Uptake and Inequalities in Exercise-Based Cardiac Rehabilitation After Decentralization

Importance: Despite clinical benefits and guideline recommendations, uptake of exercise-based cardiac rehabilitation (CR) following coronary artery disease remains suboptimal, with barriers including transportation issues, travel distance, and geographic location. To overcome these barriers, decentralization strategies that move health care to local settings have been developed across several countries. Objective: To determine whether CR uptake improved following decentralization, and whether geographic and social inequalities were reduced. Design, Setting, and Participants: This register-based cohort study used data from 2013 to 2022, with data analysis performed from April to August 2025. This population-based study was conducted within 21 Danish municipalities. All participants were patients aged 30 years or older discharged alive after acute myocardial infarction, percutaneous coronary intervention, or coronary artery bypass grafting. Patients were identified in the Danish National Patient Register. Patients were excluded if they had a previous diagnosis or procedure or did not reside within the study area. Exposures: Travel distance from home to nearest CR facility and educational level. Main Outcomes and Measures: Uptake (attending at least 1 training session within 180 days from discharge) was analyzed using modified Poisson regression to quantify differences in proportions before and after decentralization with adjustment for relevant covariates. Results: A total of 19 375 patients were eligible for the study, and 295 patients with missing information on exposures or covariates were excluded. Among the included 19 080 patients, 13 355 (70.0%) were male, and 10 868 (57.0%) were aged 60 to 79 years. The median (IQR) travel distance was reduced from 15.1 (5.9-25.7) km to 7.2 (2.8-14.8) km after decentralization, and uptake increased by 16% (risk ratio [RR], 1.16; 95% CI, 1.12-1.19). Among the 20% of patients with the longest travel distance, uptake increased by 45% (RR, 1.45; 95% CI, 1.33-1.58), and geographic inequality was significantly reduced. Among patients with short education, uptake increased by 27% (RR, 1.27; 95% CI, 1.20-1.35), and social inequality was significantly reduced. Conclusions and Relevance: In this cohort study of 19 080 patients, there was increased uptake of CR after decentralization to primary care, accompanied by significant reductions in geographic and social inequalities. The findings support decentralized delivery of CR as a feasible and equitable model, but ongoing monitoring of quality and safety remains essential.