Research shows that a lack of guidelines and a lack of professional confidence and competence are preventing health professionals from referring their patients to cardiac rehabilitation.

In a recent survey of 28 European countries, only 32% had official guidelines on cardiac rehabilitation, just over 60% had formal educational programmes, 29% had accreditation systems and 35% had databases.¹

“It is difficult in that context to fly the flag for cardiac rehabilitation, and say that it is an important service, and also to demonstrate that there is professional competence and recognition of that competence in terms of its provision,” said Dr Margaret Cupples, from Queen’s University, Belfast, and the UK Clinical Research Collaboration (UKCRC) Centre of Excellence for Public Health.

Dr Cupples was speaking at the EuroPRevent 2012 conference of the European Society of Cardiology (ESC), which took place in Dublin in May. 

She believes that there is a need to change the behaviour and perceptions of both health professionals and patients when it comes to cardiac rehabilitation.

“It is the doctors who are physically active, and who themselves feel that they have competent knowledge and are aware of current recommendations of physical activity guidelines, that are most likely to promote physical activity guidelines to their patients,” she said. “And it’s those patients who receive information from such doctors who are most likely to change their behaviour.” 

Belief in the value of referral

The perceived strength of recommendation in referral is important when it comes to attendance to cardiac rehabilitation, according to Dr Cupples. The manner of invitation is another strong influence in attendance.

“Perhaps we don’t recognise as health professionals how implicit and explicit clues can be picked up by the patient that we inadvertently have attributed to our belief in the value of cardiac rehabilitation,” said Dr Cupples. “Communication is important.”

When it comes to secondary prevention and cardiac rehabilitation, the most successful strategies combine population approaches and individual interventions.

“The individual is not an island, isolated from all other influences, and cardiac rehabilitation, and the patient’s involvement in it and the doctor’s involvement in it, has to be recognised as not being isolated from what goes on in the broader context of cardiovascular disease management and prevention,” said Dr Cupples.

Attendance barriers

A recent study showed that 25% of all patients who are invited to attend cardiac rehab decline. The highest reason for decline by patients is that they are simply ‘not interested’.

Other reasons for decline may be due to the fact that there are ongoing medical investigations with regard to the patient’s health; there may be a distance problem in terms of where the patient resides and where the cardiac rehabilitation is taking place; the patient perceives they are too ill to attend; they perceive they are too well to attend and have already returned to work; or they believe that attending cardiac rehabilitation is an inconvenience to their everyday routine. 

According to Dr Cupples, there are also local exclusion criteria for invitation to cardiac rehabilitation programmes.

The physical barriers that affect attendance include: lack of transport; inconvenient location of the rehab; no access to suitable transport; or the patient may be unable to drive due to their illness.

Certain social issues may also affect attendance at cardiac rehab, including familial responsibilities.

“Perhaps children need to be looked after, perhaps sick relatives, perhaps older people in their family. Perhaps people don’t like going to the hospital without having some form of family or friends there to support them and that’s just not available,” explained Dr Cupples.

“Illness beliefs can also be act as barriers to attendance because of people’s perceptions of how they are,” said Dr Cupples. “Or perhaps because they perceive that it doesn’t matter what they do, their mother and father has dropped dead in the street and they’re likely to do likewise.”

Misperceptions 

There exist many misperceptions among the public about what cardiac rehabilitation involves, its effectiveness, and whether or not they are suitable candidates for the treatment.

“Sometimes people think that it’s all about exercise and that it’s not for them,” said Dr Cupples. “Sometimes people think it’s only for men, some people think it’s mostly the women that go, some think it’s the old, some think it’s the young. 

There are ways of precipitating attendance to cardiac rehabilitation. Healthcare professionals should make efforts not only to explore their patients’ false perceptions of cardiac rehabilitation, but to also challenge them.

“There are all sorts of misperceptions out there, and sometimes it’s embarrassment that’s a huge barrier. Because people are perceived to be in a certain age group they don’t want to go because they don’t want to show themselves as being unfit or too fat, or not having the right clothes.”

Dr Cupples highlighted the need for cardiac rehabilitation programmes to be ‘individually tailored’. She believes that patients should be given different options with regard to cardiac rehabilitation and that they should be given an opportunity to choose a programme that suits them.

“We can ensure that the programmes are more convenient and timed conveniently, more sensitive to people’s needs in terms of their language or culture,” said Dr Cupples. 

She suggested that more effort is needed to explain cardiovascular disease more clearly to patients. We must take on board their misconceptions about cardiac rehabilitation and attempt to correct them in order to ensure that their understanding of the process is accurate.

Cultural context

The influence of subjective norms is extremely relevant to rehab programmes, and therefore, understanding the cultural context of the patient is vital in increasing attendance to programmes.

Dr Cupples said: “If people want to change their diet, they want to change their physical activity level, if they want to take their medication, if that is not in keeping within the norms of people with whom they live, they are a lost cause. It’s a much more difficult barrier for them to overcome if the [cultural] situation is different.”

She said: “We may work in communities, but we may not fully understand what goes on in the community and it’s essential that we do that, in order to actually meet the needs of patients. We don’t know how big the drug dealing problem is that that mother has to contend with, in terms of her sons getting involved; we don’t know how poor the financial situation is and we don’t know what other demands are put on people, either men or women, within home situations or social situations.

She continued: “So we need to make sure we know, and if we don’t know, we shouldn’t be afraid to admit we don’t know and ask the patient.”

Communication is key

Understanding the patients’ cultural context also includes taking account of the language they use.

Dr Cupples believes that cardiologists, GPs and other health service workers must gain an understanding of the colloquial terms that are commonly used in the community in which they work. This will allow them to communicate with and understand their patients better.

According to the Queen’s University lecturer, it is also important that they look at the level of literacy of their patients with regard to the health information they are given to take home with them.

“It’s all very well to explain something in the surgery setting or in the clinic setting, but when people go home, we should offer them the opportunity for written information or an electronic source of information as back up to what we’ve told them,” she said. 

Information distributed to cardiac patients should:

• Be relevant
• Demonstrate the importance of cardiac rehabilitation
• Be short and simple 
• The approach should recognise the constraint and context of the patient 

Be provided via a collaborative participation of healthcare professionals.

Better communication between all members of a patient’s healthcare team would also improve their likelihood of attending a cardiac rehabilitation programme. 

Supporting patient choice

“We should provide information to other health professionals who are involved in the patient’s care, and we should offer programmes that are available to be adapted to patients’ needs, to give them this menu-driven approach and to make them responsible for making choices. We need to let them see that they’re the people who have a responsibility in making this choice, and that we are not forcing a specific management plan upon them,” suggested Dr Cupples. 

She believes that primary care can play an important role in providing support for cardiac rehabilitation patients and in offering patients a programme that is in line with their needs. This support can be provided in the background or in the foreground, where there is more convenience for the patients. For example, community-based programmes that are set in rehabilitation centres, in GP surgeries, or supervised programmes set in patients’ own homes. 

“Cardiac rehabilitation programmes are extremely effective in terms of mortality, morbidity and wellbeing. However, in order to improve programme attendance, we must first improve the professional skills, accreditation and education of cardiology professionals and change patients’ misperceptions about the rehabilitation process,” Dr Cupples said.

References 

1. The British Heart Foundation. The National Audit of Cardiac Rehabilitation. Annual Statistic Report 2011.  Available at www.cardiacrehabilitation.org.uk/nacr/docs/2011.pdf 
2. Zwisler A-D et al. Can level of education, accreditation and use of databases in cardiac rehabilitation be improved? Results from the European Cardiac Rehabilitation Inventory Survey. EJPC April 2012; 18(2):143-50