Cardiac rehabilitation: socially deprived patients are less likely to attend but patients ineligible for thrombolysis are less likely to be invited

Prognostic Value of Serial N-Terminal Pro-Brain Natriuretic Peptide Testing in Patients With Acute Myocardial Infarction

Natriuretic peptides (NPs) are important predictors of outcomes in patients with acute myocardial infarction (AMI) but can change over time. The association of patterns of NP changes after AMI on outcomes is less clear. We measured N-terminal pro-brain natriuretic peptide (NT-proBNP) during the AMI admission and at 1 month in a prospective AMI registry. Outcomes included 1-year readmission and 2-year mortality. An elevated NT-proBNP was defined using age-specific criteria. Patients were classified into 3 groups (low/low [referent group], high/low, high/high) based on NT-proBNP value at enrollment and 1 month. The incremental predictive value of NT-proBNP was determined after adjusting for 6-month GRACE risk score, diabetes, and ejection fraction <40%. Among 773 patients, 303 (38%) were low/low, 240 (30%), and were high/high, 230 (29%) were high/low. Two-year mortality was highest in high/high patients but similar in the high/low and low/low patients (13.1% vs 2.7% and 2.3%, respectively). Similarly, readmission was significantly more likely in the high/high versus the high/low and low/low groups. After adjustment, mortality was significantly higher in the high/high group (hazard ratio 4.02, 95% CI 1.67 to 9.66) compared with the low/low group, although readmission was no longer statistically different (hazard ratio 1.37, 95% CI 0.93 to 2.03). In conclusion, a persistently elevated NT-proBNP assessed 1 month after discharge was associated with a higher risk of mortality in patient with AMI. Postdischarge risk stratification using NT-proBNP has the potential to identify higher risk patients after AMI.

Effect of Socioeconomic Status on Propensity to Change Risk Behaviors Following Myocardial Infarction: Implications for Healthy Lifestyle Medicine

Failure to change risk behaviors following myocardial infarction (MI) increases the likelihood of recurrent MI and death. Lower-socioeconomic status (SES) patients are more likely to engage in high-risk behaviors prior to MI. Less well known is whether propensity to change risk behaviors after MI also varies inversely with SES. We performed a systematized literature review addressing changes in risk behaviors following MI as a function of SES. 2160 abstracts were reviewed and 44 met eligibility criteria. Behaviors included smoking cessation, cardiac rehabilitation (CR), medication adherence, diet, and physical activity (PA). For each behavior, lower-SES patients were less likely to change after MI. Overall, lower-SES patients were 2 to 4 times less likely to make needed behavior changes (OR's 0.25-0.56). Lower-SES populations are less successful at changing risk behaviors post-MI. Increasing their participation in CR/secondary prevention programs, which address multiple risk behaviors, including increasing PA and exercise, should be a priority of healthy lifestyle medicine (HLM).

Predictors of Cardiac Rehabilitation Utilization in England: Results From the National Audit

BACKGROUND

Cardiac rehabilitation (CR) is grossly underused, with major inequities in access. However, use of CR and predictors of initiation in England where CR contracting is available is unknown. The aims were (1) to investigate CR utilization rates in England, and (2) to determine sociodemographic and clinical factors associated with CR initiation including social deprivation.

METHODS AND RESULTS

Data from the National Audit of CR, between January 2012 and November 2015, were used. Utilization rates overall and by deprivation quintile were derived. Logistic regression was performed to identify predictors of initiation among enrollees, using the Huber-White-sandwich estimator robust standard errors method to account for the nested nature of the data. Of the 234 736 (81.5%) patients referred to CR, 141 648 enrolled, 97 406 initiated CR, and of those initiating, 37.2% completed a program of ≥8 weeks duration. The significant characteristics associated with CR initiation were younger age (odds ratio [OR] 0.98, 95% CI 0.98-0.99), having a partner (OR 1.31, 95% CI 1.17-1.48), not being employed (OR 0.86, 95% CI 0.77-0.96), not having diabetes mellitus (OR 0.84, 95% CI 0.77-0.92), greater anxiety (OR 1.02, 95% CI 1.003-1.04), not being a medically managed myocardial infarction patient (OR 0.57, 95% CI 0.42-0.76), and having had coronary artery bypass graft surgery (OR 1.64, 95% CI 1.09-2.47).

CONCLUSIONS

CR enrollment does not meet English National Health Service targets; however it compares with that in other countries. Evidence-based approaches increasing CR enrollment and initiation should be applied, focusing on the identified characteristics associated with CR initiation, specifically older, single, employed individuals with diabetes mellitus and those not revascularized.

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.

Psychological Morbidity after Myocardial Infarction in an Area of Deprivation in the UK: Evaluation of a Self-Help Package

BACKGROUND

Psychological morbidity after an acute myocardial infarction (AMI) is known to be common, but can be addressed by appropriate rehabilitation. The area in which this research was conducted experiences high rates of deprivation and of coronary heart disease and limited access to hospital-based rehabilitation. Responding to concern about psychological needs of AMI patients, a self-help package was introduced and evaluated alongside standard hospital-based cardiac rehabilitation.

AIMS

To evaluate the impact of a home-based self-help package (the Heart Manual), alongside existing cardiac rehabilitation provision, on psychological morbidity and health status after AMI. A secondary aim was to assess the suitability of the Heart Manual for older patients aged over 80 years.

METHODS

A controlled observational study, comparing two cohorts of patients discharged from hospital after AMI. The intervention group was given the self-help package in addition to standard care. The control group received standard care alone. Outcome measures used were the Hospital Anxiety and Depression Scale and the EuroQol.

RESULTS

The intervention group showed significant improvement in anxiety and depression scores after 3 months and nonsignificant improvement in general health status. Patients who attended hospital-based rehabilitation classes, and those aged over 80 years, also benefited from the intervention.

CONCLUSION

A home-based self-help rehabilitation package is an effective tool alongside hospital-based rehabilitation classes and can be given to all age groups.

Socioeconomic inequalities in access to treatment for coronary heart disease: A systematic review

Strong socioeconomic inequalities exist in cardiovascular mortality and morbidity. The current review aims to synthesize the current evidence on the association between socioeconomic status (SES) and access to treatment of coronary heart disease (CHD). We examined quantitative studies analyzing the relationship between SES and access to CHD treatment that were published between 1996 and 2015. Our data sources included Medline and Web of Science. Our search yielded a total of 2066 records, 57 of which met our inclusion criteria. Low SES was found to be associated with low access to coronary procedures and secondary prevention. Access to coronary procedures, especially coronary angiography, was mainly related to SES to the disadvantage of patients with low SES. However, access to drug treatment and cardiac rehabilitation was only associated with SES in about half of the studies. The association between SES and access to treatment for CHD was stronger when SES was measured based on individual-level compared to area level, and stronger for individuals living in countries without universal health coverage. Socioeconomic inequalities exist in access to CHD treatment, and universal health coverage shows only a minor effect on this relationship. Inequalities diminish along the treatment pathway for CHD from diagnostic procedures to secondary prevention. We therefore conclude that CHD might be underdiagnosed in patients with low SES. Our results indicate that there is an urgent need to improve access to CHD treatment, especially by increasing the supply of diagnostic angiographies, to reduce inequalities across different healthcare systems.

Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation

Background

A strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.

Objectives

To generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.

Design

Cross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).

Results

The utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.

Conclusions

We found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The impact of social deprivation on mortality following acute myocardial infarction, stroke or subarachnoid haemorrhage: a record linkage study

Background

The impact of social deprivation on mortality following acute myocardial infarction (AMI), stroke and subarachnoid haemorrhage (SAH) is unclear. Our objectives were, firstly, to determine, for each condition, whether there was higher mortality following admission according to social deprivation and secondly, to determine how any higher mortality for deprived groups may be correlated with factors including patient demographics, timing of admission and hospital size.

Methods

Routinely collected, linked hospital inpatient, mortality and primary care data were analysed for patients admitted as an emergency to hospitals in Wales between 2004 and 2011 with AMI (n = 30,663), stroke (37,888) and SAH (1753). Logistic regression with Bonferroni correction was used to examine, firstly, any significant increases in mortality with social deprivation quintile and, secondly, the influence of patient demographics, timing of admission and hospital characteristics on any higher mortality among the most socially deprived groups.

Results

Mortality was 14.3 % at 30 days for AMI, 21.4 % for stroke and 35.6 % for SAH. Social deprivation was significantly associated with higher mortality for AMI (25 %; 95 % CI = 12 %, 40 %) higher for quintile V compared with I), stroke (24 %; 14 %, 34 %), and non-significantly for SAH (32 %; −7 %, 87 %).

The higher mortality at 30 days with increased social deprivation varied significantly according to patient age for AMI patients and time period for SAH. It was also highest for both AMI and stroke patients, although not significantly for female patients, for admissions on weekdays and during autumn months.

Conclusions

We have demonstrated a positive association between social deprivation and higher mortality following emergency admissions for both AMI and stroke. The study findings also suggest that the influence of patient demographics, timing of admission and hospital size on social inequalities in mortality are quite similar for AMI and stroke.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-015-0045-x) contains supplementary material, which is available to authorized users.

Does pain severity guide selection to multimodal pain rehabilitation across gender?

BACKGROUND

Studies have addressed the effect of multimodal pain rehabilitation (MMR), whereas criteria for selection are sparse. This study examines whether higher scores on musculoskeletal pain measures are associated with selection to MMR, and whether this differs across gender.

METHOD

A clinical population of 262 male and 589 female patients was recruited consecutively during 3 years, 2007-2010. The patients were referred from primary care to a pain rehabilitation clinic in Northern Sweden for assessment and selection to MMR. Register-based data on self-reported pain were linked to patients' records where outcome (MMR or not) was stated. We modelled odds ratios for selection to MMR by higher scores on validated pain measures (pain severity, interference with daily life, pain sites and localized pain vs. varying pain location). Covariates were age, educational level and multiple pain measures. Anxiety and depression (Hospital, Anxiety and Depression Scale) and working status were used in sensitivity tests.

RESULTS

Higher scores of self-reported pain were not associated with selection to MMR in multivariate models. Among women, higher scores on pain severity, pain sites and varying pain location (localized pain = reference) were negatively associated with selection to MMR. After adjustment for multiple pain measures, the negative odds ratio for varying location persisted (OR = 0.59, 95% CI = 0.39-0.89).

CONCLUSION

Higher scores on self-reported pain did not guide selection to MMR and a negative trend was found among women. Studies of referral patterns and decision processes may contribute to a better understanding of the clinical practice that decides selection to MMR.

Low-educated women with chronic pain were less often selected to multidisciplinary rehabilitation programs

Background

There is a lack of research about a potential education-related bias in assessment of patients with chronic pain. The aim of this study was to analyze whether low-educated men and women with chronic pain were less often selected to multidisciplinary rehabilitation than those with high education.

Methods

The population consisted of consecutive patients (n = 595 women, 266 men) referred during a three-year period from mainly primary health care centers for a multidisciplinary team assessment at a pain rehabilitation clinic at a university hospital in Northern Sweden. Patient data were collected from the Swedish Quality Registry for Pain Rehabilitation National Pain Register. The outcome variable was being selected by the multidisciplinary team assessment to a multidisciplinary rehabilitation program. The independent variables were: sex, age, born outside Sweden, education, pain severity as well as the hospital, anxiety and depression scale (HADS).

Results

Low-educated women were less often selected to multidisciplinary rehabilitation programs than high-educated women (OR 0.55, CI 0.30–0.98), even after control for age, being born outside Sweden, pain intensity and HADS. No significant findings were found when comparing the results between high- and low-educated men.

Conclusion

Our findings can be interpreted as possible discrimination against low-educated women with chronic pain in hospital referrals to pain rehabilitation. There is a need for more gender-theoretical research emphasizing the importance of taking several power dimensions into account when analyzing possible bias in health care.

Long-term survival among older patients with myocardial infarction differs by educational level: results from the MONICA/KORA myocardial infarction registry

Background

Socioeconomic disparities in survival after acute myocardial infarction (AMI) have been found in many countries. However, population-based results from Germany are lacking so far. Thus, the objective of this study was to examine the association between educational status and long-term mortality in a population-based sample of people with AMI.

Methods

The sample consisted of 2,575 men and 844 women, aged 28–74 years, hospitalized with a first-time AMI between 1 January 2000 and 31 December 2008, recruited from a population-based AMI registry. Patients were followed up until December 2011. Data on education, risk factors and co-morbidities were collected by individual interviews; data on clinical characteristics and AMI treatment by chart review. Cox proportional hazards models were used to assess the relationship between educational status and long-term mortality.

Results

During follow-up, 19.1% of the patients with poor education died compared with 13.1% with higher education. After adjustment for covariates, no effect of education on mortality was found for the total sample and for patients aged below 65 years. In older people, however, low education level was significantly associated with increased mortality (hazard ratio (HR) 1.44, 95% confidence interval (CI) 1.05–1.98, p = 0.023). Stratified analyses showed that women older than 64 years with poor education were significantly more likely to die than women in the same age group with higher education (HR 1.57, 95% CI 1.02–2.41, p = 0.039).

Conclusions

Elderly, poorly educated patients with AMI, and particularly women, have poorer long-term survival than their better educated peers. Further research is required to illuminate the reasons for this finding.

Racial disparities in cardiac rehabilitation initiation and the effect on survival

OBJECTIVES

To examine predictors of initiation and adherence, identify racial disparities, and compare the survival benefit of cardiac rehabilitation between a white and a unique predominantly non-white minority in an urban environment.

DESIGN

A retrospective cohort study.

SETTING

The outpatient cardiac rehabilitation program at Montefiore Medical Center, Bronx, New York.

PATIENTS

Consecutive patients (n = 822) referred to outpatient cardiac rehabilitation were evaluated.

METHODS

Baseline characteristics and outcomes were ascertained from medical records. Multivariate logistic regression was used to examine the association among initiation, age, gender, race, reason for referral, and copayment. Kaplan-Meier analysis was performed to evaluate mortality outcomes.

MAIN OUTCOME MEASUREMENTS

Racial disparities in rates of initiation, adherence and completion, and survival benefit associated with cardiac rehabilitation.

RESULTS

Among 822 patients referred (51.5% non-white minorities, 61.1% male), 59.4% initiated cardiac rehabilitation. Non-white minorities initiated cardiac rehabilitation less often than did white patients (54.4% versus 65.2%, P = .003). After adjustment, white patients were 77.5% more likely to initiate cardiac rehabilitation (odds ratio 1.78; 95% confidence interval 1.13-2.80). Both white populations and non-white minorities who participated in cardiac rehabilitation had a lower risk of death (P = .0022).

CONCLUSIONS

In a predominantly minority population, racial disparities exist among cardiac rehabilitation participants. Minorities were less likely to initiate cardiac rehabilitation. Gender, referral patterns, and the presence of copayment did not influence initiation. Cardiac rehabilitation initiation was associated with decreased mortality.

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.

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 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.

Geographic issues in cardiac rehabilitation utilization: a narrative review

OBJECTIVE

The purpose of this study was to review the current evidence regarding the relationship between geographic indicators and cardiac rehabilitation (CR) utilization among coronary heart disease (CHD) patients.

RESULTS

Seventeen articles were identified for inclusion, where nine studies assessed rurality, 10 studies assessed travel time/distance, and two of these studies assessed both. Nine of the 17 studies (52.9%) showed a significant negative relationship between geographic barrier and CR use. Four of the 17 studies (23.5%) showed a null relationship, while four studies (23.5%) showed mixed findings. Inconsistent findings identified appeared to be related to restricted geographic range, regional density, and socioeconomic status.

CONCLUSIONS

Overall, 52.9% of the identified studies reported a significant negative relationship between geographic indicators and CR utilization. This relationship appeared to be particularly consistent in North American and Australian settings, but somewhat less so in the United Kingdom where there is greater population density and availability of public transport.

Drive time to cardiac rehabilitation: at what point does it affect utilization?

BACKGROUND

A 30 minute drive time threshold has often been cited as indicative of accessible health services. Cardiac rehabilitation (CR) is a chronic disease management program designed to enhance and maintain cardiovascular health, and geographic barriers to utilization are often cited. The purpose of this study was to empirically test the drive time threshold for CR utilization.

METHODS

A prospective study, using a multi-level design of coronary artery disease outpatients nested within 97 cardiologists. Participants completed a baseline sociodemographic survey, and reported CR referral, enrollment and participation in a second survey 9 months later. CR utilization was verified with CR sites. Geographic information systems were used to generate drive times at 60, 80 and 100% of the speed limit to the closest CR site from participants' homes, to take into consideration various traffic conditions. Bivariate analysis was used to test for differences in CR referral, enrollment and degree of participation by drive time. Logistic regression was used to test drive time increments where significant differences were found.

RESULTS

Drive times were generated for 1209 outpatients. Overall, CR referral was verified for 523 (43.3%) outpatients, with verified enrollment for 444 (36.7%) participating in a mean of 86.4 +/- 25.7% of prescribed sessions. There were significant differences in CR referral and enrollment by drive time (ps < .01), but not degree of participation. Logistic regression analysis (ps < .001) revealed that the drive time threshold at 80% of the posted speed limit for physician referral may be 60 minutes (OR = .26, 95% CI: 0.13-0.55), and the threshold for patient CR enrollment may also be 60 minutes (OR = .11, 95% CI: 0.04-0.33).

CONCLUSIONS

Physicians may be taking geography into consideration when referring patients to CR. Empirical consideration also reveals that patients are significantly less likely to enroll in CR where they must drive 60 minutes or more to the closest program. Once enrolled, distance has no significant effect on degree of participation.

Improving care in cardiac rehabilitation for minority ethnic populations

INTRODUCTION

In the United Kingdom (UK) ethnic minority groups from the Indian sub-continent (India, Pakistan and Bangladesh) are at increased risk of coronary heart disease (CHD) related mortality and morbidity. The aim of this study was to assess the variation in recording of clinical data by ethnicity following the implementation of an electronic centralised cardiac rehabilitation register in the North West of England.

METHODS

Data were collected over 18 months for all individuals (n=1993) assessed for entry into the cardiac rehabilitation programme. Analysis of the recording of clinical data was undertaken by ethnicity with adjustment for gender, age group and deprivation.

RESULTS

Most patients on the database had their ethnicity recorded (94.4%). South Asians (Indian, Pakistani and Bangladeshi) were less likely to have clinical data items recorded compared to the majority White British group. The disparity in recording of clinical data was most marked for the Hospital Anxiety and Depression Scale score (adjusted OR 0.16, 95% CI 0.07-0.36), body mass index (adjusted OR 0.54, 95% CI 0.37-0.79), pulse (0.60, 95% CI 0.42-0.88), blood glucose (adjusted OR 0.64, 95% CI 0.44-0.93) and cholesterol (adjusted OR 0.64, 965% CI 0.44-0.95).

CONCLUSION

Recording of clinical data relevant to successful cardiac rehabilitation was poorer among South Asian patients.

The involvement of pharmacists in cardiac rehabilitation: a review of the literature

Objective

To identify, review and evaluate the literature regarding the role of the pharmacist in cardiac rehabilitation (CR).

Method

Electronic databases searched up to October 2004 were Medline, Pharmline, Iowa Drug Information service, International Pharmacy Abstracts, Embase, Scanners and Web of Science. Reference lists of identified papers were searched and a Zetoc email alert was created to identify additional papers. Papers were included only if they referred specifically to a CR programme or CR patients, and also referred to the involvement of pharmacists or concerned pharmacy practice research. Reports were not excluded on the basis of quality, however reports that met the criteria for inclusion were allocated an evidence grade to indicate quality.

Key findings

Thirteen reports were identified, of which six reports were purely descriptive accounts of pharmacists' involvement in CR (all were from the US) and seven were evaluative reports (four from the US, two from the UK and one from Canada). Descriptions of the involvement of pharmacists in CR included providing medicines information and education to patients, and optimising drug therapy. The lack of substantial research was notable among the evaluative reports. One study found quality of life and economic benefits as a result of the involvement of a pharmacist in CR, and another found that health professionals provide most of the medicines information and education required by CR patients. However these studies were weakened by a lack of meaningful outcome measures.

Conclusion

There is insufficient evidence on which to base firm conclusions about the effectiveness of the involvement of pharmacists in CR. This has implications for pharmacy practitioners, researchers and policymakers in CR.

The association between deprivation and hospital mortality for admissions to critical care units in England

INTRODUCTION

Few studies have investigated the association between level of social deprivation and acute hospital outcome for admissions to adult general critical care units. It is important to be aware if an association exists because risk prediction models do not adjust for deprivation.

MATERIALS AND METHODS

Deprivation was measured using the Index of Multiple Deprivation (IMD) 2004, developed using 2001 census data in England. Eighty-four thousand four hundred twenty-three admissions to 138 adult general critical care units in England were selected from the Case Mix Programme Database from 1 year before to 1 year after the census date and linked to the IMD using postcodes. Logistic regression analysis was used to investigate a possible association between quintile of IMD and acute hospital mortality.

RESULTS

As deprivation increased, acute hospital mortality also increased (P < .001). This association remained after adjusting for age, sex, acute severity, medial history, source of admission, and reason for admission to critical care (adjusted odds ratio for most vs least deprived quintile, 1.19; 95% confidence interval, 1.10-1.28).

CONCLUSIONS

There is an association between increasing deprivation and increasing risk of mortality for admissions to adult general critical care unit units in England. Further research is required to identify other unmeasured potential confounders (eg, smoking, alcohol consumption) as possible explanations for this association.

Interaction between income and education in predicting long-term survival after acute myocardial infarction

Background

Population-based data on the impact of socioeconomic status (SES) on long-term survival after myocardial infarction (Ml) are lacking. We evaluated the association of income and education with all-cause mortality and cardiac mortality post-MI and assessed income-by-education interaction.

Design

Prospective cohort study.

Methods

Between February 1992 and February 1993, 1521 consecutive patients aged 65 years or less (19% women) discharged from all hospitals in central Israel after incident acute MI were enrolled and followed up through December 2005. Data on SES indicators, cardiovascular risk factors, MI characteristics and severity, comorbidities, and acute treatment were assessed at baseline.

Results

Low SES, as defined by income and education, was associated with older age, female sex, and higher prevalence of risk factors and comorbidities. Further, low SES patients presented with more severe disease and received fewer cardiac procedures and medications. During follow-up, 427 patients died. Income and education strongly interacted ( P = 0.003). The hazard ratio for death associated with income (below average vs. average/above average) was considerably higher for less educated (≤12 years) patients [2.64, 95% confidence interval (CI): 1.92–3.63] than for more educated (≥12 years) patients (1.53, 95% CI: 1.02–2.29). Adjustment for various prognostic indicators attenuated these estimates, yet excess risk persisted for the less educated group (hazard ratio = 1.58, 95% CI: 1.13–2.21). Similar patterns were noted for cardiac mortality.

Conclusion

Among patients with incident MI, low SES is related to higher risk profile and poorer treatment. Low income is associated with a large increase in mortality risk when accompanied by low education, suggesting a double jeopardy phenomenon.

Contribution of patient and physician factors to cardiac rehabilitation referral: a prospective multilevel study

BACKGROUND

Cardiac rehabilitation (CR), in most developed countries, is a proven means of reducing mortality but it is grossly underutilized owing to factors involving both the health system and patients. These issues have not been investigated concurrently. To this end, we employed a hierarchical design to investigate physician and patient factors that affect verified CR referral.

METHODS

This study was prospective with a multilevel design. We assessed 1,490 outpatients with coronary artery disease attending 97 cardiology practices. Cardiologists completed a survey about attitudes to CR referral. Outpatients were surveyed prospectively to assess sociodemographic, clinical, behavioral, psychosocial and health system factors that affected CR referral. Responses were analyzed by mixed logistic regression analyses. After 9 months, CR referral was verified at 40 centers.

RESULTS

Health-care providers referred 550 (43.4%) outpatients to CR. Factors affecting verified referral included positive physician perceptions of CR (P = 0.03), short distance to the closest CR site (P = 0.003), the perception of fewer barriers to CR (P < 0.001) and a sense of personal control over their condition by the patient (P = 0.001).

CONCLUSIONS

Physician-related and patient-related factors both contribute to CR referral. The most relevant physician perceptions of such programs are program quality and perceived benefit. For patients, the most relevant factors are perceived barriers to CR, which might be conveyed during prereferral discussions. Work to improve physicians' perceptions and patients' understanding might improve use of rehabilitation services.

Neighborhood income and individual education: effect on survival after myocardial infarction

OBJECTIVE

To evaluate the association of neighborhood-level income and individual-level education with post-myocardial infarction (MI) mortality in community patients.

PARTICIPANTS AND METHODS

From November 1, 2002, through May 31, 2006, 705 (mean+/-SD age, 69+/-15 years; 44% women) residents of Olmsted County, MN, who experienced an MI meeting standardized criteria were prospectively enrolled and followed up. The neighborhood's median household income was estimated by census tract data; education was self-reported. Demographic and clinical variables were obtained from the medical records.

RESULTS

Living in a less affluent neighborhood and having a low educational level were both associated with older age and more comorbidity. During follow-up (median, 13 months), 155 patients died. Neighborhood income (hazard ratio [HR], 2.10; 95% confidence interval [CI], 1.42-3.12; for lowest [median, $34,205] vs highest [median, $60,652] tertile) and individual education (HR, 2.21; 95% CI, 1.47-3.32; for <12 vs >12 years) were independently associated with mortality risk. Adjustment for demographics and various post-MI prognostic indicators attenuated these estimates, yet excess risk persisted for low neighborhood income (HR, 1.62; 95% CI, 1.08-2.45). Modeled as a continuous variable, each $10,000 increase in annual income was associated with a 10% reduction in mortality risk (adjusted HR, 0.90; 95% CI, 0.82-0.99).

CONCLUSION

In this geographically defined cohort of patients with MI, low individual education and poor neighborhood income were associated with a worse clinical presentation. Poor neighborhood income was a powerful predictor of mortality even after controlling for a variety of potential confounding factors. These data confirm the socioeconomic disparities in health after MI.

Ethnicity and cardiovascular disease prevention in the United Kingdom: a practical approach to management

The United Kingdom is a diverse society with 7.9% of the population from black and minority ethnic groups (BMEGs). The causes of the excess cardiovascular disease (CVD) and stroke morbidity and mortality in BMEGs are incompletely understood though socio-economic factors are important. However, the role of classical cardiovascular (CV) risk factors is clearly important despite the patterns of these risk factors varying significantly by ethnic group. Despite the major burden of CVD and stroke among BMEGs in the UK, the majority of the evidence on the management of such conditions has been based on predominantly white European populations. Moreover, the CV epidemiology of African Americans does not represent well the morbidity and mortality experience seen in black Africans and black Caribbeans, both in Britain and in their native African countries. In particular, atherosclerotic disease and coronary heart disease are still relatively rare in the latter groups. This is unlike the South Asian diaspora, who have prevalence rates of CVD in epidemic proportions both in the diaspora and on the subcontinent. As the BMEGs have been under-represented in research, a multitude of guidelines exists for the 'general population.' However, specific reference and recommendation on primary and secondary prevention guidelines in relation to ethnic groups is extremely limited. This document provides an overview of ethnicity and CVD in the United Kingdom, with management recommendations based on a roundtable discussion of a multidisciplinary ethnicity and CVD consensus group, all of whom have an academic interest and clinical practice in a multiethnic community.

Falling through the net of stroke care

The provision of healthcare services has been shown to differ by social characteristics such as gender, age and social status. The processes by which such differences arise are unclear. We report findings from a qualitative interview study with stroke service providers undertaken during an investigation of inequalities in stroke care. We interviewed 41 professionals from hospital and community settings in south London. Participants' accounts are used to explore how it is that patients' trajectories of care might not follow evidence-based guidelines, focusing on stroke unit admission, provision of hospital rehabilitation therapies and community health and social services. Categories of patients who might not receive best care were people who were cognitively impaired, those regarded as having 'complex problems', those with communication problems and younger people. Additionally, the local availability of services was thought to affect individuals' chances of receiving particular components of care. Although professionals spoke of certain types of patients as 'falling through the net' (of services), their accounts suggest that they channel patients through services according to an implicit template of the individual suited to the service. Those who do not fit the service as currently resourced may have reduced access to specific components of care. If inequalities in access to care are to be addressed we require a better understanding of how professionals' decision-making processes test the fit between service users and the implicit template of 'suitable' patient or client.

Improving evidence based cardiac care and policy implementation over the patient journey: the potential of coronary heart disease registers

Coronary heart disease registers offer considerable potential for providing increased support for practitioners, facilitating improvements in patient care, and allowing efficient monitoring of care provision and outcomes.

Factors affecting the uptake of cardiac rehabilitation services in a rural locality

INTRODUCTION

A number of studies have investigated factors affecting uptake of cardiac rehabilitation services. However, little information on factors affecting uptake of services in rural localities is available.

STUDY DESIGN

A cross-sectional survey.

METHODS

A survey of patients eligible for cardiac rehabilitation was undertaken to investigate uptake of services. The effects of individual and geographic factors on service utilization were explored.

RESULTS

Utilization rates for cardiac rehabilitation services within the South Staffordshire locality are low, with 59.3% of eligible patients invited to attend cardiac rehabilitation services following discharge from hospital, 38.6% attending and 22.5% completing the programme. Two factors were independently associated with low service utilization. Patients under the age of 65 years are 1.90 [95% confidence intervals (CI) 1.01-3.65] times more likely to complete rehabilitation than patients aged over 65 years, and women are only 0.48 (95% CI 0.22-1.03) times as likely as men to complete rehabilitation. The major reported barrier to utilization of services was access. This included problems with public transport, parking and the time and location of classes. Access and medical problems were significantly higher in older people and may have contributed to their low overall completion rate. Electoral ward deprivation, geographical access score, living in an urban or rural electoral ward, electoral ward of residence and provider were not significantly associated with service utilization.

CONCLUSIONS

Overall, utilization rates were low. No geographical factors were associated with uptake of services, although the possible effect may have been mediated by the relative affluence of the locality. Two individual factors, age and sex, were most likely to influence uptake.

The impact of social deprivation on chronic back pain outcomes

Chronic low back pain is the commonest cause of disability for adults of working age. It is a complex problem frequently encapsulated as a bio-psychosocial issue, yet the social element has received less attention than it deserves, particularly for low-income and socially deprived patients. Rehabilitation programmes are often based on increasing function through cognitive and behavioural techniques, which, for many reasons, may be less effective for the socially disadvantaged. In this paper we discuss the potential barriers to successful rehabilitation in socially deprived groups and we look at possible factors that may need to be considered when designing interventions.

Socioeconomic Status and Outcome From Intensive Care in England and Wales

OBJECTIVE

The objective of this study was to estimate the association between socioeconomic status (SES) and outcome for admissions to intensive care.

RESEARCH DESIGN

Retrospective cohort study.

SUBJECTS

We studied 51,572 admissions to 99 intensive-care units in England and Wales between 1995 and 2000.

MEASURES

The SES of admissions was measured using Carstairs deprivation scores. Outcome was hospital mortality after adjustment for case mix using the APACHE II method.

RESULTS

Admissions of lower SES were, on average, younger and less likely to be following surgery. There was evidence of a SES gradient for hospital mortality in admissions after elective surgery after adjusting for case mix (test for trend P <0.001), with higher SES associated with lower mortality. In the least-deprived quintile of SES, the odds ratio for hospital mortality was 0.70 (95% confidence interval, 0.58-0.84) compared with the most deprived quintile. There was no evidence of a SES gradient for hospital mortality in nonsurgical or emergency surgical admissions, and the decision to withdraw active treatment did not differ by SES.

CONCLUSIONS

There is a SES gradient for hospital mortality in elective surgical admissions that is not explained by differences in case mix or the withdrawal of active treatment. Further research is required to establish if this finding can be explained by unmeasured differences in health status at admission to an intensive-care unit or differences in care and to establish the potential impact these results may have on interpreting comparative surgical performance data.

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.

Capacity and equity in cardiac rehabilitation in the eastern region: good and bad news

AIM

To document current baseline eligibility for Phase 3 cardiac rehabilitation (CR) and the capacity to meet this need in hospitals in the Eastern Regional Health Authority.

METHODS

Information on the eligible population and the capacity for CR was collected in all nine hospitals retrospectively (February-March 2001).

RESULTS

Forty-seven per cent of eligible patients were invited to participate with only two-thirds attending. Completion rates were very high (89%) in attenders. Age and health board area were significant independent predictors of being invited to CR. Gender was not independent of age. Fifty-three per cent of the need for this service was met by capacity in the region's nine hospitals in 2000 rising to 59% in 2002.

CONCLUSIONS

Many eligible patients are not invited to CR. Lack of capacity is a problem. Among the invited, non-participation is a factor. Inequity in age and inter-hospital variation in invitation is noted.

Cardiac rehabilitation: goals, interventions and action plans

Cardiac rehabilitation services are now well established in the UK. There is a growing evidence base for cardiac rehabilitation interventions but, despite this, there remains much variation in service models and delivery. The 'National Service Framework for Coronary Heart Disease' sets out goals for cardiac rehabilitation interventions based on lifestyle change; however, many people do not have access to cardiac rehabilitation towards menu-driven approaches, which may suit individual need more than a standardized approach. Nurses play a crucial role in the delivery of cardiac rehabilitation services and hold the necessary skills and expertise so to do. Future challenges to cardiac rehabilitation include developing increasingly patient-focused services across the boundaries of primary, secondary and social care, and increasing patient and public involvement in services.

Factors Associated With Referral to Outpatient Cardiac Rehabilitation Services

BACKGROUND

Although practice guidelines and policy statements for cardiac rehabilitation recommend that it be offered to all patients with cardiovascular disease, the participation rates in most Western countries are low.

PURPOSE

This study aimed to determine the factors associated with referral to outpatient cardiac rehabilitation in the Hunter region of New South Wales, Australia.

METHODS

The study sample comprised 1933 patients discharged from public hospitals in the Hunter region between March 1, 1998 and February 28, 1999 who were eligible for cardiac rehabilitation, and for inclusion on the Hunter Area Heart and Stroke Register (the Register). Data were obtained from the Register database (gender, age, clinical information) and via a self-completed questionnaire eliciting referral, sociodemographic, and cardiovascular disease risk factor information. Multiple logistic regression analysis was conducted to determine the factors independently associated with referral.

RESULTS

: Of the respondents (1202/1933), 41% (493/1202; 95% confidence interval, 38-44%) reported that they had been referred to outpatient cardiac rehabilitation. The factors independently associated with referral were age younger than 65 years, previous participation in an outpatient cardiac rehabilitation program, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery.

CONCLUSIONS

Younger age, previous participation in outpatient cardiac rehabilitation, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery were associated with referral to cardiac rehabilitation. Research testing strategies designed to increase cardiac rehabilitation referral rates are needed and could include testing the potential role of modern quality management methods.

Attendance and Graduation Patterns in a Group-model Health Maintenance Organization Alternative Cardiac Rehabilitation Program

PURPOSE

Poor rates of participation in cardiac rehabilitation programs are well documented, especially among women and older patients. The Colorado Kaiser Permanente Cardiac Rehabilitation (KPCR) program is a home-based, case-managed, goal-oriented program with an active recruitment process and unlimited program length. This study evaluated the participation rates for the program and the predictors of attendance and graduation.

METHODS

Patients hospitalized with acute myocardial infarction, coronary artery bypass graft, and percutaneous coronary intervention from June 1999 to May 2000 (n = 1030) were identified from the administrative database, and the proportion captured by the KPCR staff was determined. Subsequent attendance and graduation patterns were evaluated.

RESULTS

Nearly 94% of patients with one of the three aforementioned conditions were identified by the rehabilitation staff, and 41% of all patients attended the KPCR program. More than 75% of the patients who participated went on to graduate from the program. Gender comparisons showed no difference in participation between men (66.8%) and women (59.7%) (P =.07). Participation rates were inversely associated with age, yet age was not associated with graduation from the program. Surgical interventions and two or more events experienced within the first 4 weeks of the index event were the strongest predictors of attendance and graduation from the KPCR program.

CONCLUSIONS

Innovative approaches for the capture and retention of patients in cardiac rehabilitation programs are urgently needed. The alternative program evaluated in this study showed little difference in participation between men and women, yet participation among older patients remained poor. Overall, patients who underwent surgical interventions or multiple events were more likely to attend and graduate from the program.

Unmet health needs in patients with coronary heart disease: implications and potential for improvement in caring services

BACKGROUND

Improving the quality of health care services requires tailoring facilities to fulfil patients' needs. Satisfying patients' healthcare needs, listening to patients' opinions and building a closer provider-user partnership are central to the NHS. Few published studies have discussed cardiovascular patients' health needs, but they are not comprehensive and fail to explore the contribution of outcome to needs assessment.

METHOD

A comprehensive self-administered health needs assessment (HNA) questionnaire was developed for concomitant use with generic (Short Form-12 and EuroQOL) and specific (Seattle Angina Questionnaire) health-related quality of life (HRQL) instruments on 242 patients admitted to the Acute Cardiac Unit, Nottingham.

RESULTS

38% reported difficulty accessing health facilities, 56% due to transport and 32% required a travelling companion. Mean HRQOL scores were lower in those living alone (P < 0.05) or who reported unsatisfactory accommodation. Dissatisfaction with transport affected patients' ease of access to healthcare facilities (P < 0.001). Younger patients (<65 y) were more likely to be socially isolated (P = 0.01). Women and patients with chronic disease were more likely to be concerned about housework (P < 0.05). Over 65 s (p < 0.05) of higher social classes (p < 0.01) and greater physical needs (p < 0.001) had more social needs, correlating moderately (0.32 < r < 0.63) with all HRQL domains except SAQ-AS. Several HRQL components were highly correlated with the HNA physical score (p < 0.001).

CONCLUSIONS

Patients wanted more social (suitable accommodation, companionship, social visits) and physical (help aids, access to healthcare services, house work) support. The construct validity and intra-class reliability of the HNA tool were confirmed. Our results indicate a gap between patients' health needs and available services, highlighting potential areas for improvement in the quality of services.

Cardiac rehabilitation with nurse care management and telephonic interactions at a community hospital: program evaluation of participation and lipid outcomes

Cardiac rehabilitation (CR) can help patients with heart disease control some risk factors, limit new coronary artery lesions, and decrease death rates. However, participation rates in CR are low. Using a descriptive design, we evaluated a modified CR program in which nurse care managers used telephonic communication with patients in their homes by comparing it to a traditional CR program in a hospital setting. Using multivariate analysis we compared the patient cohorts eligible for each of the programs, and program participants to the nonparticipants for each program. Compared to traditional CR, the modified CR program with nurse care management was associated with significantly improved participation rates (11% vs. 22%) and the apparent overcoming of several well-described barriers to CR participation (distance from the hospital and domestic isolation). Risk factor management, including testing of serum lipids and achieving goals for lipid reduction, for participants in both CR programs was superior to risk factor management for nonparticipants.

Aerobic exercise and the post myocardial infarction patient: a review of the literature

Meta analyses of randomized controlled tests of cardiac rehabilitation after myocardial infarction demonstrate that regular exercise reduces the risk of overall mortality and cardiovascular mortality. In patients with established coronary artery disease, exercise is associated with improved activity tolerance, modification of risk factors, and improvement in quality of life. Randomized controlled tests demonstrate that whereas older patients after coronary events are substantially less fit than younger patients, they obtain a similar relative improvement of aerobic capacity with a graded conditioning program. However, older adults are enrolled in such programs at a lower rate than other age groups. Despite similar clinical profiles to men, women are less likely to participate in exercise rehabilitation. In this article we discuss the principles of program development, guidelines for monitoring of patients, and facilitation of exercise programs in the Australian context.

'I'm still waiting...': barriers to accessing cardiac rehabilitation services

BACKGROUND

The United Kingdom (UK) National Service Framework for coronary heart disease challenges health services to address existing problems regarding the quality and content of cardiac rehabilitation services. Concern also exists regarding inequalities in access to services. The South Yorkshire Coalfields Health Action Zone (SYCHAZ) funded this study to harness the views and experiences of staff and patients regarding existing services. The intention is to use the information gained to develop acceptable and accessible services for the future.

AIMS

To explore what barriers exist for patients in accessing cardiac rehabilitation services within the South Yorkshire Coalfield locality.

ETHICAL ISSUES AND APPROVAL

Patients were identified and recruited with the assistance of staff responsible for their care. Informed consent was obtained prior to participation. Approval was obtained from the relevant Ethics Committees.

METHODS

Qualitative methods were used, including semi-structured interviews and Framework Analysis techniques. Purposive sampling was used to select participants.

INSTRUMENTS

Semi-structured individual interviews of 15 staff and 20 postmyocardial infarction patients. One group interview with seven health visitors and two with lay members of heart support groups.

OUTCOMES

Barriers to accessing cardiac rehabilitation.

RESULTS

This study revealed a limited service capacity. Big gaps exist between patches of service activity that most patients appear to slip through. Problems in accessing the service were categorized into five themes: absence, waiting, communication, understanding, and appropriateness. Some groups fared worse in terms of access to services, for example women, the elderly and those in traditional working class coalfields communities. Professional and more affluent participants appeared better able to negotiate their way around the system by seeking out advice or 'going private'.

LIMITATIONS

The omission of medical staff and ethnic minority patients.

CONCLUSIONS

Cardiac rehabilitation in the policy targets in UK will only be met with substantial investment to address the barriers identified here.

Preparing for change in the secondary prevention of coronary heart disease: a qualitative evaluation of cardiac rehabilitation within a region of Scotland

BACKGROUND

Secondary prevention of Coronary Heart Disease (CHD) is often poorly managed and its benefits attained in only a minority of those with CHD. Guidelines developed in the United Kingdom and North America suggest that in future cardiac rehabilitation programmes should provide services through individualized programmes that cater for a wide range of conditions associated with CHD. This will involve substantial and costly changes to current programmes that are mostly standardized and for postmyocardial infarction patients. Based on change theory, this study examined the dynamics, strengths and weaknesses of an existing programme in a Scottish region which was due to undergo the changes suggested by guidelines.

AIM

To examine the perceived provision of secondary prevention services for CHD from the perspectives of health professionals within one region in the West of Scotland.

METHODS

A purposive sample of 14 health professionals (eight primary and six secondary care health professionals) was selected to cover a range of professional roles including both specialists and generalists. Separate focus group discussions (2) were held with primary care and secondary care professionals.

FINDINGS

Whilst the health professionals were enthusiastic about CHD prevention and their involvement, they perceived barriers to the success of the existing service as being complex and multifactorial, including patient, social and service-related factors. Although both groups identified motivation as the most influential personal factor, secondary care staff tended to focus on the importance of patient factors in influencing motivation to change, whereas the primary care staff referred more to the cumulative effects of social and cultural factors. Professionals highlighted weaknesses in the transition between hospital and community-based services with regard to the information flow between primary and secondary care.

CONCLUSIONS

Although the study has immediate relevance for the local area, it highlighted issues of more general relevance to cardiac rehabilitation programme development and intersectoral working, such as communications and role perceptions in multi-professional working and the need to adapt services to local socio-economic conditions.

Factors associated with cardiac rehabilitation attendance: a systematic review of the literature

BACKGROUND

Many eligible patients fail to attend cardiac rehabilitation courses.

OBJECTIVE

To undertake a systematic literature review of studies that have investigated factors associated with cardiac rehabilitation attendance.

METHODS

Literature published between 1978 and 2001 was searched using the MEDLINE, PSYCINFO and CINAHL computerized databases. Studies were sought that examined course attendance in eligible patient samples. Studies had to include at least one baseline predictor variable.

RESULTS

Fifteen studies were identified and predictor variables were usually categorized as sociodemographic, medical and psychological. Nonattenders are more likely to be older, to have lower income/greater deprivation, to deny the severity of their illness; they are less likely to believe they can influence its outcome or to perceive that their physician recommends cardiac rehabilitation. Job status, gender and health concerns play an indirect role in attendance behaviour. Comparison of results between studies could be influenced by different case-mix, measurement instruments and country of origin.

CONCLUSION

A number of factors predict cardiac rehabilitation attendance and some of these are potentially modifiable.

Temporal trends and associated factors of inpatient cardiac rehabilitation in patients with acute myocardial infarction: a community-wide perspective

PURPOSE

Cardiac rehabilitation (CR) has been shown to be an important therapeutic intervention after the development of acute myocardial infarction (AMI), but historically has been underused. Inpatient CR often represents cardiac patients' first exposure to risk factor modification education and acts as a gateway to outpatient programs.

METHODS

The authors performed a longitudinal study of the use of inpatient CR in 5204 Worcester residents hospitalized with validated AMI in seven 1-year periods between 1986 and 1997.

RESULTS

The overall rate of referral to inpatient CR was 68%, with a slight decline in use to less than 60% in the authors' most recent study year of 1997. Referred patients were significantly more likely to be younger, male, or enrolled in a health maintenance organization; they were less likely to have a history of heart failure or stroke. They were significantly more likely to receive medications shown to be of benefit in the management of AMI and to undergo cardiac interventional procedures. In 1997, patients participating in inpatient CR were more likely to have documented inpatient counseling about nutrition, exercise, smoking, and stress reduction.

DISCUSSION

The results of this multihospital community-wide study suggest relatively stable, but recently decreasing, use of inpatient CR over the past decade. Women and the elderly are underrepresented in these programs. Patients not referred to inpatient rehabilitation were less likely to be prescribed effective cardiac medications and undergo risk factor modification counseling prior to discharge. Further studies are needed to better understand the reasons for patient exclusion from the benefits of inpatient CR.