Women and Referral to Outpatient Cardiac Rehabilitation: Does the Gender Bias Still Exist?, a Meta-Analysis

Monday, 22 July 2013: 11:25 AM

Tracey J. F. Colella, ACNP, PhD
Cardiac Program, Toronto Rehabilitation Institute / University of Toronto, Toronto, ON, Canada

Learning Objective 1: Learner will be able to develop an understanding of the historical and international issue of under-referral to outpatient cardiac rehabilitation post cardiac event.

Learning Objective 2: Learner will be able to understand the meta-analysis approach and results regarding the gender bias and referral to cardiac rehabilitation.


Cardiovascular disease continues to be among the leading causes of morbidity, mortality, and health care costs among men and women globally. There is compelling evidence that women are significantly underrepresented in Cardiac Rehabilitation (CR) programs, which have been shown to reduce recurrent cardiac events and related premature death. CR typically includes structured exercise, education, support, and risk reduction to effect positive change in health behaviors. The preponderance of evidence shows that approximately 15-30% of eligible patients participate in CR, with the rate for women being much lower at 11-20%. Building upon elements of a prior systematic review (Benz Scott 2002), the aim of this study was to critically appraise published studies that examined factors and referral rates by gender as they relate to women’s referral to outpatient CR Programs.  


 A systematic search of 6 databases (2001-July 2011) was conducted according to the PRISMA reporting protocol, using STROBE (observational) and CONSORT (interventional) guidelines for quality assessment. Selected studies were analyzed by two independent reviewers.


 The search yielded 6022 abstracts, of which 623 were assessed for eligibility and 19 met  inclusion/exclusion criteria for meta-analysis. One was a non-randomized controlled trial while the remaining were observational studies. Preliminary results reveal consistency in factors associated with under-referral as well as significant differences in referral rates according by gender (despite much study heterogeneity).


Ten years later, women continue to be under-referred to CR programs. While there has been much growth in the body of research, there remains a dearth of intervention studies. The gender disparity in CR utilization must be addressed, and these findings demonstrate the need for intervention research to successfully overcome identified barriers for women to access and participate in CR.