McDonall, Joanne RN, BN (Hons); Botti, Mari PhD; Redley, Bernice PhD; Wood, Beverley PhD
Epworth/Deakin Centre for Clinical Nursing Research, Epworth Healthcare, Richmond, Victoria, Australia.
Correspondence: Joanne McDonall, RN, BN (Hons), Epworth/Deakin Centre for Clinical Nursing Research, 185 Hoddle St, Richmond, Victoria 3121, Australia (email@example.com).
The authors declare no conflicts of interest.
PURPOSE: Cardiac rehabilitation programs (CRPs) aim to help patients with cardiovascular disease achieve lifestyle changes. However, attendance and completion of programs are poor worldwide. The rationale for this study was to explore patterns of attendance and completion of a CRP located in a private hospital in metropolitan Melbourne, Victoria, Australia.
METHODS: This exploratory descriptive study involved linking 2 databases to analyze demographic and cardiac characteristics of patients who did or did not attend the CRP.
RESULTS: Only 11.9% of patients likely to benefit attended the CRP. Predictors of attendance included marital status, gender, age, and proximity of the program to home. The crucial area identified in need of improvement is the referral process to increase the rate of participation.
CONCLUSION: The major finding is the need for improvement in referral and recruitment structures to increase awareness of the program and the participation rate. Practices such as automatic referral and followup of patients are recommended. The study outcomes will benefit future research on referral processes to the CRP at the hospital.
Despite evidence that participation in a cardiac rehabilitation program (CRP) confers clinically significant benefits for patients diagnosed with cardiovascular disease (CVD), reports indicate that attendance and completion rates are suboptimal.1,2 Research shows that only 15% to 30% of patients who have an acute cardiac event complete a CRP.1,3 The National Heart Foundation of Australia4 and the World Health Organization5 recommend that outpatient cardiac rehabilitation should be available and routinely offered to all patients with CVD.
In Australia, there are more than 550 centers that provide cardiac rehabilitation and just more than 150 are located in the state of Victoria. These programs vary in terms of referral structures, including the proportion of external and internal referrals. The content and duration of the programs differ in response to the population they serve. For example, some centers predominately cater to patients with acute coronary syndrome, and others may have largely cardiac intervention patients. There is also variability in terms of demographic characteristics of patients between CRPs. As there can be significant variations between programs in attendance patterns and factors associated with attendance, CRPs should each evaluate these patterns to improve participation.6 It is, however, also likely that the experiences from a single center can have relevance for similar centers. The CRP in this study had not been evaluated since its commencement in 1993 and did not formally collect data related to patients who chose to attend and those who did not.
The purpose of this research was to explore patterns of attendance and completion of a CRP located in a private hospital in metropolitan Victoria, Australia. The specific aims were to investigate key aspects of attendance and completion of the CRP in terms of the demographic and cardiac characteristics of patients who do and do not attend the program.
The outpatient CRP in this study commenced at the hospital in 1993 and was offered in 2 distinct formats: a 6-week, single session per week, day program, and a 3-week, single session per week, evening (fast-track) program. Eligible patients with CVD were identified by a cardiac rehabilitation coordinator and, together with their partner or family, invited to attend either of these programs. The decision on which program to attend was up to each individual patient based on his or her personal circumstances. Both of these programs were offered postdischarge and were conducted at the hospital.
Approval to conduct the study was obtained from the Human Research and Ethics Committees of the hospital and the affiliated university. The single-institution case study methodology was conducted incorporating a retrospective analysis of hospital admission and CRP attendance data. All patients discharged between January 1, 2004, and July 31, 2006, with a specific Victorian diagnostic related group code related to CVD, were identified from the Hospital Information System database. Demographic characteristics and admission/discharge data were extracted for these patients and linked to the CRP attendance database logbook to identify patients who (1) attended and completed the program and (2) commenced but did not complete the program. Attendance was defined as having attended at least 3 sessions of the 6-week program or at least 1 session of the 3-week program. Patients were considered to have completed the CRP if they attended 5 or more sessions of the 6-week program or 2 or more sessions of the 3-week program. As the program had no structured referral procedures, referral to the hospital CRP was examined by asking nursing staff, clerical staff, and the cardiac rehabilitation coordinator to ascertain how patients were referred to the program. Bivariate and logistic regression analyses were used to investigate relationships between attendance and completion of the CRP and patient characteristics.
During the review period, 5331 patients, eligible to attend a CRP, were discharged from the hospital; significantly more men (65%) than women were discharged with a diagnosis of CVD. The mean age for women was 71.3 years and 66.9 years for men. The majority of patients were partnered (68.9%) and half (50.7%) lived less than 30 km from the hospital.
A total of 637 patients attended the hospital CRP, a participation rate of 11.9%. The CRP completion rate was 66.8%, with only 17.7% being women. Most (83.2%) traveled less than 30 km from home to attend the hospital CRP. There were notable differences in the diagnoses of patients who attended and did not attend the CRP (Table 1). For example, few patients with a myocardial infarction attended the CRP and none of those discharged with coronary artery disease (n = 74) or unstable angina (n = 90) attended. Alternatively, all patients discharged after angioplasty/stent following a myocardial infarction (n = 24) attended.
Predictors of Attendance and Completion of the CRP
Logistic regression analysis to identify variables that predicted attendance at CRP was reliable (χ2 = 399.53, df = 7, P < .001) and the prediction variables accounted for 91.5% of variability in attendance. Regression statistics provided in Table 2 indicate that having a partner, male gender, younger in age, and living less than 30-km distance from CRP affected attendance in this cohort.
The coefficient values revealed that increased age was associated with a decrease in the odds of attendance by a factor of 0.97; for every 1-year increase in age, the odds of attending the CRP decreased by 3%. The findings also revealed that partnered patients were 1.5 times more likely to attend CRP than nonpartnered patients; men were 2.5 times more likely to attend than women; and patients who resided less than 30 km from the hospital were 3.2 times more likely to attend the CRP than those who lived further away than 150 km or more.
Of the 404 patients who completed the CRP (Table 2), the predictor variables of marital status, gender, age, length of stay, discharge diagnosis, and distance from home to CRP accounted for 68.3% of variability in CRP completion. The regression model indicates that younger age and a nonsurgical diagnosis reliably predicted completion of the program in this cohort.
Despite the well-established benefits of participation,7 attendance in the study CRP was low but was consistent with rates reported in other studies.2,8 Similar to other studies,9,10 few older patients with CVD participated in the CRP studied. Older patients often have difficulty deciding to participate in extended programs because of the inconvenience of repeated hospital visits, and the belief that CRPs are mostly exercise-based, which can be a deterrent for them.11
Similarly, women accounted for only 16.6% of attendees at the CRP. Not only were women underrepresented, but those who did attend were older than male participants. This may be explained by the finding that the mean age of women discharged from the hospital with CVD was higher, as is common in CVD populations. Previous studies have indicated that low participation rates in women is often due to lack of referral to CRP,8,12 whereas good family support is a significant facilitator of CRP attendance in women.13 It is not clear in this study whether women were not referred to the CRP or whether they chose not to attend. Based on the study findings, exploration of the factors influencing the attendance of older patients and women at the hospital CRP is warranted.
Referral to CRP
Referral methods are a significant factor impacting attendance at CRPs.6,14 However, attendance patterns suggested that criteria, more restrictive than that recommended by National Heart Foundation of Australia and World Health Organization, were used to identify patients eligible for referral. This study found variation in the criteria and processes used to identify and refer patients, factors likely to negatively influence CRP attendance. It is possible that as a result of this variation, many patients who could benefit from attending a CRP were not identified or referred. This warrants further investigation as only 9 patients (5.5%) with a myocardial infarction and none of those discharged with a diagnosis of coronary artery disease attended the CRP. These findings suggest that there is a significant gap in CRP participation by those likely to benefit. Selective referral may have been used to balance demand for the local CRP with available capacity. However, the use of recommended criteria to refer eligible patients to the CRP could address this gap. Attendance at the outpatient CRP may also be improved by the introduction of automatic and consistent referral practices in cardiac wards.8 Standardized automatic processes can also reduce the workload of the CRP coordinator by ensuring that all eligible patients are invited to attend.8
Previous studies have reported that proximity to the patient residence and ease of access are significant enablers to attendance and participation in CRP.1,6,15 The finding that 83.2% of those who attended the hospital CRP resided less than 30 km from the hospital suggests that targeted referral of those patients living close to the hospital may support increased CRP attendance. Alternatively, patients living 30 km or more from the hospital may benefit from a choice of referral to the hospital CRP or a program closer to their home. Such an approach may ensure that all eligible patients are referred to a program they are likely to attend. Automatic referral systems that use the postcode of the patient residence to facilitate this process would be ideal. In addition, referral to community-based programs and/or home- or Internet-based programs could be considered for those who return to work early, older patients, or those for whom transportation may be difficult.
This study has provided valuable information regarding participation of patients with a discharge diagnosis of CVD at the CRP of a single hospital. As such, it is not possible to generalize findings to other hospitals or programs. However, the process used in this study may prove useful for others examining attendance and participation at their CRP.
This study identified opportunities to improve CRP attendance. Findings suggest the use of accepted criteria for eligibility for referral, introduction of a standardized referral process, and specific targeting of patients who reside close to the hospital could all have a positive impact on attendance and participation in the CRP examined. The study outcomes will contribute to future research on referral processes to the CRP at the hospital and exploration of barriers to attendance, in particular for older people and women.
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attendance; barriers; cardiac rehabilitation; facilitators; patient participation
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