Publicly versus privately funded cardiac rehabilitation: access and adherence barriers. A cross-sectional study

Giovanna Lombardi Bonini Borges Mayara Moura Alves da Cruz Ana Laura Ricci-Vitor Paula Fernanda da Silva Sherry Lynn Grace Luiz Carlos Marques Vanderlei About the authors

ABSTRACT

BACKGROUND:

Cardiac rehabilitation (CR) barriers are well-understood in high-resource settings. However, they are under-studied in low-resource settings, where access is even poorer and the context is significantly different, including two-tiered healthcare systems and greater socioeconomic challenges.

OBJECTIVE:

To investigate differences in characteristics of patients attending publicly versus privately funded CR and their barriers to adherence.

DESIGN AND SETTING:

Observational, cross-sectional study in public and private CR programs offered in Brazil.

METHODS:

Patients who had been attending CR for ≥ 3 months were recruited from one publicly and one privately funded CR program. They completed assessments regarding sociodemographic and clinical characteristics and the CR Barriers Scale.

RESULTS:

From the public program, 74 patients were recruited, and from the private, 100. Participants in the public program had significantly lower educational attainment (P < 0.001) and lower socioeconomic status (P < 0.001). Participants in the private program had more cognitive impairment (P = 0.015), and in the public program more anxiety (P = 0.001) and depressive symptoms (P = 0.008) than their counterparts. Total barriers among public CR participants were significantly higher than those among private CR participants (1.34 ± 0.26 versus 1.23 ± 0.15/5]; P = 0.003), as were scores on 3 out of 5 subscales, namely: comorbidities/functional status (P = 0.027), perceived need (P < 0.001) and access (P = 0.012).

CONCLUSION:

Publicly funded programs need to be tailored to meet their patients’ requirements, through consideration of educational and psychosocial matters, and be amenable to mitigation of patient barriers relating to presence of comorbidities and poorer health status.

KEYWORDS (MeSH terms):
Cardiac rehabilitation; Cardiovascular diseases; Delivery of health care; Private sector; Surveys and questionnaires; Public sector

AUTHORS’ KEYWORDS:
Barriers to cardiac rehabilitation; Public healthcare system; Patients’ characteristics

INTRODUCTION

Cardiovascular rehabilitation (CR) programs are recommended in clinical guidelines,11 Smith SC Jr, Benjamin EJ, Bonow RO, 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):2458-73. PMID: 22052934; https://doi.org/10.1161/CIR.0b013e318235eb4d. Erratum in: Circulation. 2015;131(15):e408.
https://doi.org/10.1161/CIR.0b013e318235...
,22 Authors/Task Force members, Windecker S, Kolh P, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014;35(37):2541-619. PMID: 25173339; https://doi.org/10.1093/eurheartj/ehu278.
https://doi.org/10.1093/eurheartj/ehu278...
because participation results in significantly lower mortality and morbidity,33 Kabboul NN, Tomlinson G, Francis TA, et al. Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis. J Clin Med. 2018;7(12):514. PMID: 30518047; https://doi.org/10.3390/jcm7120514.
https://doi.org/10.3390/jcm7120514...
including in low and middle-income countries (LMICs).44 Mamataz T, Uddin J, Ibn Alam S, et al. Effects of cardiac rehabilitation in low and middle-income countries: A systematic review and meta-analysis of randomized controlled trials. Prog Cardiovasc Dis. 2021:S0033-0620(21)00072-4. PMID: 34271035; https://doi.org/10.1016/j.pcad.2021.07.004.
https://doi.org/10.1016/j.pcad.2021.07.0...
However, CR participation remains low, at around 20%-30% in high-income countries,55 Grace SL, Russell KL, Reid RD, et al. Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study. Arch Intern Med. 2011;171(3):235-41. PMID: 21325114; https://doi.org/10.1001/archinternmed.2010.501.
https://doi.org/10.1001/archinternmed.20...
77 Grace SL, Kotseva K, Whooley MA. Cardiac rehabilitation: Under-utilized globally. Current Cardiology Reports. 2021;23(9):118. PMID: 34269894; https://doi.org/10.1007/s11886-021-01543-x.
https://doi.org/10.1007/s11886-021-01543...
and 14% in LMICs such as Brazil.88 Turk-Adawi KI, Grace SL. Narrative review comparing the benefits of and participation in cardiac rehabilitation in high-, middle- and low-income countries. Heart Lung Circ. 2015;24(5):510-20. PMID: 25534902; https://doi.org/10.1016/j.hlc.2014.11.013.
https://doi.org/10.1016/j.hlc.2014.11.01...

The reasons for underuse of CR have been well-characterized in high-resource settings77 Grace SL, Kotseva K, Whooley MA. Cardiac rehabilitation: Under-utilized globally. Current Cardiology Reports. 2021;23(9):118. PMID: 34269894; https://doi.org/10.1007/s11886-021-01543-x.
https://doi.org/10.1007/s11886-021-01543...
,99 Clark AM, King-Shier KM, Duncan A, et al. Factors influencing referral to cardiac rehabilitation and secondary prevention programs: a systematic review. Eur J Prev Cardiol. 2013;20(4):692-700. PMID: 23847263; https://doi.org/10.1177/2047487312447846.
https://doi.org/10.1177/2047487312447846...
,1010 Clark AM, King-Shier KM, Spaling MA, et al. Factors influencing participation in cardiac rehabilitation programmes after referral and initial attendance: qualitative systematic review and meta-synthesis. Clin Rehabil. 2013;27(10):948-59. PMID: 23798748; https://doi.org/10.1177/0269215513481046.
https://doi.org/10.1177/0269215513481046...
and include factors at the healthcare system, provider and patient levels. However, barriers in lower-resource settings have not been well-studied. A recent review identified only 13 studies globally,1111 Ragupathi L, Stribling J, Yakunina Y, et al. Availability, Use, and Barriers to Cardiac Rehabilitation in LMIC. Glob Heart. 2017;12(4):323-334.e10. PMID: 28302548; https://doi.org/10.1016/j.gheart.2016.09.004.
https://doi.org/10.1016/j.gheart.2016.09...
and there are also few studies in South America1212 Sanchez-Delgado JC, Jacome-Hortua A, Pinzon S, Angarita-Fonseca A. Validez de contenido de la escala de barreras para la rehabilitacion cardiaca. Universidad y Salud. 2015;17(2):170-6. https://doi.org/https://doi.org/10.22267/rus.151702.2.
https://doi.org/https://doi.org/10.22267...
or Brazil to date.1313 Ghisi GL, Santos RZ, Schveitzer V, et al. Development and validation of the Brazilian Portuguese version of the Cardiac Rehabilitation Barriers Scale. Arq Bras Cardiol. 2012;98(4):344-51. PMID: 22426990; https://doi.org/10.1590/s0066-782x2012005000025.
https://doi.org/10.1590/s0066-782x201200...
1616 Ghisi GL, dos Santos RZ, Aranha EE, et al. Perceptions of barriers to cardiac rehabilitation use in Brazil. Vasc Health Risk Manag. 2013;9:485-91. PMID: 24039433; https://doi.org/10.2147/VHRM.S48213.
https://doi.org/10.2147/VHRM.S48213...
This is problematic, given the different contexts in these settings. Firstly, patients would be more socioeconomically disadvantaged, and hence face different barriers. Secondly, healthcare systems are more often two-tier.1717 Moghei M, Pesah E, Turk-Adawi K, et al. Funding sources and costs to deliver cardiac rehabilitation around the globe: Drivers and barriers. Int J Cardiol. 2019;276:278-86. PMID: 30414751; https://doi.org/10.1016/j.ijcard.2018.10.089.
https://doi.org/10.1016/j.ijcard.2018.10...
So, for example, half of CR programs in Brazil are solely publicly-funded (53.3%), a third privately-funded, and the remainder a mixture.1818 Britto RR, Supervia M, Turk-Adawi K, et al. Cardiac rehabilitation availability and delivery in Brazil: a comparison to other upper middle-income countries. Braz J Phys Ther. 2020;24(2):167-76. PMID: 30862431; https://doi.org/10.1016/j.bjpt.2019.02.011.
https://doi.org/10.1016/j.bjpt.2019.02.0...
It has been established that CR funding sources affect program characteristics, such as scale, healthcare providers on the team and component comprehensiveness.1717 Moghei M, Pesah E, Turk-Adawi K, et al. Funding sources and costs to deliver cardiac rehabilitation around the globe: Drivers and barriers. Int J Cardiol. 2019;276:278-86. PMID: 30414751; https://doi.org/10.1016/j.ijcard.2018.10.089.
https://doi.org/10.1016/j.ijcard.2018.10...
However, to our knowledge, it has yet to be investigated how barriers might differ for patients accessing privately and publicly-funded programs in any country worldwide.1919 Mair V, Breda AP, Nunes ME, Matos LD. Evaluating compliance to a cardiac rehabilitation program in a private general hospital. Einstein (Sao Paulo). 2013;11(3):278-84. PMID: 24136752; https://doi.org/10.1590/s1679-45082013000300004.
https://doi.org/10.1590/s1679-4508201300...

OBJECTIVES

Therefore, the objectives of this study were to compare: (1) the sociodemographic and clinical characteristics of patients accessing publicly versus privately funded CR programs; and (2) multi-level barriers to adherence in each of these types of programs. While the world needs more CR,2020 Turk-Adawi K, Supervia M, Lopez-Jimenez F, et al. Cardiac Rehabilitation Availability and Density around the Globe. EClinicalMedicine. 2019;13:31-45. PMID: 31517261; https://doi.org/10.1016/j.eclinm.2019.06.007.
https://doi.org/10.1016/j.eclinm.2019.06...
and offering privately funded programs may enable greater availability, the CR community needs to consider the inequities that this might raise.

METHODS

Design and procedure

This was an observational cross-sectional study. Participants signed an informed consent statement. The local ethics committee approved all procedures on June 28, 2018 (CAAE number: 88504718.0.0000.5402).

A convenience sample was recruited between March and August 2019. Participants in the public or private CR programs offered in the city of Presidente Prudente, São Paulo, Brazil, were approached with a view to inviting them to take part in this study and undergo assessments. These assessments were administered by physiotherapists who were not part of the programs.

Setting

The publicly funded CR program for this study is offered by the Cardiology Division of the Center for Studies and Attendance in Physiotherapy and Rehabilitation, School of Technology and Sciences, Universidade Estadual Paulista (UNESP), Presidente Prudente, São Paulo, Brazil. The CR program is funded by the Brazilian National Health System and is delivered through the physiotherapy program. The program is indefinite in length (i.e. phase II and maintenance).

The privately funded CR program is offered through the city's Heart Institute. The program is funded by the patient or through medical health insurance (25.9% of Brazilians have health insurance).2121 Marques RM, Piola SF, Roa AC, organizadores. Sistema de Saúde no Brasil: organização e financiamento. Rio de Janeiro: Ministério da Saúde, Departamento de Economia da Saúde, Investimentos e Desenvolvimento; 2016. Most patients who use the private program have a health plan, for which they pay a monthly fee. This health plan covers 36 sessions, after which it is necessary to request coverage of further sessions if the doctor perceives more are required. When the patient does not have a health plan, they pay out-of-pocket monthly (R$ 390.00).

To start either program, patients require a written medical referral. The public program offers sessions three times/week, while the private program offers two to three per week, depending on the patient. In both programs, exercises are performed in groups; the public program serves on average 18 patients/session and the private one, 12 patients/session. With regard to staffing, in the private program, care is delivered by physiotherapy cardiology specialists; in the public program, care is provided by physiotherapy students supervised by professors.

The programs are primarily centered on structured exercises, and the exercise prescriptions are quite consistent between programs: they are based on heart rate reserve, and are re-evaluated each month. Exercises in the public program are done on treadmills and stationary bikes. In the private program, there are also resistance exercises. In addition, in the public program, there are group educational lectures and patients are provided with written materials. In the private program, there is informal counselling regarding risk factor control during the one-to-one sessions only.

Participants

The inclusion criteria were that the participants needed to be aged over 18 years, with a diagnosis of cardiovascular disease or with cardiovascular risk factors (as per the program inclusion criteria), and needed to have been in the CR program for ≥ 3 months (frequency of attendance was not considered). There were no exclusion criteria.

Measurements

The independent variable of interest was CR program funding type (public or private), which was coded based on the program attended. For objective one, the participants’ sociodemographic characteristics (e.g. age, sex, education and work status) and clinical characteristics (e.g. body mass index, CR indication/cardiac diagnosis and number of months in CR) were first assessed. The participants then completed psychometrically-validated scales assessing factors that are known to impact CR access and which may be particularly important in lower-resource settings, along with the CR Barriers Scale (CRBS; https://sgrace.info.yorku.ca/cr-barriers-scale/crbs-instructions-and-languages-translations/).

To quantify the participants’ socioeconomic level, a questionnaire from the Brazilian Association of Market Research Companies (ABEP) was administered. This asks about education level, family income, possession of certain items (e.g. number of televisions) and services offered in patients’ homes.2222 Associação Brasileira de Empresas e Pesquisa (ABEP). Critério Brasil 2020. Available from: http://www.abep.org/criterio-brasil. Accessed in 2021 (Jun 3).
http://www.abep.org/criterio-brasil...

To evaluate cognitive function, the psychometrically validated Brazilian-Portuguese version of the Mini-Mental State Examination (MMSE)2323 de Melo DM, Barbosa AJ. O uso do Mini-Exame do Estado Mental em pesquisas com idosos no Brasil: uma revisão sistemática [Use of the Mini-Mental State Examination in research on the elderly in Brazil: a systematic review]. Cien Saude Colet. 2015;20(12):3865-76. PMID: 26691810; https://doi.org/10.1590/1413-812320152012.06032015.
https://doi.org/10.1590/1413-81232015201...
was used. The test scores were adjusted based on level of education2424 Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-98. PMID: 1202204; https://doi.org/10.1016/0022-3956(75)90026-6.
https://doi.org/10.1016/0022-3956(75)900...
and categorized based on the presence of any cognitive impairment (e.g. participants who had four years of education and scored less than 25 were considered at least mildly cognitively impaired).

To quantify mental health symptoms, the psychometrically validated Brazilian-Portuguese version of the Hospital Anxiety and Depression Scale (HADS)2525 Sousa C, Pereira MG. Morbilidade psicológica e representações da doença em pacientes com esclerose múltipla: estudo de validação da “Hospital Anxiety and Depression Scale” (HADS). Psicologia, Saúde & Doenças. 2008;9(2):283-98. Available from: https://www.redalyc.org/articulo.oa?id=36219057008. Accessed in 2021 (Jun 3).
https://www.redalyc.org/articulo.oa?id=3...
was administered.

Lastly, CR barriers were assessed in relation to the second objective. The psychometrically validated Brazilian-Portuguese version of the Cardiac Rehabilitation Barriers Scale (CRBS) was administered.1313 Ghisi GL, Santos RZ, Schveitzer V, et al. Development and validation of the Brazilian Portuguese version of the Cardiac Rehabilitation Barriers Scale. Arq Bras Cardiol. 2012;98(4):344-51. PMID: 22426990; https://doi.org/10.1590/s0066-782x2012005000025.
https://doi.org/10.1590/s0066-782x201200...
This assesses patient perceptions of 21 barriers at the healthcare system, healthcare provider and patient levels on a scale from 1 (“strongly disagree”) to 5 (“strongly agree”). Higher scores indicate higher barriers to CR adherence.2626 Shanmugasegaram S, Gagliese L, Oh P, et al. Psychometric validation of the cardiac rehabilitation barriers scale. Clin Rehabil. 2012;26(2):152-64. PMID: 21937522; https://doi.org/10.1177/0269215511410579.
https://doi.org/10.1177/0269215511410579...
A total mean score is computed, and there are five subscales: comorbidities/functional status, perceived need, personal/family issues, travel/work conflicts and access.

Statistical analysis

To investigate differences in patient characteristics and barriers between participants attending public versus private programs, Fisher's exact tests or independent-sample t tests were used (or the Mann-Whitney U test if the variables were not normally distributed, as per the Kolmogorov-Smirnov test), as appropriate. Statistical significance was set at 5%. The analyses were performed using the IBM Statistical Package for the Social Sciences (SPSS) software, version 22.0 (SPSS Inc., Chicago, Illinois, United States).

RESULTS

During the period of this study, 178 patients were approached, of whom 174 (97.75%) participated; 57.5% were from the private program. The sample characteristics are shown in Table 1.

Table 1
Sociodemographic and clinical characteristics of the participants, according to cardiac rehabilitation program funding type

With regard to sociodemographic characteristics, the participants in the public program had significantly lower educational attainment and lower socioeconomic status (plus a trend regarding work status). With regard to clinical characteristics, the participants in the private program had more cognitive impairment, and in the public program more anxiety and depressive symptoms than their counterparts. Participants were in the public program for significantly longer durations than those in the private program. Moreover, the total barriers were higher, the longer the participants were in the program (r = 0.244; P < 0.05).

As shown in Table 2, the total barrier scores in this sample of participants attending CR for ≥ 3 months were quite low. Regardless of the program accessed, travel/work conflicts were the greatest barrier, followed by personal/family issues and comorbidities/functional status. There was an open-ended question about any other barriers; no unique barriers were raised by participants.

Table 2
Cardiac rehabilitation barriers according to program funding type

As also shown in Table 2, the barriers were significantly higher among participants accessing the public program than among those accessing the private program. Moreover, scores on three of the five subscales were significantly higher among participants accessing the public program than among those accessing the privately funded program.

DISCUSSION

There have been few studies on CR barriers outside of Western, high-income settings.1111 Ragupathi L, Stribling J, Yakunina Y, et al. Availability, Use, and Barriers to Cardiac Rehabilitation in LMIC. Glob Heart. 2017;12(4):323-334.e10. PMID: 28302548; https://doi.org/10.1016/j.gheart.2016.09.004.
https://doi.org/10.1016/j.gheart.2016.09...
In many of these countries, the healthcare systems are two-tier. It is known that there may be differences in program quality, and that there are significant differences in cost according to funding source,1717 Moghei M, Pesah E, Turk-Adawi K, et al. Funding sources and costs to deliver cardiac rehabilitation around the globe: Drivers and barriers. Int J Cardiol. 2019;276:278-86. PMID: 30414751; https://doi.org/10.1016/j.ijcard.2018.10.089.
https://doi.org/10.1016/j.ijcard.2018.10...
yet to our knowledge there has been no investigation of how this impacts patients. In this study, we began to investigate differences in the nature of patients accessing these programs, and how their barriers to adherence might differ, and indeed some important differences emerged.

It was promising to observe fewer differences than expected, in the characteristics of those accessing a publicly funded program rather than a privately funded program. For instance, there were no differences with regard to sex, age or diagnostic indication. As expected, the chief differences were socioeconomic, which are likely to explain the differences in mental health as well as cognition.2727 Schultz WM, Kelli HM, Lisko JC, et al. Socioeconomic Status and Cardiovascular Outcomes: Challenges and Interventions. Circulation. 2018;137(20):2166-78. PMID: 29760227; https://doi.org/10.1161/CIRCULATIONAHA.117.029652.
https://doi.org/10.1161/CIRCULATIONAHA.1...

The differences in the nature of patients accessing public or private programs, if replicated, hold implications for program delivery. Public programs would need to consider the health literacy of their patients, and tailor their educational programming accordingly.2828 Ghisi GLM, Scane K, Sandison N, et al. Development of and educational curriculum for cardiac rehabilitation patients and their families. Journal of Clinical and Experimental. 2015;6:5. https://doi.org/10.4172/2155-9880.1000373.
https://doi.org/10.4172/2155-9880.100037...
They would also want to ensure that they have staff who can assess and treat mental health issues, or have a close relationship with a referral source that does not have a long waitlist. Private programs could serve as important settings where patients who need more staff time could safely receive CR. If so, staff would need to have specialized training to successfully work with these patient groups.

The top barriers observed here were consistent with those reported in other studies, in Brazil, South America and beyond.1212 Sanchez-Delgado JC, Jacome-Hortua A, Pinzon S, Angarita-Fonseca A. Validez de contenido de la escala de barreras para la rehabilitacion cardiaca. Universidad y Salud. 2015;17(2):170-6. https://doi.org/https://doi.org/10.22267/rus.151702.2.
https://doi.org/https://doi.org/10.22267...
,1414 Sérvio TC, Britto RR, de Melo Ghisi GL, et al. Barriers to cardiac rehabilitation delivery in a low-resource setting from the perspective of healthcare administrators, rehabilitation providers, and cardiac patients. BMC Health Serv Res. 2019;19(1):615. PMID: 31477103; https://doi.org/10.1186/s12913-019-4463-9.
https://doi.org/10.1186/s12913-019-4463-...
,2929 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;12:72. PMID: 23985017; https://doi.org/10.1186/1475-9276-12-72.
https://doi.org/10.1186/1475-9276-12-72...
3232 Sánchez-Delgado JC, Angarita-Fonseca A, Hortúa AJ, et al. Barreras para la participación en programas de rehabilitación cardiaca en pacientes sometidos a revascularización percutánea por enfermedad coronaria. Rev Colomb Cardiol. 2016;23(2):141-7. https://doi.org/10.1016/j.rccar.2015.08.009.
https://doi.org/10.1016/j.rccar.2015.08....
Overall, the barriers were low, which was consistent with other CRBS studies in enrollees.3333 Grace SL, Gravely-Witte S, Kayaniyil S, Brual J, Suskin N, Stewart DE. A multisite examination of sex differences in cardiac rehabilitation barriers by participation status. J Womens Health (Larchmt). 2009;18(2):209-16. PMID: 19183092; https://doi.org/10.1089/jwh.2007.0753.
https://doi.org/10.1089/jwh.2007.0753...
This was to be expected, given the sample was composed of patients who had already completed ≥ 3 months of CR. Still, the patients accessing public programs did report significantly more barriers to adherence than did their counterparts in private programs. Socioeconomic differences in the cohorts do seem to explain the differences; for example, factors such as transportation costs, distance, time constraints and not getting support from healthcare providers to attend were more strongly endorsed by patients in the public than in the private system. Efforts to tackle the social determinants of health continue to be needed.

Study limitations

Caution is warranted when interpreting these results. Their generalizability is limited, particularly given that we sampled from only one public and one private program. Moreover, the programs were of long duration, compared with other programs internationally.3434 Chaves G, Turk-Adawi K, Supervia M, et al. Cardiac Rehabilitation Dose Around the World: Variation and Correlates. Circ Cardiovasc Qual Outcomes. 2020;13(1):e005453. PMID: 31918580; https://doi.org/10.1161/CIRCOUTCOMES.119.005453.
https://doi.org/10.1161/CIRCOUTCOMES.119...
This study was also limited to participants who had been able to access CR and had adhered to the program for ≥ 3 months. Arguably these participants were among the few who had been able to successfully access and adhere to CR, even in a low-resource setting. In future studies, the barriers among participants should be investigated at the time of diagnosis (considering that referral is perceived as the main barrier in Brazil),1818 Britto RR, Supervia M, Turk-Adawi K, et al. Cardiac rehabilitation availability and delivery in Brazil: a comparison to other upper middle-income countries. Braz J Phys Ther. 2020;24(2):167-76. PMID: 30862431; https://doi.org/10.1016/j.bjpt.2019.02.011.
https://doi.org/10.1016/j.bjpt.2019.02.0...
as well as very early in their program. Lastly, the sample size was modest, and this was the first study examining these differences. Therefore, replication is warranted prior to implementing any changes based on these preliminary findings.

CONCLUSIONS

In summary, as expected, but for the first time, we have shown that within a two-tier healthcare system in a lower-resource setting, patients accessing publicly funded CR programs are of significantly lower socioeconomic status and have poorer mental health and cognitive ability than those accessing privately funded programs. Publicly funded programs will need to tailor their delivery to meet the needs of their patients through educational and psychosocial programming. While referral and time conflicts remain key barriers in these settings, once patients do access CR, the barriers are greater for those in publicly funded programs than in privately funded ones, particularly with regard to comorbidities/functional status, perceived need and access.

  • Universidade Estadual Paulista (UNESP), Presidente Prudente (SP), Brazil
  • Sources of funding: The present study was developed under grant support from the Institutional Scientific Initiation Scholarship Program (PIBIC/CNPq/UNESP); Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), under no. 2018/18276-6; and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), under financing code 46124

Acknowledgements:

The authors would like to thank the Laboratory of Stress Physiology and Laboratory of the Faculty of Sciences and Technology, Universidade Estadual Paulista (UNESP), for all their assistance during this work. They are also grateful for the support from the Heart Institute of Presidente Prudente (SP), Brazil, which provided the space for conducting part of the study

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Publication Dates

  • Publication in this collection
    05 Jan 2022
  • Date of issue
    Jan-Feb 2022

History

  • Received
    22 Dec 2020
  • Reviewed
    26 Apr 2021
  • Accepted
    31 May 2021
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