Comparing disparities in geographic proximity to exercise-based cardiac rehabilitation before and after decentralisation of services: a repeated cross-sectional study using individual-level register data

BACKGROUND: Despite well-known benefits, cardiac rehabilitation (CR) programs suffer from non-participation, and travel distance is repeatedly reported as a participation barrier. Based on individual-level data, the objective of this study was to evaluate geographic proximity to exercise-based CR and assess how geographic and sociodemographic disparities were affected by decentralisation of services from hospitals to primary care.

METHODS: Based on nationwide individual-level Danish data, travel distance, calculated as the shortest route along the road network, was used to assess geographic proximity to exercise-based CR. Travel distance was mapped using Inverse Distance Weighting to produce a surface map. Boxplots were used to illustrate the distribution of travel distance within the study population, and sociodemographic disparities in median travel distance were evaluated by assessment of the concentration index.

RESULTS: The study included 2,460,639 addresses and 3,693,053 residents (≥ 30 years old). Overall, the median travel distance to exercise-based CR was reduced with ≥ 40% after decentralisation. Non-central and rural parts of the country benefitted most. Inequality in travel distance associated with older age and multimorbidity was eliminated, while inequality associated with low educational level was significantly reduced.

CONCLUSIONS: Based on unique national data, this study is the first to demonstrate how decentralisation increased geographic proximity to exercise-based CR. Remote and rural areas, and certain vulnerable groups benefitted particularly, leading to reduced inequality in geographic proximity after decentralisation. With lack of geographic proximity being a known barrier to participation in CR programs, the study supports decentralisation of services as an instrument to be considered in an ongoing strive to improve CR participation, overall and within vulnerable groups. Moreover, the results may serve as a general illustration of what can be achieved by decentralisation, regardless of the specific service.