Do Men and Women Achieve Similar Benefits From Cardiac Rehabilitation?

‘A bridge to normal’: a qualitative study of Indonesian women’s attendance in a phase two cardiac rehabilitation programme

Background:

Cardiac rehabilitation is effective in reducing mortality and morbidity, in improving life expectancy and quality of life for people with cardiovascular disease. Despite these recognised benefits, women’s attendance rates in cardiac rehabilitation programmes remain suboptimal.

Aims:

This paper details the study that explored factors that influence women’s attendance of a phase two cardiac rehabilitation programme in Indonesia

Methods:

An exploratory qualitative research design was used in the study. Semi-structured interviews were used as the main method of data collection. Data were collected from June to September 2016. Twenty-three women aged between 30 and 66 years were interviewed. Transcribed interview data were analysed using a qualitative framework analysis.

Results:

Three major themes were inferred from the analysis: (a) a bridge to normal; (b) connecting with others; and (c) contextual factors. The first theme is illustrated by two subthemes: ‘making my heart work again’ and ‘performing social roles’. The second theme was illustrated by the following subthemes: ‘exchanging knowledge and experience’ and ‘developing a give-and-take relationship’. The third theme was illustrated by three subthemes: ‘recommendations from the staff’, ‘family support’ and ‘availability of health insurance’.

Conclusion:

Women’s attendance in cardiac rehabilitation in Indonesia is mainly influenced by their expectations and desire to be able to resume their previous social roles in the family and society. The findings of this study can assist healthcare professionals to understand better the needs of women and the fit between women’s needs and existing cardiac rehabilitation programmes. Such understanding could provide direction for more effective approaches to the cardiac rehabilitation programmes that are currently offered in Indonesia.

"When what is taken for granted disappears": women's experiences and perceptions after a cardiac event

BACKGROUND AND PURPOSE

On entering Cardiac Rehabilitation (CR), the female cardiac population shows greater fear of overexertion and sense of uncertainty than similarly affected men. The purpose of this study was to explore how women experienced the recovery process after a cardiac event and what impact the event had on bodily experiences.

METHODS

A qualitative, descriptive design, inspired by a phenomenological approach. Information was collected from 20 women through focus groups and individual in-depth interviews. The material was analyzed with a method of systematic text condensation.

RESULTS

The women's recovery after a CE could be a lonely and difficult process. Their own perspectives on what they need in the process is often overlooked, focus being on medical care and clinical recovery in the early phase. Returning home, the women suffered vulnerability, fragility, and insecurity, affecting well-being as well as activity levels. Lack of support and follow-up post-discharge seemed to disturb the progress of the recovery process.

CONCLUSIONS

Helping the women regain confidence in their new bodies, supporting the personal recovery processes, and bridging the gap between discharge and enrolling in a CR-program could reduce personal stress and withdrawal, thereby empowering more women to start and complete CR programs.

Gender-specific issues in cardiac rehabilitation: do women with ischaemic heart disease need specially tailored programmes?

Ischaemic heart disease (IHD) has changed from a disease of middle-aged men in the late 1970s to a disease of elderly women in the 2000s. Most clinical studies during the past three decades have been conducted with men. Cardiac rehabilitation programmes were also developed with special regard to improving the rate of return to work in middle-aged men. The rehabilitation needs of older patients and women in particular have been largely neglected. The aim of this review is briefly to outline our present knowledge on gender issues in cardiac rehabilitation, and to specify barriers with regard to physical activities especially in (older) women. Coping with a cardiac event, women tend to minimize or play down the impact of their health situation and avoid burdening their social contacts. After a first cardiac event, women report greater psychological distress and lower self-efficacy and self-esteem. In addition, older age, lower exercise levels and reduced functional capacity or co-morbid conditions such as osteoporosis and urinary incontinence are barriers to physical activities in women with IHD. Recent studies on psychosocial intervention revealed less favourable results in women compared with men. These findings have not yet been well explained. This emphasizes our current lack of knowledge about the processes and determinants of successful psychosocial interventions in men and women with IHD. A large (European) trial on gender-specific coping styles, needs, and preferences of older women, and the effects of psychosocial intervention is proposed.

Recall of information received in hospital by female cardiac patients

BACKGROUND

The type and source of health information supplied to patients following cardiac events significantly improve adherence and health behaviours. The impact of health information upon female patients, however, is not well documented. This study investigates women's recall of the type and source of information provided to them in hospital about resuming daily activities after a cardiac event. It also identified women least likely to recall receiving information.

METHODS

Interviews were conducted with female cardiac patients consecutively admitted to four metropolitan hospitals after acute myocardial infarction or for coronary artery bypass graft surgery. The women were interviewed on admission and at 2, 4 and 12 months after discharge. Participants were asked about in-hospital information provision at the 2-month interview (n=224).

RESULTS

Most women recalled receiving verbal information about medication, exercise and smoking cessation, but few recalled receiving verbal information about gardening, sexual activity, driving or sport. Women who were obese or physically inactive recalled limited advice about diet and physical activity, whereas women with diabetes or hypertension were no more likely than others to recall receiving information about medication, despite the personal relevance of this information. Older women were most at risk of recalling limited advice, including information about cardiac rehabilitation. Over half of the women attended a cardiac rehabilitation programme, with uptake being related to information provision.

CONCLUSIONS

The findings support other research suggesting that advice about activities after a cardiac event is inadequate for some women and confirms the influence of information provision on participation in cardiac rehabilitation.

A secondary meta-synthesis of qualitative studies of gender and access to cardiac rehabilitation

AIMS

To discuss issues in the theorization and study of gender observed during a qualitative meta-synthesis of influences on uptake of secondary prevention and cardiac rehabilitation services.

BACKGROUND

Women and men can equally benefit from secondary prevention/cardiac rehabilitation and there is a need to understand gender barriers to uptake.

DESIGN

Meta-method analysis secondary to meta-synthesis. For the meta-synthesis, a systematic search was performed to identify and retrieve studies published as full papers during or after 1995 and contained: a qualitative research component wholly or in a mixed method design, extractable population specific data or themes for referral to secondary prevention programmes and adults ≥18 years.

DATA SOURCES

Databases searched between January 1995-31 October 2011 included: CSA Sociological Abstracts, EBSCOhost CINAHL, EBSCOhost Gender Studies, EBSCOhost Health Source Nursing: Academic Edition, EBSCOhost SPORTDiscus, EBSCOhost SocINDEX.

REVIEW METHODS

Studies were reviewed against inclusion/exclusion criteria. Included studies were subject to quality appraisal and standardized data extraction.

RESULTS

Of 2264 screened articles, 69 were included in the meta-method analysis. Only four studies defined gender or used gender theories. Findings were mostly presented as inherently the characteristic of gendered worldviews of participants. The major themes suggest a mismatch between secondary prevention/cardiac rehabilitation services and consumers' needs, which are usually portrayed as differing according to gender but may also be subject to intersecting influences such as age or socioeconomic status.

CONCLUSION

There is a persistent lack of theoretically informed gender analysis in qualitative literature in this field. Theory-driven gender analysis will improve the conceptual clarity of the evidence base for gender-sensitive cardiac rehabilitation programme development.

[Cardiac rehabilitation after myocardial infarction in France: still not prescribed enough]

Despite well-documented benefits for patients after myocardial infarction, cardiac rehabilitation is underutilized in most countries. In France, a recent study showed a participation rate of 22.7 %, with huge regional disparities for unknown reasons. In this paper, we analyze some demographic particularities for explaining these curious results. Then, we review in the literature the complex factors influencing patient's referral in cardiac rehabilitation (patient's believes, role of the physician, health system's organization…), and the best ways of improving cardiac rehabilitation rate or finding adequate alternatives.

Hospital-based comprehensive cardiac rehabilitation versus usual care among patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease: 12-month results of a randomized clinical trial

BACKGROUND

Current guidelines broadly recommend comprehensive cardiac rehabilitation (CCR), although evidence for this is still limited. We investigated the 12-month effect of hospital-based CCR versus usual care (UC) for a broadly defined group of cardiac patients within the modern therapeutic era of cardiology.

METHODS

We conducted a centrally randomized single-center clinical trial with blinded assessment of the primary outcome: registry-based composite of total mortality, myocardial infarction, or acute first-time readmission due to heart disease. Other outcomes were hospitalization, risk profile, and quality of life. The trial included 770 participants (20-94 years) with congestive heart failure (12%), ischemic heart disease (58%), or high risk of ischemic heart disease (30%). Comprehensive cardiac rehabilitation is composed of 6 weeks of intensive intervention and systematic follow-up for 10.5 months.

RESULTS

We randomized 380 patients to CCR versus 390 to UC. Randomization was well balanced. The primary outcome occurred in 31% of both groups (relative risk 0.96, 95% confidence interval 0.78-1.26). Compared with the UC group, CCR significantly reduced length of stay by 15% (95% confidence interval 1.1%-27.1%, P = .04), mean number of cardiac risk factors above target (4.5 vs 4.1, P = .01), patients with systolic blood pressure below target (P = .003), physically inactivity (P = .01), and unhealthy dietary habits (P = .0003). Short-Form-36 and Hospital Anxiety and Depression Scale did not differ significantly.

CONCLUSION

At 12 months, the CCR and UC groups did not differ regarding the primary composite outcome. Comprehensive cardiac rehabilitation significantly reduced length of hospital stay and improved cardiac risk factors.

Exercise and heart rate recovery

PURPOSE

This study examines whether heart rate recovery (HRR) improves as a result of exercise training during cardiac rehabilitation (CR).

METHODS

A retrospective study was performed that included 100 patients who completed phase II CR and had entry and exit exercise stress tests. HRR was compared for the sample. Improvements in HRR were compared between gender and age groups. Correlation between age and HRR was performed.

RESULTS

The total sample improved HRR (P = .020). There was no significant difference in the improvement of HRR based on gender, indicating males and females improve at similar rates (P = .833). Similarly, there was no significant difference in the improvement of HRR based on age, indicating older subjects improve similarly to younger subjects (P = .700). There was no relationship between age and HRR; therefore, as age increases there is no decrease in HRR.

CONCLUSION

HRR improves in patients who complete CR.

Psychosocial predictors of cardiac rehabilitation quality-of-life outcomes

OBJECTIVE

This study investigated hostility, social support, coping, depression, and their contributions to concurrent and posttreatment quality of life (QoL) among a group of patients participating in a 6-week cardiac rehabilitation program.

METHOD

Both direct and mediational relationships among psychosocial factors, QoL baseline, and QoL outcome were examined using structural equation modeling analysis, while age, education, and severity of illness (risk for future event) were controlled.

RESULTS

The final model was well supported (chi(2)=64.88, df=56, P>.05; CFI=.99, RMSEA=.04). Results indicated that baseline QoL, hostility, and depressive symptom severity directly and independently predicted QoL outcome, while depression and hostility were also associated with baseline QoL. Hostility, social support, and maladaptive coping also contributed to baseline and follow-up QoL by their associations with depression.

CONCLUSION

Psychosocial characteristics were interrelated, and they predicted postrehabilitation QoL outcome directly or indirectly through depression symptom severity.

Women in cardiac rehabilitation: outcomes and identifying risk for dropout

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A randomized clinical trial of hospital-based, comprehensive cardiac rehabilitation versus usual care for patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease (the DANREHAB trial)--design, intervention, and population

BACKGROUND

Current guidelines broadly recommend comprehensive cardiac rehabilitation (CR), although evidence for this is still limited. It is not known whether evidence from before 1995 is still valid.

STUDY DESIGN

The DANish Cardiac ReHABilitation (DANREHAB) trial was designed as a centrally randomized clinical trial to clarify whether hospital-based comprehensive CR is superior to usual care for patients with congestive heart failure, ischemic heart disease, or high risk for ischemic heart disease. A combined primary outcome measure included total mortality, myocardial infarction, or readmissions due to heart disease based on linkage to public registries. The CR was an individually tailored, multidisciplinary program (6 weeks of intensive CR and 12 months of follow-up) including patient education, exercise training, dietary counseling, smoking cessation, psychosocial support, risk factor management, and clinical assessment.

STUDY POPULATION

Of 5060 discharged patients, 1614 (32%) were eligible for the trial and 770 patients were randomized (47% of those eligible). Participants were younger (P < .001) and had less comorbidity than nonparticipants (P < .03).

CONCLUSION

Our trial shows that a large-scale, centrally randomized clinical trial on comprehensive CR can be conducted among a broadly defined patient group, but reaching the stipulated number of 1800 patients was difficult. Although the study included relatively many women and older people, elderly patients and patients with high comorbidity were underrepresented, which may influence the external validity.

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.