Curriculum in CardiologyA qualitative systematic review of influences on attendance at cardiac rehabilitation programs after referral
Section snippets
Background
Why are effective health services not used? Cardiac rehabilitation (CR) and secondary prevention programs are common across high-income countries, but up to 50% of eligible patients who are referred do not subsequently participate.1, 2, 3, 4 Attendance after referral is essential if patients are to benefit from these evidence-based interventions. Although modifiable cardiovascular risk remains very high in populations with coronary heart disease,5, 6 patients who participate in programs are up
Methods
Because this study was focused on the complex factors and processes that influence attendance rather than preidentified predictors of attendance,3, 4 qualitative research studies were the focus of this review.13 Qualitative research methods have been used frequently to understand patient and health professional decision making in complex settings and organizations, including the provision of primary care14 and cardiac services.15, 16, 17, 18
To be included, studies had to contain a primary,
Results
From 2264 unique studies screened (Figure 2), 90 studies contained data on CR attendance (2010 patients: 1051 male, 907 female, 52 not described; mean age 62.1 ± 11.5 years; range 27-90 years; 120 caregivers; 312 professionals). A third of the studies were conducted in the United Kingdom (n = 31), and study quality was moderate (Table I).
Low insight and knowledge into services
Numerous studies identified that a lack of personal insight or knowledge regarding the nature of programs was a common barrier to attendance.48, 50, 53, 56, 58, 59, 61, 65, 73, 83, 84, 92, 99, 101, 107 Patients perceived that programs would not be beneficial generally47, 82 or for people “like them”23, 93and reported receiving little information from health professionals on what programs consisted of37, 45, 50, 58, 59, 84, 90or program benefits51, 58, 59 and little encouragement to attend.47, 58
Heart disease as controllable
A high sense of control over heart disease was commonly associated with attendance24, 26, 27, 55, 58, 59, 76, 93, 95, 97, 102, 108 and was reinforced by experiences of controlling other diseases,56 the sense of mastery33 or security associated with participating in programs,26, 30, 75, 88, 93 and self-reliance in the face of the demands created by heart disease.24, 44, 54, 95
Positive views of services
Service benefits perceived to increase attendance included reducing stress,76, 78, 79, 86 improving general health,39, 76
Long distances to services
Long travel distances to CR programs were cited as a common barrier to attendance,58, 59, 64, 65, 80, 92, 99, 109 particularly from rural settings33, 53 or when transport links were poor.55, 65
Lack of support from family
Family members curtailed attendance through both active and passive actions. Families were seen to overprotect the patient24 or “take charge” of risk factor reduction.28, 53, 57, 61, 68, 89, 101 Families also constrained attendance due to demands on patients for caregiving67, 85 or similar familial
The family and social networks
Families could also facilitate attendance97 by providing social support,67 transportation to centers,33, 40, 52, 55, 96 accompanying the patient to the program,30, 77, 93, 98 providing information on services,24, 67 communicating with health professionals,96 or making exercise normal.24, 67 Encouragement to participate in programs from previous attending patients was also cited to promote attendance.30, 34 A sense of camaraderie between patients in CR programs existed and could sustain
Discussion
Decisions to attend CR programs were strongly influenced by patients' psychosocial factors, context, and other occupational and personal commitments, including social comparisons, perceived benefits and control, occupational demands and constraints, distance to settings, and families. The influence of such a wide range of factors is common in acute111, 112, 113, 114, 115, 116and chronic stages of heart disease,117, 118 but medical reasons for low attendance (such as symptoms and comorbidities)
Research and practice
There is strong evidence from clinical trials that patients who are unable to participate in hospital-based programs can have equally positive outcomes from specially tailored programs as patients who attend hospital-based programs.121, 122, 123, 124 In preference to providing hospital-based programs outside traditional work hours, more types of programs that allow remote access via the Web, e-mail, or telephone could be available to ensure that time and distance do not act as barriers to
Limitations
This review used a recognized approach to qualitative synthesis19 to harness and synthesize relevant data from qualitative studies of diverse populations. As with all reviews, it is constrained by the quality and scope of existing published studies.21 Across the included studies, there was limited analysis of the influence of sex, age, or ethnic group membership. Study quality was moderate overall and mostly confined to high-income countries with well-funded health care systems. Attendance was
Conclusion
Attendance in CR is influenced by a range of psychosocial, familial, and contextual factors. Future interventions to promote higher access should include family members and foster patients' sense of control of cardiovascular risk, harness similarities rather than differences with patients who participate, and harness family members to support rather than curtail attendance. Peer support of both patients and families may be a particularly promising and efficient means to facilitate these aims.
References (138)
- et al.
Predictors of cardiac rehabilitation referral in coronary artery disease patients
J Am Coll Cardiol
(2009) - et al.
Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries
Lancet
(2009) - et al.
Cultural factors facilitating cardiac rehabilitation participation among Canadian South Asians: a qualitative study
Heart Lung
(2010) - et al.
Recovery patterns and lifestyle changes after coronary angioplasty: the patient's perspective
Heart Lung
(1998) - et al.
Financial, family, and social factors impacting on cardiac rehabilitation attendance
Heart Lung
(2007) - et al.
The patients' perception of recovery after coronary angioplasty
Aust Crit Care
(2000) - et al.
‘Getting back to normal’: patients' expectations of cardiac rehabilitation
Physiotherapy
(2004) - et al.
Gender differences in motivations and perceived effects of mind-body therapy (MBT) practice and views on integrative cardiac rehabilitation among acute coronary syndrome patients: why do women use MBT?
Complement Ther Med
(2008) - et al.
Exercise motives of long-term phase IV cardiac rehabilitation participants
Physiotherapy
(2008) - et al.
Cardiac Rehabilitation Section European Association of Cardiovascular Prevention and Rehabilitation. Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey
Eur J Cardiovasc Prev Rehabil
(2010)
Improving uptake and adherence in cardiac rehabilitation: literature review
J Adv Nurs
EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 European countries
Eur J Cardiovasc Prev Rehabil
Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes
Circulation
Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery
Circulation
Automatic referral to cardiac rehabilitation
Med Care
Effects of cardiac rehabilitation referral strategies on referral and enrollment rates
Nat Rev Cardiol
Cardiac rehabilitation care continuity through automatic referral evaluation (CRCARE) investigators. Effect of cardiac rehabilitation referral strategies on utilization rates a prospective, controlled study
Arch Intern Med
Qualitative research: reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research
BMJ
General practices as emergent research organizations: a qualitative study into organizational development
Fam Pract
Preparing for change in the secondary prevention of coronary heart disease: a qualitative evaluation of cardiac rehabilitation within a region of Scotland
J Adv Nurs
The role of age in moderating access to cardiac rehabilitation in Scotland
Aging Soc
Discipline and resistance: order and disorder in a cardiac rehabilitation clinic
Qual Health Res
Understanding and practice: a 7-year follow-up study on implementation of a cardiac rehabilitation program
Qual Health Res
Meta-ethnography: synthesizing qualitative data
Women exposed to intimate partner violence: expectations and experiences when they encounter health professionals: a meta analysis of qualitative studies
Arch Intern Med
Prescribing exercise for cardiac patients: Knowledge, practices, and needs of family physicians and specialists
J Cardiopulm Rehabil
“Maybe it could be a heart attack…but I'm only 31”: young men's lived experience of myocardial infarction an exploratory study
Am J Mens Health
Patients' illness perception four months after a myocardial infarction
J Clin Nurs
Home is where the heart is: women's experiences of homemaking and self care after aortocoronary bypass surgery [PhD]
Group experiences in cardiac rehabilitation exercise programs [PysD]
“Others had similar problems and you were not alone”: evaluation of an open-group mutual aid model in cardiac rehabilitation
J Cardiovasc Nurs
Family support and cardiac rehabilitation: a comparative study of the experiences of South Asian and White-European patients and their carer's [sic] living in the United Kingdom
Eur J Cardiovasc Nurs
Older rural women moving up and moving on in cardiac rehab [PhD]
Hospital versus community-based phase III cardiac rehabilitation
Br J Nurs
Acute myocardial infarction: a descriptive study of the experience [PhD]
Lives of rural women after myocardial infarction
Can J Nurs Res
Exploring uptake of cardiac rehabilitation in a minority ethnic population in England: a qualitative study
Eur J Cardiovasc Nurs
Participation in community-based exercise maintenance programs after completion of hospital-based cardiac rehabilitation: a mixed-method study
J Cardiopulm Rehabil Prev
Cardiac rehabilitation: Influences on attendance [PsyD]
A qualitative study investigating patients' beliefs about cardiac rehabilitation
Clin Rehabil
The contribution of qualitative research in designing a complex intervention for secondary prevention of coronary heart disease in two different healthcare systems
BMC Health Serv Res
The effectiveness of a newly developed cardiac rehabilitation phase III program—a quantitative and qualitative approach to enhance service delivery
Physiotherapy Ireland
Motivation for self-care in older women with heart disease and diabetes: balancing act [PhD]
A cardiac rehabilitation program to improve psychosocial outcomes of women with heart disease
J Womens Health
A qualitative approach to the evaluation of a cardiac education follow-up program
Can J Cardiovasc Nurs
Cardiac rehabilitation for women: one size does not fit at all
Aust J Adv Nurs
Exploring the barriers and enablers to attendance at rural cardiac rehabilitation programs
Aust J Rural Health
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Funding was provided by the Canadian Institutes of Health Research via a Knowledge Synthesis Grant (G118160769).