.073 (0.030–0.177)
	5–6	1.133 (0.976–1.316)
	≥ 7	Ref.

CCI = Charlson comorbidity index, CI = confidence interval, CR = cardiac rehabilitation, OR = odds ratio.

^aSignificance below 0.05; ^bP for trend.

DISCUSSION

Despite the recommendations accentuating the role of CR in AMI patients,4 5 6 only 1.5% of these patients participated in the CR program in Korea. There was geographical variance in participation, ranging from 0.0% to 6.4%. The relatively high AMI incidence obtained in this study compared to that of the Statistics Korea18 and a range of 71.4%–73.1% accuracy of the operational definition for diagnosing AMI16 could have resulted in the underestimation of the participation rate. Nevertheless, even considering these limitations, the participation rate of 1.5% was remarkably lower than that of Europe (30%–50%)19 and the United States (10.3%–16.3%).20 According to our calculation, the CR density in Korea was about 10. This means that approximately 234 more CR facilities should be established to cover the annual incidence of AMI.

In hospitals with > 10 CR participants, the CR participation rate was similarly insufficient (9.5%). This suggests that efforts are required to promote CR participation even in actively-operating CR facilities; the identification of CR barriers is important to plan effective promotion strategies. This study showed a markedly lower CR participation in patients with old age, female sex, and rural residence, in line with the results of previous studies.21 22 23 The reasons for inadequate CR participation among these populations are multifactorial.24 25 Proposed explanations for low participation in elderly patients include inadequate physician referral, comorbidity-associated mobility issues, and transportation issues.26 Poor CR participation in females might be attributed to insufficient physician referral, more familial responsibilities, and less spare time to attend CR programs.27 Self-reliant rural attitudes and low accessibility to medical facilities might have contributed to poor CR participation among rural residents.28 To overcome these issues, strategies should be implemented, including automated referral systems, improved awareness of CR, flexible therapy hours, and alternative CR delivery models such as home- and community-based CR.24 29

In this study, no difference was observed between the participants and the nonparticipants with regard to income status; this is different from previous studies that revealed higher income earning patients attend CR more in Europe30 and the United States.31 One possible explanation for the unobserved difference is the decreased economic burden of CR due to its coverage by the National Health Insurance in Korea. Another possible explanation is that high income earning patients are more likely to be economically active with insufficient time to participate32; this can offset the beneficial effects of high income on CR participation. Therefore, further study is required to clarify the effect of socioeconomic status on CR participation in Korea. Similarly, CCI was not a significant factor in previous studies investigating CR barriers.23 33 34 However, the fewer comorbidities group (the group with the lowest CCI ranging between 0–4) participated least often in this study; this could be due to the less motivation and fewer needs of these patients, which could have resulted in nonparticipation in CR.11 35 In addition, CCI is determined by the number of comorbid diseases, and this may not directly reflect the patient's physical or cardiac function, which are important factors for CR participation.36 Therefore, a further study including variables such as cardiorespiratory fitness level or ejection fraction is needed.

In this study, only a limited number of potential barriers were retrospectively investigated. Nevertheless, various CR barriers have been reported in the literature21 37 38 and they may differently affect CR participation depending on the particular clinical situation in each hospital or region. Therefore, efforts to identify CR barriers in each region and planning effective CR promotion strategies according to identified barriers are required.39

There are several limitations to this study. First, the diagnosis of AMI was operationally defined using medical claim records. In a previous study, this method has been known to have an accuracy ranging between 71.4%–73.1% and fair-to-good reliability.16 Nevertheless, there are possibilities of false exclusion or inclusion. Second, national CR density was calculated using the median capacity of Korean hospital-based CR facility participating in a previous global survey.12 Most of the hospitals used in the estimation of the CR capacity were tertiary or general hospitals that probably had larger CR capacity, and the CR density may have been underestimated. In addition, the distance from a CR facility to a patient's home is an important influencing factor for CR participation27 that was not considered. For example, a CR facility with a large capacity could be situated extremely far from the patient's home; therefore, the required number of CR facilities based on CR density in this study could have been equally underestimated. Third, there could be mismatch between procedure, benefits, and claim record. Because the period of index admission in this study was the transition period of the change in benefits type for CR, there is a possibility of incomplete reimbursement for any reason. Therefore, follow-up research until the post-transitional period is important. Fourth, other known factors that affect participation in CR, including physician referral pattern, the ability to drive, and education level, were not evaluated.21 23 Further comprehensive studies should be performed to evaluate CR barriers. Fifth, indication for CR was confined to AMI in this study. Current indications for CR are broader, including other cardiovascular diseases such as unstable angina, valvular heart disease, heart failure, and peripheral arterial diseases.5 6 40 41 Therefore, the possibility of unrevealed demand for CR exists. Further studies, including these group of patients, are needed. Finally, this is the initial report of CR utilization (in the period of CR utilization) in Korea. Three more regional cardiocerebrovascular centers were installed in 2019, and more hospitals may provide CR at this time. Therefore, a follow-up study is required.

In conclusion, hospital-based CR participation rate after AMI was only 1.5% nationally, and the overall supply was insufficient in Korea, despite coverage by the National Health Insurance, compared to CR use in other high-income countries. To overcome these problems, more CR facilities and effective strategies to overcome CR barriers are required. Therefore, a follow-up study with a more comprehensive evaluation of barriers to CR is needed in the future.

ACKNOWLEDGMENTS

This study used National Health Information Database (NHIS-2019-1-086) made by National Health Insurance Service (NHIS). The authors would like to thank the Korean NHIS for supporting data access and analysis.

Notes

Funding: This work was supported by grant from the Seoul National University Bundang Hospital (SNUBH) Research Fund (No. 06-2017-257) and from the Korean National Health Insurance Service.

Disclosure: The authors have no potential conflicts of interest to disclose.

Author Contributions:

Conceptualization: Kim Y, Kim WS.
Data curation: Ro JS, Leigh JH.
Formal analysis: Kim SH, Ro JS, Leigh JH, Kim WS.
Funding acquisition: Kim Y, Leigh JH, Kim WS.
Investigation: Kim SH, Ro JS, Kim Y, Leigh JH, Kim WS.
Methodology: Kim SH, Ro JS, Leigh JH, Kim WS.
Project administration: Kim Y, Leigh JH, Kim WS.
Resources: Ro JS, Kim Y, Leigh JH.
Software: Ro JS.
Supervision: Kim Y.
Validation: Kim SH, Ro JS, Leigh JH, Kim WS.
Visualization: Kim SH, Leigh JH, Kim WS.
Writing - original draft: Kim SH, Kim WS.
Writing - review & editing: Kim SH, Ro JS, Kim Y, Leigh JH, Kim WS.

References

1. Lee KS, Park JH. Burden of disease in Korea during 2000–10. J Public Health (Oxf). 2014; 36(2):225–234. PMID: 23759601.

2. Dalen JE, Alpert JS, Goldberg RJ, Weinstein RS. The epidemic of the 20(th) century: coronary heart disease. Am J Med. 2014; 127(9):807–812. PMID: 24811552.

3. Cha S, Park JJ, Kim S, Ahn HY, Han K, Lee Y, et al. Need for systematic efforts to modify health-related behaviors after acute myocardial infarction in Korea. Circ J. 2018; 82(10):2523–2529. PMID: 30068823.

4. Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, 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(22):2458–2473. PMID: 22052934.

5. Piepoli MF, Corrà U, Adamopoulos S, Benzer W, Bjarnason-Wehrens B, Cupples M, et al. Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery: a policy statement from the cardiac rehabilitation section of the European Association for Cardiovascular Prevention & Rehabilitation. Eur J Prev Cardiol. 2014; 21(6):664–681. PMID: 22718797.

6. Kim C, Sung J, Lee JH, Kim WS, Lee GJ, Jee S, et al. Clinical practice guideline for cardiac rehabilitation in Korea. Ann Rehabil Med. 2019; 43(3):355–443. PMID: 31311260.

7. Anderson L, Thompson DR, Oldridge N, Zwisler AD, Rees K, Martin N, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2016; 2016(1):CD001800.

8. Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J. 2011; 162(4):571–584.e2. PMID: 21982647.

9. Lee YH, Hur SH, Sohn J, Lee HM, Park NH, Cho YK, et al. Impact of home-based exercise training with wireless monitoring on patients with acute coronary syndrome undergoing percutaneous coronary intervention. J Korean Med Sci. 2013; 28(4):564–568. PMID: 23580444.

10. Benzer W, Rauch B, Schmid JP, Zwisler AD, Dendale P, Davos CH, et al. Exercise-based cardiac rehabilitation in twelve European countries results of the European cardiac rehabilitation registry. Int J Cardiol. 2017; 228:58–67. PMID: 27863363.

11. Im HW, Baek S, Jee S, Ahn JM, Park MW, Kim WS. Barriers to outpatient hospital-based cardiac rehabilitation in Korean patients with acute coronary syndrome. Ann Rehabil Med. 2018; 42(1):154–165. PMID: 29560336.

12. Turk-Adawi K, Supervia M, Lopez-Jimenez F, Pesah E, Ding R, Britto RR, et al. Cardiac Rehabilitation Availability and Density around the Globe. EClinicalMedicine. 2019; 13:31–45. PMID: 31517261.

13. Institute for Health Metrics and Evaluation. Updated 2017. Accessed February 3, 2020. http://ghdx.healthdata.org/gbd-results-tool.

14. Song SO, Jung CH, Song YD, Park CY, Kwon HS, Cha BS, et al. Background and data configuration process of a nationwide population-based study using the Korean national health insurance system. Diabetes Metab J. 2014; 38(5):395–403. PMID: 25349827.

15. Seong SC, Kim YY, Khang YH, Park JH, Kang HJ, Lee H, et al. Data resource profile: The National Health Information Database of the National Health Insurance Service in South Korea. Int J Epidemiol. 2017; 46(3):799–800. PMID: 27794523.

16. Kimm H, Yun JE, Lee SH, Jang Y, Jee SH. Validity of the diagnosis of acute myocardial infarction in Korean national medical health insurance claims data: the Korean heart study (1). Korean Circ J. 2012; 42(1):10–15. PMID: 22363378.

17. Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005; 43(11):1130–1139. PMID: 16224307.

18. Korean Statistical Information Service. Updated 2019. Accessed February 4, 2020. http://kosis.kr/statHtml/statHtml.do?orgId=411&tblId=DT_41104_212&conn_path=I2.

19. Humphrey R, Guazzi M, Niebauer J. Cardiac rehabilitation in Europe. Prog Cardiovasc Dis. 2014; 56(5):551–556. PMID: 24607021.

20. Beatty AL, Truong M, Schopfer DW, Shen H, Bachmann JM, Whooley MA. Geographic variation in cardiac rehabilitation participation in medicare and veterans affairs populations: opportunity for improvement. Circulation. 2018; 137(18):1899–1908. PMID: 29305529.

21. Dunlay SM, Witt BJ, Allison TG, Hayes SN, Weston SA, Koepsell E, et al. Barriers to participation in cardiac rehabilitation. Am Heart J. 2009; 158(5):852–859. PMID: 19853708.

22. Witt BJ, Jacobsen SJ, Weston SA, Killian JM, Meverden RA, Allison TG, et al. Cardiac rehabilitation after myocardial infarction in the community. J Am Coll Cardiol. 2004; 44(5):988–996. PMID: 15337208.

23. Cooper AF, Jackson G, Weinman J, Horne R. Factors associated with cardiac rehabilitation attendance: a systematic review of the literature. Clin Rehabil. 2002; 16(5):541–552. PMID: 12194625.

24. Supervía M, Medina-Inojosa JR, Yeung C, Lopez-Jimenez F, Squires RW, Pérez-Terzic CM, et al. Cardiac rehabilitation for women: a systematic review of barriers and solutions. Mayo Clin Proc. 2017; 92(4):565–577.

25. Deaton C. Addressing the paradox of age and participation in cardiac rehabilitation. Eur J Prev Cardiol. 2019; 26(10):1050–1051. PMID: 30922103.

26. Schopfer DW, Forman DE. Cardiac rehabilitation in older adults. Can J Cardiol. 2016; 32(9):1088–1096. PMID: 27297002.

27. Ruano-Ravina A, Pena-Gil C, Abu-Assi E, Raposeiras S, van 't Hof A, Meindersma E, et al. Participation and adherence to cardiac rehabilitation programs. A systematic review. Int J Cardiol. 2016; 223:436–443. PMID: 27557484.

28. De Angelis C, Bunker S, Schoo A. Exploring the barriers and enablers to attendance at rural cardiac rehabilitation programs. Aust J Rural Health. 2008; 16(3):137–142. PMID: 18471183.

29. Fiatarone Singh MA. Tailoring assessments and prescription in cardiac rehabilitation for older adults: the relevance of geriatric domains. Clin Geriatr Med. 2019; 35(4):423–443. PMID: 31543176.

30. Nielsen KM, Faergeman O, Foldspang A, Larsen ML. Cardiac rehabilitation: health characteristics and socio-economic status among those who do not attend. Eur J Public Health. 2008; 18(5):479–483. PMID: 18614608.

31. Shanmugasegaram S, Oh P, Reid RD, McCumber T, Grace SL. Cardiac rehabilitation barriers by rurality and socioeconomic status: a cross-sectional study. Int J Equity Health. 2013; 12(1):72. PMID: 23985017.

32. Grace SL, Shanmugasegaram S, Gravely-Witte S, Brual J, Suskin N, Stewart DE. Barriers to cardiac rehabilitation: Does age make a difference? J Cardiopulm Rehabil Prev. 2009; 29(3):183–187. PMID: 19471138.

33. Shanks LC, Moore SM, Zeller RA. Predictors of cardiac rehabilitation initiation. Rehabil Nurs. 2007; 32(4):152–157. PMID: 17650782.

34. Allen JK, Scott LB, Stewart KJ, Young DR. Disparities in women's referral to and enrollment in outpatient cardiac rehabilitation. J Gen Intern Med. 2004; 19(7):747–753. PMID: 15209588.

35. De Vos C, Li X, Van Vlaenderen I, Saka O, Dendale P, Eyssen M, et al. Participating or not in a cardiac rehabilitation programme: factors influencing a patient's decision. Eur J Prev Cardiol. 2013; 20(2):341–348. PMID: 22345682.

36. Blackburn GG, Foody JM, Sprecher DL, Park E, Apperson-Hansen C, Pashkow FJ. Cardiac rehabilitation participation patterns in a large, tertiary care center: evidence for selection bias. J Cardiopulm Rehabil. 2000; 20(3):189–195. PMID: 10860201.

37. Evenson KR, Fleury J. Barriers to outpatient cardiac rehabilitation participation and adherence. J Cardiopulm Rehabil. 2000; 20(4):241–246. PMID: 10955265.

38. van Engen-Verheul M, de Vries H, Kemps H, Kraaijenhagen R, de Keizer N, Peek N. Cardiac rehabilitation uptake and its determinants in the Netherlands. Eur J Prev Cardiol. 2013; 20(2):349–356. PMID: 22345699.

39. Ades PA, Keteyian SJ, Wright JS, Hamm LF, Lui K, Newlin K, et al. Increasing cardiac rehabilitation participation from 20% to 70%: a road map from the million hearts cardiac rehabilitation collaborative. Mayo Clin Proc. 2017; 92(2):234–242. PMID: 27855953.

40. Kim SH, Cha S, Kang S, Han K, Paik NJ, Kim WS. High prevalence of physical inactivity after heart valve surgery and its association with long-term mortality: A nationwide cohort study. Eur J Prev Cardiol. 2020; 2047487320903877. PMID: 32053015.

41. Ades PA, Keteyian SJ, Balady GJ, Houston-Miller N, Kitzman DW, Mancini DM, et al. Cardiac rehabilitation exercise and self-care for chronic heart failure. JACC Heart Fail. 2013; 1(6):540–547. PMID: 24622007.

TOOLS

Similar articles