https://orcid.org/0000-0003-3640-2119
The EUROASPIRE surveys determined that a large majority of coronary artery disease (CAD) patients has unhealthy lifestyles and poor cardiovascular risk factor control.1 Cardiac rehabilitation (CR) requires programmes delivered by interdisciplinary teams of healthcare professionals addressing all aspects of lifestyle and risk factor management. Norwegian centres did not participate in the EUROASPIRE surveys, and few national data exist on adherence to clinical practice guidelines on CAD prevention.2 Further, national data on CR participation are very scarce3 and have not been reported when separating single module interventions from modern interdisciplinary multimodal CR. Therefore, the aim of this nationwide analysis was to assess CR participation among all myocardial infarction (MI) survivors diagnosed during 2018–21.
Data from the Norwegian Patient Registry (NPR) and the Norwegian Registry for Primary Health Care (KPR) were linked using the unique personal identifier number of all patients hospitalized with acute MI (ICD-10 I21) as primary diagnosis between January 2018 and December 2021. All MI survivors were followed for 182 days (six months) after discharge to observe whether they had received CR or not. All 21 hospital referral areas in Norway were grouped into the four health regions. Cardiac rehabilitation was defined as ICD-10 codes of Z50.0, Z50.80, Z50.89, or Z50.9. The percentage of CR during follow-up was calculated as the number of patients recorded to have received any one of the above codes divided by the total number of MIs adjusted for age and sex. In order to adjust for the differences in age and sex structure of the general MI population and patients who received CR between health regions, we used the age distribution of MI patients for 2020 as a standard population and standardized the percentages for age and sex using the direct method. We also calculated days to the first CR episode. We performed sensitivity analyses stratified for the pre- and post-COVID-19 period (see Supplementary material online, Table S1). From the NPR registry, we also obtained information on educational courses (procedure code WPCK00) and guided physical exercise training (procedure code OBAB00) in the municipalities, and from KPR information on exercise training at private institutes. Statistical analyses were performed by R Studio version 2023.03.0. The study was approved by the Norwegian Directorate of Health (17/2144–57 and 21/5961–3) and evaluated by the Regional Committee for Medical and Health Research Ethics (2023/647257).
In all, 37 136 patients (mean age 70 ± 13 years, 32% women) were discharged with MI in Norway during the 4-year period (see Supplementary material online, Table S2), of which 14% (n = 5260) participated in CR. There was a geographic variation ranging from 4% (Northern region) to 16% (South-Eastern region) (Figure 1A). Breaking down into hospital referral areas, the variation across the country is shown in more detail (Figure 1B). We also observed a geographic variation related content of the CR provided reflected in the ICD-10 codes used (see Supplementary material online, Figure S1). The median number of days to CR was 53 (IQR = 55) with some geographic variation (Figure 1C). The 40–59-year-old patients most often received CR, but still <25% of those below 60 years participated (Figure 2). The participation rate was comparable in women and men. However, when taking all age groups into account, 16% of men participated compared to 11% of women. The participation rate dropped dramatically for both sexes after 65 years. If we also include other rehabilitative activities like lone-standing educational courses or exercise training, the total percentage of MI survivors in Norway receiving any follow-up care increased to 26% (n = 9776). Exercise training at private physiotherapy institutes was rare, and numbers were driven particularly by one geographical area (n = 1635, 4.4%). We found only slightly lower CR activity during and after the Covid-19 pandemic (13.7%) compared to the years before (14.6%) (see Supplementary material online, Figure S1).
(A) Participation in cardiac rehabilitation across four health regions and nationally. (B) Percentage of patients in cardiac rehabilitation across the 21 hospital referral areas (C) Days to first cardiac rehabilitation episode across health regions (median at a national level marked by the dotted line).
Percentage of cardiac rehabilitation according sex and age categories.
There are inevitable methodological limitations. Misclassification of MI diagnoses and codes for CR may have influenced the study results. However, the quality of the ICD-10 codes in Norwegian Patient Registry has been found to be very good.4 To mitigate the risk of overestimating the proportion of patients eligible for CR, we only included MI cases recorded as the primary diagnosis. We only have access to administrative and demographic data, and further investigation is needed to gain knowledge about the content of the CR programmes5 as well as to elucidate potential reasons for the low participation rate.
Nevertheless, these nationwide data documents that only a minority of MI survivors in Norway receive guideline recommended aftercare. This applies to both women and men, and at all ages. Time to enrolment was also too long. Geographic variations within the country were large. The results are worrying since CR is a Class IA recommendation in European guidelines,2 which leaves no doubt of its efficiency when delivered by interdisciplinary teams in multimodal programmes targeting effective risk factor management. Cardiac rehabilitation is cost effective,6 which is yet another argument for improving the situation. Cardiac rehabilitation targeting all age groups is recommended,7 although tailored care may be needed, particularly for older adults.8 Norway has long distances and remote areas where it may be challenging to establish place-based CR. Geographic variations may be mitigated by home-based9 and digital10 programmes, which is also recommended in guidelines.2 In summary, the participation rate in CR in Norway is very low and with great geographic variation. We need a call for action to improve the care of MI patients.
Authors’ contributions
All authors contributed to the conception or design of the work. M.B. was responsible for the acquisition of data, H.K.B. performed the data analyses, and all authors contributed to interpretation of data. T.M.N., H.K.B., and J.M. drafted the manuscript. All authors gave final approval and agreed to be accountable for all aspects of the work ensuring integrity and accuracy.
Supplementary material
Supplementary material is available at European Journal of Preventive Cardiology.
Acknowledgements
We thank Marie Hayes for assistance in development of the figures.
Funding
We do not declare a specific grant for this research from any funding agency in public, commercial, or not-for-profit sectors.
Data availability
The data that support the findings of this report will be available at www.helseatlas.no.
Disclaimer
Data from the Norwegian Patient Register and the Norwegian Registry for Primary Health Care have been used in this publication. The interpretation and reporting of these data are the sole responsibility of the authors, and neither endorsement by the Norwegian Directorate of Health is intended nor should be inferred.
References
Author notes
Conflict of interest: None declared.
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