1. Introduction

Cardiovascular diseases (CVDs) represent a formidable global health challenge and are the primary cause of death and disability worldwide. In 2019, CVDs were responsible for an estimated 18.6 million deaths, representing 31% of global fatalities [1]. Over 80% of these deaths occur in developing countries, where the prevalence of CVDs has increased over the past three decades, from 4,624 to 7,769 cases per 100,000 individuals [2]. Coronary heart disease (CHD) remains the predominant cause of mortality among CVD patients, with a death rate of 112.37 per 100,000 reported in 2020 [3]. The Middle East, North Africa, Eastern European countries, and Central Asia are among the most impacted regions of the developing world [3]. In the Kingdom of Saudi Arabia (KSA), CVDs account for more than 45% of all fatalities, with CHD accounting for 23.1% of the total deaths nationwide [4,5].

The management of CVD places an extensive financial burden on healthcare systems [6]. Moreover, the higher rates of premature death associated with CVDs impose a significant economic impact at both the familial and national levels in developing nations [2]. Secondary prevention therapy, aimed at identifying and managing risk factors and controlling associated morbidities, can substantially mitigate this burden. Cardiac rehabilitation (CR) is a multifaceted process aimed at restoring individuals’ optimal physical, mental, emotional, social, and economic well-being [7]. As a comprehensive, interdisciplinary secondary prevention strategy, CR has demonstrated efficacy in reducing mortality rates [8,9], enhancing health-related outcomes [8–12], and minimizing rehospitalization and overall treatment costs [8,13]. CR benefits have also been recognized in countries with low and middle incomes [8,14].

Comprehensive CR programs incorporate essential elements delivered in three phases of progression depending on the patient’s diagnosis [15,16]. Phase I CR is administered during the inpatient period and involves patient education, early supervised physical exercise, and the management of risk factors [15,16]. Phase II, the early outpatient stage, commences upon the patient’s discharge from the hospital and includes a supervised program of physical training, dietary management, risk factor control, and mental health support [15,16]. Phase III, the late stage of outpatient CR, focuses on maintaining the lifestyle modifications established in Phases I and II and encompasses regular reassessments of risk factors, medication adherence, and psychological well-being [15,16].

Enrollment in outpatient CR programs after a cardiac event or revascularization procedure is strongly recommended as a Class IA guideline by prominent international bodies such as the European Society of Cardiology, American Heart Association, and American College of Cardiology [7,9]. Unfortunately, CR programs are underused worldwide [8,17,18], and participation is less than 30% in high-income countries [17]. In low/middle-income countries, the availability of such programs is inadequate [19], and the utilization of these services, when available, is very poor [20,21]. Numerous studies, predominantly conducted in developed countries, have explored the factors contributing to this low uptake of CR programs and categorized them into three levels: patient, physician, and health system [22–24].

Despite the substantial burden imposed by the care of patients with CVDs in developing nations, there remains a notable dearth of data concerning the three-level factors leading to low participation rates [21], especially in KSA. Cardiologists are instrumental in encouraging patients to participate in CR, and their awareness and perspectives on these programs can substantially influence their referral practices, which are crucial for patients to initiate the program [25]. Therefore, this study aimed to assess the knowledge, attitudes, and practices of CR among cardiac specialists practicing in KSA. This study also aimed to identify the perceived barriers that could inhibit the referral of patients with CHD following percutaneous coronary intervention (PCI) to these programs. Strategies from international evidence to promote the uptake of CR services have also been proposed to solicit insights and recommendations for future program implementation within the country.

2. Materials and methods

3. Results

2.6 Participant demographics

Table 1 summarizes the demographics of the participants. Most survey respondents (73.6%) were aged 35--55 years, with a predominantly male cohort (n = 94; 88.7%). Almost 60% (n = 63) of the participants were Saudi Arabian citizens, 67.0% (n = 71) were consulting cardiologists, 15.1% were cardiology fellows, and 17.9% were specialist cardiologists. The participants specialized in general cardiology (29.2%), interventional cardiology (21.7%), and echocardiography (20.8%), with few in critical care or cardiac rehabilitation (<5%). One-third of the surveyed cardiologists had received education in KSA (32.1%). Furthermore, 18.9% had received their education in Canada, and 12.3% had received their education in other countries within the Middle East. Fewer than 10% had received their education in Europe, the United States of America, or South Asia. More than 14% did not report where they had received education. Half of the participants had 5–15 years of medical practice, and almost a quarter had more than 20 years of medical practice experience.

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Table 1. Demographics.

https://doi.org/10.1371/journal.pone.0323694.t001

2.7 Participant workplace characteristics

Most participating cardiologists worked in the public sector (78.3%), as shown in Table 2. Nearly 10.4% worked within the private sector, and 11.3% worked in both sectors. Workplace sizes varied from 0 beds to more than 1000 beds, but most physicians worked in health facilities with fewer than 300 beds (54.7%). Most respondents (90.6%) worked with CHD-diagnosed patients who underwent PCI. The number of PCI-treated patients varied from one-third of cardiologists who only saw 0–10 patients per week to 10% who saw more than 40 patients per week. Most participants practiced in the central region of KSA, which includes the capital Riyadh (54.7%). Another quarter was found in the western (17.9%) and eastern (10.4%) regions. Few cardiac-specialized doctors were located in the northern (1.9%) or southern region (8.5%). Seven cardiologists did not specify the city or region where they worked.

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Table 2. Workplace characteristics.

https://doi.org/10.1371/journal.pone.0323694.t002

2.8 Barriers and facilitators to the referral of patients following percutaneous coronary intervention to cardiac rehabilitation

Participants were surveyed on the barriers they saw to refer patients with CHD to CR following PCI and who should take the initiative to implement this service. For these questions, the participants could choose more than one option. The lack of access to specialist CR services in their area was most significant, with 72.6% (n = 77) of participants selecting this barrier. A lack of local systems to support CR referrals was cited by 41.5% (n = 44) of the respondents. Approximately one-third of the cardiologists reported a lack of knowledge about CR services in my area (28.3%, n = 30) and patient factors, such as the cost of care and distance (32.1%, n = 34). Almost 10% (9.4%, n = 10) had no barriers in referring patients to CR.

Cardiologists were asked “who do they think should take the initiative to implement outpatient CR programs in Saudia Arabia?”. Most (59.4%, n = 63) reported that all professional care providers should, followed by the Ministry of Health (52.8%, n = 56) and physicians (52.8%, n = 56). Fewer cardiologists were recorded by insurance companies (44.3%, n = 47) or policymakers (39.6%, n = 42). In a free-text response, participants were also asked what they considered a priority for the implementation of a future CR program in Saudi Arabia. A schematic representation of the variety of responses is presented in Fig 1. The participants recommended staff education and patient coaching. They suggested that rehabilitation should be timed early before hospital discharge and that it should be resourced through facilities with specific programs that include policies, protocols, and guidelines. The lack of availability of CR services and proper financing are highlighted. Finally, participants recognized that CR was required for better patient outcomes.

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Fig 1. Concept map.

https://doi.org/10.1371/journal.pone.0323694.g001

2.9. Cardiologist attitudes

The participants were asked five questions related to their attitudes toward CR on a five-point Likert scale ranging from strongly disagree (score = 1) to strongly agree (score = 5). The questions and responses are shown in Fig 2a. The participants were positive and agreed to more than 90% of the four attitudes; however, they did not agree when they were asked if CR within KSA was effective. The Cronbach’s alpha for these five questions was poor at 0.45; thus, the items were treated separately through further analyses.

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Fig 2. Knowledge and attitude responses.

https://doi.org/10.1371/journal.pone.0323694.g002

2.10. Cardiologist knowledge

Cardiologists were asked two questions regarding their knowledge of CR in improving patient outcomes and core services, as shown in Fig 2b. Both questions were ranked from very poor (score = 1) to excellent (score = 5). Together, they had a Cronbach’s alpha of 0.753 and were thus summed to produce a total knowledge score with a possible range of 2--10, with a mean of 7.97 (SD 1.437).

Univariate linear regression was used to determine which demographic and workplace characteristics plus barrier and facilitator responses influenced the total knowledge score (see S1 Table. Variables with a significance of less than p < 0.05 in the univariate models were added to a multivariable linear regression model. These were sex (male, female), attitudes (Likert scores of 1--5), workplace type (public, private, or both), management of patients following PCI (yes, no), and referral of patients to CR (yes/no). A backward methodology was used to select the final variables in the linear regression model (Table 3, Model 1). The final model had four predictors that explained 19% of the variance (adjusted R2 = 0.197, F = 7.015, P < 0.001). The results revealed that females had almost one-unit higher total knowledge score than males did (β = 0.896, P = 0.027), with higher agreement with one attitude question (Do you think that your patients’ outcomes improved when they were enrolled in CR?) The results revealed an increase of 0.68 in the total knowledge score per step of the attitude Likert scale (β = 0.681, P < 0.001); those participants who managed patients after PCI were predicted to have higher knowledge scores of more than one unit than those who did not (β= 1.309, P = 0.012), and cardiologists who referred any patient to CR had a greater knowledge score of 0.6 units higher (β= 0.602, P = 0.033).

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Table 3. Multivariable models.

https://doi.org/10.1371/journal.pone.0323694.t003

2.11. Cardiologist practice

Cardiologists were surveyed on their current practice with patients who underwent PCI procedures, and the results are shown in Table 4. More than half of the participants (52.8%) chose to quit smoking, followed by more than a quarter who recommended a CR program (28.3%). Thirty percent of the cardiologist participants reported that CR was not an option available to their patients, either they did not refer them or they could not refer them. However, 37.8% referred 50% or fewer of their PCI-treated patients to CR, and 25.5% sent more than 50% of their patients to the program. Half of the cardiologists wanted their patients to start CR in hospital settings before discharge, with another 35.6% starting shortly after discharge. Fifteen percent indicated that they would not prescribe CR to their patients who underwent PCI. Most of the participating cardiologists reported that it was difficult to refer patients to the CR in KSA (74.5%), with only 10.4% reporting that it was easy.

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Table 4. Practice for post-PCI patients.

https://doi.org/10.1371/journal.pone.0323694.t004

4. Discussion

This study revealed low referral rates for CR among cardiologists in KSA, primarily due to the limited availability of CR programs and systemic barriers, such as inadequate referral systems. However, positive attitudes toward CR suggest opportunities for improvement through targeted interventions such as home-based CR (HBCR). This study is the first national survey in KSA to assess the awareness, perceptions, and practices of cardiology specialists regarding CR for patients with CHD post-PCI and identify factors influencing their referral decisions. Nevertheless, a similar cross-sectional study conducted in KSA recently investigated the attitudes of physicians, including internal medicine specialists, general physicians, and pulmonologists, toward prescribing pulmonary rehabilitation programs for patients with chronic obstructive pulmonary disease, identifying factors influencing their referral practices [30]. Additionally, a simultaneous survey in the same year evaluated the perspectives of physiotherapists in providing CR to patients with heart failure (HF), uncovering barriers that affect their referrals [31].

Our results reveal a significant gap in referral practices, with 63.3% of cardiologists reporting that they refer eligible patients with CHD to CR programs at varying rates: 50% or less by 37.8% and 50% or more by 25.4%. Conversely, one-third of the participating cardiologists were reluctant to refer patients at all. This low referral rate is corroborated by a recent study that examined 104 Saudi patients with CHD who underwent PCI at a prominent cardiac center in Riyadh. This study aimed to assess adherence to secondary prevention measures and identify barriers to CR program enrollment. Only 11 patients (10.6%) had been referred to a CR program, with 88% citing the absence of physician support as a major obstacle to accessing CR services [32].

Most of the specialized physicians who participated in our survey reported difficulties in the referral process, primarily because of limited access to specialist CR services in their regions. This challenge is mirrored in the findings of Al dhaihir et al. (2022) [31], who surveyed 553 physiotherapists across KSA and reported that 59.9% perceived the scarcity of available programs as the principal barrier affecting referrals to CR for patients with HF. This issue of low program availability is a global concern, with fewer than 25% of developing countries providing CR services to their populations [21]. In KSA, the situation is particularly critical, with only five active governmental CR centers, three of which are located in Riyadh and two in the country’s eastern region [33]. This distribution contributes to the observed regional disparities in referral practices in our study, with physicians located in the western or southern provinces being less likely to refer patients than their counterparts in the central or eastern parts of the country were. Research has demonstrated that a wider geographic distribution of CR services is correlated with higher referral rates [34]. The maldistribution of healthcare facilities mainly affects patients in remote areas, who are less likely to enroll in CR programs owing to geographic barriers [34].

The delivery of CR in KSA is significantly hindered by a lack of integration across various levels of cardiac care, stemming from the nation’s fragmented healthcare system. The healthcare system in KSA is divided into two main sectors: the governmental sector, which provides free services to citizens, and the private sector, which operates on a fee-for-service basis [35]. The Ministry of Health directly manages and funds 60% of governmental healthcare institutions, while the remaining 40% fall under the jurisdiction of various other agencies, including military and educational institutions [35]. This fragmentation is evident in our findings, where 74.5% of physicians reported difficulties in issuing CR referrals, along with significant delays in referrals reaching eligible patients, who struggle to navigate the healthcare system [32].

The situation is further complicated by poor coordination and communication between cardiologists in provinces with limited cardiology care and CR providers, who are primarily concentrated in major cardiac centers within only two regions (Central and Eastern). Interviews with directors of cardiac centers and CR coordinators in KSA provided valuable insights into the factors contributing to the delayed expansion and uneven distribution of CR services across the country [36]. The qualitative analysis revealed widespread recognition of CR and its benefits among healthcare leaders, accompanied by significant concerns regarding the inadequacy of the current infrastructure to meet national demand [36]. According to policymakers, this challenge is primarily attributed to limited resources, particularly insufficient funding and a shortage of CR-trained personnel [36].

Our results further indicate that cardiologists might preferentially refer patients who they perceive as more likely to engage in treatment, with a third acknowledging that patient-related factors such as financial costs and long commuting distances influence their referral decisions. For example, a cohort study conducted in Sweden involving 31,297 patients with CHD referred to CR revealed that a commuting distance greater than 16 km significantly increased the likelihood of nonattendance [37]. Similarly, in Iran, patients who were required to travel more than 30 minutes to a CR service site had lower participation rates [38]. Patients with CHD in KSA also cited distance to CR sites as a major personal barrier, particularly for 69% of those living in rural areas [32].

The successful implementation of alternative models, such as HBCR, has the potential to significantly extend service reach, particularly for patients who are less likely to participate in hospital-based programs [38]. The cardiologists who participated in our survey strongly endorsed the implementation of HBCR models within the country. This aligns with the findings of the survey conducted by Aldhahir et al. (2022), which reported that 74% of cardiac physicians across KSA preferred delivering the HBCR model to patients with HF [29]. Additionally, Saudi patients with CHD who had undergone PCI demonstrated a marked preference for HBCR, with 58.7% favoring it over the hospital-based model (17.3%) or hybrid model (11.5%) [32]. This preference was even more pronounced among individuals residing in rural areas (78.4%) than among those in urban settings (59.3%) [32]. The strong endorsement of the HBCR highlights its potential to overcome geographic and systemic barriers, particularly in rural regions, where traditional CR facilities are inaccessible.

The home-based model has proven effective in overcoming several barriers to CR accessibility, addressing challenges such as limited facilities, geographic constraints, transportation difficulties, financial burdens, and scheduling conflicts [39]. Globally, HBCR has been shown to be as safe and effective as traditional hospital-based CR for patients at low to moderate risk following revascularization, offering comparable costs while enhancing participation and adherence rates [40,41]. In KSA, a recent three-arm RCT—the first conducted in the country and the Gulf region—demonstrated the feasibility and suitability of HBCR in the local context, showing it to be as effective as outpatient CR and superior in maintaining post-intervention improvements in patients with CHD following coronary artery bypass grafting [42]. Additionally, patient preferences and acceptance must be considered, particularly in terms of digital literacy, cultural factors, and willingness to engage in remote rehabilitation. The successful and sustainable expansion of HBCR programs in KSA further depends on strong policy support, the development of viable financial models, and ongoing professional training and education [36]. Despite its potential, successful implementation of HBCR in KSA also requires addressing infrastructure challenges, such as the availability of telemonitoring technologies, trained personnel, and home-based medical equipment.

Administrative challenges, such as the absence of standardized criteria for patient eligibility and clear pathways for accessing CR programs, significantly hinder patient engagement [25]. Physicians identified the lack of local systems to support referrals as a substantial barrier affecting their referral practices, with almost half of them noting this as an issue. The integration of effective referral systems, such as the automation of referrals from discharge order sets or electronic records, is suggested to increase both referral rates and enrollment in CR programs [39]. This claim is supported by a retrospective cohort study in Canada that analyzed the registry and CR databases from 1996--2016. Employing interrupted time series analysis, the study evaluated the impact of automated referrals implemented in 2007 on the referral rates of eligible patients with CHD. After implementation, there was a notable increase in referral rates from 39.5% to 75.0% (P < 0.001), underscoring the effectiveness of automation in improving CR referral processes [41].

Most participants expressed moderate-to-good knowledge about CR attributes and their benefits in patients treated with PCI. Our findings revealed greater CR referral practices among cardiologists with higher knowledge levels. Additionally, one-third of the respondent cardiac physicians reported that inadequacy of awareness about the programs led to their insufficient CR endorsement. Similarly, in Lebanon, one-third of cardiologists demonstrated a moderate level of knowledge about CR content (31.3%), while an equal proportion presented good to excellent knowledge (31.3%) and 39.9% to 43.3% regarding program benefits [32]. Despite generally positive attitudes toward CR among our study’s respondents, two-thirds of the participants doubted the efficacy of local programs, which correlated with their reduced likelihood of referring patients. This contrasted with the remaining third, who believed in their effectiveness and showed a significantly greater inclination to refer. A similar trend was observed in Iran, where a qualitative study employing focus group discussions and conventional content analysis revealed that cardiologists’ hesitancy to refer to CR was often due to insufficient knowledge of the program and uncertainties regarding its effectiveness in treatment [43].

5. Conclusion

This study assessed cardiologists’ knowledge, attitudes, and practices regarding CR in KSA, identifying key barriers such as limited program availability and inadequate referral systems. While specialized physicians generally reported moderate to good knowledge of CR and its benefits for patient health, nearly one-third cited a lack of comprehensive understanding as detrimental to their treatment planning. Other impediments included the limited availability of CR programs, the absence of standardized referral systems, and patient personal reasons. Despite these challenges, participants displayed a positive attitude toward comprehensive secondary prevention programs and the adoption of diverse models within local contexts. However, two-thirds of the respondents expressed concerns about the quality of CR service delivery in the country. Referral behaviors varied, with those with higher knowledge levels and confidence in existing CR services and those working in the Central and Eastern provinces being more likely to recommend CR to their patients. Future research should include comprehensive randomized trials involving all levels of cardiology specialists in KSA, including graduate medical students enrolled in cardiology fellowships, to evaluate their KAP regarding CR. Additionally, research should prioritize the development and implementation of HBCR models and automated referral systems to enhance CR accessibility, particularly in underserved regions.

Supporting information

Acknowledgments

The authors would like to thank the Deanship of Scientific Research at Shaqra University for supporting this work.