Cardiovascular disease (CVD) remains the leading cause of death in the United States, with more than 2150 deaths daily.1,2 However, significant advances in health care have led to an increase in the number of individuals living with CVD.3 These individuals may struggle with self-management and debilitating symptoms, and many patients with CVD discharged from the hospital are readmitted within 30 days.4–6 Poor dietary habits and physical inactivity are common modifiable risk factors for patients with CVD.7 CVD is particularly common among the home care population; heart failure (HF) and acute myocardial infarction/ischemic heart disease are leading conditions among home care patients.5 Homebound patients with CVD are particularly vulnerable to poor outcomes due to their advanced age, functional deficits, multiple comorbidities, and polypharmacy.8,9
Improving patient care through secondary prevention of CVD posthospitalization is an opportunity for outcome improvement and impact.10 Home care clinicians are often the first line of rehabilitation and support for patients posthospitalization. Home-based cardiovascular rehabilitation (CR) models represent a promising approach to improving care and reducing hospital readmissions among patients with CVD.
CR can reduce all-cause mortality and cardiac mortality rates, and benefit patients through exercise and modifications of controllable risk factors.11 Despite the clinical effectiveness of CR, participation rates remain low. Only 13.9% of acute myocardial infarction patients and 31.0% of coronary artery bypass graft surgery patients attend CR posthospitalization.12 Cardiac patients with Medicare may qualify for a 60-day episode of home care if they are deemed “homebound,” meaning unable to leave home unassisted.13 However, skilled home care services do not typically include standardized cardiac rehabilitative care. The average time from hospital discharge to outpatient CR enrollment is approximately 35 days, resulting in a gap in specialized cardiac care for patients when functional decline and uncontrolled symptoms can occur.14,15 There is a need for alternate models of secondary preventative cardiac care to fill this gap and prevent poor outcomes.
Home-based and center-based CR programs have proven to be equally effective in improving clinical outcomes and health-related quality of life, with improved adherence among home-based participants.16,17 Although home-based programs are potentially an effective and low-cost method of care,18 most home care agencies have yet to integrate the core competencies of CR programs into their practices due to a lack of reimbursement mechanisms and the challenges associated with designing a model within the scope of a typical home care episode.
Professionals providing CR and secondary prevention require the knowledge and skills of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) core competencies: patient assessment; nutritional counseling; weight, blood pressure, lipid, and diabetes management; tobacco cessation; psychosocial management; physical activity counseling; and exercise training evaluation.19 Home care clinicians may require additional training in these competencies, as they may not have sufficient evidence-based knowledge of CVD principles and management.20,21 The purpose of our training was to educate clinicians on the core competencies of CR professionals, adapted for the home care setting. This study reports the development and implementation of a CR training program adapted for home care clinicians, which incorporated the viewpoints of homebound patients with CVD.
The Figure illustrates the curriculum development process and training implementation for this project. The training curriculum was based on the AACVPR core competencies, supplemented through interdisciplinary workgroup meetings, literature and clinical guideline reviews, and interviews and focus groups with patients and home care clinicians, respectively. Outpatient CR professionals contributed to the curriculum design as well. A pretest/posttest design was used to evaluate knowledge among home care clinicians participating in the training. Project protocols were approved by the Visiting Nurse Service of New York Institutional Review Board.
Medicare patients were eligible for recruitment with a recent admission to home care and an International Classification of Diseases, Ninth Revision diagnosis code(s) for HF, atrial fibrillation, coronary artery disease, or myocardial infarction. We recognize that atrial fibrillation is an atypical diagnosis for inclusion in CR. Atrial fibrillation was included due to the high volume of home care patients with cardiac dysrhythmias,6 and the potential benefits of physical activity with this population.22,23 Nine patients were selected on the basis of their geographic location and were contacted through their registered nurse (RN) or physical therapist (PT) via telephone.
Interdisciplinary teams had a total of 54 clinicians, composed of RNs, PTs, and occupational therapists (OTs), who participated in the training and corresponding knowledge tests. An invitation was sent prior to the training to solicit participation in the focus groups.
Interview sessions averaged 45 minutes and were conducted in patients' homes. Patients were asked about their health status, goals, willingness to make lifestyle changes, sources of health information, and barriers to self-management.
Focus groups averaged 30 minutes, including 2 focus groups with RNs (4-7 per group) and 2 focus groups of PTs and OTs (3-5 per group). Home care clinicians were asked about their experiences caring for patients with CVD, including facilitators and barriers to patient self-management and educational needs.
A 15-item pre- and posttraining knowledge test was created to assess comprehension of training content and CR services (Table 1) and included select questions from the following tools: Nurses' Knowledge of Heart Failure Education Principles Survey, Coronary Artery Disease Education Questionnaire (CADE- Q II), and Heart Disease Knowledge Questionnaire. These tools are useful in identifying gaps in knowledge regarding HF management, and assessing knowledge of CVD management and CR.24–29 Items were selected to represent the newest material for the clinicians. Knowledge of traditional components of CR that were not tested in the knowledge tests, such as determining target heart rates, had been previously part of the clinicians' education and practice. Although the training reinforced and standardized these components, the tests were designed to evaluate concepts that were newly reinforced in the training.
Interviews and Focus Groups
Recordings of the interviews and focus groups were transcribed. Transcripts were analyzed independently by 3 authors using the constant comparative method to identify common themes.30 Each researcher individually read and coded the transcripts, then grouped codes to form categories. The authors returned to the data to confirm the frequency of codes, then presented categories as a group to finalize themes.
Clinicians' knowledge of CVD was compared before and after implementation of the training program. A paired sample t test was used to compare pre- and posttest results and assess for statistical significance (P < .05). Data were analyzed using R version 22.214.171.124
Two 4-hour training sessions were held and the adapted CR curriculum was taught to home care clinicians (Table 2). These sessions were led by an exercise physiologist with expertise in outpatient CR and home care, a registered dietician, 2 nurse practitioners specializing in cardiovascular care, and the program director. Both sessions reviewed the same content and materials, and were recorded and transcribed.
Nine patients (67% male) participated in interviews and ranged in age from 68 to 91 years (mean age = 85 years). The primary cardiac diagnoses for these patients included HF (n = 5), coronary artery disease (n = 2), myocardial infarction (n = 1), and atrial fibrillation (n = 1). Number of medications prescribed ranged from 4 to 29 (mean = 12). Self-reported race/ethnicity was 78% (n = 7) and 22% (n = 2) white and Asian, respectively.
Fifty-four clinicians (RNs = 25; PTs = 24; OTs = 5) participated in the training, of those 46 (67% female) provided informed consent to participate in research activities. Demographic information was collected from agency records. Clinicians ranged in age from 28 to 64 years (mean = 45 years), with 5 months to 32 years (mean = 10 years) of experience working at the home care agency. Nineteen clinicians (RNs = 11; PTs/OTs = 8) volunteered to participate in focus groups. Forty-one clinicians (RNs = 16; PTs = 20; OTs = 5) completed the knowledge tests.
FINDINGS FROM PATIENT INTERVIEWS
Awareness of Heart Disease
Patients lacked awareness about their condition and frequently denied having heart disease. When asked about their heart disease, patients did not talk about symptoms of their disease, but responded with a description of their feelings related to pain or breathing difficulties (eg, “[I was] feeling ill [and having trouble breathing] and didn't know [why], so I went to the hospital.”).
Patients often did not recognize feelings of discomfort as a symptom of their disease. However, when patients denied experiencing feelings of discomfort, they connected this lack of feelings with not having a heart problem. When asked about his heart condition, a patient explained, “[my heart] is quiet. I do not feel anything”. Many patients were uncertain about the cause of their hospital encounter. When asked about their hospital stay, patients spoke about the feeling that brought them into the hospital, such as breathing problems or syncope, but few connected these feelings to CVD. Patients expressed confusion about their discharge instructions and what to do at home after their hospital stay.
Motivation and Caregivers' Importance
Patients described fluctuating levels of motivation. Those who expressed a limited willingness to change felt they had been caring for themselves a certain way for years and were apprehensive about learning new information (eg, “do not tell me anything and I do not worry about it”). Other patients demonstrated higher motivation levels to improve their health, expressing optimism and willingness to follow their provider's instructions. A common motivator for improving health was to spend more time with their families. Patients also relied on family members as their source of health information and to inquire when something was wrong (eg, “I will talk to my daughter and her husband. He is not a doctor but he is very smart”).
Barriers to Attendance at Outpatient CR
Patients described a functional decline when they returned home from the hospital and the challenges of regaining their strength (eg, “If you are in the hospital, you deteriorate physically. I need to be able to get back to normal.”). Despite rehabilitative progress during home care, patients expressed challenges with continuing their exercises independently. A patient explained that when he receives home care physical therapy, “[The PT] gives me some exercises. My problem is continuing after he's left.” Furthermore, patients indicated a lack of awareness of outpatient services and resources available when discharged from home care services. Only 1 patient was familiar with CR services, but he reported feeling too weak to attend.
FINDINGS FROM CLINICIAN FOCUS GROUPS
Patient Awareness of Heart Disease
Clinicians reaffirmed patients' lack of awareness about their disease by explaining patients “don't realize their diagnosis. They complain of this and that, but they do not realize it's under the conditions of having CHF.” A rehabilitation therapist illustrated that patients believe “[having a diagnosis of] heart failure means [that you are] dying.” Clinicians verified the need for further education for patients, stating that patients often lack information about how to modify their diets, such as identifying low-sodium foods. A nurse explained that patients receive “a long list of things that they shouldn't eat, but are never really told what they can eat.”
Motivation and Caregivers' Importance
The clinicians reported varying motivation levels and goal-setting strategies among patients. Clinicians described patients who expressed optimism about their care and condition, but also patients who appear unmotivated to change their habits. One rehabilitation therapist quoted a patient who said, “What do you expect from me? I'm 92 years old.” Another nurse explained, “[patients] want to continue eating what they're eating and doing what they're doing”. Clinicians felt patients were content in their habits and did not want to make lifestyle changes, such as monitoring their weight daily. One strategy used by clinicians was setting simple and affirmative goals with patients, such as walking to the mailbox daily. Clinicians also emphasized the importance of involving family caregivers in patient goal-setting, as a strategy for increasing patient compliance (eg, “I felt like I [made more progress with the patient] when his son was there versus when I saw [the patient] by myself”). They discussed that patients often rely on caregivers for an understanding of their health and to make decisions about their condition.
Barriers to Attendance at Outpatient CR
Clinicians who were familiar with outpatient CR identified barriers to patient attendance. They illustrated that patients were not aware of available resources, and lacked transportation to facilities or access to programs near their homes. A nurse stated, “Patients really want to go [to cardiac rehabilitation] but when I explain [to the patient that he] can't have a nurse at home and go there, [the patient says] ‘how will I get there. Will you get me there?’”. Rehabilitation therapists also identified transportation and geographic barriers to patient attendance at outpatient CR programs, “We usually recommend [patients] go to cardiac rehabilitation after home care. The problem with cardiac rehabilitation is often [the patient] is on the east side and [cardiac rehabilitation] is on the west side.”
Gaps in Care Transitions
Clinicians identified gaps in care transitions between the hospital and home care setting. Clinicians often lacked information about the patient's hospitalization and prior functioning. Without further knowledge of their patients' conditions and discharge instructions, rehabilitation therapists were hesitant to “push” patients when exercising. Clinicians expressed challenges with connecting with provider(s) to coordinate treatment plans. The rehabilitation therapists explained that when they call a provider with questions for cardiac patients, they need a response “right then and there, otherwise we have to send the patient to the emergency room, which no one is happy about.” Clinicians lack the support needed to make autonomous decisions in the home without standardized guidelines and contact with providers.
Although some clinicians acknowledged CR, others expressed an uncertainty or said they “do not know what cardiac rehab is.” One misconception held by some clinicians was that CR is designed for younger patients, but is not appropriate for the elderly. Clinicians demonstrated a need for further education about assessments and interventions for cardiac patients, such as caring for a patient with a cardiac device. Rehabilitation therapists explained they wanted more information on the followup procedures and how to identify when there was a problem with these devices, such as ventricular assist devices. They also expressed the need for “specific protocols of increasing [activity] load, with cardiovascular training or weight training” to complement their knowledge from experience. Examples of quotations from patients and clinicians illustrating patient and clinician themes are provided in Table 3.
FINDINGS FROM CLINICIAN PRE- AND POSTTRAINING KNOWLEDGE TEST
Paired sample t tests revealed significant differences pre- and posttraining in clinicians' knowledge of cardiovascular conditions and rehabilitation. Pretraining knowledge test scores did not differ significantly between RNs (n = 16) and PTs/OTs (n = 25) participating in the training (RN mean score = 13.04; PT/OT mean score = 12.66). Posttraining knowledge test scores improved an average of 1.8 points out of a total possible score of 15 points (pretraining and posttraining mean scores = 12.81 and 14.63, respectively; P < .001). Separate t tests for each clinical discipline demonstrated significantly greater knowledge (RNs and PTs/OTs both P < .001) posttraining compared with pretraining (Table 4). There was no significant difference observed in posttraining knowledge scores by discipline (posttraining mean scores for RNs and PTs/OTs were 14.72 and 14.56, respectively).
There is limited research on the delivery of CR services to homebound patients with CVD. After an extensive literature review and synthesis of qualitative findings, we developed an adapted CR training program based on the AACVPR guidelines for clinicians providing care to homebound patients. Training was provided to RNs, PTs, and OTs at a certified home health agency with a comprehensive overview of CR, emphasizing exercise physiology, nutrition counseling, and CVD risk factor reduction. The training attempted to address knowledge gaps identified among clinicians and patients, which led us to develop specific protocols for progressing patients and intervention checklists for home care visits. The pre- and posttraining knowledge test scores demonstrated significant improvements in clinicians' knowledge of CVD and CR.
Our findings yielded a lack of awareness among homebound patients regarding CVD and how to self-manage their conditions at home, consistent with the literature emphasizing a lack of awareness of CVD across settings.32,33 When asked about their heart disease, many patients described their “feelings,” such as feeling short of breath. Patients did not connect these “feelings” with symptoms of a condition. To address this lack of awareness among patients, clinicians were educated on interactive education strategies, such as the teach-back method.34 Transitional care practices that encourage patients to take an active role in managing their condition have been shown to reduce hospitalization rates.35,36
Both patients and clinicians demonstrated a lack of awareness of CR and its purpose, consistent with prior literature correlating a lack of knowledge about CR with low participation rates.37 There is limited time to discuss CR with hospitalized patients and to coordinate referrals, highlighting the importance of educating home care clinicians on these programs.38 The misconception among clinicians that only younger patients may benefit from CR reinforced the need for further education about eligibility criteria. Furthermore, the limited number of outpatient CR centers near patients' homes poses an additional barrier, especially for older home care patients, and represents a predictor of attendance at outpatient CR.39,40 The development of CR programs adapted for the home care setting may help patients overcome these barriers and aid homebound patients in receiving CR services.
Our training integrated interprofessional education to train RNs, PTs, and OTs to function as an interdisciplinary team of CR specialists.41 Disciplines were educated to reinforce interventions to increase patient adherence to lifestyle changes. The results from the pre- and posttraining knowledge tests did not differ significantly between nurses and rehabilitation therapists, indicating the effectiveness of collaborative education for nurses and rehabilitation therapists.
We recommend future studies include interviews or focus groups with patients and clinicians before developing educational training. Engaging clinicians beforehand allowed us to obtain baseline knowledge and assess deficits to tailor the training to the individual needs of our clinicians. As we deduced from the focus groups, clinicians would benefit from standardized cardiac care plans with exercise protocols, to help identify how and when to progress patients, and how to safely monitor their responses. Feedback illustrating the need for education on cardiac devices influenced us to include a review of cardiac devices in the curriculum. We incorporated a behavioral change section into the training, including an overview of behavioral change strategies and motivational interviewing, to address the challenges described with motivation and goal-setting.42
To ensure operational feasibility, we focused on restructuring and improving care based on clinicians' practice and regulations within the current model of home care. The synergy among patient and clinician themes demonstrated a need for further education for both parties. The training increased knowledge among clinicians with the potential to empower patients and address patients' educational needs. This study represents the first phase of a larger initiative to implement and evaluate the feasibility of delivering CR services to homebound patients in a certified home health agency. Next steps will be to assess clinician fidelity to program interventions and feasibility by tracking patients who were enrolled in the home-based CR pilot program.
A limitation of the study is that the small patient and clinicians samples were taken from 1 home health agency in New York, and patients were predominantly white and male, limiting generalizability. Second, without obtaining the characteristics of the 13 clinicians who chose not to share their data, there is a risk of clinician bias in the training evaluation. Third, the restricted amount of time to conduct the training limited the information included in the curriculum. Despite these limitations, there was evidence to support the need for further implementation and evaluation of training on the core competencies of CR for home care clinicians.
Home-based CR programs may help address the gap in care between hospital discharge and traditional outpatient CR. For patients with HF enrolled in Medicare, who must wait 6 weeks before being eligible for outpatient participation, a home-based CR program provides a head-start. Furthermore, many other patients may never have access to or the ability to attend an outpatient facility. Home-based CR programs may help provide the education and motivation these patients need to better self-manage their chronic disease. This project will contribute additional data to addressing the feasibility of implementing a home-based CR model within the structure of a home care agency.
The authors thank the University of Pennsylvania President's Engagement Prize for funding and supporting the Home Heart Health initiative and the Visiting Nurse Service of New York Center for Home Care Policy & Research for hosting this study. The authors also thank the content experts from NYU Langone Medical Center, Visiting Nurse Service of New York, and University of Pennsylvania School of Nursing for their expertise. Lastly, a special thanks to the patients and clinicians whose enthusiastic participation was integral to this project.
1. Kochanek KD, Murphy SL, Xu J, Arias E. Mortality in the United States, 2013. NCHS data brief, no 178. Hyattsville, MD: National Center for Health Statistics; 2014.
2. Mozaffarian D, Benjamin E, Go AS, et al Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131:e29–e322.
3. Levine GN, Bates ER, Blankenship JC, et al 2011 ACCF/AHA/SCAI Guideline for percutaneous coronary intervention. J Am Coll Cardiol. 2011;58:e44–e122.
4. Corra U, Giannuzzia P, Adamopoulos S, et al Exercise summary of the position paper of the Working Group on Cardiac Rehabilitation
and Exercise Physiology of the European Society of Cardiology (ESC): core components of cardiac rehabilitation
in chronic heart failure. Eur J Cardiovasc Prev Rehabil. 2005;12:321–325.
5. Acee A. Co-morbid depression and cardiovascular disease in the older adult homecare patient. Home Healthc Now. 2015;33:333–336.
6. Murtaugh C, Peng T, Totten A, Costello B, Moore S, Aykan H. Complexity in geriatric home healthcare. J Healthc Qual. 2009;31:34–43.
7. Sandesara P, Lambert C, Gordon N, et al Cardiac rehabilitation
and risk reduction: time to “rebrand and reinvigorate.” J Am Coll Cardiol. 2015;65:389–395.
8. Coviello J. Cardiac assessment 101: a new look at the guidelines for cardiac homecare patients. Home Healthc Nurse. 2004;22:116–123.
9. Shellman J, Lacey K, Clemmens D. A cardiac management program for home care. Home Healthc Nurse. 2006;26:582–588.
10. Kottke TE, Faith DA, Jordan CO, Pronk NP, Thomas RJ, Capewell S. The comparative effectiveness of heart disease prevention and treatment strategies. Am J Prev Med. 2009;36:82–88.
11. Taylor RS, Brown A, Ebrahim S, et al Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116:682–692.
12. Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Statson WB. Use of cardiac rehabilitation
by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2007;116:1653–1662.
13. Lichtman SW. Cardiac rehabilitation
in the inpatient and transitional settings. In: Williams M, Roitman J, eds. Guidelines for Cardiac Rehabilitation
and Secondary Prevention Programs. 5th ed. Champaign, IL: Human Kinetics; 2013:53–54.
14. Zullo MD, Jackson LW, Whalen CC, Dolansky MA. Evaluation of the recommended core components of cardiac rehabilitation
practice: an opportunity for quality improvement. J Cardiopulm Rehabil Prev. 2012;32:32–40.
15. Russell KL, Holloway TM, Brum M, Caruso V, Chessex C, Grace SL. Cardiac rehabilitation
wait times: effect on enrollment. J Cardiopulm Rehabil Prev. 2011;31:373–377.
16. Dalal HM, Zawada A, Jolly K, Moxham T, Taylor RS. Home based versus centre based cardiac rehabilitation
: Cochrane Systematic Review and meta-analysis. BMJ. 2010;340:b56631.
17. Jolly K, Lip G, Taylor RS, et al The Birmingham rehabilitation uptake maximization study (BRUM): a randomized controlled trial comparing home-based with center-based cardiac rehabilitation
. Heart. 2009;95:36–42.
18. Clark AM, Haykowski M, Kryworuchko J, et al A meta-analysis of randomized control trails of home-based secondary prevention programs for coronary artery disease. Eur J Cardiovasc Prev Rehabil. 2010;17:261–270.
19. Hamm L, Sanderson B, Ades P, et al Core competencies for cardiac rehabilitation
/secondary prevention professionals: 2010 update: position statement of the American Association of Cardiovascular and Pulmonary Rehabilitation. J Cardiopulm Rehabil Prev. 2011;31:2–10.
20. Delaney C, Apostolidis B, Lachapelle L, Fortinsky R. Home care nurses' knowledge of evidence-based education topics for management of heart failure. Heart Lung. 2011;40:285–292.
21. Fowler S. Improving community health nurses' knowledge of heart failure education principles: a descriptive study. Home Healthc Nurse. 2012;30:91–99.
22. Plisiene J, Blumberg A, Haager G, et al Moderate physical exercise: a simplified approach for ventricular rate control in older patients with atrial fibrillation. Clin Res Cardiol. 2008;97:820–826.
23. Yamamoto K, Miyachi M, Saitoh T, et al Effects of endurance training on resting and post- exercise cardiac autonomic control. Med Sci Sports Exerc. 2001;33:1496–1502.
24. Albert NM, Collier S, Sumodi V, et al Nurses' knowledge of heart failure education principles. Heart Lung. 2002;31:102–112.
25. Lima de Melo Ghisi G, Grace S, Thomas S, Evans M, Oh P. Development and psychometric validation of the second version of the Coronary Artery Disease Education Questionnaire (CADE-Q II). Patient Educ Couns. 2015;98:378–383.
26. Bergman H, Reeve B, Moser R, Scholl S, Klein W. Development of a Comprehensive Herat Disease Knowledge Questionnaire. Am J Health Educ. 2011;42:74–87.
27. Hart P, Spiva L, Kimble L. Nurses' knowledge of heart failure education principles survey: a psychometric study. J Clin Nurs. 2011;20:3020–3028.
28. Washburn SC, Hornberger CA, Klutman A, Skinner L. Nurses' knowledge of heart failure education topics as reported in a small Midwestern community hospital. J Cardiovasc Nurs. 2005;20:215–220.
29. Willette EW, Surrells D, Davis LL, Bush CT. Nurses' knowledge of heart failure self-management. Prog Cardiovasc Nurs. 2007;22:190–195.
30. Glaser BG. The constant comparative method of qualitative data analysis. Grounded Theory Review. 2008;7(3).
31. Team RC. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2012.
32. Butler J, Fonraow G, Gheorghiade M. Need for increased awareness and evidence-based therapists for patients hospitalized for heart failure. JAMA. 2013;310:2035–2036.
33. Kayaniyil S, Ardern C, Winstanley J, et al Degree and correlates of cardiac knowledge and awareness among cardiac inpatients. Patient Educ Couns. 2009;75:99–107.
34. White M, Garbez R, Carroll M, Brinker E, Howie- Esquivel J. Is “teach-back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients? J Cardiovasc Nurs. 2013;28:137–146.
35. Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley K M, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675–684.
36. Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc. 2004;52:1817–1825.
37. McCarthy MM, Dickson VV, Chyun D. Barriers to cardiac rehabilitation
in women with cardiovascular disease: an integrative review. J Cardiovasc Nurs. 2011;26:E1–E10.
38. Valencia HE, Savage PD, Ades PA. Cardiac rehabilitation
participation in underserved populations: minorities, low socioeconomic, and rural residents. J Cardiopulm Rehabil Prev. 2011;31:203–210.
39. De Vos C, Li X, Vlaenderen IV, et al Participating or not in a cardiac rehabilitation
programme: factors influencing a patient's decision. Eur J Prev Cardiol. 2012;20:341–348.
40. Zutz A, Ignaszewski A, Bates J, Lear SA. Utilization of the internet to deliver cardiac rehabilitation
at a distance: a pilot study. Telemed J E Health. 2013;13:323–330.
41. McPherson K. Working and learning together: good quality care depends on it. But how can we achieve it? Qual Health Care. 2001;10:ii46–ii53.
42. Williams SL, French DP. What are the most effective intervention techniques for changing physical activity and self- efficacy and physical activity behavior—are they the same? Health Educ Res. 2011;26:308–322.