Importance of baseline functional and socioeconomic factors for participation in cardiac rehabilitation

Motivational Strategies and Concepts to Increase Participation and Adherence in Cardiac Rehabilitation: AN INTEGRATIVE REVIEW

INTRODUCTION

Low participation and adherence to cardiac rehabilitation (CR) leads to ineffective care and increased risk of cardiac complications. There is a need to identify effective motivational strategies and concepts to increase participation and adherence to CR.

PURPOSE

The aim of this review was to synthesize and integrate the current knowledge about motivational strategies and concepts to increase participation and adherence to CR.

METHODS

A literature search was performed using five electronic databases: CINAHL, Medline via PubMed, Scopus, Embase, and Rehabilitation & Sports Medicine Source. The search was limited to peer-reviewed studies, written in English, and publications from 2010 to 2019. A matrix and narrative synthesis were employed to organize and synthesize the findings, respectively.

RESULTS

Eight of 522 articles met the inclusion criteria. Four articles used motivational interviewing (MotI) and counseling strategy, three articles investigated the autonomy, competence, and relatedness of self-determination theory (SDT) concepts, and one article used a reinforced motivational strategy. Use of MotI led to improving the CR completion rate from 14% to 39%. The number of sessions attended/patient improved from 12 to 20 when the staff was provided attendance feedback and a reward. Autonomy, competence, and relatedness motivated patients to participate in and adhere to CR.

CONCLUSIONS

Motivational interviewing and counseling, motivational and reinforcement strategies, and the autonomy, competence, and relatedness of SDT concepts should be utilized to promote participation and motivation for CR. The effects of these techniques on long-term CR require further research, including combining the identified methods to investigate the efficacy of these techniques on CR adherence.

Participants' Perspectives of a Primary Exercise-Based Prevention Program for Cardiac Patients: A Prepost Intervention Qualitative Case Study

Perseverance in exercise-based, cardiovascular disease prevention programs is generally very low. The purpose of this case study is to understand the experience of participants enrolled in a 6-month primary and secondary exercise-focused, cardiovascular disease prevention out of hospital program. Ten participants were interviewed about their experiences at entry and after it ended 6 months later to understand the facilitators and difficulties encountered by participants in such exercise programs. Four out of ten participants completed the 6-month program. The six participants who left the program accepted to contribute to the postprogram interview. The results showed that the four participants who persevered in the program became aware of cardiac risk factors and their conditions were willing to make changes in their lifestyles to reach their objectives, felt a strong perception of self-efficacy, and felt like they belonged in the program. Both persevering and nonpersevering participants experienced many episodes of discouragement during the program and faced many barriers that interfered with their progress. Suggestions to help coping with these barriers while reinforcing self-efficacy and the sentiment of belonging are discussed.

Validation of the Yale Food Addiction Scale 2.0 and estimation of the population prevalence of food addiction

BACKGROUND & AIMS

Food addiction (FA) is likely to contribute to the global obesity epidemic. Most studies of FA have been conducted within clinical and/or highly selected populations, suggesting that prevalence estimates of FA may be biased. This is problematic as valid estimates of the population prevalence of FA is a requirement for informing and designing public health initiatives focusing on this phenotype. Therefore, we aimed to estimate the weighted prevalence of food addiction in the adult general population of Denmark.

METHODS

A random sample of 5000 individuals aged 18 to 62 from the Danish population was invited to participate in a survey, which included the Yale Food Addiction Scale (YFAS 2.0) and several rating scales measuring eating pathology and other psychopathology. Health, demographic and socioeconomic data from the Danish registers were linked to all invitees to allow for attrition analysis. The analysis had three steps: I) Psychometric validation of the Danish version of YFAS 2.0 II) Attrition analysis to examine selection bias, and III) Estimation of the weighted prevalence of FA taking attrition into account.

RESULTS

The confirmatory factor analysis of the YFAS 2.0 supported a one-factor model, and the scale had good internal consistency. The YFAS 2.0 score correlated with eating pathology including binge eating frequency, impulsivity and body mass index (BMI). The survey response rate was 34.0% (n = 1699) with a slight overrepresentation of respondents with higher socioeconomic status. The crude prevalence of FA was 9.0%. When taking attrition into account, the weighted prevalence of FA was 9.4% CI 95% [7.9-10.9].

CONCLUSIONS

The psychometric properties of the Danish version of the YFAS 2.0 were good. The weighted prevalence of FA was very similar to the crude prevalence estimate. This suggests that attrition may not be a large problem when estimating the prevalence of FA with the YFAS 2.0.

Access to cardiac rehabilitation and the role of language barriers in the provision of cardiac rehabilitation to migrants

BACKGROUND

Cardiac rehabilitation (CR) has proven health benefits and, according to international guidelines, CR must be offered to all eligible patients. Studies have reported lower uptake of CR among migrants, and migrants are known to face several barriers in their access to healthcare, of which language is the most common. The aim of this study is to examine the provision of CR core components for migrants; and the role of language barriers in the provision of CR in Danish hospitals and municipalities.

METHODS

This is a descriptive study based on repeated nationwide surveys conducted in 2013 and 2015 by the Danish Cardiac Rehabilitation Database. The surveys collected information on provision and organization of CR in hospitals (n = 35) and municipalities (n = 98) in Denmark. The survey in 2015 had additional items related to migrants, such as provision of interpreter services and multilingual information material.

RESULTS

Not all CR core components were provided by hospitals to non-Danish speaking patients. There was no improvement from 2013 to 2015. Hospitals had full coverage (19/19) of interpreter services compared to 84% (26/31) of municipalities. Provision of multilingual information material was low in hospitals 32% (6/19) and in municipalities 3% (1/31).

CONCLUSION

This study found language-related barriers in migrants' access to CR, in the form of inadequate provision of CR core components for non-Danish speaking patients at some Danish hospitals and suboptimal provision of interpreter services in municipalities. The findings call for increased attention to language barriers and further studies are needed to map the extent of the problem.

Early Predictors of Global Functional Outcome after Traumatic Spinal Cord Injury: A Systematic Review

Accurately predicting functional recovery is an asset for all clinicians and decision makers involved in the care of patients with acute traumatic spinal cord injury (TSCI). Unfortunately, there is a lack of information on the relative importance of significant predictors of global functional outcome. There is also a need for identifying functional predictors that can be timely optimized by the medical and rehabilitation teams throughout the hospitalizations phases. The main objective of this work was to systematically review and rate early factors that are consistently and independently associated with global functional outcome in individuals with TSCI. A literature search using MEDLINE, EMBASE, and Cochrane databases from January 1, 1970 to April 1, 2017 was performed. Two authors independently reviewed the titles and abstracts yielded by this literature search and subsequently selected studies to be included based on predetermined eligibility criteria. Disagreements were resolved by a consensus-based discussion, and if not, by an external reviewer. Data were extracted by three independent reviewers using a standardized table. The quality of evidence of the individual studies was assessed based on the Oxford Center for Evidence-Based Medicine modified by Wright and colleagues (2000) as well as the National Institutes of Health (2014). Fifteen articles identifying early clinical predictors of functional outcome using multiple regression analyses were included in this systematic review. Based on the compiled data, this review proposes a rating of early factors associated to global functional outcome according to their importance and their potential to be modified by the medical/rehabilitation team throughout the early phases of hospitalization. It also proposes a new conceptual framework that illustrates the impact of specific categories of factors and their interaction with each other. Ultimately, this review aims to guide clinicians and researchers in improving the continuum of care throughout early phases post-SCI.

Disparities in Cardiac Rehabilitation Among Individuals from Racial and Ethnic Groups and Rural Communities-A Systematic Review

PURPOSE

Despite the well-described benefits of cardiac rehabilitation (CR) on long-term health outcomes, CR is a resource that is underutilized by a significant proportion of patients that suffer from cardiovascular diseases. The main purpose of this study was to examine disparities in CR referral and participation rates among individuals from rural communities and racial and ethnic minority groups with coronary heart disease (CHD) when compared to the general population.

METHODS

A systematic search of standard databases including MedlLine, PubMed, and Cochrane databases was conducted using keywords that included cardiac rehabilitation, women, race and ethnicity, disparities, and rural populations. Twenty-eight clinical studies from 1990 to 2017 were selected and included 478,955 patients with CHD.

RESULTS

The majority of available clinical studies showed significantly lower CR referral and participation rates among individuals from rural communities, women, and racial and ethnic groups when compared to the general population. Similar to geographic region, socioeconomic status (SES) appears to directly impact the use of CR programs. Patients of lower SES have significantly lower CR referral and participation rates than patients of higher SES.

CONCLUSIONS

Data presented underscores the need for systematic referrals using electronic health records for patients with CHD in order to increase overall CR referral and participation rates of minority populations and other vulnerable groups. Educational programs that target healthcare provider biases towards racial and ethnic groups may help attenuate observed disparities. Alternative modalities such as home-based and internet-based CR programs may also help improve CR participation rates among vulnerable populations.

Barriers to Outpatient Hospital-Based Cardiac Rehabilitation in Korean Patients With Acute Coronary Syndrome

Objective

To investigate factors associated with enrollment and participation in cardiac rehabilitation (CR) in Korea.

Methods

Patients admitted to four university hospitals with acute coronary syndrome between June 2014 and May 2016 were enrolled. The Cardiac Rehabilitation Barriers Scale (CRBS) made of 21-item questionnaire and divided in four subdomains was administered during admission. CRBS items used a 5-point Likert scale and ≥2.5 was considered as a barrier. Differences between CR non-attender and CR attender, or CR non-enroller and CR enroller in subscale and each items of CRBS were examined using the chi-square test.

Results

The CR participation rate in four hospitals was 31% (170 of the 552). Logistical factors (odds ratio [OR]=7.61; 95% confidence interval [CI], 4.62-12.55) and comorbidities/functional status (OR=6.60; 95% CI, 3.95-11.01) were identified as a barrier to CR enrollment in the subdomain analysis. Among patients who were enrolled (agreed to participate in CR during admission), only work/time conflict was a significant barrier to CR participation (OR=2.17; 95% CI, 1.29-3.66).

Conclusion

Diverse barriers to CR participation were identified in patients with acute coronary syndrome. Providing the tailored model for CR according to the individual patient's barrier could improve the CR utilization. Further multicenter study with large sample size including other CR indication is required.

Disparities in Cardiac Rehabilitation Participation in the United States: A SYSTEMATIC REVIEW AND META-ANALYSIS

PURPOSE

Phase 2 cardiac rehabilitation (CR) is a class I recommendation for all patients following an acute cardiac event or cardiac surgery according to the The American Heart Association and the American College of Cardiology Foundation. Studies have shown that there are differences in cardiac rehabilitation participation rates between sociodemographic groups. The purpose of this systematic review and meta-analyses was to synthesize quantitative data on the relationship between outpatient cardiac rehabilitation (OCR) attendance and various sociodemographic factors.

METHODS

We conducted a search of PubMed, PsycINFO, CINAHL, Google Scholar, Dissertations & Theses A&I, and conference abstracts for observational studies conducted in the United States that fit our inclusion criteria. A total of 21 studies were included in our final review and meta-analyses.

RESULTS

Our meta-analyses showed that overall, attenders were younger than nonattenders (mean difference=-3.74 years, 95% CI =-5.87 to -1.61) and the odds of participation were lower among females (OR = 0.59; 95% CI = 0.51-0.69), individuals with a high school degree or less (OR = 0.67; 95% CI = 0.50-0.91), and the uninsured or self-payers (OR = 0.32; 95% CI = 0.14-0.71). Full- or part-time employees were more likely to participate than those not employed (OR = 1.45; 95% CI = 1.08-1.95).

CONCLUSIONS

Our systematic review and meta-analyses showed that there are significant sociodemographic disparities in CR participation. On the basis of this knowledge, clinicians and policy makers should focus on identifying and eliminating barriers to participation.

Return to Work and Risk of Subsequent Detachment From Employment After Myocardial Infarction: Insights From Danish Nationwide Registries

BACKGROUND

Limited data are available on return to work and subsequent detachment from employment after admission for myocardial infarction (MI).

METHODS AND RESULTS

Using individual-level linkage of data from nationwide registries, we identified patients of working age (30-65 years) discharged after first-time MI in the period 1997 to 2012, who were employed before admission. To assess the cumulative incidence of return to work and detachment from employment, the Aalen Johansen estimator was used. Incidences were compared with population controls matched on age and sex. Logistic regression was applied to estimate odds ratios for associations between detachment from employment and age, sex, comorbidities, income, and education level. Of 39 296 patients of working age discharged after first-time MI, 22 394 (56.9%) were employed before admission. Within 1 year 91.1% (95% confidence interval [CI], 90.7%-91.5%) of subjects had returned to work, but 1 year after their return 24.2% (95% CI, 23.6%-24.8%) were detached from employment and received social benefits. Detachment rates were highest in patients aged 60 to 65 and 30 to 39 years, and significantly higher in patients with MI compared with population controls. Predictors of detachment were heart failure (odds ratio 1.20 [95% CI, 1.08-1.34]), diabetes mellitus (odds ratio 1.13 [95% CI, 1.01-1.25]), and depression (odds ratio 1.77 [95% CI, 1.55-2.01]). High education level and high income favored continued employment.

CONCLUSIONS

Despite that most patients returned to work after first-time MI, about 1 in 4 was detached from employment after 1 year. Several factors including age and lower socioeconomic status were associated with risk of detachment from employment.

Cardiovascular Disease and Patterns of Change in Functional Status Over 15 Years: Findings From the Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of premature disability, yet few prospective studies have examined functional status (FS) among persons with CVD. Our aim was to examine patterns of change in FS prior to and after hospitalization for nonfatal myocardial infarction, stroke, and heart failure among members of the Atherosclerosis Risk in Communities (ARIC) study cohort.

METHODS AND RESULTS

FS was assessed using a modified Rosow-Breslau questionnaire administered during routine annual telephone interviews conducted from 1993 through 2007 among 15 277 ARIC study participants. An FS score was constructed as a summary measure of responses to questions about participants' ability to perform selected tasks of daily living (eg, walking half a mile, climbing stairs). Incidence of CVD was assessed through ARIC surveillance of hospitalized events. Rate of change in FS over time prior to and following a CVD event was examined using generalized estimating equations. A decline in FS was observed on average 2 years prior to a myocardial infarction hospitalization and on average 3 years prior to a stroke or heart failure hospitalization. FS post-myocardial infarction declined relative to pre-event levels but improved to close to pre-myocardial infarction levels within 3 years. Decline in FS following incident heart failure and stroke remained over time. Observed patterns of change in FS did not differ appreciably by race or sex.

CONCLUSIONS

This study documents that a decline in FS precedes incidence of CVD-related hospitalization by at least 2 years, providing a strong argument for routine preventative assessment of FS among older adults.

Financial incentives to promote cardiac rehabilitation participation and adherence among Medicaid patients

PURPOSE

Cardiac rehabilitation (CR) improves medical outcomes after myocardial infarction or coronary revascularization. Lower socioeconomic status (SES) patients are less likely to participate in and complete CR. The aim of this study was to test whether financial incentives may increase participation and adherence to CR among lower-SES patients.

METHODS

Patients eligible to participate in CR with Medicaid insurance coverage were approached for inclusion. Patients were placed on an escalating incentive schedule of financial incentives contingent upon CR attendance. CR participation was compared to a usual care group of 101 Medicaid patients eligible for CR in the 18months prior to the study. Attendance (participating in ≥one CR sessions) and adherence (sessions completed out of 36) were compared between groups. The study was conducted in Vermont, USA, 2013-2015.

RESULTS

Of 13 patients approached to be in the study and receive incentives, 10 (77%) agreed to participate. All 10 patients completed at least one session of CR, significantly greater than the 25/101 (25%) in the control condition (p<0.001). Of patients in both groups who attended at least one session of CR, adherence was higher in the intervention group (average of 31.1 sessions completed vs. 13.6 in the control group, p<0.001). CR completion rates were also higher during the intervention with 8 of 10 (80%) intervention patients completing all 36 sessions compared to only 2 of 25 (8%) control patients (p<0.001).

CONCLUSIONS

Financial incentives may be an efficacious strategy for increasing CR participation and adherence among Medicaid patients.

Cardiac rehabilitation programmes: predictors of non-attendance and drop-out

BACKGROUND

Despite evidence of its benefits, attendance at cardiac rehabilitation (CR) programmes is poor. Past studies to identify predictors of non-attendance have been limited by their small sample size, particularly for female patients. The present study was designed to identify socio-demographic and clinical predictors of non-attendance and drop-out separately for men and women automatically referred to CR programmes.

METHOD AND SUBJECTS

Prospective study of CR programme attendance amongst 808 patients consecutively admitted over an 11-month period to one of two hospitals in Melbourne, Australia, after acute myocardial infarction (AMI), or to undergo coronary artery bypass graft surgery (CABGS) or percutaneous coronary intervention (PCI).

RESULTS

Of the 652 eligible patients, 573 (88%) were successfully tracked at 4 months. Of these, 284 (49.6%) had attended a CR programme, while 272 (47.5%) had not. Using logistic regression, the significant predictors of programme non-attendance among men were having had a PCI, being a non-driver, and being aged 70 or more. The only factor predictive of non-attendance for women was being aged 70 or more. Amongst attenders, 67 (23.6%) patients discontinued the programme. Being a smoker, having diabetes and being unemployed at the time of hospital admission were predictive of programme drop-out by men. Being physically inactive at admission was predictive of programme drop-out by women.

CONCLUSIONS

The present study demonstrated a relatively high rate of CR programme attendance. Special attention needs to be directed towards males who are older, PCI patients, smokers, unemployed or non-drivers, and females who are older or inactive.

Cardiac Rehabilitation for Aboriginal and Torres Strait Islander people in Western Australia

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in Australia. Australian Aboriginal and Torres Strait Islander (Indigenous) people have higher levels of CVD compared with non-Indigenous people. Cardiac Rehabilitation (CR) is an evidence-based intervention that can assist with reducing subsequent cardiovascular events and rehospitalisation. Unfortunately, attendance rates at traditional CR programs, both globally and in Australia, are estimated to be as low as 10-30 % and Indigenous people are known to be particularly under-represented. An in-depth assessment was undertaken to investigate the provision of CR and secondary preveniton services in Western Australia (WA) with a focus on rural, remote and Indigenous populations. This paper reports on the findings for Indigenous people.

METHODS

Cardiac rehabilitation and Aboriginal Medical Services (n = 38) were identified for interview through the Heart Foundation Directory of Western Australian Cardiac Rehabilitation and Secondary Prevention Services 2012. Semi-structured interviews with CR coordinators were conducted and included questions specific to Indigenous people.

RESULTS

Interviews with coordinators from 34 CR services (10 rural, 12 remote, 12 metropolitan) were conducted. Identification of Indigenous status was reported by 65 % of coordinators; referral and attendance rates of Indigenous patients differed greatly across WA. Efforts to meet the cultural needs of Indigenous patients varied and included case management (32 %), specific educational materials (35 %), use of a buddy or mentoring system (27 %), and access to an Aboriginal Health Worker (71 %). Staff cultural awareness training was available for 97 % and CR guidelines were utilised by 77 % of services.

CONCLUSION

The under-representation of Indigenous Australians participating in CR, as reported in the literature and more specifically in this study, mandates a concerted effort to improve services to better meet the needs of Indigenous patients with CVD as part of closing the gap in life expectancy. Improving access to culturally appropriate CR and secondary prevention in WA must be an important component of this effort given the high rates of premature cardiovascular disease affecting Indigenous people. Our findings also highlight the importance of good systematic data collection across services. Health pathways that ensure continuity of care and alternative methods of CR delivery with dedicated resources are needed.

Factors Associated with Non-Attendance at a Secondary Prevention Clinic for Cardiac Patients

Background: A randomised controlled trial was undertaken to test the effectiveness of a secondary prevention clinic. Secondary prevention programs can improve prognosis after an acute cardiac illness. It is therefore important to encourage high participation rates. Aim: The present study was a post-hoc analysis to identify factors associated with patients’ non-attendance at the clinic. Methods: We compared the baseline socio-demographic and clinical characteristics of 83 (73.5% male) non-attending patients and a random sample of 96 (85.4% male) attending patients. Self-reported data were gathered during interviews conducted on an average of 30 months after hospital admission to investigate long-term outcomes of the clinic. Results: Using logistic regression analysis, we found that non-attendance was significantly and independently associated with being female, being under 60 years of age, having no history of high cholesterol and having no angina prior to the event. In bivariate analyses, non-attendance was also associated with being born overseas and not having private health insurance. Conclusions: Likely non-attending patients should be identified early and more effective strategies should be devised to facilitate their participation in secondary prevention programs.

Cardiac rehabilitation using the Family-Centered Empowerment Model versus home-based cardiac rehabilitation in patients with myocardial infarction: a randomised controlled trial

Objective

To determine if a hybrid cardiac rehabilitation (CR) programme using the Family-Centered Empowerment Model (FCEM) as compared with standard CR will improve patient quality of life, perceived stress and state anxiety of patients with myocardial infarction (MI).

Methods

We conducted a randomised controlled trial in which patients received either standard home CR or CR using the FCEM strategy. Patient empowerment was measured with FCEM questionnaires preintervention and postintervention for a total of 9 assessments. Quality of life, perceived stress, and state and trait anxiety were assessed using the 36-Item Short Form Health Survey (SF-36), the 14-item Perceived Stress, and the 20-item State and 20-item Trait Anxiety questionnaires, respectively.

Results

70 patients were randomised. Baseline characteristics were similar. Ejection fraction was significantly higher in the intervention group at measurements 2 (p=0.01) and 3 (p=0.001). Exercise tolerance measured as walking distance was significantly improved in the intervention group throughout the study. The quality of life results in the FCEM group showed significant improvement both within the group over time (p<0.0001) and when compared with control (p<0.0001). Similarly, the perceived stress and state anxiety results showed significant improvement both within the FCEM group over time (p<0.0001) and when compared with control (p<0.0001). No significant difference was found either within or between groups for trait anxiety.

Conclusions

The family-centred empowerment model may be an effective hybrid cardiac rehabilitation method for improving the physical and mental health of patients post-MI; however, further study is needed to validate these findings. Clinical Trials.gov identifier NCT02402582.

Trial registration number

NCT02402582.

Smoking and cardiac rehabilitation participation: Associations with referral, attendance and adherence

OBJECTIVE

Continued smoking after a cardiac event greatly increases mortality risk. Smoking cessation and participation in cardiac rehabilitation (CR) are effective in reducing morbidity and mortality. However, these two behaviors may interact; those who smoke may be less likely to access or complete CR. This review explores the association between smoking status and CR referral, attendance, and adherence.

METHODS

A systematic literature search was conducted examining associations between smoking status and CR referral, attendance and completion in peer-reviewed studies published through July 1st, 2014. For inclusion, studies had to report data on outpatient CR referral, attendance or completion rates and smoking status had to be considered as a variable associated with these outcomes.

RESULTS

Fifty-six studies met inclusion criteria. In summary, a history of smoking was associated with an increased likelihood of referral to CR. However, smoking status also predicted not attending CR and was a strong predictor of CR dropout.

CONCLUSION

Continued smoking after a cardiac event predicts lack of attendance in, and completion of CR. The issue of smoking following a coronary event deserves renewed attention.

Experience of Spiritual Care in Cardiac Rehabilitation: An Interpretative Phenomenological Analysis

The aim of the study was to explore the experience of spiritual care among a cardiac rehabilitation team. Spiritual care is an important dimension of providing comprehensive care, and understanding the views of health professionals is pivotal to making recommendations for caring. This study used an interpretive phenomenological approach. Semi-structured interviews were undertaken with 13 cardiac rehabilitation professionals. Seven persons participated in individual interviews and six in focus group discussions. Data were analyzed using Smith and Osborn’s interpretative phenomenological analysis method. Study data were categorized into more than 150 initial themes, 12 clustered and four superordinate themes, included: ‘Helping patients to obtain a meaningful sense of being’, ‘Providing religious/spiritual focused care’, ‘holistic approach to rehabilitation is needed’ and ‘spirituality as a neglected aspect of rehabilitation’. Participants described that they did not have sufficient training in providing spiritual care. Nurses’ awareness of spiritual care meaning among a cardiac rehabilitation team is helping to respond to rehabilitation care in a holistic approach. Helping patients to get a meaningful sense of being is an important part of assisting in recovery and adjustment following an acute cardiac event. Providing clear guidelines and support for providing spiritual care in cardiac rehabilitation is required.

Evaluating compliance to a cardiac rehabilitation program in a private general hospital

Objective:

Identify the primary factors that influenced the participant in our cardiovascular rehabilitation program towards missing their therapy sessions, and to correlate those factors with age, cardiovascular risk, and motivation of our population.

Methods:

We conducted a retrospective study with 42 patients (69.15±13.93 years) participating in the cardiac rehabilitation program at a general hospital in São Paulo, through the analysis of two scales applied during the initial evaluation: Cardiac Rehabilitation Barriers Scale and scale of the original provision. We used Spearman correlation to relate them to absenteeism, cardiovascular risk age and duration of cardiac rehabilitation.

Results:

The total score of barriers was 31±6 and the mean score of 1.47±0.31. The main barriers subscales were related to “travel/labor dispute” and “personal problems/family.” The percentage of absenteeism was 8.4% in the number of sessions that could be made in the month. The faults and cancellations were positively correlated with cardiovascular risk (p=0.01; r=0.4) and negatively with scale provision of baseline (p=0.03; r=-0.35) and age (p=0.02; r=-0.35).

Conclusion:

“Travel/labor dispute”, “personal/ family problems”, and low initial provision are the main factors absenteism in a cardiac rehabilitation program in a general hospital in São Paulo.

Anti-normative lifestyles in cardiac rehabilitation: Underprivileged men’s post-heart incident lives

Cardiovascular diseases are leading causes of premature mortality and disability. Although health institutions have developed and promoted cardiac rehabilitation programs, they have not attained their desired outcomes, especially among the most vulnerable groups of the population. This study qualitatively examines socially and materially deprived men’s (n = 20) noncompliance with cardiovascular health guidelines following a medical intervention to the heart. By drawing on Pierre Bourdieu’s sociocultural theory of practice, results indicate that precarious living conditions obstruct long-term physical recovery and illness prevention by underemphasizing the value of “health capital” and reducing the capacity to sustain lifestyle change. This study calls into question health policies that have little to no consideration of embodied practical knowledge and lived experiences.

Fatalism and short-termism as cultural barriers to cardiac rehabilitation among underprivileged men

Cardiovascular diseases are a leading cause of death and disability in Canada, and individuals of low socioeconomic status appear particularly vulnerable to such disorders. Although many health-related institutions have promoted cardiovascular health and have created cardiac rehabilitation programmes, they have not attained their desired outcomes, especially amongst socioeconomically deprived men. Drawing on Pierre Bourdieu's sociocultural theory, this qualitative study aims to understand the social mechanisms underpinning the lifestyles and health practices of men who had suffered a cardiovascular incident requiring hospitalisation. In all, 20 interviews were conducted with francophone men aged 40 to 65 years living in the province of Québec, Canada. The analysis strongly suggests that the respondents' living conditions and disease were significant obstacles to their adoption of a healthy lifestyle. Their despair and pessimism, apparently originating in the harshness of their financial realities, physical limitations and social networks, led them to believe that they could do little to control their lives, thereby limiting the fulfillment of any long-term ambitions. Therefore, the adoption of a habitus characterised by fatalistic and short-term perceptions of health influenced their lifestyle choices, leading them to maintain lives that were in stark contrast with the recommendations made by health promotion experts.

Access to cardiac rehabilitation does not equate to attendance

BACKGROUND/AIMS

Timely access to appropriate cardiac care is critical for optimizing positive outcomes after a cardiac event. Attendance at cardiac rehabilitation (CR) remains less than optimal (10%-30%). Our aim was to derive an objective, comparable, geographic measure reflecting access to cardiac services after a cardiac event in Australia.

METHODS

An expert panel defined a single patient care pathway and a hierarchy of the minimum health services for CR and secondary prevention. Using geographic information systems a numeric/alpha index was modelled to describe access before and after a cardiac event. The aftercare phase was modelled into five alphabetical categories: from category A (access to medical service, pharmacy, CR, pathology within 1 h) to category E (no services available within 1 h).

RESULTS

Approximately 96% or 19 million people lived within 1 h of the four basic services to support CR and secondary prevention, including 96% of older Australians and 75% of the indigenous population. Conversely, 14% (64,000) indigenous people resided in population locations that had poor access to health services that support CR after a cardiac event.

CONCLUSION

Results demonstrated that the majority of Australians had excellent 'geographic' access to services to support CR and secondary prevention. Therefore, it appears that it is not the distance to services that affects attendance. Our 'geographic' lens has identified that more research on socioeconomic, sociological or psychological aspects to attendance is needed.

A systematic review of patient reported factors associated with uptake and completion of cardiovascular lifestyle behaviour change

BACKGROUND

Healthy lifestyles are an important facet of cardiovascular risk management. Unfortunately many individuals fail to engage with lifestyle change programmes. There are many factors that patients report as influencing their decisions about initiating lifestyle change. This is challenging for health care professionals who may lack the skills and time to address a broad range of barriers to lifestyle behaviour. Guidance on which factors to focus on during lifestyle consultations may assist healthcare professionals to hone their skills and knowledge leading to more productive patient interactions with ultimately better uptake of lifestyle behaviour change support. The aim of our study was to clarify which influences reported by patients predict uptake and completion of formal lifestyle change programmes.

METHODS

A systematic narrative review of quantitative observational studies reporting factors (influences) associated with uptake and completion of lifestyle behaviour change programmes. Quantitative observational studies involving patients at high risk of cardiovascular events were identified through electronic searching and screened against pre-defined selection criteria. Factors were extracted and organised into an existing qualitative framework.

RESULTS

374 factors were extracted from 32 studies. Factors most consistently associated with uptake of lifestyle change related to support from family and friends, transport and other costs, and beliefs about the causes of illness and lifestyle change. Depression and anxiety also appear to influence uptake as well as completion. Many factors show inconsistent patterns with respect to uptake and completion of lifestyle change programmes.

CONCLUSION

There are a small number of factors that consistently appear to influence uptake and completion of cardiovascular lifestyle behaviour change. These factors could be considered during patient consultations to promote a tailored approach to decision making about the most suitable type and level lifestyle behaviour change support.

Cardiac rehabilitation may not provided a quality of life benefit in coronary artery disease patients

Background

Improvements in patient-reported health-related quality of life (HRQoL) are important goals of cardiac rehabilitation (CR). In patients undergoing coronary angiography for angina and with documented coronary artery disease (CAD), the present study compared HRQoL over 6 months in CR participants and non-participants. Clinical predictors of CR participants were also assessed.

Methods

A total of 221 consecutive patients undergoing angiography for angina with documented CAD and who were eligible for a CR program were recruited. CR participants were enrolled in a six-week Phase II outpatient CR course (31%, n = 68) within 2 months following angiography and the non-participants were included as a control. At baseline (angiography), one and six months post angiography, clinical and HRQoL data were obtained including the Short Form-36 (SF-36) and the Seattle Angina Questionnaire (SAQ). The response rate for the HRQoL assessment was 68% (n = 150). Cross sectional comparisons were age-adjusted and performed using logistic or linear regression as appropriate. Longitudinal changes in HRQoL were assessed using least squares regression. Finally, a multiple logistic regression was fitted with CR participant as the final outcome.

Results

At angiography, the CR non-participants were older, and age-adjusted analyses revealed poorer physical (angina limitation: 54 ± 25 versus 64 ± 22, p <0.05) and mental HRQoL (significant psycho-social distress: 62%, n = 95 versus 47%, n = 32, p <0.05) compared to the CR participants. In addition, the CR participants were more likely to have undergone angiography for myocardial infarction (OR = 2.8, 95% CI 1.5-5.3, p = 0.001). By six months, all patients showed an improvement in HRQoL indices, however the rate of improvement did not differ between the controls and CR participants.

Conclusion

Following angiography, CAD patients reported improvements in both generic and disease-specific HRQoL, however CR participation did not influence this outcome. This may be explained by biases in CR enrollment, whereby acute patients, who may be less limited in HRQoL compared to stable, chronic patients, are targeted for CR participation. Further investigation is required so CR programs maximize the quality of life benefits to all potential CR patients.

The role of systematic inpatient cardiac rehabilitation referral in increasing equitable access and utilization

BACKGROUND

While systematic referral strategies have been shown to significantly increase cardiac rehabilitation (CR) enrollment to approximately 70%, whether utilization rates increase among patient groups who are traditionally underrepresented has yet to be established. This study compared CR utilization based on age, marital status, rurality, socioeconomic indicators, clinical risk, and comorbidities following systematic versus nonsystematic CR referral.

METHODS

Coronary artery disease inpatients (N = 2635) from 11 Ontario hospitals, utilizing either systematic (n = 8 wards) or nonsystematic referral strategies (n = 8 wards), completed a survey including sociodemographics and activity status. Clinical data were extracted from charts. At 1 year, 1680 participants completed a mailed survey that assessed CR utilization. The association of patient characteristics and referral strategy on CR utilization was tested using χ.

RESULTS

When compared to nonsystematic referral, systematic strategies resulted in significantly greater CR referral and enrollment among obese (32 vs 27% referred, P = .044; 33 vs 26% enrolled, P = .047) patients of lower socioeconomic status (41 vs 34% referred, P = .026; 42 vs 32% enrolled, P = .005); and lower activity status (63 vs 54% referred, P = .005; 62 vs 51% enrolled, P = .002). There was significantly greater enrollment among those of lower education (P = .04) when systematically referred; however, no significant differences in degree of CR participation based on referral strategy.

CONCLUSION

Up to 11% more socioeconomically disadvantaged patients and those with more risk factors utilized CR where systematic processes were in place. They participated in CR to the same high degree as their nonsystematically referred counterparts. These referral strategies should be implemented to promote equitable access.

Cardiac rehabilitation participation in underserved populations. Minorities, low socioeconomic, and rural residents

Cardiac rehabilitation (CR) services in the United States are underutilized and participation is particularly low for racial and ethnic minorities, low socioeconomic status patients, and rural residents. Reduced participation may not only indicate a failure in transitional cardiac care during the in hospital referral process but also could be due to barriers attributed to patients, providers, employers, or medical systems. In-depth analysis of this problem is impeded by difficulties with the identification of underserved groups in clinical settings. Disparities in CR participation certainly contribute to poor medical outcomes in these populations that stand to benefit greatly from lifestyle modifications. It is critical that CR providers survey their communities for underserved populations and coordinate creative efforts aimed at overcoming barriers to participation. Moreover, it is likely that referral to, and participation in, CR will soon be considered a quality indicator, providing further incentive for programs to optimize CR utilization among all eligible patients.

Gender differences in recovery goals in patients after acute myocardial infarction

PURPOSE

: While cardiac rehabilitation has been established as an essential part of comprehensive cardiac care, participation rates for female patients are substantially lower than for male patients. Lower referral rates and higher ages of female patients partly explain this underutilization. Gender differences in recovery goals of cardiac patients have not been examined.

METHODS

: Five hundred ninety patients (22.2% women) admitted to the hospital because of an acute myocardial infarction answered a questionnaire regarding 24 goals in 5 domains of recovery (physical functioning, risk-factor modification, psychological well-being, independence in daily life, and return to work). In addition, psychological symptoms and medical data were assessed. Gender differences were tested by using χ and Student t tests, as well as multivariate logistic and linear regression models.

RESULTS

: Gender differences were found in 7 of the 24 recovery goals. After adjustment for psychosocial and clinical characteristics, women still reported a higher importance of "performance of household duties" (odds ratio [OR] = 8.62; 95% confidence interval [CI], 5.43-13.66), "independence in activities of daily living" (OR = 2.38; CI, 1.58-3.59), and "emotional equilibrium" (OR = 1.58, CI, 1.01-2.46). Men rated "physical endurance" and "reducing strain at workplace" as more important goals (OR = 0.64; CI, 0.42-0.97 and OR = 0.39; CI, 0.17-0.93). Except for psychological distress, gender differences in health status were not related to differences in goals.

CONCLUSIONS

: Gender roles and differences in social-life conditions may have an important influence on the recovery goals of patients after an acute myocardial infarction. Recovery goals should be explored when planning intervention programs for individual patients.

Current state of cardiac rehabilitation in Germany: patient characteristics, risk factor management and control status, by education level

Background

After the acute hospital stay, most cardiac patients in Germany are transferred for a 3–4-week period of inpatient cardiac rehabilitation. We aim to describe patient characteristics and risk factor management of cardiac rehabilitation patients with a focus on drug treatment and control status, differentiated by education level (low level, elementary school; intermediate level, secondary modern school; high level, grammar school/university).

Methods

Data covering a time period between 2003 and 2008 from 68,191 hospitalized patients in cardiac rehabilitation from a large-scale registry (Transparency Registry to Objectify Guideline- Oriented Risk Factor Management) were analyzed descriptively. Further, a multivariate model was applied to assess factors associated with good control of risk factors.

Results

In the total cohort, patients with a manifestation of coronary artery disease (mean age 63.7 years, males 71.7%) were referred to cardiac rehabilitation after having received percutaneous coronary intervention (51.6%) or coronary bypass surgery (39.5%). Statin therapy increased from 76.3% at entry to 88.9% at discharge, and low density lipoprotein cholesterol < 100 mg/dL rates increased from 31.1% to 69.6%. Mean fasting blood glucose decreased from 108 mg/dL to 104 mg/dL, and mean exercise capacity increased from 78 W to 95 W. Age and gender did not differ by education. In contrast with patients having high education, those with low education had more diabetes, hypertension, and peripheral arterial disease, had lower exercise capacity, and received less treatment with statins and guideline-orientated therapy in general. In the multivariate model, good control was significantly more likely in men (odds ratio 1.38; 95% confidence interval 1.30–1.46), less likely in patients of higher age (0.99; 0.99–0.99), with diabetes (0.90; 0.85–0.95), or peripheral arterial disease (0.88; 0.82–0.95). Compared with a low level education, a mid level education was associated with poor control (0.94; 0.89–0.99), while high education did not have a significant effect (1.08; 0.99–1.17).

Conclusion

Patients with different levels of education treated in cardiac rehabilitation did not differ relevantly in terms of demographics, but did differ in some clinical aspects. With respect to the ultimate goal of cardiac rehabilitation, ie, optimal control of risk factors, education level does not play an important role.

Examining the Matthew effect on the motivation and ability to stay at work after heart disease

AIMS

Cardiac rehabilitation should safeguard that socioeconomic factors or other differences that affect people's cardiovascular health are not further aggravated after healthcare treatment. The study examines whether socioeconomic status, emotional problems, or the severity of disease affect people's ability to continue to work after heart disease. We also examined if these effects can be explained by differences in motivational factors.

METHODS

217 patients (41 women) from the Krokeide Rehabilitation Centre in Bergen participated. Multiple linear regression analysis was used to examine motivational differences, and logistic regression analysis was used to examine whether socioeconomic factors or other differences affected people's ability to continue to work after heart disease.

RESULTS

Self-efficacy for future work strongly impacted the likelihood of being incapacitated for work during the 2-year follow-up. The household's total income and emotional problems were statistically significant related to patients dropping out from work in the course of the observation. The association between emotional problems and future work was mediated by motivational problems. The relation between income and future incapacity for work could not be explained by motivational factors.

CONCLUSIONS

The study shows a clear Matthew effect on people's ability to continue to work after heart disease as low-income groups and people with emotional problems are more at risk of dropping out of work. This Matthew effect was, however, only explained by the motivational difficulties for the association between emotional distress and dropping out of work and not for the impact of household income on the likelihood of leaving work.

Assessing historical compliance with medical recommendations among transplant candidates: preliminary findings

CONTEXT

Noncompliance with medical recommendations by transplant candidates and recipients carries serious consequences for morbidity and mortality. Few patient-specific, objective measures for assessing historical compliance exist.

OBJECTIVE

To address this gap, a psychometric and exploratory analysis of an interview-based, global measure of clinician-rated judgment of historical compliance was undertaken.

METHODS

All findings are based on a retrospective chart review of the medical and psychosocial evaluations of 96 consecutive potential heart transplant candidates seen at a large Southeastern academic medical center.

RESULTS

Preliminary results demonstrated adequate interrater reliability and discriminant validity for the measure. Additionally, results from hierarchical multivariable regression analysis revealed years of education to be positively associated with clinician-rated judgment of historical compliance.

CONCLUSIONS

This study provides preliminary psychometric support for the use of a measure of historical compliance among heart transplant candidates. Findings from this study also are consistent with the literature to date and may be reflective of a psychobiological process that mediates the relationship between socioeconomic status and health outcomes.

Socioeconomic position, not race, is linked to death after cardiac surgery

BACKGROUND

Health disparities have been associated with the prevalence of cardiovascular disease. In cardiac surgery, association has been found between race, sex, and poorer prognosis after surgery. However, there is a complex interplay between race, sex, and socioeconomic position (SEP). In our investigation we sought to identify which of these was the driver of risk-adjusted survival.

METHODS AND RESULTS

From January 1, 1995, and December 30, 2005, 23 330 patients (15 156 white men, 6932 white women, 678 black men, and 564 black women) underwent isolated coronary artery bypass grafting, valve, or combined coronary artery bypass grafting and valve procedures. Median follow-up was 5.8 years (25th and 75th percentiles: 3 and 8.6 years). Effect of race, sex, and SEP on all-cause mortality was examined with 2-phase Cox model and generalized propensity score technique. As expected, blacks and women had lower SEP as compared with whites and men for all 6 SEP indicators. Patients with lower SEP had more atherosclerotic disease burden, more comorbidity, and were more symptomatic. Lower SEP was associated with a risk-adjusted dose-dependent reduction in survival after surgery (men, P<0.0001; women, P=0.0079), but black race, once adjusted for SEP, was not.

CONCLUSIONS

Our large investigation demonstrates that disparities in SEP are present and significantly affect health outcomes. Although race per se was not the driver for reduced survival, patients of low SEP were predominantly represented by blacks and women. Socioeconomically disadvantaged patients had significantly higher risk-adjusted mortality after surgery. Further investigation and targeted intervention should focus specifically on patients of low SEP, their health behaviors, and secondary prevention efforts.

Assessing Historical Compliance with Medical Recommendations among Transplant Candidates: Preliminary Findings

Context

Noncompliance with medical recommendations by transplant candidates and recipients carries serious consequences for morbidity and mortality. Few patient-specific, objective measures for assessing historical compliance exist.

Objective

To address this gap, a psychometric and exploratory analysis of an interview-based, global measure of clinician-rated judgment of historical compliance was undertaken.

Methods

All findings are based on a retrospective chart review of the medical and psychosocial evaluations of 96 consecutive potential heart transplant candidates seen at a large Southeastern academic medical center.

Results

Preliminary results demonstrated adequate interrater reliability and discriminant validity for the measure. Additionally, results from hierarchical multivariable regression analysis revealed years of education to be positively associated with clinician-rated judgment of historical compliance.

Conclusions

This study provides preliminary psychometric support for the use of a measure of historical compliance among heart transplant candidates. Findings from this study also are consistent with the literature to date and may be reflective of a psychobiological process that mediates the relationship between socioeconomic status and health outcomes.

Women's and men's exercise adherence after a cardiac event

The purpose of this secondary analysis was to determine whether age affects women's and men's exercise adherence after a cardiac event. In a convenience sample of 248 adults ages 38 to 86 who had a cardiac event, exercise adherence (three exercise sessions per week) was compared between men and women in three age groups (younger than 60, 61 to 70, and older than 70). Exercise patterns were recorded by heart rate monitors worn during exercise. No differences were found in adherence between the age groups for women; older men were nonadherent sooner than younger men when controlling for fitness level, pain, comorbidity, self-efficacy, depressed mood, and social support. Exercise adherence after a cardiac event was higher for younger men compared with older men. For all age groups, less than 37% of the total sample adhered to a three-times-per-week exercise regimen after 1 year, suggesting that interventions to maintain exercise adherence are needed.

Cardiac rehabilitation: health characteristics and socio-economic status among those who do not attend

BACKGROUND

Cardiac rehabilitation (CR) is well documented, in randomised trials, to reduce mortality risk after myocardial infarction (MI). Selection of healthy patients for CR is a relatively unexplored problem. Our aims were to identify predictors of CR-attendance and to describe the prognosis as concerns mortality, re-admission and invasive treatment among CR-attendees as compared to CR-non-attendees.

METHODS

From a cohort of 138 290 persons aged 30-69 years, we identified consecutive MI patients, between 1 April 2000 and 31 March 2002. There were 206 MI patients, who survived until admission, and among the 200 who survived 30 days, 145 (72.5%) attended a comprehensive CR programme. Data were obtained from patient charts and from Danish population registers, and as a result we had no non-participation for the study.

RESULTS

The 2-year mortality proportions for patients surviving the first 30 days of admission were 2.8 and 21.8% among CR-attendees and CR-non-attendees, respectively (P < 0.0001). Among CR-non-attendees, there was a smaller fraction having an invasive treatment performed as compared with CR-attendees. By multiple logistic regression controlling for age and sex, CR-attendance was associated with chest pain, whereas CR-non-attendance was associated with low gross income, single living and inverted T-wave in the electrocardiogram.

CONCLUSION

CR attendance rate was 72.5%. Non-attendees have a higher mortality risk, which in part may be attributed to selection of healthy patients. Non-attendees are older and more likely to have atypical symptoms at admission, a low socioeconomic status and to live alone. Special attention is needed to improve CR attendance among such patients.

Motives for (not) participating in a lifestyle intervention trial

Background

Non-participants can have a considerable influence on the external validity of a study. Therefore, we assessed the socio-demographic, health-related, and lifestyle behavioral differences between participants and non-participants in a comprehensive CVD lifestyle intervention trial, and explored the motives and barriers underlying the decision to participate or not.

Methods

We collected data on participants (n = 50) and non-participants (n = 50) who were eligible for inclusion in a comprehensive CVD lifestyle interventional trial. Questionnaires and a hospital patient records database were used to assess socio-demographic, health-related and lifestyle behavioral variables. Univariate and multivariate logistic regression was used to describe the relationship between explanatory variables and study participation. Furthermore, motives and barriers that underlie study participation were investigated by means of questionnaires.

Results

Participants were younger, single, had a higher level of education and were employed. No statistically significant differences were found in health measures and behavioral variables. The motives for participation that were most frequently reported were: the perception of being unhealthy and willingness to change their lifestyle. The main barriers reported by non-participants were financial arguments and time investment.

Conclusion

The differences between participants and non-participants in a lifestyle intervention trial are in mainly demographic factors. The participants consent in order to alter their lifestyle, and/or because they want to improve their health. To minimize non-participation, it is recommended that access to a lifestyle intervention program should be easy and cause no financial restraints.

Trial registration

ISRCTN69776211.