Participation in cardiac rehabilitation depends on a number of factors, including age, sex and socioeconomic group, and patients’ beliefs about such programmes
Audits of cardiac rehabilitation in the UK have consistently found that the goals set out in the National Service Framework for Coronary Heart Disease are not being met. This article, the first in a two-part series, reports on a review aimed at identifing themes that influence whether patients attend cardiac rehabilitation services. Part 2 reports the results of a research project looking at patients’ views of cardiac rehabilitation on the island of Guernsey.
Citation: O’Connell S (2014) Cardiac rehabilitation 1: barriers to attending cardiac rehabilitation. Nursing Times; 110: 19, 15-17.
Author: Sophie O’Connell is clinical nurse specialist in cardiac rehabilitation at Princess Elizabeth Hospital, Guernsey.
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Cardiac rehabilitation (CR) is an important component of riskfactor modification after acute myocardial infarction and coronary revascularisation (National Institute for Health and Care Excellence, 2007). In the UK, CR has four phases (Box 1).
Box 1. Four phases of cardiac rehabilitation
- Phase i: in hospital
- Phase ii: the immediate outpatient period
- Phase iii: outpatient education and exercise programme
- Phase iV: life-long maintenance of lifestyle and behavioural change. Guidelines recommend that all patients attend Phase III.
Source: Scottish Intercollegiate Guidelines Network (2002)
The National Service Framework for Coronary Heart Disease (Department of Health, 2000) set targets, including targets on outcomes, around the provision of CR after an myocardial infarction (MI) and revascularisation. These include:
- 85% of eligible patients are referred for CR; eligible patients are those who have had coronary artery stenting or coronary bypass grafting;
- One year after their event, 50% of patients are non-smokers, take 30 minutes of exercise five days a week and have a body mass index of <30.
Audits of CR in the UK have consistently found that these goals are not being met. I reviewed the literature to identify potential predicting factors and barriers to non-attendance at CR to inform a study of our local CR programme. The search method is outlined in Box 2.
Box 2. Literature search method
Literature published between 2001 and 2011 was searched using the databases CINAHL Plus with Full Text, MEDLINE, PsycARTICLES, Psychology and Behavioral Sciences Collection, and SocINDEX with Full Text. The search was limited to English-language, full-text and research articles about adults. I identified 32 suitable articles for review. I also searched the ScienceDirect database and chose 39 articles for further review, then worked through the reference lists of the journal articles for other relevant studies.
The importance of timely provision of CR, particularly in the immediate discharge period, has been highlighted (Hanssen et al, 2005). Dalal et al (2007) identified flexibility and individualisation as an important factor in meeting patients’ needs. One study by Baigi et al (2009) suggested patients had specific preferences for the type of information provided in the CR setting and who provided the information. Non-attendees considered information about hypertension and sedentary lifestyle was the most important content for CR. Women preferred to discuss smoking issues with nurses while men preferred physicians.
Lane et al (2001) found people were less likely to attend CR if they were female and lived alone. Their findings were in keeping with those of Dunlay et al (2009), who suggested that participation in CR was higher among men and also among younger people. A large prospective study of 906 patients (586 men and 320 women) found that fewer women than men were referred for CR (Grace et al, 2002). Yohannes et al (2007) also found that women were more likely than men to drop out of CR. These findings suggest that gender could be an issue in referral and non-completion of CR. Evans et al (2011) identified that the number of women referred increased over a 14 year period and the mean age of patients rose over time. However, three studies did not find a relationship between gender, age and participation in CR (Kerins et al, 2011; Jones et al, 2007; Farley et al, 2003). The results of these studies may be influenced by their smaller sample size, and all of them had more male than female participants. These findings were similar to those reported in a retrospective study of 450 patients by Weingarten et al (2011), who also found that gender did not affect enrolment in CR. Of the 286 CR attendees in Weingarten et al’s study, 62% were women.
A statistically significant link was found to exist between socioeconomic status and attendance at CR in a number of studies (Kerins et al, 2011; Worcester et al, 2004; Lane et al, 2001). All of the studies included in the review demonstrated that employment status, residence in a deprived area and access to transport were important predictors of attendance at CR. Patients were less likely to attend if they were unemployed or could not drive (Dunlay et al, 2009).
A number of studies have highlighted diagnosis, treatment and previous cardiac history as significant predictors for attendance at CR (Worcester et al, 2004; Gallagher et al, 2003). Non-attendance was more likely in patients who had:
- A severe MI;
- A history of MI;
- Not received thrombolysis (Dunlay et al, 2009).
Having attended CR before was identified as a predicting factor for nonattendance at CR sessions in Dunlay et al’s (2009) study, although the reasons for this were not reported. Referral to CR while in hospital was cited in one study as a predicting factor for attendance (Dunlay et al, 2009). Worcester et al (2004) found that men who had undergone percutaneous coronary intervention (PCI) were less likely to attend CR; they were also less likely to be referred, even though CR has been shown to reduce the incidence of re-stenosis and major cardiac events after PCI.
In another study, Lauck et al (2009) suggested that patients who had had a PCI might have a limited understanding of the chronicity of their condition, believing the intervention to be a cure. This could affect their beliefs about the importance of CR and subsequent enrolment in a programme.
Pre-existing conditions, such as diabetes, as well as minor ailments, such as colds, also had a negative impact on attendance and completion of CR (Kerins et al, 2011; Jones et al, 2007). Health professionals’ role Two of the studies reviewed suggested the emphasis medical staff placed on attendance at CR was as important as that placed on the patient’s diagnosis (Sherwood et al, 2011; Grace et al, 2008). One respondent in a study by Sherwood et al (2011) indicated her surgeon had told her she was cured. While this could not be verified, and generalisations could not be made because of the small nature of the study, the authors concluded that it was concerning and highlighted how health professionals could reinforce misconceptions about the nature and treatment ofcoronary heart disease.
Psychosocial factors were found to be a significant risk factor for coronary heart disease in the INTERHEART Study (Yusuf et al, 2004). Participants who reported high levels of work stress, general stress, financial stress or permanent stress had a statistically significant increased risk of experiencing an acute MI. This is relevant because Grace et al (2002) found that psychosocialfactors were a significant predictor of attendance at CR.
Raised levels of depression and anxiety have been associated with an impaired quality of life after a cardiac event and an increase in the risk of future events (Dickens et al, 2006). In the studies included in this review, depression was not found to be a predictor of attendance at CR. Grace et al (2002) found depression was not associated with participation in CR. Farley et al (2003) found a high rate of depression among patients in their study but also said it did not predict attendance at CR. They also found there was a statistically non-significant tendency for men with mild anxiety to attend. Grace et al (2002) found that anxiety was a statistically significant predictor of attendance. However, Kuhl et al (2009) linked anxiety to non-attendance at CR and poor adherence to secondary prevention measures after a cardiac event.
Beliefs about health or illness have been identified as factors influencing attendance or non-attendance at CR (Grace et al, 2008). These beliefs are affected by family, friends, culture, religion and experience and determine how patients make sense of and respond to symptoms and illness. Work carried out with patients with angina by Furze et al (2005) found no statistically significant correlation between illness perceptions and attendance at CR, but the researchers identified a statistically significant relationship between illness perceptions and health-related quality of life at six months. The study did not look at attendance at cardiac rehabilitation but its findings are important because it highlights the long-term effect that negative illness perceptions can have on quality of life.
French et al (2006) found four components of illness perceptions were associated with CR attendance. These relate to:
- Identity: the symptoms the patient associates with the illness;
- Cure/control: beliefs about how the illness can be treated or cured;
- Consequences: beliefs about the expected effects and outcome of the illness;
- Coherence beliefs: patients’ beliefs about the cause of the illness.
Patients’ beliefs about CR itself were also found to be an important factor in predicting attendance. Dunlay et al (2009) found that one in six did not know what CR involved. The most common reason for non-attendance was a lack of interest and concerns about taking part in exercise (Kerins et al, 2011). Farley et al (2003) found non-attendees did not want to be reminded of their heart condition.
A number of behavioural factors, including previous levels of physical activity and smoking status, were reported to have a predictive value for non-attendance at CR (Worcester et al, 2004). Poor communication about when CR started was also highlighted in one small qualitative study (Jones et al, 2007) as a reason for non-attendance.
This literature review has highlighted a number of predicting factors affecting attendance at CR, including patients’ beliefs about CR and their condition. Attendance was influenced by the timing of programmes and by information given to patients by health professionals. Age and sex were also found to affect referral rates and attendance, along with socioeconomic status, communication, behavioural factors and psychological factors. Older age, female gender, unemployment, lack of transport and poor communication negatively affected attendance at cardiac rehabilitation.
This review has a number of limitations. Four studies reporting on attendance at CR were qualitative (Sherwood et al, 2011; Grace et al, 2008; Jones et al, 2007; Hanssen et al, 2005) and these findings may not apply to our local CR population. Six were not based in the UK (Kerins et al, 2011; Baigi et al, 2009; Dunlay et al, 2009; Worcester et al, 2004; Farley et al, 2003; Gallagher et al, 2003;). Four studies were carried out in large UK mainland centres so their findings may not apply to our small, offshore CR programme (Evans et al, 2011; Dalal et al, 2007; Yohannes et al, 2007; Dickens et al, 2006; French et al, 2006). This reinforced the need for a locally based study, which is reported on page 20 (O’Connell, 2014).
- Flexibility and individualised care are important factors in meeting patients’ cardiac rehabilitation needs
- Women and those who live alone are less likely to attend CR
- Patients’ perception of the value of CR can be influenced by the beliefs of health professionals
- Patients often undervalue the role CR plays in their recovery
- Offering CR at the right time can have a positive effect on programme attendance
Baigi A et al (2009) Non-attendees’ attitudes to the design of a cardiac rehabilitation programme focused on information of risk factors and professional involvement. European Journal of Cardiovascular Nursing; 8: 62-66.
Dalal HM et al (2007) Home-based versus hospital-based rehabilitation after myocardial infarction: a randomized trial with preference arms - Cornwall Heart Attack Rehabilitation Management Study (CHARMS). International Journal of Cardiology; 119: 202-211.
Department of Health (2000) National Service Framework for Coronary Heart Disease.
Dickens CM et al (2006) Contribution of depression and anxiety to impaired health-related quality of life following first myocardial infarction. The British Journal of Psychiatry; 189: 367-372.
Dunlay SM et al (2009) Barriers to participation in cardiac rehabilitation. American Heart Journal; 158: 852-859.
Evans J et al (2011) Characteristics of patients entering cardiac rehabilitation in the United Kingdom, 1993-2006: implications for the future. Journal of Cardiopulmonary Rehabilitation and Prevention; 31: 181-187.
Farley RL et al (2003) Factors influencing attendance at cardiac rehabilitation among coronary heart disease patients. European Journal of Cardiovascular Nursing; 2: 205-212.
French DP et al (2006) Illness perceptions predict attendance at cardiac rehabilitation following acute myocardial infarction: a systematic review with meta-analysis. Journal of Psychosomatic Research; 61: 757-767.
Furze G et al (2005) Does it matter what patients think? The relationship between changes in patients’ beliefs about angina and their psychological and functional status. Journal of Psychosomatic Research; 59: 323-329.
Gallagher R et al (2003) Predictors of women’s attendance at cardiac rehabilitation programs. Progress in Cardiovascular Nursing; 18: 121-126.
Grace SL et al (2008) Contribution of patient and physician factors to cardiac rehabilitation enrollment: a prospective multilevel study. European Journal of Cardiovascular Prevention and Rehabilitation; 15: 548-556.
Grace SL et al (2002) Cardiac rehabilitation II: referral and participation. General Hospital Psychiatry; 24: 127-134.
Hanssen TA et al (2005) A qualitative study of the information needs of acute myocardial infarction patients, and their preferences for follow-up contact after discharge. European Journal of Cardiovascular Nursing; 4: 37-44.
Jones M et al (2007) ‘DNA’ may not mean ‘did not participate’: a qualitative study of reasons for non-adherence at home- and centre-based cardiac rehabilitation. Family Practice; 24: 343-357.
Kerins M et al (2011) Contributing factors to patient non-attendance at and non-completion of Phase III cardiac rehabilitation. European Journal of Cardiovascular Nursing; 10: 31-36.
Kuhl EA et al (2009) Relation of anxiety and adherence to risk-reducing recommendations following myocardial infarction. The American Journal of Cardiology; 103: 1629-1634.
Lane D et al (2001 Predictors of attendance at cardiac rehabilitation after myocardial infarction. Journal of Psychosomatic Research; 51: 497-501.
Lauck S et al (2009) Self-care behaviour and factors associated with patient outcomes following same-day discharge percutaneous coronary intervention. European Journal of Cardiovascular Nursing; 8: 190-199.
National Institute for Health and Care Excellence (2007) MI: Secondary Prevention.
O’Connell S (2014) Factors in attendance at cardiac rehabilitation. Nursing Times; 110: 19, 15-17.
Sherwood SA et al (2011) Influences on women’s completion of a cardiac rehabilitation programme. International Journal of Therapy and Rehabilitation; 18: 266-279.
Scottish Intercollegiate Guidelines Network (2002) Cardiac Rehabilitation. SIGN Guideline 57.
Weingarten MN et al (2011) Rates of enrolment for men and women referred to outpatient cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation and Prevention; 31: 212-222.
Worcester MUC et al (2004) Cardiac rehabilitation programmes: predictors of non-attendance and drop-out. European Journal of Cardiovascular Prevention and Rehabilitation; 11: 328-335.
Yohannes AM et al (2007) Predictors of drop-out from an outpatient cardiac rehabilitation programme. Clinical Rehabilitation; 21: 222-229.
Yusuf S et al (2004) Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART Study): a case-control study. The Lancet; 364: 937-952.