Women and cardiac rehabilitation after heart surgery: patterns of referral and adherence

Improvements in exercise capacity of older adults during cardiac rehabilitation

AIMS

Cardiac rehabilitation plays a vital role in secondary prevention of cardiovascular patients. Female sex and higher age, however, are associated with non-referral to cardiac rehabilitation. Improving exercise capacity during cardiac rehabilitation is essential to reduce morbidity and mortality risks. The objective of this study was to closely examine the beneficial changes in exercise capacity of older patients of both sexes during cardiac rehabilitation and to identify the most important predictors of the change in exercise capacity.

METHOD

A sample of 13,612 patients (mean age = 69.10 ± 11.8 years, 63.7% men, 19% > 80 years) was analysed. Data were prospectively assessed from 2012-2018 in six Swiss in-patient cardiovascular rehabilitation clinics. Improvement in exercise capacity measured with the six-minute walking test represents the outcome variable. Univariate and multivariate analyses, as well as the random forest method were used to estimate variable importance.

RESULTS

Mean improvement in the six-minute walking test was 113.5 ± 90.5 m (men = 118.7 ± 110.0; women = 104.4 ± 93.0, Cohen's d = 0.16). The presence of heart failure, diabetes mellitus and psychiatric diagnoses was related to reduced but nonetheless clinically relevant six-minute walking test improvement. Random forest analysis suggests that baseline exercise capacity, age, time in rehabilitation and heart failure were the most important predictors for improvement in exercise capacity. Clinically relevant improvements in exercise capacity (>45 m) were also present into old age (85 years) and for both sexes.

CONCLUSION

As indicated by these results, efforts need to be increased to refer eligible patients to structured rehabilitation programmes, irrespective of patients' age and sex.

Barriers for Nonparticipation and Dropout of Women in Cardiac Rehabilitation Programs: A Systematic Review

BACKGROUND

Cardiovascular disease (CVD) is a major health problem worldwide. Cardiac rehabilitation (CR) programs are effective in reducing mortality and improving the quality of life of patients with CVD. Women are under-represented in CR and have a higher dropout rate than men. We aimed to systematically review the literature on barriers perceived by women with CVD affecting their nonparticipation in and/or dropping out from CR programs.

METHODS

Systematic review was done using MEDLINE, Embase, Scopus, Open Grey, and Cochrane Database from inception to September 2016. Search terms included (1) heart disease and other cardiac conditions, (2) CR and secondary prevention, and (3) nonparticipation in and/or dropout. Databases were searched following the "participants, interventions, comparisons, outcomes, and study design" method.

RESULTS

A total of 24 studies (17 descriptive, 6 qualitative, and 1 randomized controlled trial) reporting several barriers were grouped into five broad categories: intrapersonal barriers (self-reported health, health beliefs, lack of time, motivation, and religious reasons); interpersonal barriers (lack of family/social support and work conflicts); logistical barriers (transport, distance, and availability of personal/community resources); CR program barriers (services offered, group format, exercise component, and CR sessions); and health system barriers (lack of referral, cost, negative experiences with the health system, and language). We found differences between the barriers related to nonparticipation in and dropout from CR programs.

CONCLUSIONS

Women reported multilevel barriers for nonparticipation in and dropout from CR programs. Future clinical guidelines should evaluate and eliminate these barriers to improve adherence to CR programs in women. In addition, understanding the barriers for nonparticipation and dropout may be beneficial for future intervention trials.

Cardiac Rehabilitation for Women: A Systematic Review of Barriers and Solutions

Cardiac rehabilitation (CR) services improve various clinical outcomes in patients with cardiovascular disease, but such services are underutilized, particularly in women. The aim of this study was to identify evidence-based barriers and solutions for CR participation in women. A literature search was carried out using PubMed, EMBASE, Cochrane, OVID/Medline, and CINAHL to identify studies that have assessed barriers and/or solutions to CR participation. Titles and abstracts were screened, and then the full-text of articles that met study criteria were reviewed. We identified 24 studies that studied barriers to CR participation in women and 31 studies that assessed the impact of various interventions to improve CR referral, enrollment, and/or completion of CR in women. Patient-level barriers included lower education level, multiple comorbid conditions, non-English native language, lack of social support, and high burden of family responsibilities. We found support for the use of automatic referral and assisted enrollment to improve CR participation. A small number of studies suggest that incentive-based strategies, as well as home-based programs, may contribute to improving CR attendance and completion rates. A systematic approach to CR referral, including automatic CR referral, may help overcome barriers to CR referral in women and should be implemented in clinical practice. However, more studies are needed to help identify the best methods to improve CR attendance and completion of CR rates in women.

Physical activity and negative emotional response after percutaneous coronary intervention

BACKGROUND

The aims of this study were to investigate the association between negative emotional response (NER) and physical activity levels in percutaneous coronary intervention (PCI) patients, and to examine the extent to which physical activity levels were influenced by factors such as the patients' age, sex, and attendance at a cardiac rehabilitation (CR) programme.

METHODS

A consecutive series of 200 PCI patients [mean age 59.0 (+/-10.1) years] completed telephone interviews 2 weeks and 6 months after their procedure. NER was assessed using 12 items addressing patients' perceptions and concerns regarding symptoms, diagnosis and prognosis. Physical activity was assessed by asking four questions relating to the frequency and duration of walking and of moderate activity. CR attendance, medical history and sociodemographic data were also collected. Hierarchical linear regression was used to assess the association between NER and physical activity over time.

RESULTS

After controlling for baseline levels of moderate activity and other covariates, NER significantly predicted change in moderate activity over 6 months. Only baseline walking levels predicted the duration and frequency of walking at 6 months.

CONCLUSION

NER can be considered an inhibitive factor towards increased moderate activity uptake after PCI. Walking after PCI does not appear to be affected by NER. These findings highlight the need to focus on improving the emotional aspects of patients' recovery.

Attitudes towards acceptance of an innovative home-based and remote sensing rehabilitation protocol among cardiovascular patients in Shantou, China

BACKGROUND

Cardiac rehabilitation (CR) protocols have diversified to include home-based cardiac tele-rehabilitation (HBCTR) as an alternative to hospital-based or center-based CR. To adopt the use of home-based cardiac tele-rehabilitation, it is necessary to assess cardiac patients' attitudes towards acceptance of such e-health technology, especially in China where knowledge of such technology is deficient.

METHODS

Interviews were conducted in the First Affiliated Hospital of Shantou University Medical College, Shantou, China. After percutaneous coronary interventional (PCI) surgery, patients completed the survey.

RESULTS

Among the 150 patients, only 13% had ever heard of HBCTR. After an introduction of our HBCTR program, 60% of patients were willing to participate in the program. From our multivariate analysis of questionnaire data, age (OR: 0.92, 95% CI: 0.86-0.98; P = 0.007), average family monthly income (OR: 0.13, 95% CI: 0.05-0.34; P < 0.001), education level (OR: 0.24, 95% CI: 0.10-0.59; P = 0.002) and physical exercise time (OR: 0.19, 95% CI: 0.06-0.56; P = 0.003) were independent predictors for acceptance of HBCTR. From the reasons for participation, patients selected: enhanced safety and independence (28.3%), ability to self-monitor physical conditions daily (25.4%), and having automatic and emergency alert (23.1%). Reasons for refusal were: too cumbersome operation (34.3%) and unnecessary protocol (19.4%).

CONCLUSIONS

Most patients lacked knowledge about HBCTR but volunteered to participate after they have learned about the program. Several personal and life-style factors influenced their acceptance of the program. These indicate that both improvement of technology and better understanding of the program will enhance active participation.

Equity of access to cardiac rehabilitation: the role of system factors

Background

When patient selection processes determine who can and cannot use healthcare there can be inequalities and inequities in individuals' opportunities to benefit. This paper evaluates the influence of a hospital selection process on opportunities to access outpatient cardiac rehabilitation (CR).

Methods

A secondary data analysis was conducted on a cohort of inpatients (n = 2,375) who were all eligible for invitation to an Australian CR program. Eligibility was determined by hospital discharge diagnosis codes. Only invited patients could attend. Logistic regression analysis tested the extent to which individual patient characteristics were statistically significantly associated with the outcome 'invitation' after adjusting for cardiac disease and other factors.

Results

Less than half of the eligible patients were invited to the CR program. After allowing for known factors that may have justified not being selected, there was bias towards inviting males, younger patients, married patients, and patients who nominated English as their preferred language.

Conclusions

Health service managers typically monitor service utilisation patterns as indicators of access but often pay little attention to ways in which locally determined system factors influence access to care. The paper shows how a hospital selection process can unreasonably influence patients' opportunities to benefit from an evidence-based healthcare program.

A multisite examination of sex differences in cardiac rehabilitation barriers by participation status

BACKGROUND

Despite its proven benefits and need, women are significantly less likely than men to participate in and complete cardiac rehabilitation (CR). The purpose of this study was to quantitatively investigate sex differences in CR barriers by participation status.

METHODS

Cardiac outpatients (1496, 430 female, 28.7%) of 97 cardiologists completed a mailed survey to discern CR participation. Respondents were asked to rate 19 CR barriers on a 5-point Likert scale.

RESULTS

Five hundred twenty-nine (43%) respondents self-reported participating in CR, with men being more likely to participate (p < 0.05). There was no significant sex difference in total number of CR barriers, but differences in individual barriers were found. For CR participants, t tests revealed significant sex differences in the perception of exercise as tiring or painful (p = 0.042) and work responsibilities (p = 0.013). For CR nonparticipants, women rated the following barriers as greater than men: transportation (p = 0.025), family responsibilities (p = 0.039), lack of CR awareness (p = 0.036), experiencing exercise as tiring or painful (p = 0.002), and comorbidities (p = 0.009).

CONCLUSIONS

Overall, women do not perceive greater barriers to CR participation than men, but the nature of their barriers differs, particularly among nonparticipants. Beliefs about the value of CR, awareness, and exercise parameters are all modifiable barriers that should be addressed among women.

Barriers to cardiac rehabilitation: DOES AGE MAKE A DIFFERENCE?

PURPOSE

To quantitatively investigate age differences in barriers to cardiac rehabilitation (CR) enrollment and participation.

METHODS

Cardiac outpatients (N = 1,273, mean age = 65.9 +/- 11.2) completed a mailed survey to discern barriers to CR enrollment and participation. Both enrollees and nonenrollees were asked to rate 18 CR barriers on a 5-point Likert scale.

RESULTS

Of the respondents, 535 (43%) reported participating in CR at 1 of 40 sites, with younger patients being more likely to participate (P = .002). Older age was positively related to total CR barriers (P < .001). Older patients more strongly endorsed the following CR barriers: already exercising at home (P = .001), confidence in ability to self-manage their condition (P = .003), perception of exercise as tiring or painful (P = .001), not knowing about CR (P = .001), lack of physician encouragement (P < .001), comorbidities (P < .001), and perception that CR would not improve their health (P < .001).

CONCLUSION

Given that the benefits of CR are achieved in older patients as well as the young, interventions to overcome these modifiable barriers to enrollment and participation are needed.

Predictors of cardiac rehabilitation initiation

This study determines the effects of 15 potential predictors on cardiac rehabilitation (CR) initiation: demographic information, measures of perceived severity, perceived susceptibility, perceived cardiac threat, social support, depression, comorbid conditions, left ventricular ejection fraction, strength of physician recommendation, and benefits and barriers. Results showed that greater strength of physician recommendation and less disease severity were significant predictors of higher levels of CR initiation; female gender was a marginally significant predictor of less CR initiation. The strength of the associations for these predictors varied. Strength of physician recommendation was the strongest predictor. This information can be used to increase the number of patients starting CR through programs designed to increase physician awareness of the importance of their recommendation, the continuing need to refer women to CR, and the need to design programs that meet women's needs.

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.

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.

Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors

Comprehensive cardiac rehabilitation reduces mortality and morbidity but is utilised by only a fraction of eligible cardiac patients, with the participation rate of women being only about half that of men. This quantitative review assesses 32 studies meeting inclusion criteria, describing 16,804 patients, 5882 of whom were female. It was found that the main predictor of referral to a cardiac rehabilitation programme was the physician's endorsement of the effectiveness of such a programme. Patients were more likely to participate in rehabilitation programmes when they were actively referred, educated, married, possessed high self efficacy, and when the programmes were easily accessible. Patients were less likely to participate when they had to travel long distances to participate in a cardiac rehabilitation programme, or experienced guilt over family obligations. Women were less often referred and participated less often even after referral. In conclusion, many of the observed predictors, including those particular to women, are potentially modifiable with the help of health professionals.

State of the science for care of older adults with heart disease

This article provided an overview of the current state of knowledge related to cardiovascular disease in elders. Some depth has been provided related to CHD and HF, two common diagnoses in older persons. The most striking finding is that although trials are increasingly including older cohorts of patients, research specifically testing known therapies in older patients is essential. In particular, research testing the safety, efficacy, and acceptability of therapies in the oldest old is greatly needed.

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.

Women are neglected when it comes to cardiac rehabilitation

Heart disease is a leading cause of premature death in the UK (Peterson and Rayner, 2002). Every year 150000 people suffer a myocardial infarction (MI) (British Heart Foundation, 1999). Heart disease is the number one killer of women in the industrialized world, with MI being the primary cause of death for women who are more than 40 years of age. Meta-analysis of studies suggests that women's risk of dying during the first 2 weeks after a MI is double that of men (Schenck-Gustafsson, 1996).

Are there different predictors of distinct exercise components?

Rehabilitation nurses often recommend to aging adults that they exercise. Despite the recommendations and the widespread evidence of its benefits, few older adults exercise. This study examined the predictors of distinct components of exercise behavior: exercise intensity, frequency per week, duration of sessions, and months per year. Social cognitive theory predictors of exercise were measured with previously developed instruments. Interviews were conducted with community-dwelling elders (N = 147). The study constructs accounted for modest to moderate amounts of variance (41% of months per year, 35% of frequency, 35% of exercise intensity, and 20% of episode duration). Self-efficacy was the most important predictor of each construct, with Beta weights ranging from .23 to .53. Barriers significantly predicted months' per year, frequency per week, and exercise intensity, but not the duration of individual exercise sessions. Outcome expectancy predicted only exercise intensity. These findings support the importance of self-efficacy and perceived barriers for most components of exercise behavior.

Outcomes of cardiac rehabilitation participants and nonparticipants in a rural area

Nationally, only 11%-20% of cardiac patients, on average, enroll in cardiac rehabilitation programs after their cardiac events. The purpose of this study was to examine: (a) differences in functional health outcomes, clinical risk factor outcomes, and lifestyle behaviors between patients who participated in cardiac rehabilitation (CR) and those who did not during the first year after their cardiac event; and (b) to examine predictors of and reasons for CR participation and non-participation in a Midwestern, rural clinical population. Green's health education framework guided the study. A cross-sectional, comparative design was used to mail surveys to 538 cardiac patients who were hospitalized over a 1-year period at a regional medical center; 255 surveys were returned, and the final sample numbered 222. Of these, 154 (69%) attended CR. Compared to nonparticipants (n = 68), participants reported significantly higher levels of functioning on 7 of the 8 subscales of the Medical Outcome Study Short Form-36 (SF-36). In relation to clinical risk factor outcomes, participants had a significantly lower body mass index than nonparticipants. Patients who attended CR reported that they had switched to low-fat foods, started an exercise program, lost weight, lowered stress, lowered blood pressure, and reduced blood cholesterol at significantly higher rates than non-participants. Patients were more likely to participate in CR if their physician explained its benefits, if they were told about it during their hospitalization, and if they lived close to a CR program. Patients with coronary heart disease need to be referred to CR for improved physical and psychosocial functioning and successful risk factor modification.