Tehran University of Medical Sciences Journal of Modern Rehabilitation 2538-385X 0 - 2026 06 14 1475 1475 Azar Zare Noughabi Student Research Committee, Birjand University of Medical Sciences, Birjand, Iran Maryam Sadat Rahimi Cardiovascular Diseases Research Center, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran Seyed Mohammad Riahi Cardiovascular Diseases Research Center, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran Fateme Mahdizadeh Cardiovascular Diseases Research Center, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran Toba Kazemi Cardiovascular Diseases Research Center, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran 2025 11 24 2026 05 09 Background: Cardiac rehabilitation (CR) is a cornerstone of secondary prevention following coronary revascularization; however, its utilization remains suboptimal in underserved regions. This study aimed to evaluate referral, participation, and completion rates of CR and their associated factors in Birjand, Iran. Material and Methods: This retrospective cohort study included 758 consecutive patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) between April 2022 and May 2023. Data on demographics, insurance status, education level, and physician CR familiarity were collected using a structured checklist and phone follow-up. The CR program was defined as 36 supervised sessions. Multivariate logistic regression models were used to identify factors associated with referral, participation, and completion. All reported odds ratios were derived from fully adjusted models. Results: Among 749 eligible patients, 197 (26.3%) were referred to CR, 103 (52.3% of referred) participated, and 69 (67.0% of participants) completed the program. Multivariate analysis showed that higher education was the strongest predictor of referral (OR = 9.50, 95% CI: 4.90–18.27, p < 0.001), followed by male gender (OR = 2.12, 95% CI: [1.00-4.49], p = 0.005). Furthermore, Physicians familiar with CR had approximately a 3-fold higher referral rate compared to less-familiar colleagues. Insurance coverage was significantly associated with completion of the program (78% of insured vs. 59% of uninsured completers, p = 0.018). Conclusion: Referral is the main systemic barrier to cardiac rehabilitation utilization in this underprivileged region. Participation and completion among referred patients reflect a selected group with adequate access, highlighting the need for system‑level interventions focused on physician referral practices—particularly for women and less‑educated patients—and improved insurance coverage to enhance equitable CR access. https://jmr.tums.ac.ir/index.php/jmr/article/view/1475