Predictors of referral to cardiac rehabilitation and cardiac exercise self-efficacy

Characteristics and correlates of disease-related knowledge and exercise self-efficacy among cardiac patients attending virtual cardiac rehabilitation during the first COVID-19 lockdown in Peru

BACKGROUND

Government responses and restrictions due to the COVID-19 pandemic (e.g., limits to non-urgent health care services, including non-urgent outpatient appointments) led to the suspension of center-based (in-person) cardiac rehabilitation (CR), with many programs switching to virtual delivery. This study aimed to understand the characteristics and correlates of disease-related knowledge and exercise self-efficacy in a group of patients attending a virtual CR program during the first COVID-19 lockdown in Peru.

METHODS

In this prospective observational study, 240 patients receiving virtual CR care (exercise instructions and patient education) between August/2020 and December/2021 completed questionnaires pre- and post-CR assessing disease-related knowledge (CADE-Q SV questionnaire) and self-efficacy (SE; Bandura's Exercise SE scale). Paired t tests were used to investigate changes pre/post-CR and Pearson correlation coefficients were used to determine the association between knowledge/SE and patients' characteristics.

RESULTS

Participants were mainly comprised of men, with a cardiac diagnosis of stable coronary artery disease, who underwent percutaneous coronary intervention or had a known diagnosis of hypertension and with at least one cardiovascular risk factor (95.8%). Mean total knowledge scores improved significantly at post-CR (12.9 ± 2.4 to 15.6 ± 2.0/20; p<0.001), as well as in 4/5 knowledge areas (cardiovascular risk factors, exercise, nutrition, and psychosocial risk; p<0.001). Mean SE scores improved significantly at post-CR (1.9 ± 0.9 to 3.0 ± 0.9/5; p = 0.01). Post-CR knowledge and SE were significantly correlated with cardiac diagnosis and surgical procedures (r = 0.17, p = 0.02 and r = 0.27, p = 0.02, respectively).

CONCLUSIONS

The virtual CR program improved disease-related knowledge and SE of cardiac patients during the first months of the COVID-19 pandemic. Post-CR outcomes were correlated with cardiac diagnosis and surgical procedures and more research with other characteristics is warrantied.

VA FitHeart, a Mobile App for Cardiac Rehabilitation: Usability Study

Background

Cardiac rehabilitation (CR) improves outcomes for patients with ischemic heart disease or heart failure but is underused. New strategies to improve access to and engagement in CR are needed. There is considerable interest in technology-facilitated home CR. However, little is known about patient acceptance and use of mobile technology for CR.

Objective

The aim of this study was to develop a mobile app for technology-facilitated home CR and seek to determine its usability.

Methods

We recruited patients eligible for CR who had access to a mobile phone, tablet, or computer with Internet access. The mobile app includes physical activity goal setting, logs for tracking physical activity and health metrics (eg, weight, blood pressure, and mood), health education, reminders, and feedback. Study staff demonstrated the mobile app to participants in person and then observed participants completing prespecified tasks with the mobile app. Participants completed the System Usability Scale (SUS, 0-100), rated likelihood to use the mobile app (0-100), questionnaires on mobile app use, and participated in a semistructured interview. The Unified Theory of Acceptance and Use of Technology and the Theory of Planned Behavior informed the analysis. On the basis of participant feedback, we made iterative revisions to the mobile app between users.

Results

We conducted usability testing in 13 participants. The first version of the mobile app was used by the first 5 participants, and revised versions were used by the final 8 participants. From the first version to revised versions, task completion success rate improved from 44% (11/25 tasks) to 78% (31/40 tasks; P=.05), SUS improved from 54 to 76 (P=.04; scale 0-100, with 100 being the best usability), and self-reported likelihood of use remained high at 76 and 87 (P=.30; scale 0-100, with 100 being the highest likelihood). In interviews, patients expressed interest in tracking health measures (“I think it’ll be good to track my exercise and to see what I’m doing”), a desire for introductory training (“Initially, training with a technical person, instead of me relying on myself”), and an expectation for sharing data with providers (“It would also be helpful to share with my doctor, it just being a matter of clicking a button and sharing it with my doctor”).

Conclusions

With participant feedback and iterative revisions, we significantly improved the usability of a mobile app for CR. Patient expectations for using a mobile app for CR include tracking health metrics, introductory training, and sharing data with providers. Iterative mixed-method evaluation may be useful for improving the usability of health technology.

Correlates of Exercise Self-efficacy in a Randomized Trial of Mind-Body Exercise in Patients With Chronic Heart Failure

PURPOSE

Exercise self-efficacy is one of the strongest predictors of physical activity behavior. Prior literature suggests that tai chi, a mind-body exercise, may increase self-efficacy; however, this is not extensively studied. Little is known about the factors associated with development of exercise self-efficacy in a population with heart failure.

METHODS

We utilized data from a randomized controlled trial of 12 weeks of group tai chi classes versus education in patients with chronic heart failure (n = 100). Multivariable linear regression was used to explore possible correlates of change in exercise self-efficacy in the entire sample and in the subgroup who received tai chi (n = 50). Covariates included baseline quality of life, social support, functional parameters, physical activity, serum biomarkers, sociodemographics, and clinical heart failure parameters.

RESULTS

Baseline 6-minute walk (β=-0.0003, SE = 0.0001, P = .02) and fatigue score (β= 0.03, SE = 0.01, P = .004) were significantly associated with change in self-efficacy, with those in the lowest tertile for 6-minute walk and higher tertiles for fatigue score experiencing the greatest change. Intervention group assignment was highly significant, with self-efficacy significantly improved in the tai chi group compared to the education control over 12 weeks (β= 0.39, SE = 0.11, P < .001). In the tai chi group alone, lower baseline oxygen uptake (β=-0.05, SE = 0.01, P = .001), decreased mood (β=-0.01, SE = 0.003, P = .004), and higher catecholamine level (epinephrine β= 0.003, SE = 0.001, P = .005) were significantly associated with improvements in self-efficacy.

CONCLUSIONS

In this exploratory analysis, our initial findings support the concept that interventions like tai chi may be beneficial in improving exercise self-efficacy, especially in patients with heart failure who are deconditioned, with lower functional status and mood.

Factors Associated With Utilization of Cardiac Rehabilitation Among Patients With Ischemic Heart Disease in the Veterans Health Administration: A QUALITATIVE STUDY

BACKGROUND

Cardiac rehabilitation (CR) programs reduce morbidity and mortality in patients with ischemic heart disease but are vastly underutilized in the United States, including the Veterans Health Administration (VA) Healthcare System. Numerous barriers affecting utilization have been identified in other health care systems, but the specific factors affecting Veterans are unknown. We sought to identify barriers and facilitators associated with utilization of CR in VA facilities.

METHODS

We performed a qualitative study of 56 VA patients, providers, and CR program managers at 30 VA facilities across the United States. We conducted semistructured interviews with key informants to explore their attitudes and knowledge toward CR. Interviews were conducted until thematic saturation occurred. Analyses using grounded theory to identify key themes were conducted using the qualitative data analysis package ATLAS.ti.

RESULTS

We identified 6 themes as barriers and 5 as facilitators. The most common barriers to participation in CR were patient transportation issues (68%), lack of patient willingness to participate (41%), and no access to a nearby VA hospital with a CR program (30%). The most common facilitators were involvement of a dedicated provider or "clinical champion" (50%), provider knowledge of or experience with CR (48%), and patient desire for additional medical support (32%).

CONCLUSIONS

Our findings suggest that addressing access issues and educating and activating providers on CR may increase utilization of CR programs. Targeting these specific factors may improve utilization of CR programs.

Differences in sustainability of exercise and health-related quality of life outcomes following home or hospital-based cardiac rehabilitation

BACKGROUND

Home-based cardiac rehabilitation (CR) has been demonstrated to be as effective as institution-based CR in post-coronary artery bypass graft surgery (CABG) patients in terms of short-term physical and psychosocial outcomes. The sustainability of these effects is less well studied. The aim of this study was to examine the sustainability of observed changes in physical, quality of life (HRQL), and social support (SS) outcomes in patients 12 months after discharge from a randomized controlled trial (RCT) of 6 months of monitored home-based versus supervised hospital-based CR.

DESIGN

Two-hundred and twenty-two (n=222) patients were followed-up 12 months after discharge from a RCT of 6 months of monitored 'Home' versus supervised 'Hospital' CR after CABG.

METHODS

At discharge from the 6-month RCT, participants who consented to the 12-month follow-up study, were given individualized guidelines for ongoing exercise, and were not contacted for 1 year. The primary outcome was peak oxygen uptake (VO2). Secondary outcomes were: HRQL, SS and habitual physical activity.

RESULTS

One hundred and ninety-eight patients (89.2%), 102 'Hospital' and 96 'Home', returned for follow-up 12-months after discharge from CR. Both groups had similar medical and socio-demographic characteristics. Peak VO2 declined in 'Hospital' but was sustained in 'Home' patients 12 months after discharge from CR (P=0.002). Physical HRQL was higher in the 'Home' group at the 12-month follow-up (P<0.01). Mental HRQL showed general, minor deterioration over time in both groups (P=0.019). Twelve months after discharge from CR, physical and mental HRQL remained higher than at entry to CR in both groups. 'Home' patients had higher habitual physical activity scores compared to 'Hospital' patients.

CONCLUSIONS

This follow-up study suggests that low-risk patients whose CR is initiated in the home environment may be more likely to sustain positive physical and psychosocial changes over time than patients whose program is initially institution-based.

Exploring the Effects of Walking the Labyrinth

Purpose: This pilot study examines the effects of walking a labyrinth. Method: A convenience sample of 25 community members participated in a four-group, repeated measures study to gather information about vital signs and affect before and after labyrinth walks. Because of the small sample size, results were inspected for effect size (ES) differences in pre-to postcomparisons. Mean postwalk scores were also compared to control group scores. Findings: Systolic and diastolic blood pressures showed essentially no ES differences pre to postwalk. The remaining ES comparisons showed .14 ES for pulse differences, .37 ES for respirations, and .22 and .56 ES differences for positive and negative affect measures, respectively. Conclusions: Comparisons of postwalk scores for walkers to nonwalkers showed mixed results in significance of differences. Implications: This pilot study shows the feasibility of the procedures for assessing the effects of labyrinth walking on basic parameters of health.

Women and cardiac rehabilitation: A review of the literature

There is a wide variety of literature available about coronary heart disease (CHD). However much of the research related to CHD has been performed using either exclusively male populations or such small numbers of women that the results from the women studied were unable to be analysed independently. It is apparent that more researchers are focusing on research that examines women's responses to CHD and the care and treatment they receive. The following literature review explores some of the issues related to women's experience of cardiac rehabilitation and demonstrates that women's experience of cardiac rehabilitation may be different to that of men. There is a need for nurses working within this area of practice to have an understanding of women's experience of recovery from a heart attack in order to better meet their needs.

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Heart Failure Exercise And Training Camp: effects of a multicomponent exercise training intervention in patients with heart failure

BACKGROUND

This study tested the effects of a multicomponent exercise training intervention called "Heart Failure Exercise And Training Camp" (HEART CAMP). The intervention was theoretically derived from Bandura's social cognitive theory.

METHODS

An experimental repeated-measures design was used. Participants were randomized to the HEART CAMP intervention group (n = 22) or the attention control group (n = 20). Participants were compared on self-efficacy for exercise, symptoms, physical function, and quality of life over 12 weeks.

RESULTS

The intervention group had a 31% increase in cardiac exercise self-efficacy and significantly fewer symptoms compared with the attention control group. Quality of life increased significantly in both groups.

CONCLUSION

A theory-based intervention improved self-efficacy for exercise and symptoms in patients with heart failure.

Self-efficacy for exercise in cardiac rehabilitation: review and recommendations

Despite the numerous physical and psychosocial benefits of exercise for coronary heart disease survivors, non-adherence to cardiac rehabilitation (CR) exercise is a major problem. Adherence to the lifestyle behavior change associated with CR involves both physical and self-regulatory skills. While self-regulatory efficacy is clearly linked to exercise adherence and adjustment, the literature on the relationship between self-efficacy and exercise among CR participants has not been systematically reviewed. A search of relevant databases identified 41 CR studies. Few studies measured self-regulatory efficacy for actions that facilitate adherence. Most studies examined self-efficacy during the intensive center-based phase of CR, with little attention to long-term maintenance. The CR literature could benefit by examining (a) self-efficacy as a major rehabilitation outcome, (b) measurement of self-regulatory efficacy for behavior change, (c) suspected moderators of self-efficacy (i.e. gender, age), and (d) self-efficacy relative to maintenance.

Effects of home-based cardiac exercise program on the exercise tolerance, serum lipid values and self-efficacy of coronary patients

BACKGROUND

Exercise-based cardiac rehabilitation improves exercise capacity and reduces cardiac risk factors. The purpose of this pilot study was to examine the effects of a home-based cardiac exercise program (HBCEP) on exercise tolerance, serum lipids, and self-efficacy in coronary heart disease patients in Turkey. Self-efficacy theory provided the framework for this study's intervention.

DESIGN

The study design was a pre-test and post-test experimental, randomized assignment.

METHOD

The study included 30 participants in a home-based cardiac exercise program (HBCEP; mean age=54.7+/-7.8) and 30 in control (C; mean age=52.7+/-6.5). The Phase II cardiac exercise program included three 45-60-min sessions per week for 12 weeks, and the enhancement of self-efficacy through educational sessions and the use of goal setting, modelling, and physiological feedback strategies. Both groups were comparable in their medical regimen, exercise capacity, and other measured variables pre-intervention. At baseline and after 12 weeks, exercise capacity was evaluated by exercise testing using the Bruce Protocol, self-efficacy was measured with the Cardiac Exercise Self Efficacy Index, and serum lipid values were measured.

RESULTS

At the completion of the 12-week exercise program, the exercise capacity (P<0.001), total cholesterol (P=0.004), triglycerides (P=0.048), high-density lipoprotein-cholesterol (P=0.001), low-density lipoprotein-cholesterol (P=0.039), and self-efficacy (P<0.001) of the HBCEP Group were significantly improved compared to the control group.

CONCLUSION

These results suggest that a first-time HBCEP in Turkey can be successful in having patients adhere to a prescribed exercise program and reduce risk factors. Enhanced self-efficacy may have mediated the improved behavioural outcomes.

Physical Activity Behavior, Motivational Readiness and Self-Efficacy among Ontarians with Cardiovascular Disease and Diabetes

This cross-sectional study examined physical activity and its correlates among 355 diabetes, 144 cardiovascular disease, 75 diabetes and cardiovascular disease, and 390 residents with cardiovascular risk factors. Community residents (N=2566) were screened by telephone, and 964 participants completed a self-report survey. Non-diabetes participants participated in a greater range of physical activities (p<.001), more frequently (p=.013). Diabetes participants had lower physical activity readiness and efficacy (ps<.009). In a regression model (p<.001), region and disease, work, marital and smoking status were significant correlates of physical activity frequency. Interventions which increase motivational readiness and efficacy among diabetics are required to prevent and delay complications, particularly in regions with environmental barriers such as cold weather and homogeneous, low-density land use.

Nursing Outcomes in Coronary Heart Disease

Nursing research has contributed to our knowledge of patients with coronary heart disease (CHD), although much of the research has focused on acute cardiac events. Active and ongoing programs of research into CHD patient outcomes are essential as significant gaps remain. Consistently effective strategies to help patients change risk behaviors, recognize salient symptoms, manage their CHD and ischemic symptoms, improve function and quality of life, and prevent subsequent coronary events are needed, especially in the elderly and those with multiple comorbidities.

Cardiovascular Disease

Health Issue

Cardiovascular disease (CVD) is the leading cause of death in Canadian women and men. In general, women present with a wider range of symptoms, are more likely to delay seeking medial care and are less likely to be investigated and treated with evidence-based medications, angioplasty or coronary artery bypass graft than men.

Key Findings

In 1998, 78,964 Canadians died from CVD, almost half (39,197) were women. Acute myocardial infarction, which increases significantly after menopause, was the leading cause of death among women.

Cardiovascular disease accounted for 21% of all hospital admissions for Canadian women over age 50 in 1999. Admissions to hospital for ischemic heart disease were more frequent for men, but the mean length of hospital stay was longer for women.

Mean blood pressure increases with age in both men and women. After age 65, however, high blood pressure is more common among Canadian women. More than one-third of postmenopausal Canadian women have hypertension.

Diabetes increases the mortality and morbidity associated with CVD in women more than it does in men. Depression also contributes to the incidence and recovery from CVD, particularly for women who experience twice the rate of depression as men.

Data Gaps and Recommendations

CVD needs to be recognized as a woman's health issue given Canadian mortality projections (particularly heart failure). Health professionals should be trained to screen, track, and address CVD risk factors among women, including hypertension, elevated lipid levels, smoking, physical inactivity, depression, diabetes and low socio-economic status.

Factors influencing referral of cardiac patients for cardiac rehabilitation

This study asked the question: Are there differences in the characteristics and referral rates of men and women who are referred for cardiac rehabilitation? The sample consisted of 203 men (n = 148) and women (n = 55) who were hospitalized with at least one cardiac diagnosis and were eligible for Phase II cardiac rehabilitation. Hospital records were reviewed to obtain information on gender, age, ethnicity, insurance coverage, marital status, employment status, proximity to rehabilitation services, transportation availability, concurrent disease processes, domestic responsibilities, documentation of referral for cardiac rehabilitation, and the attending physician. A survey sent to the patients approximately 3 weeks after their discharge from the hospital also addressed these variables. Logistic regression analysis indicated only one predictor of referral: the gender of the physician. Male physicians were more likely to refer patients for cardiac rehabilitation. This finding must be viewed with caution because of the small number of female patients and female physicians included in the study. The current literature reflects conflicting findings about the proposed relationships; therefore, they merit further investigation.

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.

Barriers and facilitators of self-reported physical activity in cardiac patients

The purpose of this study was to examine the relationships of personal factors (age and gender), barriers (symptom distress and negative well-being), and facilitators (self-efficacy to exercise and positive well-being) with self-reported physical activity in cardiac patients. Sixty-four participants (50 men, 14 women) 6-12 months post-cardiac event participated in this study. We found that age and gender accounted for 14.7% of the variance, symptom distress and negative well-being accounted for an additional 21.6% of the variance, and self-efficacy accounted for the remaining 7.6% of the variance for a total of 44% of the variance in physical activity levels explained. These results suggest that personal factors and barriers are central variables, in addition to self-efficacy, in understanding the levels of physical activity achieved by patients after a cardiac event.

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.

Factors associated with the failure of patients to complete cardiac rehabilitation for medical and nonmedical reasons

PURPOSE

Cardiac rehabilitation (CR) provides effective secondary prevention services, but many patients fail to complete the recommended program. The purposes of this study were to describe completion rates in a hospital-based outpatient CR program, and to identify factors associated with patients failing to complete CR because of nonmedical and medical reasons.

METHODS

Data used for the analyses were from a hospital-based CR program involving 526 discharged patients between January 1996 and February 2002. Patient discharge status was classified into three categories: complete, noncomplete-medical reasons, and noncomplete-nonmedical reasons. Logistic regression modeling identified factors associated with the groups failing to complete CR.

RESULTS

The rate of CR completion was 58% (304/526). Among the 222 patients who did not complete CR, 139 (63%) had nonmedical reasons. As compared with the patients who completed CR, the adjusted odds ratio (AOR) for those who did not complete CR because of nonmedical reasons were more likely to be employed (AOR 2.2), to be obese (AOR 2.5), to be smokers (AOR 2.1), and to have shorter 6-minute walk distances (AOR 1.7). They were less likely to be women (AOR 0.6) or have diabetes (AOR 0.5). Patients not completing CR for medical reasons were more likely to be categorized as being at high clinical risk (AOR 4.2) and having shorter 6-minute walk distances (AOR 1.9).

CONCLUSION

Except for low functional capacity, baseline factors associated with patients failing to complete CR differed on the basis of medical or nonmedical reasons. The development of interventions that address the special needs of patients with low functional capacity may be especially important in attempts to retain this high-risk group in CR therapy.

Outcomes of cardiac rehabilitation participants and nonparticipants in a rural area

Nationally, only 11%-20% of cardiac patients, on average, enroll in cardiac rehabilitation programs after their cardiac events. The purpose of this study was to examine: (a) differences in functional health outcomes, clinical risk factor outcomes, and lifestyle behaviors between patients who participated in cardiac rehabilitation (CR) and those who did not during the first year after their cardiac event; and (b) to examine predictors of and reasons for CR participation and non-participation in a Midwestern, rural clinical population. Green's health education framework guided the study. A cross-sectional, comparative design was used to mail surveys to 538 cardiac patients who were hospitalized over a 1-year period at a regional medical center; 255 surveys were returned, and the final sample numbered 222. Of these, 154 (69%) attended CR. Compared to nonparticipants (n = 68), participants reported significantly higher levels of functioning on 7 of the 8 subscales of the Medical Outcome Study Short Form-36 (SF-36). In relation to clinical risk factor outcomes, participants had a significantly lower body mass index than nonparticipants. Patients who attended CR reported that they had switched to low-fat foods, started an exercise program, lost weight, lowered stress, lowered blood pressure, and reduced blood cholesterol at significantly higher rates than non-participants. Patients were more likely to participate in CR if their physician explained its benefits, if they were told about it during their hospitalization, and if they lived close to a CR program. Patients with coronary heart disease need to be referred to CR for improved physical and psychosocial functioning and successful risk factor modification.

Why are women missing from outpatient cardiac rehabilitation programs? A review of multilevel factors affecting referral, enrollment, and completion

OBJECTIVES

The objectives of this paper are to (1) systematically review the evidence for patient, provider, and programmatic factors that may influence women's referral to, enrollment in, and completion of outpatient cardiac rehabilitation and (2) make empirically based recommendations for future women's health research.

METHODS

Using a defined inclusion/exclusion criteria, this review involved a systematic review and description analysis of the published peer-review literature.

RESULTS

The review yielded 23 studies described in 25 publications. Although gaps in the knowledge base exist and several methodological concerns limit the evidence, this body of work suggests that age, personal resources, low rates of physician referral, and weak recommendations to participate in rehabilitation may explain why women are missing from this life-saving intervention.

CONCLUSIONS

Practitioners engaged in the care of eligible cardiac patients should be aware of the evidence for the effectiveness of cardiac rehabilitation, and researchers should examine programmatic and provider factors that affect women's participation.

Barriers to participation in and adherence to cardiac rehabilitation programs: a critical literature review

Despite the documented evidence of the benefits of cardiac rehabilitation (CR) in enhancing recovery and reducing mortality following a myocardial infarction, only about one third of patients participate in such programs. Adherence to these programs is an even bigger problem, with only about one third maintaining attendance in these programs after 6 months. This review summarizes research that has investigated barriers to participation and adherence to CR programs. Some consistent factors found to be associated with participation in CR programs include lack of referral by physicians, associated illness, specific cardiac diagnoses, reimbursement, self-efficacy, perceived benefits of CR, distance and transportation, self-concept, self-motivation, family composition, social support, self-esteem, and occupation. Factors associated with non-adherence include being older, female gender, having fewer years of formal education, perceiving the benefits of CR, having angina, and being less physically active during leisure time. However, many of the studies have methodologic flaws, with very few controlled, randomized studies, making the findings tentative. Problems in objectively measuring adherence to unstructured, non-hospital-based programs, which are an increasingly popular alternative to traditional programs, are discussed. Suggestions for reducing barriers to participation and adherence to CR programs, as well as for future research aimed at clearly identifying these barriers, are discussed.

Cardiac rehabilitation: participating in an exercise program in a quest to survive

Cardiovascular diseases are the major cause of death in the United States. The American Heart Association reports that approximately 500,000 persons die each year from heart attacks. Cardiac rehabilitation programs are based on objectives that would, when adhered to, extend and improve an individual's quality of life after experiencing a cardiac event. The purpose of this qualitative study was to explore and describe strategies that individuals who experienced a cardiac event used to overcome barriers associated with an exercise program. The sample consisted of six subjects (four females and two males) who were enrolled in a cardiac exercise program for 1 year or longer, and who continued to actively participate in at least two cardiac exercise classes per year. This study revealed that individuals who consistently participated in a cardiac exercise program did not use strategies to overcome barriers; rather, in their quest to survive, they used strategies to ensure their participation in the program.