An act of courage: women's decision-making processes regarding outpatient cardiac rehabilitation attendance

Women's Health-Related Quality of Life Substantially Improves With Tailored Cardiac Rehabilitation: A SYSTEMATIC REVIEW AND META-ANALYSIS

PURPOSE

Exercise-based cardiac rehabilitation (EBCR) offers an opportunity to improve women's otherwise poorer outcomes from coronary heart disease compared with men. However, synthesized evidence for the benefits of EBCR for health-related quality of life (HRQL) is lacking for women. The current study addresses this gap.

METHODS

Four electronic databases (PubMed, CINAHL, SCOPUS, and Cochrane) were searched for studies reporting HRQL using validated questionnaires in women attending EBCR. Two reviewers independently screened articles and extracted data. A random effects model was used for meta-analysis, where possible.

RESULTS

Eleven studies (1237 women) were included, with seven suitable for meta-analyses. Participation in EBCR improved multiple domains of HRQL, with greatest improvements in Role Physical (mean differences [MD] = 19.09: 95% CI, 2.37-35.81), Physical Functioning (MD = 10.43: 95% CI, 2.60-18.27), and Vitality (MD = 9.59: 95% CI, 0.31-18.86) domains of the 12-Item Short Form Health Survey and the 36-Item Short Form Health Survey. Adding psychosocial components tailored for women to traditional EBCR produced further gains in HRQL in Bodily Pain (MD = 9.82: 95% CI, 4.43-15.21), Role Physical (MD = 8.48: 95% CI, 1.31-9.97), Vitality (MD = 8.17: 95% CI, 3.79-12.55), General Health (MD = 5.64: 95% CI, 1.31-9.97), and Physical Functioning (MD = 5.61: 95% CI, 0.83-10.40) domains.

CONCLUSIONS

Women attending EBCR achieve clinically meaningful improvements in multiple areas of HRQL, with added benefits when strategies were tailored to their needs. These benefits should be highlighted to promote EBCR uptake in women.

A Social-Ecological Perspective of the Perceived Barriers and Facilitators to Virtual Education in Cardiac Rehabilitation: A MIXED-METHODS APPROACH

PURPOSE

This study explored the perceived barriers and facilitators to participation in patients who did and did not attend virtual cardiac rehabilitation (CR) education sessions.

METHODS

A mixed-methods approach was used. Virtual patient education was delivered during the coronavirus-19 pandemic. Phase 1 included a cross-sectional online survey completed by individuals who did and did not participate in these sessions. For phase 2, six virtual focus group sessions were conducted using the social-ecological framework to guide thematic analysis and interpretation of findings.

RESULTS

Overall, 106 online surveys were completed; 60 (57%) attended Cardiac College Learn Online (CCLO) sessions only, one (1%) Women with Heart Online (WwHO) only, 21 (20%) attended both, and 24 (22%) did not attend virtual sessions. Half of the participants who attended virtual sessions viewed between one and four sessions. Most participants were from Canada (95%) and included the Toronto Rehabilitation Institute/Toronto Western Hospital centers (76%). Focus group findings revealed six overarching themes: Intrapersonal (mixed emotions/feelings; personal learning preferences); Interpersonal (desire for warmth of human contact and interaction); Institutional (the importance of external endorsement of sessions); and Environmental (technology; perceived facilitators and barriers).

CONCLUSION

These findings highlight the unprecedented situation that patients and CR programs are facing during the pandemic. Virtual patient education may be more accessible, convenient, and responsive to the complex needs of these CR participants.

Patients' Experiences of Cardiovascular Health Education and Risk Communication: A Qualitative Synthesis

Coronary heart disease (CHD) has no cure, and patients with myocardial infarction are at high risk for further cardiac events. Health education is a key driver for patients' understanding and motivation for lifestyle change, but little is known about patients' experience of such education. In this review, we aimed to explore how patients with CHD experience health education and in particular risk communication. A total of 2,221 articles were identified through a systematic search in five databases. 40 articles were included and synthesized using thematic analysis. Findings show that both "what" was communicated, and "the way" it was communicated, had the potential to influence patients' engagement with lifestyle changes. Communication about the potential of lifestyle change to reduce future risk was largely missing causing uncertainty, anxiety, and, for some, disengagement with lifestyle change. Recommendations for ways to improve health education and risk communication are discussed to inform international practice.

Reasons for dropout from cardiac rehabilitation programs in women: A qualitative study

BACKGROUND

Empirical evidence has shown that cardiac rehabilitation programs are effective in reducing morbidity and mortality, improving quality of life in patients with cardiovascular disease. Despite the benefits, women have a high cardiac rehabilitation dropout rate. Our aim was to explore women's perceptions about the reasons they faced for dropout from these programs.

METHODS

Semi-structured interviews were conducted with women (n = 10) after dropping out from three different cardiac rehabilitation centers in Spain. In addition, a focus group and a semi-structured interview with cardiovascular professionals were conducted. From a grounded theory perspective, thematic analysis was used to derive themes from interview transcripts.

RESULTS

The women were between 41 and 70 years. We identified five general themes that illustrated reasons for cardiac rehabilitation dropout: intrapersonal reasons (self-reported health, self-reported mental health, health beliefs); interpersonal reasons (family caregiver role, work conflicts); logistical reasons (transport, distance); cardiac rehabilitation program characteristics (perception of the objective of cardiac rehabilitation, exercise component, inconvenient timing, cardiac rehabilitation equipment); and health system reasons (financial assistance for transport, long waiting list). The cardiovascular professionals found barriers to cardiac rehabilitation completion similar to those found by the women.

CONCLUSIONS

In order to prevent cardiac rehabilitation dropout in women, modular and flexible programs are needed. In addition, the inclusion of primary care centers or community resources could improve cardiac rehabilitation completion in women. Psychological assessment and counseling during cardiac rehabilitation should be included as an essential part of the programs and recommended for those women with depressive symptoms. Finally, improved financial assistance for transport from the health system is essential.

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.

Using Visual Methods to Understand Physical Activity Maintenance following Cardiac Rehabilitation

Few studies have explored the factors associated with long-term maintenance of exercise following cardiac rehabilitation. The present study used auto-photography and interviews to explore the factors that influence motivation and continued participation in physical activity among post cardiac rehabilitation patients. Twenty-three semi-structured interviews were conducted alongside participant-selected photographs or drawings with participants that had continued participation in physical activity for at least two years following the cardiac rehabilitation programme. Participants were recruited from circuit training classes in East Sussex in the UK. Thematic content analysis revealed seven main themes: fear of death and ill health avoidance, critical incidents, overcoming aging, social influences, being able to enjoy life, provision of routine and structure, enjoyment and psychological well-being. Fear of death, illness avoidance, overcoming aging, and being able to enjoy life were powerful motives for continued participation in exercise. The social nature of the exercise class was also identified as a key facilitator of continued participation. Group-based exercise suited those that continued exercise participation post cardiac rehabilitation and fostered adherence.

Factors influencing referral to cardiac rehabilitation and secondary prevention programs: a systematic review

BACKGROUND

Referral to cardiac rehabilitation and secondary prevention programs remains very low, despite evidence suggesting strong clinical efficacy. To develop evidence-based interventions to promote referral, the complex factors and processes influencing referral need to be better understood.

DESIGN

We performed a systematic review using qualitative meta-synthesis.

METHODS

A comprehensive search of 11 databases was conducted. To be included, studies had to contain a qualitative research component wholly or in a mixed method design. Population specific data or themes had to be extractable for referral to programs. Studies had to contain extractable data from adults >18 years and published as full papers or theses during or after 1995.

RESULTS

A total of 2620 articles were retrieved: out of 1687 studies examined, 87 studies contained data pertaining to decisions to participate in programs, 34 of which included data on referral. Healthcare professional, system and patient factors influenced referrals. The main professional barriers were low knowledge or scepticism about benefits, an over-reliance on physicians as gatekeepers and judgments that patients were not likely to participate. Systems factors related to territory, remuneration and insufficient time and workload capacity. Patients had limited knowledge of programs and saw physicians as key elements of referral but found the process of attaining a referral confusing and challenging.

CONCLUSIONS

The greatest increases in patient referral to programs could be achieved by allowing referral from non-physicians or alternatively, automatic referral to a choice of hospital or home-based programs. All referring health professionals should receive educational outreach visits or workshops around the ethical and clinical aspects of programs.

Factors influencing participation in cardiac rehabilitation programmes after referral and initial attendance: qualitative systematic review and meta-synthesis

Background:

Greater participation in cardiac rehabilitation improves morbidity and mortality in people with coronary heart disease, but little is understood of patients’ decisions to participate.

Methods:

To develop interventions aimed at increasing completion of programmes, we conducted a qualitative systematic review and meta-synthesis to explore the complex factors and processes influencing participation in cardiac rehabilitation programmes after referral and initial access. To be included in the review, studies had to contain a qualitative research component, population specific data on programme participation in adults >18 years, and be published ≥1995 as full articles or theses. Ten databases were searched (31 October 2011) using 100+ search terms.

Results:

Of 2264 citations identified, 62 studies were included involving: 1646 patients (57% female; mean age 64.2), 143 caregivers, and 79 professionals. Patients’ participation was most strongly influenced by perceptions of the nature, suitability and scheduling of programmes, social comparisons made possible by programmes, and the degree to which programmes, providers, and programme users met expectations. Women’s experiences of these factors rendered them less likely to complete. Comparatively, perceptions of programme benefits had little influence on participation.

Conclusions:

Factors reducing participation in programmes are varied but amenable to intervention. Participation should be viewed as a ‘consumer behaviour’ and interventions should mobilize family support, promote ‘patient friendly’ scheduling, and actively harness the social, identity-related, and experiential aspects of participation.

A qualitative systematic review of influences on attendance at cardiac rehabilitation programs after referral

BACKGROUND

Cardiac rehabilitation and secondary prevention programs can prevent heart disease in high-risk populations. However, up to half of all patients referred to these programs do not subsequently participate. Although age, sex, and social factors are common predictors of attendance, to increase attendance rates after referral, the complex range of factors and processes influencing attendance needs to be better understood.

METHODS

A systematic review using qualitative meta-synthesis was conducted. Ten databases were systematically searched using 100+ search terms until October 31, 2011. To be included, studies had to contain a qualitative research component and population-specific primary data pertaining to program attendance after referral for adults older than 18 years and be published as full articles in or after 1995.

RESULTS

Ninety studies were included (2010 patients, 120 caregivers, 312 professionals). Personal and contextual barriers and facilitators were intricately linked and consistently influenced patients' decisions to attend. The main personal factors affecting attendance after referral included patients' knowledge of services, patient identity, perceptions of heart disease, and financial or occupational constraints. These were consistently derived from social as opposed to clinical sources. Contextual factors also influenced patient attendance, including family and, less commonly, health professionals. Regardless of the perceived severity of heart disease, patients could view risk as inherently uncontrollable and any attempts to manage risk as futile.

CONCLUSIONS

Decisions to attend programs are influenced more by social factors than by health professional advice or clinical information. Interventions to increase patient attendance should involve patients and their families and harness social mechanisms.

"I don't have the heart": a qualitative study of barriers to and facilitators of physical activity for people with coronary heart disease and depressive symptoms

BACKGROUND

Physical activity has been shown to reduce depression in people with coronary heart disease (CHD), however many people with CHD do not engage in sufficient levels of physical activity to reap its positive effects. People with depression and CHD are at particular risk of non-adherence to physical activity. Little is known about the barriers to and facilitators of physical activity for people with CHD and depressive symptoms. Using qualitative interviews, the aim of this study was to explore the barriers to and facilitators of physical activity for cardiac patients with depressive symptoms.

METHODS

Fifteen participants with CHD and depressive symptoms (assessed using the Cardiac Depression Scale) participated in in-depth semi-structured interviews. The interviews were focussed on investigating participants' experiences of physical activity since their cardiac event. Interviews were content analysed to determine major themes.

RESULTS

Participants identified a number of barriers to and facilitators of physical activity. Barriers included having negative perceptions towards health and life changes as a result of the cardiac event, having low mood and low motivation to exercise, feeling physically restricted towards or fearful of exercise, lacking knowledge regarding exercise and perceiving external barriers. Facilitators included having a reason for exercising, being able to identify the psychological benefits of exercise, having positive social support and using psychological strategies. 'Inactive' participants reported more barriers and fewer facilitators than did 'active' participants.

CONCLUSIONS

The barriers reported in this study were highly salient for a number of participants. Health professionals and researchers can use this information to assist people with CHD and depressive symptoms to identify and possibly overcome barriers to physical activity. Relevant barriers and facilitators could be taken into account to increase their effectiveness when designing interventions to encourage physical activity maintenance in this population.

Participating in cardiac rehabilitation: a systematic review and meta-synthesis of qualitative data

BACKGROUND

Participation in cardiac rehabilitation (CR) benefits patients with coronary heart disease (CHD), yet worldwide only some 15–30% of those eligible attend. To improve understanding of the reasons for poor participation we undertook a systematic review and meta-synthesis of the qualitative literature.

METHODS

Qualitative studies identifying patient barriers and enablers to attendance at CR were identified by searching multiple electronic databases, reference lists, relevant conference lists, grey literature, and keyword searching of the Internet (1990–2010). Studies were selected if they included patients with CHD and reviewed experience or understanding about CR. Meta-synthesis was used to review the papers and to synthesize the data.

RESULTS

From 1165 papers, 34 unique studies were included after screening. These included 1213 patients from eight countries. Study methodology included interviews (n = 25), focus groups (n = 5), and mixed-methods (n = 4). Key reasons for not attending CR were physical barriers, such as lack of transport, or financial cost, and personal barriers, such as embarrassment about participation, or misunderstanding the reasons for onset of CHD or the purpose of CR.

CONCLUSIONS

There is a vast amount of qualitative research which investigates patients’ reasons for non-attendance at CR. Key issues include system-level and patient-level barriers, which are potentially modifiable. Future research would best be directed at investigating strategies to overcome these barriers.

Individual influences on lifestyle change to reduce vascular risk: a qualitative literature review

BACKGROUND

Management of cardiovascular risk includes adoption of healthy lifestyles. Uptake and completion rates for lifestyle programmes are low and many barriers and facilitators to lifestyle behaviour change have been reported in the literature. Clarity on which barriers and facilitators to target during consultations in primary care may support a more systematic approach to lifestyle behaviour change in those at high risk of cardiovascular events.

AIM

To identify the main barriers and facilitators to lifestyle behaviour change in individuals at high risk of cardiovascular events.

DESIGN

A content synthesis of the qualitative literature reporting patient-level influences on lifestyle change.

METHOD

Qualitative studies involving patients at high risk of cardiovascular events were identified through electronic searching and screening against predefined selection criteria. Factors (reported influences) were extracted and, using a clustering technique, organised into categories that were then linked to key themes through relationship mapping.

RESULTS

A total of 348 factors were extracted from 33 studies. Factors were organised into 20 categories and from these categories five key themes were identified: emotions, beliefs, information and communication, friends and family support, and cost/transport.

CONCLUSION

It is possible to organise the large number of self-reported individual influences on lifestyle behaviours into a small number of themes. Further research is needed to clarify which of these patient-level barriers and facilitators are the best predictors of uptake and participation in programmes aimed at helping people to change lifestyle.

A comprehensive view of sex-specific issues related to cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of mortality in women. In fact, CVD is responsible for a third of all deaths of women worldwide and half of all deaths of women over 50 years of age in developing countries. The prevalence of CVD risk factor precursors is increasing in children. Retrospective analyses suggest that there are some clinically relevant differences between women and men in terms of prevalence, presentation, management and outcomes of the disease, but little is known about why CVD affects women and men differently. For instance, women with diabetes have a significantly higher CVD mortality rate than men with diabetes. Similarly, women with atrial fibrillation are at greater risk of stroke than men with atrial fibrillation. Historically, women have been underrepresented in clinical trials. The lack of good trial evidence concerning sex-specific outcomes has led to assumptions about CVD treatment in women, which in turn may have resulted in inadequate diagnoses and suboptimal management, greatly affecting outcomes. This knowledge gap may also explain why cardiovascular health in women is not improving as fast as that of men. Over the last decades, mortality rates in men have steadily declined, while those in women remained stable. It is also becoming increasingly evident that gender differences in cultural, behavioural, psychosocial and socioeconomic status are responsible, to various degrees, for the observed differences between women and men. However, the interaction between sex-and gender-related factors and CVD outcomes in women remains largely unknown.

A realist study of the mechanisms of cardiac rehabilitation

AIM

The aim of this paper is to report patients' experiences of cardiac rehabilitation and perceptions of the mechanisms and contexts influencing its long-term effectiveness.

BACKGROUND

Cardiac rehabilitation programmes for the secondary prevention of coronary heart disease are common. The effects of these programmes, however, can be inconsistent and little is known of the personal and contextual factors that influence service effectiveness.

METHOD

Forty-seven participants with a formal diagnosis of coronary heart disease who had attended a programme of cardiac rehabilitation in Scotland 3 years previously were included in focus groups to discuss their perceptions and experiences (30 males and 17 females). The data were generated in 2002 and analysed using the realist approach of Pawson and Tilley (1997).

RESULTS

Participants' accounts indicated that the didactic content of cardiac rehabilitation was not strongly linked to longer-term health behaviour change. The main positive effects of cardiac rehabilitation were related to the effect of participation on mediating social and body-focused mechanisms that were triggered when the rehabilitation setting was perceived to be safe. Social mechanisms identified included social comparisons, camaraderie, and social capital. Body-focused mechanisms included greater knowledge of personal physical boundaries and a greater trust in the heart-diseased body. Collectively, these mechanisms had a positive effect on confidence that was perceived as being imperative to maintain health behaviour change.

CONCLUSIONS

More support is required to promote health behaviour change after the completion of cardiac rehabilitation. Use of community-based exercise services and conventional or web-based support groups for coronary heart disease patients should be encouraged, as these appear to extend the positive health effects of the mechanisms that promote behaviour change. At the completion of cardiac rehabilitation programmes, patients should be referred to safe and appropriate community-based exercise services. Further research is needed to examine the effects on health outcomes of mechanisms and contexts related to cardiac rehabilitation.

Incentives for lifestyle changes in patients with coronary heart disease

AIM

This paper reports a study exploring how patients in the rehabilitation phase of coronary heart disease experience facilitating and constraining factors related to lifestyle changes of importance for wellbeing and prognosis.

BACKGROUND

Lifestyle change is important but complex during rehabilitation after a myocardial infarction or angina pectoris. The intentions to perform behaviours and to experience control over facilitators and constraints are important determinants of behaviour.

METHODS

A total of 113 consecutive patients below 70 years of age (84 men and 29 women) were interviewed within 6 weeks of a cardiac event and again after 1 year. Interview transcriptions and notes taken by hand were qualitatively analysed using the phenomenographic framework. The distribution of statements among the categories identified was quantitatively analysed. The data were collected in 1998-2000.

FINDINGS

Four main categories portrayed patients' experiences of facilitating or constraining incentives for lifestyle changes. 'Somatic incentives' featured bodily signals indicating improvements/illness. 'Social/practical incentives' involved shared concerns, changed conditions including support/demand from social network, and work/social security issues. Practical incentives concerned external environmental factors in the patients' concrete context. 'Cognitive incentives' were characterized by active decisions and appropriated knowledge, passive compliance with limited insights, and routines/habits. 'Affective incentives' comprised fear of and reluctance in the face of lifestyle changes/disease, lessened self-esteem, and inability to resist temptations. Cognitive incentives mostly facilitated physical exercise and drug treatment. Social/practical incentives facilitated physical exercise and diet change. Physical exercise and diet changes were mainly constrained by somatic, social, and affective incentives.

CONCLUSION

The results illustrate important incentives that should be considered in contacts with patients and their families to improve the prospects of positively affecting co-operation with suggested treatment and lifestyle changes.

Patient-Provider Communication Regarding Referral to Cardiac Rehabilitation

This study investigated the dynamics of patient-provider communication in the cardiac rehabilitation (CR) referral process, to identify which aspects lead to CR participation. Semi-structured individual interviews were conducted with 31 patients eligible for CR. Questions probed the content and perception of the discussion that patients had with healthcare providers (HCP) regarding CR attendance. The interviews were audiotaped, transcribed, and imported into N6 software for grounded analyses. Key emerging themes were identified: illness perceptions; HCP encouragement; timing of discussion; and ease of referral. CR attenders were apt to self-advocate to ensure their enrollment in CR, whereas nonattenders were more likely to minimize the seriousness of their disease, and less likely to persevere to overcome obstacles in enrolling in a CR program. Surprisingly, the strength of the HCP referral did not influence the decision to attend CR as strongly when compared to the HCP's ability to facilitate enrollment in a CR program.

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.

Promoting participation in cardiac rehabilitation: patient choices and experiences

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effectiveness of home-based cardiac rehabilitation for special needs patients

BACKGROUND

The benefits of cardiac rehabilitation programmes have been well documented including reductions in mortality, improved physical performance, and improved quality of life. However, a large number of special needs patients often fail to access these programmes. Of particular concern are elderly patients with chronic illness and disability.

AIMS

To evaluate the effectiveness of a home-based cardiac rehabilitation programme in improving health outcomes and rehabilitation access for special-needs patients.

DESIGN

Using a one-group pre and post-test quasi-experimental design 40 elderly patients recently discharged from hospital following a cardiac event completed the Short Form Health Survey, the Angina Quiz, and the Exercise Assessment Questionnaire prior to undertaking home-based rehabilitation. The rehabilitation programme consisted of four community nursing contacts over a 9-week period primarily aimed at individual patient education and carer support.

ANALYSIS

Descriptive statistics provided analysis for demographic data. Repeated measures multivariate analysis of variance (manova) were computed to examine changes in health-state and practices.

RESULTS

Significant positive changes were found for measures of quality of life, knowledge of angina, and exercise tolerance. Additionally, the higher levels of participation and completion by older women was encouraging. Development of carer competence through an improved knowledge base and nursing support was also evident.

LIMITATIONS

While theoretically defensible positive outcomes were found these results need to be replicated in a larger study. Similarly, the limitations imposed by a single group pretest, post-test design suggest that claims of generalizability need to be limited to the specific variables measured in this study.

CONCLUSION

The study demonstrated medium term positive health outcomes. These positive findings suggest that home-based rehabilitation using larger samples of older patients with comorbidities, and using randomized comparative group designs, may be a fruitful area in future research.