Decentralized Cardiac Rehabilitation Drew More Patients Into Exercise Programs
Exercise-based cardiac rehabilitation became more accessible after Denmark moved services closer to where patients live, and attendance rose along with it. In a register-based cohort spanning 2013 through 2022, decentralization to primary care was associated with a clear gain in participation after acute myocardial infarction, percutaneous coronary intervention, or coronary artery bypass grafting. The signal was not modest: uptake increased by 16% overall after the service model changed. For patients who had the longest journey to care, the increase was far larger.
Access changed first, behavior followed.
The study examined 19,080 eligible patients across 21 Danish municipalities after excluding those with prior diagnoses or procedures and those without complete information. The cohort reflected a typical post-coronary population: 70.0% were male, and 57.0% were aged 60 to 79 years. Researchers compared use of rehabilitation before and after decentralization, defining uptake as attendance at at least one training session within 180 days of discharge. Modified Poisson regression was used to estimate changes in proportions while accounting for relevant covariates. That design matters because it captures a service-level policy shift in a real-world population rather than an idealized trial setting.
Travel Distance Fell, and Participation Rose With It
The geographic change was substantial. Median travel distance to the nearest rehabilitation facility dropped from 15.1 km to 7.2 km after decentralization. In cardiovascular care, this kind of change is rarely trivial. Exercise-based rehabilitation depends on repeated visits, supervised sessions, and sustained adherence over weeks to months; every added kilometer can amplify friction from transport costs, time off work, fatigue after infarction, and family logistics. By shifting care into primary care settings, the system removed a barrier that has long depressed rehabilitation use even when clinicians recommend it.
Among all eligible patients, uptake increased by 16% after decentralization, with a risk ratio of 1.16 and a 95% CI of 1.12 to 1.19. The effect was strongest in the group facing the longest distances. Among the 20% of patients with the farthest travel, uptake rose by 45%, with a risk ratio of 1.45 and a 95% CI of 1.33 to 1.58. The pattern fits the underlying mechanism: when distance is a dominant barrier, bringing rehabilitation closer produces the largest clinical response. Less travel means fewer missed appointments, fewer abandoned referrals, and less attrition before supervised exercise can begin.
Inequality Narrowed for Patients With the Greatest Burden
The benefits were not distributed evenly, and that is exactly why the findings matter. Geographic inequality in rehabilitation uptake was significantly reduced after decentralization, indicating that the new model did more than raise average participation. It changed the slope of access across distance strata. Patients with short education also saw a marked increase in uptake, with a 27% rise and a risk ratio of 1.27 (95% CI, 1.20 to 1.35), and social inequality was significantly reduced.
Educational differences often track with health literacy, transportation resources, employment flexibility, and confidence navigating specialty care. A local rehabilitation model can blunt each of those pressures at once. Primary care sites are typically closer, more familiar, and easier to reach for patients who may otherwise face compounded barriers after discharge from a major cardiac event. The study suggests that decentralization can reduce the penalty imposed by social disadvantage, not only improve nominal access for the already well connected.
A Service Model Change With Direct Bedside Consequences
Exercise-based rehabilitation is one of the few interventions that combines education, risk-factor modification, physical conditioning, and follow-up in a structured outpatient format. Its benefits depend heavily on whether patients actually show up. A system that keeps rehabilitation centralized may preserve clinical quality on paper while quietly filtering out the very patients most likely to benefit from support. Decentralization changes that equation by shrinking the gap between discharge and participation.
The findings carry practical weight for coronary care pathways. After myocardial infarction or revascularization, patients are often discharged into a period of uncertainty, medication changes, and reduced exercise tolerance. A nearby program can convert recommendation into routine. For clinicians, the takeaway is direct: referral alone is not enough if location and transportation sabotage attendance before the first session. The Danish experience shows that where rehabilitation is delivered can determine whether patients enter the program at all.
What the Cohort Can and Cannot Prove
This was a large population-based register study, not a randomized trial. It shows association, not individual-level causation, and the design cannot separate decentralization from every other contemporaneous change in care delivery over the study years. The analysis also focused on uptake, not downstream clinical endpoints such as recurrent infarction, mortality, functional capacity, or long-term adherence. Those outcomes still matter, because improved attendance only becomes fully meaningful if the quality and safety of decentralized programs hold steady over time.
Even with those limits, the study offers a strong population-level argument for bringing rehabilitation closer to home. The model improved participation, reduced geographic inequality, and narrowed the social gap linked to education. In a field where low uptake has persisted despite clear guideline support, those are not small shifts. The remaining task is to monitor whether decentralized programs maintain the same standards of exercise prescription, supervision, and secondary prevention counseling as the centralized services they replace.