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Women and Cardiac Rehabilitation: Referral and Compliance Patterns

Halm, Margo MA, RN, CCRN, CS; Penque, Sue MSN, RN, ANP, CS; Doll, Nancy MS; Beahrs, Margaret MD

The Journal of Cardiovascular Nursing: April 1999 - Volume 13 - Issue 3 - p 83-92
Infectious Cardiovascular Diseases

Heart disease is the primary killer among American women. Differences in referral for cardiac rehabilitation, as well as compliance rates, have been reported between male and female cardiac patients. This study explored the use of Phase I and Phase II cardiac rehabilitation programs by male and female patients. In particular, the study aimed to investigate the relationship between eligibility and subsequent referral to Phase II cardiac rehabilitation in both men and women, as well as their compliance rates in completing Phase II. In addition, for those patients who never started a Phase II program, their reasons for nonparticipation were explored. Structured patient interviews and chart audits were used to explore cardiac rehabilitation eligibility criteria, referral and completion rates. The sample consisted of 87 patients (46 women and 41 men) who were admitted with a medical diagnosis of angina, myocardial infarction, coronary artery bypass grafting, or valve replacement surgery. Men had higher eligibility rates for Phase I, whereas women had higher eligibility rates for Phase II; more men received a referral for Phase II from their physician than women did. Men had a higher completion rate with Phase II compared with women. For those patients who chose not to start a Phase II program, the most common reasons cited included transportation problems, insurance issues, and having exercise equipment at home. Although women are being referred for cardiac rehabilitation, fewer complete the programs. Continued education is essential to teach women the importance of cardiac rehabilitation to overall recovery and adaptation to an acute cardiac event. In addition, cardiac rehabilitation programs must be structured to meet the unique needs of women and thereby remove obstacles that have prevented higher participation rates by women in the past.

Margo Halm, MA, RN, CCRN, CS; Advanced Practice Nurse; Heart/Lung Services

Sue Penque, MSN, RN, ANP, CS; Director; Heart/Lung Services

Nancy Doll, MS; Exercise Physiologist; Cardiac Rehabilitation

Margaret Beahrs, MD; Cardiologist; St. Paul Heart Clinic; St. Paul, Minnesota

The authors acknowledge the team who assisted in the design and conduct of this study: Maureen Smith, Julianne Deutsch, Marge Van Roekel, Linda McLaughlin, and Sue Dzubay. Special thanks also to John Ficken for assistance with statistical analysis and to Sally Stirzl and Nancy Doll for their assistance with data collection.

Heart disease in women is associated with a higher in-hospital mortality rate and is the leading cause of death for women. Studies have shown a greater likelihood of recurrent events in women but fewer diagnostic and therapeutic interventions for their coronary artery disease (CAD).1-5 Cardiac rehabilitation programs serve as an important therapeutic intervention in the secondary prevention of recurrent cardiac events. However, fewer women than men are referred to cardiac rehabilitation programs after experiencing a cardiac event.6-8 Even after being referred, women are less likely than men to complete the program because of a multitude of factors ranging from medical reasons to psychosocial support while adapting to recovery from illness.

This study explores the use of Phase I and Phase II cardiac rehabilitation programs by men and women. Specifically, the aim of this study was to answer the two following research questions: (1) What percentage of men and women who are eligible for cardiac rehabilitation are being referred? and (2) are there differences between men and women in their rates of completion with Phase II cardiac rehabilitation? In addition, for those patients who never started a Phase II program, their reasons for nonparticipation were assessed.

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Exercise has been shown to increase functional capacity. After 3 months of training, maximum oxygen consumption (O2max) in patients with CAD has been demonstrated to increase from 11% to 56% with an average of about 20% in most studies.9-12O2max is the measurement of the maximal rate of oxygen consumption and standard for quantifying aerobic capacity. Other positive effects of exercise include a decrease in blood pressure, lipid levels, and adipose tissue13,14 as well as symptomatology and death rates associated with CAD.13 Studies have shown the benefits of cardiac rehabilitation in both men and women after myocardial infarction (MI) and coronary artery bypass grafting (CABG) surgery.6,7,15 In addition to exercise, cardiac rehabilitation favorably alters other cardiovascular risk factors, such as excessive weight and smoking.16

On average, women have a lower aerobic capacity at baseline. After exercise training, the magnitude of their improvement is similar to or greater than that of men's improvement.8,16,17 Women demonstrate an increased functional capacity, lowering their myocardial oxygen demands at a given submaximal workload and thus achieving the same training effects as men. Although the relative improvement in exercise capacity is similar between men and women, cardiac rehabilitation may elicit greater benefits in women because they begin with a lower functional capacity.6,13,16,18,19

Women also begin household activities early after discharge post-MI-often immediately after hospital discharge and then increase their activities by the third or fourth week. In studying psychosocial responses, women tend to experience guilt feelings if they are not able to assume their usual household activities after their cardiac illness and often resist help from their family members because they do not perceive household chores as a strenuous activity.20 Although most women appear to resume some housework early after suffering a cardiac event, many fail to return to full-time housekeeping activities at 2 months into their recovery, or even longer.21 In contrast, men tend to remain sedentary for a period of time before progressing their activity levels and return to work at approximately 3-4 weeks after discharge.20 Men tend to choose more aerobic activities such as walking, which are beneficial to cardiovascular endurance, whereas women more often choose a combination of dynamic and isometric activities such as household tasks. Women also experience more depression in association with their cardiac illness compared with men.22 This response may be associated with activity limitations as a result of recurring symptoms and poorer health.23

Women have lower attendance and higher dropout rates from Phase II cardiac rehabilitation compared with their male counterparts.7,18,23 In the early 1980s, one group of investigators found a lower attendance record for women compared with men (77% versus 87%) and a higher dropout rate of 19% for women compared with 8% in men.17 Family commitments or financial concerns pose significant challenges for some women attending cardiac rehabilitation programs. Lack of spousal support is also correlated with lower program compliance rates in women. Men usually receive more family support and are accompanied by their spouse to cardiac rehabilitation programs more often than women, a finding that may partially explain women's higher dropout rates.8,17

Women have been perceived as being less interested in exercise programs and therefore less motivated to incorporate exercise as a lifelong change.24 Reasons for noncompliance that have been cited include psychosocial factors, such as depression, guilt, not wanting to be selfish, or resistance to accepting help. Smokers-both men and women-as well as younger women are also less likely to be compliant with cardiac rehabilitation recommendations.7,16,25 Other reasons for decreased program attendance in both men and women include transportation problems, work conflicts, and medical reasons. However, women's attendance at cardiac rehabilitation programs is more often affected by medical reasons compared with men, with complaints such as increased angina and other associated symptoms. This may be partially attributed to more cardiovascular risk factors and increasing cardiac symptoms in women.7,16,20

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Design and sample

A comparative study, designed by a team of female investigators, was used to evaluate the research questions. A convenience sample of 46 adult females and 41 adult males was selected over a period of 12 months from the setting of a 572-bed tertiary hospital in a large midwestern metropolitan area. This convenience sample included the most readily available patients who met the following inclusion criteria for the study:

  • admitting medical diagnosis of angina, MI, or CABG surgery;
  • at least 21 years of age; and
  • English speaking.

The Cardiac Rehabilitation Program at this hospital consists of four phases. The first phase (inpatient) phase includes 10-30 minutes of aerobic exercise and energy conservation techniques in relation to activities of daily living. These activities are performed twice daily with patients usually exercising between 1 and 3 metabolic equivalents (METs; 1 MET = 3.5 mL O2/kg/min) for 10-30 minutes. This MET level is equivalent to light calisthenics, driving, or light housework such as sweeping or ironing. In addition, the patient receives extensive education on risk factors, medications, nutrition, exercise guidelines, and stress management. Patients are assessed for risk factors, and programs are individualized accordingly.

The second phase of cardiac rehabilitation (outpatient, immediate) begins at 1 week after discharge. Orders for Phase II are written after the physician assesses the patient's eligibility, desire, and commitment to participate. This phase includes 40 minutes of aerobic exercise training three times per week for 6-8 weeks. The sessions are monitored by electrocardiograph, and patients usually exercise between 2 and 5 METs per session. In addition, the patient has a nutritional analysis and attends extensive group education. Patients may also choose to participate in additional programs such as Tai Chi or stress management sessions. Beginning around 8 weeks, Phase III and Phase IV of cardiac rehabilitation address the maintenance needs of the patient.

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Research instruments

The primary instruments used in this study were a patient interview, chart audit, and the cardiac rehabilitation attendance record. In the patient interview, subjects were asked what their exercise pattern had previously been at home (type, frequency, and duration), what cardiac rehabilitation means to them, and any reasons why they chose not to participate in Phase II cardiac rehabilitation.

The chart audit portion of the study, including the rehabilitation attendance record, focused on determining the patient's eligibility for participation in and completion of cardiac rehabilitation. The criteria from the American College of Sports Medicine26 and the American Association of Cardiovascular and Pulmonary Rehabilitation27 were used to assess whether the patient was considered a candidate for Phase I and Phase II cardiac rehabilitation, and if so, whether it was ordered by the physician. Demographic information, such as age and ethnic background, were also collected on the subjects.

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Those patients who met the inclusion criteria were approached about entering the study. All patients who participated in the study provided written consent. This study received approval from the Collaborative Nursing Research Committee and the Institutional Review Board. After obtaining consent, data were collected from the medical record and each subject was then interviewed in person. These interviews were completed by a female critical care nurse and a female exercise physiologist employed at the institution where the study was conducted. The interviews were conducted in the patient's room 1-5 days after admission.

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Data analysis

Descriptive statistics were used to summarize the data obtained from the structured patient interviews and chart audits. Frequency distributions were tabulated to calculate the frequency and percentage of male and female subjects who were referred to cardiac rehabilitation (Phase I inpatient and Phase II outpatient), as well as completed a Phase II program. Chi-square analysis was used to determine whether there were differences between men and women in their rates of eligibility for cardiac rehabilitation, referral to, and completion of the program. A P value of ≤.05 was used to indicate statistical significance.

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Description of the sample

The total study sample included 87 subjects, 46 of whom were female and 41 of whom were male. Among the female subjects, ages ranged from 33 to 91, with an average of 70 years. For the males, ages ranged from 41 to 80, with an average of 59 years. The majority of subjects were white (78%), with the remaining 22% categorized as non-white.

In relation to medical diagnoses, the majority of patients had a documented MI. Forty-one women (89%) and 32 men (78%) had either a subendocardial or transmural MI. In contrast, only one woman (2%) and two men (5%) suffered from angina. In terms of interventions, 19 women (41%) and 20 men (49%) underwent percutaneous transluminal coronary angioplasty, whereas 11 women (24%) and 10 men (24%) underwent CABG surgery.

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Relationship between eligibility and referral for cardiac rehabilitation

The first research question evaluated the relationship between eligibility for cardiac rehabilitation and physician referral. With regard to Phase I cardiac rehabilitation, eligibility rates differed slightly between male and female subjects. As shown in Table 1, males had a slightly higher eligibility rate of 93%, compared with the 91% rate seen in females. Although small, chi-square analysis revealed that this difference was statistically significant (χ2 = 29.9, P ≤ .001). Subjects received orders for Phase I cardiac rehabilitation from their physicians at similar rates (86% in women and 89% in men) and thus were attending cardiac rehabilitation as part of their recovery during their hospitalization. Chi-square analysis revealed that this slight difference in the rate of receiving orders between the two groups was not significant (χ2 = .4, P > .05).

Table 1

Table 1

Similar to the inpatient rehabilitation findings, subjects in this study had similar rates of eligibility for Phase II programs. Males and females had eligibility rates of 88% and 91%, respectively, which again was statistically significant (χ2 = 31.9, P ≤ .001). As shown in Table 2, study findings showed that men were more likely (66%) than women (48%) to receive orders from their physician to attend Phase II cardiac rehabilitation if they met the eligibility criteria. Chi-square analysis revealed a statistically significant difference in the rate that women and men received orders for Phase II (χ2 = 7.4, P ≤ .01). All patients who received a referral entered a Phase II program.

Table 2

Table 2

During the interviews, the meaning of cardiac rehabilitation was investigated. Almost half of the subjects (n = 41) understood that cardiac rehabilitation is a multidisciplinary program focusing on exercise and lifestyle modification, and thus, more detailed explanations were not sought from this group. Only those patients (n = 46) who had a vague understanding of what cardiac rehabilitation consisted of were interviewed in greater depth and their responses were noted on the data collection tool. Men and women provided varied responses to this question. These responses may be described along a knowledge continuum from "not knowing" to identification of "some components" to "multifaceted aspects" of cardiac rehabilitation programs. For instance, a few subjects commented that cardiac rehabilitation is "something to do with the heart" or "it means I have a heart problem." More knowledgeable subjects identified that cardiac rehabilitation includes components of exercise, diet, smoking cessation, stress management, and an overall lifestyle adjustment to living with heart disease. These trends were found among both males and females, as shown in Table 3.

Table 3

Table 3

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Completion of phase II cardiac rehabilitation

The second research question investigated completion rates for Phase II cardiac rehabilitation. In those patients who met criteria and received orders to attend outpatient cardiac rehabilitation, men completed the Phase II program at higher rates (88%) compared with women (75%) (Table 2). Chi-square analysis revealed a statistically significant difference between men and women in their Phase II completion rates2 = 12.6, P ≤ .001).

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Failure to participate in phase II

Patients who never started a Phase II cardiac rehabilitation program were queried regarding their reasons. The most common reasons that women declined participation included transportation issues, having exercise equipment at home, insurance barriers, comorbidities such as arthritis and peripheral vascular disease, and need for admission to a transitional care unit after discharge. In contrast, participation by men was more likely limited by lack of insurance coverage and having their own exercise equipment.

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Patients typically enter cardiac rehabilitation programs when they meet the criteria and have a referral from their physician. Physician recommendation is viewed as the most powerful predictor of cardiac rehabilitation participation in older coronary patients.6 The findings of this study revealed that men had slightly higher eligibility rates for Phase I. Men were also slightly more likely than women to receive orders from their physician for participation in Phase I (89% versus 86%).

With regard to Phase II, women had higher eligibility rates (91%) compared with men (88%). One explanation for this finding is participants under the age of 65 often had a managed care provider who did not reimburse Phase II cardiac rehabilitation, and the men enrolled in this study were more likely to fall in this category (mean age = 59). However, men were more likely than women to receive orders for Phase II participation (66% versus 48%). The findings of this study are consistent with those of other authors6-8 who have found women are referred for cardiac rehabilitation after MI or CABG surgery less often than men and thus have lower overall participation rates.

Women in this study who met the criteria for Phase II rehabilitation had lower completion rates compared with men (75% versus 88%). Age may be one factor that accounts for this difference. On the average, women in this study were 11 years older than their male counterparts (70 versus 59 years of age). This demographic also reinforces that heart disease typically strikes women 10-20 years later than it does in men. Oldridge et al8 found dropout rates were higher for women (64%) versus men (42%). McGee and Horgan24 found that female gender and increasing age were independently associated with decreased cardiac rehabilitation attendance. Cannistra et al28 also found African American women less likely to complete Phase II (57%) than white women (64%).

In this study, women provided multiple reasons for not participating in Phase II outpatient rehabilitation. The most common responses were transportation issues, having their own exercise equipment at home, insurance barriers, medical problems, and admission to a transitional care unit. Cardiac rehabilitation programs clearly must be structured to the unique needs of women. Home-based cardiac rehabilitation programs, including transtelephonic monitoring, would be another attractive option for women, especially for the elder and homebound patients.18,19,23

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The two major limitations of this study are the convenience sample that was used and the small sample size. Both of these methodologic issues limit the ability to generalize the study findings to women patients in other geographic locations and health care settings. However, the results of this study provide an addition to the research base in the area of cardiac rehabilitation utilization and completion by women after an acute cardiac event.

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Recommendations for further research

One recommendation for future research is to replicate this study with a larger sample. In addition, it would be helpful to expand the study to include women from different cultural and ethnic backgrounds to gain an understanding of the importance women in these groups place on cardiac rehabilitation as part of the total recovery experience. Further exploration of the transportation issues of women is also needed because it is not known whether they were dependent on their spouse to drive or whether their spouse was sick or perhaps no longer living. In addition, it may be that having exercise equipment in the home increases compliance or the likelihood that patients will complete the goals for a Phase II cardiac rehabilitation program.

Other factors related to participation warrant investigation. The fact that women experience an earlier resumption of household activities may be a significant factor affecting their participation in cardiac rehabilitation. In addition, demographic variables such as comorbidities, insurance coverage, and distance from the medical center may also play a role in participation levels. The specific reasons women discontinue Phase II programs once enrolled also must be examined to identify factors that health care providers may be able to positively affect.

Replication of this study is also warranted to survey physicians regarding their definition of cardiac rehabilitation as it influences their patient's recovery. Physicians could also be asked why they did not order cardiac rehabilitation for a particular patient to determine whether this clinical decision was driven by the patient. In other words, further study is necessary to determine whether referral rates reflect individual practice patterns of physicians or whether the patient declines participation in Phase II rehabilitation.

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The findings of this study point out the need for better education of women and health care providers about the importance of cardiac rehabilitation. Increased community and public education is critical to heighten awareness of the components of cardiac rehabilitation. More than half of the sample did not realize that cardiac rehabilitation is a multifaceted program aimed at overall lifestyle modification and reduction of cardiovascular risk factors. Health care providers also need to continue working with insurance companies to document the improved clinical outcomes and secondary prevention factors of cardiac rehabilitation in women.

Transportation problems were also a significant deterrent to participation in both groups. This finding suggests the need for more home-based cardiac rehabilitation programs or hospital-provided transportation to the program. Phase II programs could partner with physician clinics and patients through periodic transtelephonic monitoring. In addition, because both groups reported the use of exercise equipment at home, it would be beneficial for health care providers to develop protocols for patients to use in their own home. The use of home health nurses and occupational therapists could assist patients in using the equipment safely and effectively.

Developing women's cardiac rehabilitation programs that focus on activities of daily living in the early stages of Phase II would support research findings that women have a psychologic need to recover and build stamina to do household chores. Tailoring cardiac rehabilitation programs to address cardiovascular risk factors unique to women, such as increased adipose tissue and triglyceride levels, lower aerobic capacity, and limited knowledge of exercise, may foster participation and attainment of postdischarge goals.17 Developing program offerings on topics of special interest to women along with scheduling and providing exercise options that women enjoy are other creative ways to meet the needs of female patients and foster participation.

Cardiac rehabilitation is a mainstay of treatment in the cardiovascular patient. This study found that men had slightly higher eligibility rates than women for Phase I and women were more eligible for participation in Phase II programs. However, women were less likely than men to be referred to Phase II rehabilitation, as well as to complete the program. Several barriers were identified with transportation and the presence of exercise equipment at home, the most common reasons women cited for not participating.

Cardiac rehabilitation programs should address the early needs of both women and men. Women tend to resume household activities during their first week after discharge after MI. As a result, cardiac rehabilitation programs should incorporate education and guidance for women on how to safely integrate these activities back into their daily routine during the beginning weeks of Phase II. Women need to be taught how to expend less energy while doing these chores. By satisfying the needs of women to become active in their homes and seeking ways to make the rehabilitation environment more attractive to women, cardiac rehabilitation programs may engender positive feelings that will motivate better completion of the programs.

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cardiac rehabilitation; completion rates; eligibility; referrals; women

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