Social Inequality in the Comprehensive Cardiac Rehabilitation Pathway. A nationwide cohort study

Background Cardiac rehabilitation (CR) is a cornerstone of secondary prevention and aims to improve patients’ functioning and quality of life. Despite universal access in Denmark, participation follows a social gradient. Evidence is limited on how social inequalities unfold across the CR pathway and affect access to key components supporting functioning. Methods We conducted a nationwide population-based cohort study including all adults hospitalised with ischaemic heart disease in Denmark from April 2019 to March 2022 (n = 45,497). Patients were followed from discharge through hospital and primary care CR. Eleven components were assessed, including early needs assessment, exercise training, patient education, depression screening, smoking cessation and completion. Socioeconomic position was measured by education, income, occupation, and cohabitation. Multivariable logistic regression examined associations with non-utilisation. Results Overall CR participation was 43%, and only 25% received a needs assessment within 14 days. Social inequalities were observed across the CR pathway. Patients with lower educational attainment had higher odds of delayed assessment (OR 1.08; 95%CI 1.01–1.15) and non-utilisation of key components supporting functioning, including exercise training, patient education, and cardiorespiratory fitness testing (e.g. OR 1.31; 95%CI 1.18–1.45). Similar patterns were found across income, occupation, and cohabitation. No consistent socioeconomic differences were observed in improvements in cardiorespiratory fitness or smoking cessation. Conclusions Even within a universal healthcare system, access to services that support functioning is unequally distributed across the CR pathway. Early needs assessment appears to be a key entry point for reducing inequalities. Strengthening systematic, person-centred and targeted approaches, particularly for people in a socially vulnerable situation, may improve equitable access to rehabilitation and its benefits. Key messages • Targeted interventions are needed to reduce socioeconomic differences in the cardiac rehabilitation pathway, this study identifies patient characteristics and activities as key markers of inequality. • As early cardiac rehabilitation enrolment enhances participation and outcomes, this study identifies socioeconomic differences in early needs assessment as a key target for reducing inequalities.