Barriers to participation in and adherence to cardiac rehabilitation programs: a critical literature review

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.

Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review

BACKGROUND

Despite the documented efficacy of cardiac rehabilitation (CR), a minority of patients with diagnosed coronary artery disease are referred. Although referral is a necessary step in the promotion of CR uptake, little is known about its determinants.

PURPOSE

The objective of this paper was to systematically review the available literature on factors predicting referral of patients to CR to appraise both their relative impact and consistency across studies.

METHODS

Studies were identified by searching MEDLINE (1966-2003), CINAHL (1982-2003), HealthSTAR (1975-2003), EMBASE (1966-2003), and The Cochrane Library Controlled Trials. Search terms were "myocardial infarction," "acute myocardial infarction," "coronary artery disease," combined with "rehabilitation," "cardiac rehabilitation," "secondary prevention," "exercise training," "referral," and/or "consultation." Forty-five studies were identified and independently assessed by 2 reviewers using predetermined eligibility criteria.

RESULTS

Ten published observational studies (1999-2004) including 30,333 coronary artery disease patients were selected. Determinants of referral to CR were grouped as sociodemographic, health status, and health care system factors. Major predictors were English speaking (RR 9.56, 95% CI 2.18-41.93), prior myocardial infarction (RR 2.73, 95% CI 1.69-4.42), being admitted to hospitals providing CR (RR 5.35, 95% CI 4.04-7.10), and having insurance coverage (RR 2.94, 95% CI 1.13-7.66).

CONCLUSION

This review highlights disparities in referral to CR and reveals a treatment gap in the secondary prevention of cardiovascular disease. Precise estimates of the impact of all factors on referral are not possible, but some hierarchies and potential priorities for action are evident.

Ethnic Differences in Barriers and Referral to Cardiac Rehabilitation Among Women Hospitalized With Coronary Heart Disease

Important gender differences in cardiac rehabilitation utilization are well established, yet few studies have documented whether reported barriers and referrals vary by ethnicity. This is a cross-sectional study to determine whether barriers and referrals to participation in cardiac rehabilitation differed by race/ethnicity in 304 women (52% ethnic minorities) hospitalized with coronary heart disease. Nearly all subjects (92%) strongly agreed that physician referral was important to participation in rehab, but only 22% of subjects reported physician instruction to attend. Whites were more likely than minorities to report instruction to attend cardiac rehabilitation, and minorities were more likely to report financial barriers when compared with whites. These disparities need to be addressed because minority women have a worse prognosis following hospitalization for coronary heart disease, and cardiac rehabilitation has been shown to improve survival.

A dyadic investigation of exercise support between cardiac patients and their spouses

The authors examined married partners' similarity in reported exercise behavior as a moderator of the association between social support for exercise provided and received by extending an actor-partner dyadic effects model. Participants were married cardiac rehabilitation patients and their spouses (N=99 couples). For couples similar in their reported exercise behavior, a significant association was found between both partners' independent reports of providing exercise support to and receiving exercise support from one another (n=49 couples). However, for couples differing in their reported exercise behavior (n=50 couples), no association was found between either partner's provision and receipt of support for exercise. Findings have the potential to inform practitioners of patients who may not be receiving adequate social support for their recommended exercise. Future interventions may consider implementing dyadic educational or motivational strategies with patients and their spouses.

Women in cardiac rehabilitation: outcomes and identifying risk for dropout

BACKGROUND

Women are underrepresented in cardiac rehabilitation (CR). Few reports describe outcomes and explore factors that may be barriers to CR participation among women. The purposes of this study were to (1) compare baseline characteristics between women who completed and did not complete CR, (2) identify factors associated with women completing CR, and (3) describe outcomes among completers.

METHODS

Study sample included women (n = 228) with coronary heart disease enrolled in CR at an academic medical center's program (January 1996-August 2003). Baseline differences between completers and noncompleters were compared; multivariate regression analyses identified factors associated with completers. Outcome measures included lipid levels, 6-minute walk distances, body mass index, Beck Depression Inventory II (BDI-II), self-reports of diet, physical activity, smoking, and perceived health status.

RESULTS

Mean age was 62 +/- 11 years, 44% were nonwhite, and 42% were stratified as high risk. Dyslipidemia was the most common risk factor (85%) followed by hypertension (81%), low physical activity (74%), obesity (53%), diabetes (39%), and smoking (18%). BDI-II scores were elevated (> or = 14) in 31% of women. In the adjusted multivariate regression model, completers were less likely to be obese (adjusted odds ratio [AOR] 0.28, CI 0.10-0.76, P = .01) or have elevated BDI-II scores (AOR 0.87, CI 0.81-0.95 P = .001) than noncompleters. Completers achieved significant improvements in all outcome measures (all P < .05) except for high-density lipoprotein.

CONCLUSION

Women enrolled in CR had a high risk factor burden and those completing achieved significant benefits. Women not completing CR were more likely to be obese or have depressive symptoms which may serve as barriers to completing CR.

Social inequality in patients??? physical and psychological state and participation in rehabilitation after myocardial infarction in Germany

Several Anglo-American studies found that vertical social characteristics made a difference in the utilization of cardiac rehabilitation programmes. A social gradient was also demonstrated for prevalence of risk factors, psychological strain and psychosocial resources. This study investigated social differences for these factors in a group of 536 patients who had suffered from a myocardial infarction. In contrast to findings in other industrialized countries, German patients of higher status groups made less use of cardiac rehabilitative services than patients with a lower and middle class status. However, similar to Anglo-American findings, patients with a lower socio-economic status were more likely to be smokers and more likely to be obese than other patients. Also they had higher levels of comorbidity and depression and lower self-efficacy expectations. Thus while there were no social disadvantages in terms of participation in cardiac rehabilitation programmes, which seems to be largely due to the specific characteristics of the German health care system, patients of lower socio-economic status seem to have worse baseline conditions and as a result of this a specific need for rehabilitative support.

Re-engineering cardiac rehabilitation programmes: considering the patient's point of view

AIMS

The aim of this paper is to report a study to describe how cardiac patients experience the first 3 months following a cardiac event requiring hospitalization, identify differences between the needs expressed by patients and the support they received during their recuperation and produce a preliminary model for the development of cardiac rehabilitation programmes, taking into account the patient perspective.

BACKGROUND

Although cardiac rehabilitation should be standard care for patients with cardiovascular disease, less than 20% begin and maintain a rehabilitation programme. Cited barriers include inadequate rehabilitation services, sub-optimal referral, low participation rates of women and older adults and travel considerations. The literature suggests that programmes better adjusted to patient needs could increase attendance, but little research has considered this perspective.

METHODS

Focus groups were conducted with a purposefully selected sample of 20 men and women who had been hospitalized for myocardial infarction, angina or percutaneous angioplasty. Data were analysed using qualitative content analysis.

FINDINGS

A gap exists between what traditional rehabilitation programmes offer and patients' expressed needs during the recuperating process after hospitalization for a cardiac event. In our study, participants focused on stress management rather than on modifying health habits. Support groups were viewed as beneficial and, according to patients, accepting their condition, knowing their limits and better continuity of care would also help reduce stress. Based on the findings, we devised a model as the basis for developing cardiac rehabilitation programmes.

CONCLUSION

Cardiac rehabilitation programmes need to shift their focus of attention from promoting healthier behaviours to responding to participants' perceived needs, alongside risk factor reduction.

Factors affecting the uptake of cardiac rehabilitation services in a rural locality

INTRODUCTION

A number of studies have investigated factors affecting uptake of cardiac rehabilitation services. However, little information on factors affecting uptake of services in rural localities is available.

STUDY DESIGN

A cross-sectional survey.

METHODS

A survey of patients eligible for cardiac rehabilitation was undertaken to investigate uptake of services. The effects of individual and geographic factors on service utilization were explored.

RESULTS

Utilization rates for cardiac rehabilitation services within the South Staffordshire locality are low, with 59.3% of eligible patients invited to attend cardiac rehabilitation services following discharge from hospital, 38.6% attending and 22.5% completing the programme. Two factors were independently associated with low service utilization. Patients under the age of 65 years are 1.90 [95% confidence intervals (CI) 1.01-3.65] times more likely to complete rehabilitation than patients aged over 65 years, and women are only 0.48 (95% CI 0.22-1.03) times as likely as men to complete rehabilitation. The major reported barrier to utilization of services was access. This included problems with public transport, parking and the time and location of classes. Access and medical problems were significantly higher in older people and may have contributed to their low overall completion rate. Electoral ward deprivation, geographical access score, living in an urban or rural electoral ward, electoral ward of residence and provider were not significantly associated with service utilization.

CONCLUSIONS

Overall, utilization rates were low. No geographical factors were associated with uptake of services, although the possible effect may have been mediated by the relative affluence of the locality. Two individual factors, age and sex, were most likely to influence uptake.

Effect of a postoperative telephone intervention on attendance at intake for cardiac rehabilitation after coronary artery bypass graft surgery

BACKGROUND

Enrollment in cardiac rehabilitation (CR) after coronary artery bypass graft (CABG) surgery is suboptimal (25%-30%).

OBJECTIVES

The purpose of this study was to examine the effect of a nurse-initiated telephone call (NIC) on attendance at a CR intake appointment.

METHODS

By using a retrospective cohort design, data were collected on 3536 patients who underwent CABG between April 1996 and March 2000 and were referred to CR. Of these, 2285 patients received standard care (no NIC) and 1251 received the NIC.

RESULTS

Patients who received the NIC were significantly more likely to attend their CR intake appointment compared with standard care (78.1% vs. 50.1%; P < .0001). Hierarchic logistic regression analysis revealed the NIC as the strongest predictor of attendance at a CR intake explaining 56.9% of the total variance (odds ratio =3.429; 95% confidence interval = 2.919-4.028; P < .0001).

CONCLUSION

These findings suggest that pre-appointment telephone contact by a cardiovascular nurse is a valuable tool to enhance attendance at a CR intake appointment after CABG.

Acute coronary syndromes: cardiac rehabilitation programmes and quality of life

AIMS

This paper reports a study examining the quality of life of clients following hospital admission with acute coronary syndrome in Hong Kong and their use of cardiac rehabilitation.

BACKGROUND

Coronary heart disease is a major source of mortality and morbidity in Hong Kong. Western studies have suggested that participation in cardiac rehabilitation improves the quality of life of clients with coronary heart disease yet the use of cardiac rehabilitation has been reported to be low. Better understanding is needed of the psychosocial status of these clients in Hong Kong and their use of cardiac rehabilitation services.

METHODS

A prospective, pretest-post-test study was carried out, with data collected over a period of 6 months with convenience sample of 182 participants. Baseline data were obtained within one week after hospital admission for individuals experiencing ACS. The second phase of data collection commenced at 6 months after hospital discharge. Total period of data collection took over 12 months between 2002 and 2003. The Chinese version of the SF-36 was used to assess quality of life, and demographic data and the extent to which clients participated in the cardiac rehabilitation programme were assessed.

RESULTS

Only 25% of the participants attended at least one session of the cardiac rehabilitation programme. Significant improvement occurred in all clients' perceived quality of life 6 months following initial hospital admission. No significant group differences in perceived quality of life were found according to whether or not clients used the cardiac rehabilitation services.

CONCLUSION

Improvement in perceived health-related quality of life was evident over a 6-month period. Yet our findings suggested that participation in the cardiac rehabilitation programme did not have any apparent effects in subjects' perceived quality of life. Further studies using both generic and disease-specific health-related quality of life instruments, as well as the inclusion of control group, are recommended. Continual improvement in cardiac rehabilitation programmes, and consideration of alternative modes of delivery other than the traditional attendance at hospital outpatient services, are also recommended.

Improving uptake and adherence in cardiac rehabilitation: literature review

AIMS

This paper presents a comprehensive systematic review of literature carried out to identify studies of interventions to improve uptake, adherence and professional compliance in cardiac rehabilitation.

BACKGROUND

Guidelines recommend that cardiac rehabilitation should be offered to patients following acute myocardial infarction and revascularization. Uptake and adherence are low, particularly in women, older people, and socially deprived and ethnic minority patients. Although patient, service and professional barriers to rehabilitation uptake have been described, no attempt has been made to evaluate systematically interventions aimed at improving uptake and adherence in cardiac rehabilitation.

METHODS

A comprehensive search strategy identified studies of cardiac rehabilitation, using the terms uptake, adherence and compliance. The search included grey literature, hand searching of specialist journals and conference abstracts. No language restriction was applied. Studies were summarized in three qualitative overviews and assessed by quality of evidence.

RESULTS

From 3261 publications identified, 957 were acquired on the basis of title or abstract. Few studies were of sufficient quality to make specific recommendations. Six, 12 and five studies, respectively, provided adequate information on methods to improve uptake, adherence or professional compliance. A minority of studies were randomized controlled trials. Studies of motivational and self-management strategies and use of lay volunteers showed some promise in improving rehabilitation uptake or lifestyle change. Nurse-led coordination of care after hospital discharge may have a role in improving rehabilitation uptake. Limited information was provided on resource implications, and there was a lack of studies with under-represented groups. The literature contained numerous suggested interventions which merit evaluation in appropriately designed studies.

CONCLUSIONS

Little research has been reported evaluating interventions to improve uptake, adherence and professional compliance in cardiac rehabilitation. A wide range of possible interventions was identified and further evaluations of methods are indicated.

Quality-of-life changes following the completion of phase II cardiac rehabilitation

In this study, 302 patients who were completing Phase II cardiac rehabilitation were assessed at their entrance to cardiac rehabilitation and at 3 months. After 3 months, subjects improved on 8 of 9 dimensions. Greatest gains were in Fitness (22.5%, P < .0001) and Daily Activities (24.4%, P < .0001). Despite stratification by gender, a sedentary lifestyle, and tobacco use, quality of life was markedly improved at the completion of rehabilitation. Completion of a Phase II cardiac rehabilitation program can lead to statistically significant increases in the quality of life following consequential cardiac events.

Physical activity and mortality across cardiovascular disease risk groups

PURPOSE

Several cohort studies suggest that sedentary individuals have an increased risk of death compared with individuals who are physically active. Most of these studies have been conducted in highly selected patient populations who tend to be healthier and are from higher socioeconomic status (SES) groups. We examined the impact of a sedentary lifestyle on mortality by cardiovascular disease (CVD) risk group in a national sample of U.S. adults who represent a wide range of activity levels, health conditions, and SES groups.

METHODS

Using data from the HRS, a nationally representative, observational study of 9824 U.S. adults aged 51-61 yr in 1992, we estimated the relative risk of death comparing sedentary individuals with those who are physically active by CVD risk group in a multivariate logistic regression model.

RESULTS

Even after adjusting for confounders, regular moderate to vigorous physical activity was associated with substantially lower overall mortality (odds ratio (OR) = 0.62 (95% CI 0.44-0.86)) compared with sedentary individuals. High CVD risk individuals (21% of the population) accounted for 64% of deaths attributable to a sedentary lifestyle. Those with high CVD risk had the most significant benefit from being active (regular moderate to vigorous exercisers OR = 0.55 (95% CI 0.31-0.97) and occasional or light exercisers OR 0.55 (95% CI 0.41-0.74)) compared with high CVD risk individuals who were sedentary.

CONCLUSION

A sedentary lifestyle is associated with a higher risk of death in preretirement-aged U.S. adults. Individuals with high CVD risk appear to get the largest benefit from being physically active. Physical activity interventions targeting high CVD risk individuals should be a medical and public health priority.

Early and late mortality after myocardial infarction in men and women: prospective observational study

OBJECTIVE

To compare characteristics, management, and outcome of myocardial infarction (MI) in men and women.

DESIGN

Prospective observational study.

SETTING

District general hospital in southwest Scotland.

PARTICIPANTS

966 men and 597 women admitted with first MI between 1994 and 2000 with follow up to the end of 2001.

RESULTS

393 (40.7%) men and 305 (51.1%) women died during a median follow up of 3.4 years for the survivors. Univariate analysis indicated an excess mortality among women (hazard ratio (HR) 1.45, 95% confidence interval (CI) 1.25 to 1.68), which disappeared after adjustment for age, smoking, co-morbidity, previous vascular disease, diabetes, hypertension, and social deprivation (HR 1.02, 95% CI 0.87 to 1.20). There was also an excess early mortality within 30 days among women (HR 1.54, 95% CI 1.20 to 1.98), though this did not retain significance after adjustment for the same covariates (HR 1.04, 95% CI 0.79 to 1.37). Small and insignificant differences were found in the proportion of men and women receiving thrombolysis on admission and secondary prophylactic drugs at discharge, except for statins and beta blockers, which were respectively more (adjusted odds ratio 1.48, 95% CI 1.10 to 1.98) and less (adjusted odds ratio 0.78, 95% CI 0.60 to 1.00) commonly prescribed to women.

CONCLUSION

Results suggest that the poorer outcome for women after MI reported in other studies may reflect sex bias in management as well as differences in age and co-morbidity and support the view that if women have access to the same quality of care as men then survival will be the same.

Referral rate and outcomes of cardiac rehabilitation after cardiac catheterization in a large Canadian city

PURPOSE

The benefits of cardiac rehabilitation (CR) for patients with coronary artery disease are extensive and compelling, demonstrating reductions in mortality. However, some reports suggest that only 10% to 20% of eligible patients currently participate in formal CR programs. The purpose of this study was to identify the proportion of patients referred to CR in a large Canadian city, and to determine their statistically adjusted survival rates relative to patients not referred to CR.

METHODS

Subjects eligible for this study included all adult residents with coronary artery disease from 1995 to 1999 in the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry. All 5,081 patients who survived 6 months or more after catheterization were included in the analysis. Survival data were adjusted using a Cox proportional hazards model.

RESULTS

Referral to a CR program (28.9% of patients) was significantly more likely for young male patients who had undergone a prior revascularization procedure, presented with an ejection fraction exceeding 50%, and did not report cerebrovascular, peripheral vascular, or renal disease. Crude hazard ratios indicated that referral to a CR program remained significantly associated with lower mortality after control was used for clinical, anatomic, treatment and comorbid conditions recorded at catheterization (hazard ratio, 0.68; 95% confidence interval, 0.51-0.90; P = .005).

CONCLUSIONS

Despite the proven efficacy of CR in clinical trials, fewer than one third of the patients undergoing cardiac catheterization are referred to a CR program. The better survival outcomes noted for patients referred to CR suggests that there is an opportunity to improve care and outcomes through increased referral of patients to such programs.

Psychosocial profiling: a holistic management tool for non-compliance*

We introduce a new concept of psychosocial profiling as a tool that provides the transplant team with a psychosocial framework for identification, intervention and management of non-compliance. This will also increase our understanding of emotional problems experienced by patients before transplant, as a result of living with the uncertainty and medical side effects of chronic illness. Psychosocial profiling is adaptable throughout the transplant process and gives every patient an opportunity of psychosocial support to help him or her into a position of emotional stability and compliance with their medications and postoperative care. Implementation of this strategy will move health care professionals from being gatekeepers to managers and facilitators of holistic care in recipients of transplants.

Promoting participation in cardiac rehabilitation: patient choices and experiences

BACKGROUND

Cardiac rehabilitation can be an effective means for the secondary prevention of coronary heart disease, but a majority of eligible individuals fail to attend or drop out prematurely. Little research has examined patients' decisions about attendance.

AIMS

This paper reports a study examining patients' beliefs and decision-making about cardiac rehabilitation attendance.

METHODS

A purposive sample of patients from a mixed urban-rural region of Scotland was studied in 2001 using focus groups. Those who were eligible for a standardized 12-week cardiac rehabilitation programme were compared, with separate focus groups held for individuals with high attendance (>60% attendance; n = 27), high rates of attrition (<60% attendance; n = 9) and non-attendance (0% attendance; n = 8). A total of 44 patients (33 men; 11 women) took part in eight focus groups.

RESULTS

Participants from all groups held sophisticated and cohesive frameworks of beliefs that influenced their attendance decisions. These beliefs related to the self, coronary heart disease, cardiac rehabilitation, other attending patients, and health professionals' knowledge base. An enduring embarrassment about group or public exercise also influenced attendance. Those who attended reported increased faith in their bodies, a heightened sense of fitness and a willingness to support new patients who attended.

CONCLUSIONS

Reassurance to ease exercise embarrassment should be given before and during the early stages of programmes, and this could be provided by existing patients. Strategies to promote inclusion should address the inhibiting factors identified in the study, and should present cardiac rehabilitation as a comprehensive programme of activities likely to be of benefit to the individual irrespective of personal characteristics, such as age, sex or exercise capacity.

Automatic referral to cardiac rehabilitation

OBJECTIVES

Cardiac rehabilitation (CR) remains underused and inconsistently accessed, particularly for women and minorities. This study examined the factors associated with CR enrollment within the context of an automatic referral system through a retrospective chart review plus survey. Through the Behavioral Model of Health Services Utilization, it was postulated that enabling and perceived need factors, but not predisposing factors, would significantly predict patient enrollment.

SUBJECTS

A random sample of all atherosclerotic heart disease (AHD) patients treated at a tertiary care center (Trillium Health Centre, Ontario, Canada) from April 2001 to May 2002 (n = 501) were mailed a survey using a modified Dillman method (71% response rate).

MEASURES

Predisposing measures consisted of sociodemographics such as age, sex, ethnocultural background, work status, level of education, and income. Enabling factors consisted of barriers and facilitators to CR attendance, exercise benefits and barriers (EBBS), and social support (MOS). Perceived need factors consisted of illness perceptions (IPQ) and body mass index.

RESULTS

Of the 272 participants, 199 (73.2%) attended a CR assessment. Lower denial/minimization, fewer logistical barriers to CR (eg, distance, cost), and lower perceptions of AHD as cyclical or episodic reliably predicted CR enrollment among cardiac patients who were automatically referred.

CONCLUSION

Because none of the predisposing factors were significant in the final model, this suggests that factors associated with CR enrollment within the context of an automatic referral model relate to enabling factors and perceived need. A prospective controlled evaluation of automatic referral is warranted.

Capacity and equity in cardiac rehabilitation in the eastern region: good and bad news

AIM

To document current baseline eligibility for Phase 3 cardiac rehabilitation (CR) and the capacity to meet this need in hospitals in the Eastern Regional Health Authority.

METHODS

Information on the eligible population and the capacity for CR was collected in all nine hospitals retrospectively (February-March 2001).

RESULTS

Forty-seven per cent of eligible patients were invited to participate with only two-thirds attending. Completion rates were very high (89%) in attenders. Age and health board area were significant independent predictors of being invited to CR. Gender was not independent of age. Fifty-three per cent of the need for this service was met by capacity in the region's nine hospitals in 2000 rising to 59% in 2002.

CONCLUSIONS

Many eligible patients are not invited to CR. Lack of capacity is a problem. Among the invited, non-participation is a factor. Inequity in age and inter-hospital variation in invitation is noted.

Social support as a predictor of participation in cardiac rehabilitation after coronary artery bypass graft surgery

PURPOSE

Cardiac rehabilitation promotes recovery and enhances quality of life after a coronary artery bypass graft (CABG), but participation in such rehabilitation is low. The role of social support in promoting participation has been suggested by prior studies, but is not clearly defined. The purpose of this study was to investigate the role of social support as an independent predictor of participation in cardiac rehabilitation.

METHODS

This study examined 944 patients who underwent first isolated CABG between May 1999 and February 2001, then were followed for 6 months after surgery. Social support before CABG and 6 weeks after CABG was assessed using the Enhancing Recovery in Coronary Heart Disease (ENRICHD) Social Support Inventory (ESSI) and evaluated for its association with participation in cardiac rehabilitation.

RESULTS

Of 944 patients, 524 (56%) reported participation in rehabilitation. The participants were younger, better educated, more often employed, and less financially strained. The participants also had a lower prevalence of cardiovascular disease risk factors and better physical function. According to unadjusted analysis, the patients with low social support (ESSI </= 22) before surgery were less likely to participate in rehabilitation than the other patients (52% vs 59%; risk ratio [RR], 0.89; 95% confidence interval [CI], 0.78-0.99). However, adjustment for demographic factors, medical history, cardiovascular disease risk factors, physical and psychological function, and hospital complications attenuated this association (adjusted RR, 0.92; 95% CI, 0.78-1.07). A low ESSI score measured 6 weeks after CABG similarly did not significantly affect participation in rehabilitation (adjusted RR, 0.96; 95% CI, 0.81-1.11).

CONCLUSIONS

Contrary to what is believed generally, social support may not be a strong determinant of participation in rehabilitation after CABG. Correlates of social support such as gender, socioeconomic status, and comorbidity burden may have a more important role in cardiac rehabilitation participation than social support itself. When marital status was examined as a main predictive variable, the analyses yielded similar results (unadjusted RR, 0.72; 95% CI, 0.58-0.86; RR adjusted for the same covariates, 0.80; 95% CI, 0.60-1.02).

An evaluation of training responses using self-regulation in a residential rehabilitation program

BACKGROUND

The efficacy of exercise training for patients with cardiovascular disease is well established. Given recent changes in reimbursement patterns for cardiac rehabilitation and therefore a greater need for self-monitoring, home programs, and the like, a need exists to determine the capability of patients to regulate their own exercise intensity and assess the efficacy of self-regulated exercise. This study assessed the training responses of a group instructed to train at an intensity they perceived as "somewhat hard," and compared their responses to standardized methods of exercise prescription.

METHODS

A total of 78 patients (86% male; mean age, 56 +/- 10 years; mean ejection fraction, 64% +/- 12%) referred to a residential rehabilitation program after myocardial infarction or bypass surgery were randomized to three different groups, for which exercise intensity was prescribed using different methods. For group 1, 70% of heart rate reserve was maintained using precise, continuous electronic heart rate-controlled resistance on a cycle ergometer. Group 2 gauged their own exercise intensity according to a level they perceived as "somewhat hard" (13 on the Borg scale) and were given no feedback in terms of heart rate or work rate. For group 3, exercise intensity was determined using both objective (heart rate reserve and work rate targeted to 60% to 80% of maximal exercise) and subjective (Borg scale 12 to 14) indices. The subjects exercised daily for 1 month. Training frequency, duration, and mode were equivalent between the groups.

RESULTS

The exercise capacity of the three groups was increased significantly after the training period: 33.7% in group 1, 22.9% in group 2, and 31.2% in group 3 (P <.005 for all). Other measures of the training response also were similar between the groups, including a significant increase in work rate at a perceived exertion of 13 and maximal watts achieved. The magnitude of the training response was not different between the groups. There were no complications during training.

CONCLUSIONS

The training response was similar between the three methods used to monitor exercise intensity. Thus, patients are able to gauge their own exercise intensity reasonably when instructed to exercise at a perceived exertion of 13. This suggests that close heart rate monitoring may not always be necessary for many stable patients with cardiovascular disease to achieve the benefits of a rehabilitation program.

Are Rural People Getting HeartSmart?

OBJECTIVE

This study evaluates the impact of a cardiac rehabilitation program (HeartSmart) in a rural area on the quality of life, dietary behaviour, weight loss and physical activity participation of patients with cardiovascular disease (CVD) or at high risk of CVD.

DESIGN

The evaluation of the program consisted of a single group pre and post-test design with follow-up at 3, 6 and 12 months after program completion, complemented with a cross-sectional survey of non-participants as a pseudo comparison group.

SETTING

The HeartSmart program is a hospital-based cardiac rehabilitation program in Bunbury, a regional centre of Western Australia.

SUBJECTS

A total of 203 participants and 159 non-participants.

INTERVENTIONS

The program consisted of 7 weeks of education and exercise sessions.

RESULTS

The program had a high rate of completion (92%). Evaluation results suggested that HeartSmart participants demonstrated significant improvements in quality of life, compliance with medication, dietary behaviour, weight loss and physical activity participation. The largest changes were mostly observed between pre and post-program stages, with sustained behaviour change at 6 months after the completion of the program. Further evidence of the HeartSmart benefits was provided through significantly better health-related behaviour, confidence to diet and exercise, dietary fat intake, cardiac knowledge and quality of life scores among HeartSmart participants compared with non-participants.

CONCLUSIONS

While this program has achieved its objectives, there are a few issues that need to be considered by similar programs: the post-program stage of patient follow-up by general practitioners; the geographical disadvantage of those living outside regional centres to access the service; enhancing the primary prevention aspect of the program; adapting the program to the needs of Aboriginal clients; facilitating evaluations by resourcing and training program staff in computer skills. WHAT IS ALREADY KNOWN ON THIS SUBJECT: The viability of establishing cardiac rehabilitation programs in rural Australia has been questioned and few if any have been formally evaluated, particularly using a follow-up design and a control group.

WHAT THIS PAPER ADDS

This study ascertains the benefits of secondary prevention programs in rural areas not only on the quality of life but also shows positive outcomes in lifestyle modification for program participants compared to non-participants. The lessons learnt can improve the effectiveness of similar prevention programs.

Factors Associated With Referral to Outpatient Cardiac Rehabilitation Services

BACKGROUND

Although practice guidelines and policy statements for cardiac rehabilitation recommend that it be offered to all patients with cardiovascular disease, the participation rates in most Western countries are low.

PURPOSE

This study aimed to determine the factors associated with referral to outpatient cardiac rehabilitation in the Hunter region of New South Wales, Australia.

METHODS

The study sample comprised 1933 patients discharged from public hospitals in the Hunter region between March 1, 1998 and February 28, 1999 who were eligible for cardiac rehabilitation, and for inclusion on the Hunter Area Heart and Stroke Register (the Register). Data were obtained from the Register database (gender, age, clinical information) and via a self-completed questionnaire eliciting referral, sociodemographic, and cardiovascular disease risk factor information. Multiple logistic regression analysis was conducted to determine the factors independently associated with referral.

RESULTS

: Of the respondents (1202/1933), 41% (493/1202; 95% confidence interval, 38-44%) reported that they had been referred to outpatient cardiac rehabilitation. The factors independently associated with referral were age younger than 65 years, previous participation in an outpatient cardiac rehabilitation program, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery.

CONCLUSIONS

Younger age, previous participation in outpatient cardiac rehabilitation, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery were associated with referral to cardiac rehabilitation. Research testing strategies designed to increase cardiac rehabilitation referral rates are needed and could include testing the potential role of modern quality management methods.

Delivery of Outpatient Cardiac Rehabilitation in a Managed Care Organization

PURPOSE

This study aimed to assess referral and enrollment rates for postdischarge outpatient cardiac rehabilitation in a managed care organization.

METHODS

A prospective cohort study investigated Atlanta area managed care members, age 30 years or older, hospitalized for acute myocardial infarction or coronary revascularization during 1997-1999. Postdischarge cardiology medical records were abstracted for evidence of postdischarge visits; counseling on diet, weight, or exercise; and referral to outpatient cardiac rehabilitation. Enrollment in outpatient cardiac rehabilitation was confirmed by chart abstraction. Referral and enrollment rates were estimated using logistic regression models.

RESULTS

Of the 945 hospitalized patients, 783 remained alive and enrolled in the managed care organization 12 months after discharge. Of these 783 patients, 73.8% had at least one postdischarge cardiologist visit. Among these, 24.4% were referred by a cardiologist to outpatient cardiac rehabilitation, and 7.1% enrolled. Enrollment was significantly higher among patients with a documented referral than among patients not referred (P <.05). Patients 65 years of age or older were significantly less likely than younger patients to be referred to cardiac rehabilitation and enroll (P<.05). Of the patients with a postdischarge cardiologist visit, 31.5% received counseling on diet, weight, or exercise. The men and the patients with a body mass index of at least 30 were more likely to receive this counseling than women and those with body mass index less than 30 (P <.05).

CONCLUSIONS

The low rates of referral and enrollment for postdischarge outpatient cardiac rehabilitation in this managed care population are consistent with rates observed at academic medical centers. Despite demonstrated benefits after acute coronary events, outpatient cardiac rehabilitation remains underused.

Improving access to cardiac rehabilitation for remote Indigenous clients

OBJECTIVE

To identify barriers to Indigenous patients taking up a rural general practice-based cardiac rehabilitation program. We investigated the accessibility and appropriateness of the program and the role of Indigenous health workers (IHWs) in caring for Indigenous cardiac patients.

METHODS

A cross-sectional survey of knowledge and views relating to cardiac rehabilitation was undertaken with 47 Indigenous cardiac patients and 41 health professionals in remote Queensland.

RESULTS

Only three patients were fully engaged in the program. Reasons for non-participation included: lack of knowledge about rehabilitation, low income, and having a large extended family. Although the program incorporated a training component for IHWs covering prevention and follow-up, most did not monitor patients specifically for their heart problems and thought they did not have adequate skills. Shared care was occurring in some settings but without the participation of IHWs.

CONCLUSIONS

There was general agreement that IHWs do have a role in cardiac rehabilitation. There is a need for ongoing in-service education or inclusion in training programs. Lack of understanding of the role of IHWs is a barrier to shared care. Cardiovascular disease needs to be addressed as part of the raft of chronic illnesses.

IMPLICATIONS

Training about chronic illnesses and their management needs to be linked to structural adaptations in the delivery of health services to allow efficient use of each professional's skills. Clear role delineation needs to be negotiated to allow all health professionals to carry out their job effectively.

Utilisation of outpatient cardiac rehabilitation in Queensland

OBJECTIVES

To determine patient participation rates in outpatient cardiac rehabilitation (OCR) programs; ascertain the barriers to participation; and evaluate the quality of OCR programs.

DESIGN AND SETTING

Retrospective cohort study of patient separations from selected public and private Queensland hospitals; questionnaire survey of hospitals and all registered OCR programs.

PARTICIPANTS

Patients discharged with cardiac diagnoses between 1 July 1999 and 30 June 2000 from 31 hospitals (24 public; 7 private).

MAIN OUTCOME MEASURES

Rates of referral of hospitalised patients to OCR programs; rates of program attendance and completion; barriers to OCR referral and attendance.

RESULTS

15 186 patients were discharged with cardiac diagnoses from participating hospitals, of whom 4346 (29%) were referred to an OCR program after discharge, compared with an estimated 59% (8895/15 186) of patients who were eligible for such a program. Proportionately more patients were referred from secondary (38% [1720/4500]) and private (52% [2116/4031]; P < 0.001) hospitals than from tertiary (25% [2626/10 686]) and public (20% [2230/11 155]) hospitals. Patients undergoing coronary revascularisation procedures comprised 35% of discharges, but accounted for 56% of all program attendances. Fewer than a third of all referred patients completed OCR programs, and only 39% of available OCR program places were fully utilised. Catchment populations of programs with unused places had excess coronary mortality.

CONCLUSION

There is significant underutilisation of facility-based OCR programs in Queensland. Procedures are required for identifying and referring eligible patients to existing programs and improving program compliance. Alternative OCR models are also required.

Predictors of women's attendance at cardiac rehabilitation programs

This descriptive study was conducted to identify the factors that influence womens attendance at cardiac rehabilitation programs and womens adherence to risk factor modification following a cardiac event. Women (N=196) admitted to hospital for a cardiac event were followed-up at 12 weeks postdischarge. Despite eligibility, only 64% (n=112) had been referred to cardiac rehabilitation programs. By 12 weeks postdischarge only 32% of the total sample (n=57) attended programs and 12% of the total sample (n=21) had dropped out before completion. The odds of a woman attending cardiac rehabilitation were decreased by myocardial infarction diagnosis, lack of employment, <55 years or >70 years, and experiencing a personal stressful event during follow-up. Women were likely to adhere to smoking, medication, and stress modification guidelines but unlikely to adhere to modification guidelines for diet and exercise.

Factors associated with the failure of patients to complete cardiac rehabilitation for medical and nonmedical reasons

PURPOSE

Cardiac rehabilitation (CR) provides effective secondary prevention services, but many patients fail to complete the recommended program. The purposes of this study were to describe completion rates in a hospital-based outpatient CR program, and to identify factors associated with patients failing to complete CR because of nonmedical and medical reasons.

METHODS

Data used for the analyses were from a hospital-based CR program involving 526 discharged patients between January 1996 and February 2002. Patient discharge status was classified into three categories: complete, noncomplete-medical reasons, and noncomplete-nonmedical reasons. Logistic regression modeling identified factors associated with the groups failing to complete CR.

RESULTS

The rate of CR completion was 58% (304/526). Among the 222 patients who did not complete CR, 139 (63%) had nonmedical reasons. As compared with the patients who completed CR, the adjusted odds ratio (AOR) for those who did not complete CR because of nonmedical reasons were more likely to be employed (AOR 2.2), to be obese (AOR 2.5), to be smokers (AOR 2.1), and to have shorter 6-minute walk distances (AOR 1.7). They were less likely to be women (AOR 0.6) or have diabetes (AOR 0.5). Patients not completing CR for medical reasons were more likely to be categorized as being at high clinical risk (AOR 4.2) and having shorter 6-minute walk distances (AOR 1.9).

CONCLUSION

Except for low functional capacity, baseline factors associated with patients failing to complete CR differed on the basis of medical or nonmedical reasons. The development of interventions that address the special needs of patients with low functional capacity may be especially important in attempts to retain this high-risk group in CR therapy.

Cardiac rehabilitation secondary prevention programs

Contemporary cardiac rehabilitation programs are more accurately described as "secondary prevention centers." They offer comprehensive care for the patient with cardiovascular disease, resulting in decreased mortality, improvement of most cardiac risk factors, and an enhanced quality of life. Although overall participation has increased with enhanced recognition of the importance of secondary prevention, 80% of eligible patients still do not participate, in part due to lack of insurance reimbursement. This rate can be significantly increased by specific endorsement from the physician.