Identifying barriers to participation in cardiac prevention and rehabilitation programmes via decision tree analysis: Establishing targets for remedial interventions

Background: Participation rates of patients with acute coronary syndrome (ACS) in efficacious cardiac prevention and rehabilitation programmes (CPRPs) are low, particularly in ethnic minorities. Few studies have evaluated the full array of potential barriers to participation in a multiethnic cohort with identical insurance coverage. Objective: To assess the hierarchy of multiple barriers (ie, sociodemographic, systemic, illness related, psychological and cultural) to participation in CPRP of Jewish and Arab patients served by a regional hospital in Israel. Methods: Patients with ACS (N=420) were interviewed during hospitalisation about potential barriers and subsequently about participation in CPRP. Decision tree analysis determined, hierarchically, the best predictors of participation in CPRP. Results: Ethnicity was the salient predictor of participation in CPRP (61.1% (95% CI 55.6% to 66.5%) of Jewish patients versus 17.2% (95% CI 11.2% to 24.9%) of Arab patients). Among Jewish patients the dominant determinant was a recommendation for CPRP in the hospital discharge letter (32.5% (95% CI 23.1% to 43.1%) vs 71.9% (95% CI 65.8% to 77.6%) participation without and with a recommendation, respectively). Other major hierarchical determinants included age, discharge diagnosis, socioeconomic position and perceived benefits of exercise. Among Arab patients, anxiety was the main predictor (5.5% (95% CI 1.1% to 14.1%) vs 27.9% (95% CI 17.7% to 40.0%) participation among those with high vs lower anxiety levels). Additional contributors were a predischarge visit to the rehabilitation centre (familiarisation) and car ownership (access). Conclusions: Utilisation of decision tree analysis enables us to identify the key barriers to participation in CPRP in an ethnic-specific mode. Interventions to improve participation can then be designed to address each group's specific barriers.