A qualitative study investigating patients' beliefs about cardiac rehabilitation

Perceptions of exercise among people who have not attended cardiac rehabilitation following myocardial infarction

Perceptions of exercise among nonattenders of cardiac rehabilitation (CR) were explored using semi-structured interviews. Analysis indicated that participants did not recognize the cardiovascular benefits of exercise, and perceived keeping active through daily activities as sufficient for health. Health professionals were perceived to downplay the importance of exercise and CR, and medication was viewed as being more important than exercise for promoting health. The content of CR programmes and the benefits of exercise need to be further explained to patients post-MI, and in a manner that communicates to patients that these programmes are valued by significant others, particularly health professionals.

‘It Got Right to the Spot’ The Patient Experience of Primary Angioplasty: A Qualitative Study

Background: Primary angioplasty is becoming an established treatment for myocardial infarction. Yet we have a limited understanding of patients' attitudes toward this treatment and their experiences of receiving it in practice.

Aims: Exploration of patients' experiences and perceptions of primary angioplasty as treatment for their heart attack.

Methods: Qualitative study of a purposive sample of patients admitted to a tertiary cardiology unit in east London, UK. Participants were interviewed either in their own homes or in hospital. Recruitment continued until no new substantial themes emerged. Eleven men and four women aged 35 to 74 years who had sustained a myocardial infarction were interviewed 13 to 90 days after primary angioplasty. We used the framework method of analysis to identify and explore emerging themes.

Results: Informants were expecting open-heart surgery as treatment for their heart attack. They were impressed by the service they actually received. They were generally not engaged in decisions about their treatment in the acute setting and this passivity sometimes persisted after discharge. Expectations of follow up in primary care were not often met.

Conclusions: Patients are satisfied with the primary angioplasty as treatment for acute myocardial infarction but have poor understanding of the management of this condition.

Cardiac rehabilitation: Adding years to life and life to years

Abstract

Cardiac rehabilitation is an integral component of comprehensive cardiac care and is effective in reducing morbidity and mortality and improving quality of life. However, despite a 50-year-history and extensive evidence base attesting to its clinical and cost-effectiveness, including adding years to life and life to years, and exhortations that its implementation should be a key priority, the majority of cardiac patients do not receive rehabilitation. There is a comparative dearth of funding and wide variation in service provision, with a health care system that often fails to address issues such as sub-optimal referral, enrolment and completion, particularly amongst certain potential user groups that could benefit. This paper reviews these issues and suggests ways of overcoming the obstacles identified. It also highlights some of the knowledge gaps and areas that warrant further research.

Improving uptake of cardiac rehabilitation: using theoretical modelling to design an intervention

BACKGROUND

Attendance rates at cardiac rehabilitation remain low with typically fewer than 35% of eligible patients attending. Much of the poor attendance stems from invited patients failing to attend.

AIM

To design a theoretically based intervention to improve attendance at cardiac rehabilitation.

METHODS

Our methods followed recommendations that have been developed from the Medical Research Council (MRC) framework for the design of complex interventions. We conducted three processes that progressed simultaneously: 1) literature review for evidence on epidemiology, behavioural theory, and efficacy of interventions; 2) expert meetings on behavioural theory and to select target points for intervention; and 3) development and theoretical modelling of the intervention.

RESULT

Our final interventions were a theoretically worded invitation letter and leaflet based on the Theory of Planned Behaviour and the Common Sense Model of Illness, designed to: a) motivate patients through professional recommendation; b) provide simple information on the contents of cardiac rehabilitation emphasising ease for participants; c) reassure participants that the programme is tailored to their personal needs in a safe supervised environment; and d) reinforce the benefits of attending cardiac rehabilitation.

CONCLUSION

A theoretically worded letter and leaflet could be an inexpensive intervention to improve attendance at cardiac rehabilitation. The letters and leaflets will now be evaluated in a randomised trial.

Cardiac misconceptions: comparisons among nurses, nursing students and people with heart disease in Taiwan

AIM

This paper is a report of a study to examine the misconceived and potentially maladaptive beliefs (cardiac misconceptions) about heart disease held by nurses, nursing students and people with heart disease in Taiwan.

BACKGROUND

Research suggests that misconceived and maladaptive beliefs about heart disease influence outcomes in people with heart disease, and that eliciting and dispelling incorrect beliefs can reduce disability in this population. However, nurses do not routinely elicit maladaptive beliefs or attempt to dispel them.

METHOD

Between October 2005 and March 2006, a survey was conducted using version 1 of the York Cardiac Beliefs Questionnaire to measure cardiac misconceptions in 64 hospital-based nurses (13 of whom were cardiac nurses), 134 nursing students and 238 people with heart disease.

RESULTS

Nursing students held fewer cardiac misconceptions than nurses (P = 0.042). There were no statistically significant differences in the numbers of misconceptions between cardiac and general nurses, and no statistically significant associations between level of qualification, years of nursing experience and number of misconceptions. Nurses with higher levels of education were more likely to hold fewer misconceptions (P = 0.24). Patients held statistically significantly more misconceptions about heart problems than nurses (P < 0.001).

CONCLUSION

Nurses who are involved in the care for people with heart disease have a responsibility to assess and dispel people's misconceptions about their condition, and therefore continuing professional education is required to develop this clinical expertise. Future research should focus on methods of dispelling cardiac misconceptions in both nursing and patient education.

“Maybe It Could Be a Heart Attack . . . But I'm Only 31”: Young Men's Lived Experience of Myocardial Infarction—An Exploratory Study

This study examines the lived experience of myocardial infarction (MI) in younger men. Seven men, aged between 32 and 58, all of whom had suffered MI within the previous 12 months, were interviewed. Thematic analysis of the interview transcripts revealed four main themes. The themes were “disillusionment with life,” “tension and stress,” “keeping up appearances,” and “invincibility.” Collectively the four themes reflected the complexities, subtleties, and consensus of the experiences of these younger men who have survived MI. This study reveals that the individuals within the authors' sample appear to allude to the ideal or hegemonic form of masculine identity. Utilization of a qualitative approach with this younger male sample has enabled the authors to elicit the defining features of their experience as identified by themselves. Implications for these findings are discussed.

Participation and drop-out in pulmonary rehabilitation: a qualitative analysis of the patient's perspective

OBJECTIVE

To examine patients' pretreatment beliefs and goals regarding pulmonary rehabilitation.

DESIGN

Qualitative study using semi-structured interviews.

SETTING

Interviews conducted at participants' homes.

SUBJECTS

Twelve patients with chronic obstructive pulmonary disease who had been referred to a rehabilitation clinic.

MAIN MEASURES

Patients' beliefs about pulmonary rehabilitation, self-set treatment goals and anticipated reasons for drop-out.

RESULTS

Patients' beliefs about pulmonary rehabilitation comprised positive aspects (participation as an opportunity for improvement, a safe and multidisciplinary setting, presence of motivating and supporting patients) and negative aspects of exercising in a rehabilitation centre (e.g. disruption of normal routine, being tired after training, transportation difficulties, limited privacy and confrontation with severely ill patients). Four types of treatment goals were formulated: increase in functional performance, weight regulation, reduction of dyspnoea, and improvement of psychosocial well being. Four clusters of anticipated reasons for drop-out were identified: the intensity of the programme, barriers to attending (e.g. transportation problems, sudden illness and other duties/responsibilities), lack of improvement and social factors. Four different attitudes towards pulmonary rehabilitation could be distinguished: optimistic, 'wait and see', sceptic and pessimistic. Follow-up data revealed that whereas a pessimistic attitude (high disability, low self-confidence, many concerns) was related to decline, the 'sceptic' patients had dropped out during the course.

CONCLUSIONS

Uptake and drop-out may be related to patients' perceived disabilities, expected benefits and concerns with regard to rehabilitation, practical barriers and confidence in their own capabilities.

Illness perceptions predict attendance at cardiac rehabilitation following acute myocardial infarction: a systematic review with meta-analysis

OBJECTIVE

Early reports indicated that the illness perceptions of patients following acute myocardial infarction (AMI) predict attendance at cardiac rehabilitation. However, null findings have subsequently been reported, and there is variation between studies in terms of which illness perception constructs predict attendance. The aim of this meta-analysis was to examine whether illness perceptions really predict attendance at cardiac rehabilitation and to examine factors that moderate this relationship.

METHODS

The strategy and procedures recommended by Hunter and Schmidt [Hunter JE, Schmidt FL. Methods of meta-analysis: correcting error and bias in research findings. Thousand Oaks (CA): Sage, 2004] were followed. Based on a systematic literature search, eight studies (N=906 patients) that examined the relationship between illness perceptions and attendance at cardiac rehabilitation were included.

RESULTS

Four illness perception constructs significantly predicted attendance at cardiac rehabilitation: patients with more positive identity (r=.123), cure/control (r=.111), consequences (r=.081), and coherence (r=-.160) beliefs were more likely to attend cardiac rehabilitation. For all relationships, except that between cure/control beliefs and rehabilitation attendance, there was significant heterogeneity, which was attributable to two studies: one that assessed illness perceptions after leaving the hospital yielded higher effect size estimates, whereas another that involved an intervention yielded effect size estimates in the direction opposite to those of most other studies. The exclusion of these studies resulted in largely unchanged, but homogeneous, effect size estimates.

CONCLUSION

Illness perceptions of AMI patients predict attendance at cardiac rehabilitation, although the effect sizes are small and often heterogeneous. AMI patients who view their condition as controllable, as symptomatic, and with severe consequences, and who feel that they understand their condition are more likely to attend.

Assessing patients' beliefs about cardiac rehabilitation as a basis for predicting attendance after acute myocardial infarction

BACKGROUND

Some sociodemographic and psychological variables such as patients' belief about illness are associated with attendance at cardiac rehabilitation. Exploration of patients' beliefs about treatment regarding cardiac rehabilitation has been limited to qualitative studies; their role in relation to attendance at cardiac rehabilitation after acute myocardial infarction (AMI) remains speculative.

OBJECTIVES

To develop a valid and reliable measure of patients' beliefs regarding cardiac rehabilitation and to ascertain the relationship between such beliefs and attendance.

DESIGN

A prospective questionnaire-based study.

SETTING

Coronary care unit of a London teaching hospital.

PATIENTS

130 patients with AMI; 104 (83%) men; mean age 58.4 (standard deviation (SD) 10.7) years.

INTERVENTIONS

Patients completed a 26-item questionnaire consisting of statements pertaining to beliefs about cardiac rehabilitation.

MAIN OUTCOME MEASURES

Cardiac rehabilitation attendance; beliefs of patients about cardiac rehabilitation.

RESULTS

Four subscales pertaining to patients' beliefs about cardiac rehabilitation were produced, accounting for 65.3% of the attendance variance: perceived necessity of cardiac rehabilitation (alpha = 0.71), concerns about exercise (alpha = 0.79), practical barriers (alpha = 0.70) and perceived personal suitability (alpha = 0.74). Patients who attended were more likely to believe that cardiac rehabilitation was necessary and to understand its role compared with non-attenders (17.7 (SD 2.7) v 16.9 (SD 3.0), p = 0.029). Patients who thought cardiac rehabilitation was suitable for a younger, more active person were less likely to attend (5.6 (SD 1.9) v 4.6 (SD 1.7), p = 0.007). Patients who expressed concerns about exercise or who reported practical barriers to attendance were less likely to attend, although these did not reach statistical significance.

CONCLUSION

Beliefs about cardiac rehabilitation can be quantified and differ between attenders and non-attenders of cardiac rehabilitation.

Investigating patients' preferences for cardiac rehabilitation in Denmark

OBJECTIVES

The objective of this study was to analyze preferences for activities comprised in comprehensive cardiac rehabilitation programs among former cardiac patients from three different hospitals in Copenhagen County, Denmark.

METHODS

A discrete choice experiment was applied to elicit the preferences for the offer of participation in various cardiac rehabilitation program activities: smoking cessation course, physical exercise program, personal meetings with cardiac nurse, group meetings managed by cardiac nurses, and nutritional counseling guidance. The questionnaire was sent to 742 former cardiac patients. We had a response rate of 69 percent.

RESULTS

We found that preferences differed with respect to gender and age and that the offer of participation in cardiac rehabilitation activities was not highly valued by older patients, in particular among older men.

CONCLUSIONS

The discrete choice experiment proved a valuable instrument for the measurement of preferences for cardiac rehabilitation. The study provides important information on patients' preferences for cardiac rehabilitation for healthcare professionals and decision makers.

Cardiac rehabilitation and survival of dialysis patients after coronary bypass

Patients who are on renal dialysis are at high risk for cardiac death and have a large burden of cardiovascular disease and cardiovascular disease risk factors. Cardiac rehabilitation can promote improved survival of nondialysis patients after coronary artery bypass grafting (CABG) surgery and is covered by Medicare, but no previous studies have investigated whether dialysis patients' survival after CABG may be improved as a function of cardiac rehabilitation. A prospective cohort study was conducted using Medicare claims (1998 to 2002) for CABG and cardiac rehabilitation and patient information from the United States Renal Data System database for 6215 renal patients who initiated hemodialysis and underwent CABG between January 1, 1998, and December 31, 2002, with mortality follow-up to December 31, 2003. Cardiac rehabilitation was defined by Current Procedural Terminology codes for monitored and nonmonitored exercise in Medicare claims data. Dialysis patients who received cardiac rehabilitation after CABG had a 35% reduced risk for all-cause mortality and a 36% reduced risk for cardiac death compared with dialysis patients who did not receive cardiac rehabilitation, independent of sociodemographic and clinical risk factors, including recent hospitalization. Only 10% of patients received cardiac rehabilitation after CABG, compared with an estimated 23.4% of patients in the general population, and lower income patients of all ages as well as women and black patients who were aged 65+ were significantly less likely to receive cardiac rehabilitation services. This observational study suggests a survival benefit of cardiac rehabilitation for dialysis patients after CABG.