Patient Adherence to a Cardiovascular Rehabilitation Program: What Factors Are Involved?
Author(s)
María José Bustamante1,
Giovanna Valentino1,
Verónica Krämer1,
Marcela Adasme1,
Dominique Guidi1,
Camila Ibara1,
Cinthia Casasbellas1,
Lorena Orellana1,
Marcelo Fernández1,
Carlos Navarrete2,
Mónica Acevedo1*
Affiliation(s)
1 División de Enfermedades Cardiovasculares, Facultad de Medicina, Escuela de Medicina, Pontificia Universidad Católica, Santiago, Chile. 2 Departamento de Matemáticas, Facultad de Ciencias, Universidad de La Serena, La Serena, Chile.
1 División de Enfermedades Cardiovasculares, Facultad de Medicina, Escuela de Medicina, Pontificia Universidad Católica, Santiago, Chile. 2 Departamento de Matemáticas, Facultad de Ciencias, Universidad de La Serena, La Serena, Chile.
ABSTRACT
Background: Phase II cardiac rehabilitation (CR) is a class IA indication in patients suffering a cardiovascular event (CV). Current guidelines suggest 36 exercise sessions over a period of 3 months. The main aim of this study was to analyze the rate of adherence to a cardiac rehabilitation program and the factors influencing it. Methods: This was a cross-sectional study in 421 secondary prevention patients, who assisted to a Phase-II-CR program between 2007 and 2014. At baseline and program end, patients completed a 6-minute walk test and the Short-Form 36 Health Survey (SF-36). Vital signs and anthropometric measurements were also collected. Adherence was quantified as the percentage of individuals who attended all 36 sessions of the program. Factors considered for affecting adherence included: cardiovascular risk factors (RFs), type of health insurance (public or private), aerobic capacity, and SF-36 score parameters. Results: Adherence to Phase-II-CR was 33%, with no significant differences between men and women. The regression model fully adjusted for age, sex, RFs, type of health insurance and SF-36 score, showed that a SF-36 score <50 on physical health (odds ratio (OR): 11.47; 3.99 - 32.99; p < 0.0001) and smoking (OR: 4.41; 1.25 - 15.62; p = 0.02) were strong predictors for non-adherence. A trend for better adherence was observed in subjects older than 50 years compared to those aged between 17 and 50 years (37% versus 23%, respectively; p = 0.05). No significant differences were observed in adherence according to RFs clustering. Conclusions: Adherence to Phase-II-CR is low in our population. Patient-related factors, such as SF-36 score and smoking, were the best determinants of Phase-II-CR adherence. Health system-related factors did not influence adherence in this population. Prospective studies are warranted to determine all the factors which may influence adherence to Phase-II-CR programs.
Background: Phase II cardiac rehabilitation (CR) is a class IA indication in patients suffering a cardiovascular event (CV). Current guidelines suggest 36 exercise sessions over a period of 3 months. The main aim of this study was to analyze the rate of adherence to a cardiac rehabilitation program and the factors influencing it. Methods: This was a cross-sectional study in 421 secondary prevention patients, who assisted to a Phase-II-CR program between 2007 and 2014. At baseline and program end, patients completed a 6-minute walk test and the Short-Form 36 Health Survey (SF-36). Vital signs and anthropometric measurements were also collected. Adherence was quantified as the percentage of individuals who attended all 36 sessions of the program. Factors considered for affecting adherence included: cardiovascular risk factors (RFs), type of health insurance (public or private), aerobic capacity, and SF-36 score parameters. Results: Adherence to Phase-II-CR was 33%, with no significant differences between men and women. The regression model fully adjusted for age, sex, RFs, type of health insurance and SF-36 score, showed that a SF-36 score <50 on physical health (odds ratio (OR): 11.47; 3.99 - 32.99; p < 0.0001) and smoking (OR: 4.41; 1.25 - 15.62; p = 0.02) were strong predictors for non-adherence. A trend for better adherence was observed in subjects older than 50 years compared to those aged between 17 and 50 years (37% versus 23%, respectively; p = 0.05). No significant differences were observed in adherence according to RFs clustering. Conclusions: Adherence to Phase-II-CR is low in our population. Patient-related factors, such as SF-36 score and smoking, were the best determinants of Phase-II-CR adherence. Health system-related factors did not influence adherence in this population. Prospective studies are warranted to determine all the factors which may influence adherence to Phase-II-CR programs.
Cite this paper
Bustamante, M. , Valentino, G. , Krämer, V. , Adasme, M. , Guidi, D. , Ibara, C. , Casasbellas, C. , Orellana, L. , Fernández, M. , Navarrete, C. and Acevedo, M. (2015) Patient Adherence to a Cardiovascular Rehabilitation Program: What Factors Are Involved?. International Journal of Clinical Medicine, 6, 605-614. doi: 10.4236/ijcm.2015.69081.
Bustamante, M. , Valentino, G. , Krämer, V. , Adasme, M. , Guidi, D. , Ibara, C. , Casasbellas, C. , Orellana, L. , Fernández, M. , Navarrete, C. and Acevedo, M. (2015) Patient Adherence to a Cardiovascular Rehabilitation Program: What Factors Are Involved?. International Journal of Clinical Medicine, 6, 605-614. doi: 10.4236/ijcm.2015.69081.
References
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http://dx.doi.org/10.1161/CIRCULATIONAHA.109.876383 [8] Suaya, J.A., Shepard, D.S., Normand, S.L., Ades, P.A., Prottas, J. and Stason, W.B. ( 2007) Use of Cardiac Rehabilitation by Medicare Beneficiaries after Myocardial Infarction or Coronary Bypass Surgery. Circulation, 116, 1653-1662.
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http://dx.doi.org/10.1161/01.CIR.0000151788.08740.5C [10] Yohannes, A.M., Yalfani, A., Doherty, P. and Bundy, C. (2007) Predictors of Drop-Out from an Outpatient Cardiac Rehabilitation Programme. Clinical Rehabilitation, 21, 222-229.
http://dx.doi.org/10.1177/0269215506070771 [11] Santibáñez, C., Pérez-Terzic, C., López-Jiménez, F., Cortés-Bergoderi, M., Araya M.V. and Burdiat, G. (2012) Situación actual de la rehabilitación cardiaca en Chile. Revista médica de Chile, 140, 561-568.
http://dx.doi.org/10.4067/S0034-98872012000500002 [12] Scott, L.A., Ben-Or, K. and Allen J.K. (2002) Why Are Women Missing from Outpatient Cardiac Rehabilitation Programs? A Review of Multilevel Factors Affecting Referral, Enrollment, and Completion. Journal of Women’s Health, 11, 773-791.
http://dx.doi.org/10.1089/15409990260430927 [13] Todaro, J.F., Shen, B.J., Niaura, R., Tilkemeier, P.L. and Roberts, B.H. (2005) Do Men and Women Achieve Similar Benefits from Cardiac Rehabilitation? Journal of Cardiopulmonary Rehabilitation, 24, 45-51. [14] Jackson, L., Leclerc, J., Erskine, Y. and Linden, W. (2005) Getting the Most Out of Cardiac Rehabilitation: A Review of Referral and Adherence Predictors. Heart, 91, 10-14.
http://dx.doi.org/10.1136/hrt.2004.045559 [15] Grundy, S.M., Brewer Jr., H.B., Cleeman, J.I., Smith Jr., S.C. and Lenfant, C. (2004) Definition of Metabolic Syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on Scientific Issues Related to Definition. Circulation, 109, 433-438.
http://dx.doi.org/10.1161/01.CIR.0000111245.75752.C6 [16] Alberti, K.G.M.M., Eckel, R.H., Grundy, S.M., Zimmet, P.Z., Cleeman, J.I., Donato, K.A., et al. (2009) Harmonizing the Metabolic Syndrome: A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation, 120, 1640-1645.
http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192644 [17] Ministerio de Salud, Pontificia Universidad Católica y Universidad Alberto Hurtado (2011) Encuesta Nacional de Salud. Chile 2009-2010.
http://www.redsalud.gov.cl/portal/url/item/99c12b89738d80d5e04001011e0113f8.pdf [18] Krämer, V., Acevedo, M., Orellana, L., Chamorro, G., Corbalán, R., Bustamante, M.J., et al. (2009) Actividad física y potencia aeróbica: Cómo influyen sobre los factores de riesgo cardiovascular clásicos y emergentes? Revista Médica de Chile, 137, 737-745.
http://dx.doi.org/10.4067/S0034-98872009000600002 [19] (1998) U.S. Population Norms. United States of America.
http://www.sf-36.org/research/sf98norms.pdf [20] Perk, J., De Backer, G., Gohlke, H., Graham, I., Reiner, Z., Verschuren, M., et al. (2012) European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (Version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (Constituted by Representatives of Nine Societies and by Invited Experts). European Heart Journal, 33, 1635-1701.
http://dx.doi.org/10.1093/eurheartj/ehs092 [21] Corrá, U., Piepoli, M.F., Carré, F., Heuschmann, P., Hoffmann, U., Verschuren, M., et al. (2010) Secondary Prevention through Cardiac Rehabilitation: Physical Activity Counseling and Exercise Training: Key Components of the Position Paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. European Heart Journal, 31, 1967-1974.
http://dx.doi.org/10.1093/eurheartj/ehq236 [22] Turk-Adawi, K.I., Oldridge, N.B., Tarima, S.S., Stason, W.B. and Shepard, D.S. (2013) Cardiac Rehabilitation Patient and Organizational Factors: What Keeps Patients in Programs? Journal of the American Heart Association, 2, e000418.
http://dx.doi.org/10.1161/JAHA.113.000418 [23] Worcester, M.U., Murphy, B.M., Mee, V.K., Roberts, S.B. and Goble, A.J. (2004) Cardiac Rehabilitation Programmes: Predictors of Non-Attendance and Drop-Out. European Journal of Cardiovascular Prevention and Rehabilitation, 11, 328-335.
http://dx.doi.org/10.1097/01.hjr.0000137083.20844.54 [24] Oldridge, N.B. and Streiner, D.L. (1990) The Health Belief Model: Predicting Compliance and Dropout in Cardiac Rehabilitation. Medicine & Science in Sports & Exercise, 22, 678-683.
http://dx.doi.org/10.1249/00005768-199010000-00020 [25] Wakefield, M., Roberts, L. and Rosenfeld, E. (1997) Smoking Cessation among People with Diabetes: Beliefs and Barriers. Health Promotion Journal of Australia, 7, 46-51. [26] McGee, H.M. and Horgan, J.H. (1992) Cardiac Rehabilitation Programmes: Are Women Less Likely to Attend? British Medical Journal, 305, 283-284.
http://dx.doi.org/10.1136/bmj.305.6848.283-a [27] Jones, M., Jolly, K., Raftery, J., Lip, G.Y., Greenfield, S. and BRUM Steering Committee (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.
http://dx.doi.org/10.1093/fampra/cmm021 [28] Dunlay, S.M., Witt, B.J., Allison, T.G., Hayes, S.N., Weston, S.A., Koepsell, E., et al. (2009) Barriers to Participation in Cardiac Rehabilitation. American Heart Journal, 158, 852-859.
http://dx.doi.org/10.1016/j.ahj.2009.08.010
[1] INE (2010) Estadísticas Vitales: Informe Anual 2008.
http://www.ine.cl/canales/menu/publicaciones/calendario_de_publicaciones/
pdf/21_12_10/vit_08211210.pdf [2] Nazzal, C. and Alonso F.T. (2011) Incidencia y letalidad por infarto agudo del miocardio en Chile: 2001-2007. Revista médica de Chile, 139, 1253-1260.
http://dx.doi.org/10.4067/S0034-98872011001000002 [3] Lawler, P.R., Filion, K.B. and Eisenberg, M.J. (2011) Efficacy of Exercise-Based Cardiac Rehabilitation Post-Myocardial Infarction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. American Heart Journal, 162, 571.e2-584.e2.
http://dx.doi.org/10.1016/j.ahj.2011.07.017 [4] Smith S.C., Benjamin E.J., Bonow R.O., Braun L.T., Creager M.A., Franklin B.A., et al. (2011) AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2011 Update: A Guideline from the American Heart Association and American College of Cardiology Foundation endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association. Circulation, 124, 2458-2473.
http://dx.doi.org/10.1161/CIR.0b013e318235eb4d [5] Hsu, C.J., Chen, S.Y., Su, S., Yang, M.C., Lan, C., Chou, N.K., et al. (2011) The Effect of Early Cardiac Rehabilitation on Health-Related Quality of Life among Heart Transplant Recipients and Patients with Coronary Artery Bypass Graft Surgery. Transplantation Proceedings, 43, 2714-2717.
http://dx.doi.org/10.1016/j.transproceed.2011.04.025 [6] Acevedo, M., Krämer, V., Bustamante, M.J., Yañez, F., Guidi, D., Corbalán, R., et al. (2013) Rehabilitación cardio-vascular y ejercicio en prevención secundaria. Revista médica de Chile, 141, 1305-1312.
http://dx.doi.org/10.4067/s0034-98872013001000010 [7] Hammill, B.G., Curtis, L.H., Schulman, K.A. and Whellan, D.J. (2010) Relationship between Cardiac Rehabilitation and Long-Term Risks of Death and Myocardial Infarction among Elderly Medicare Beneficiaries. Circulation, 121, 63-70.
http://dx.doi.org/10.1161/CIRCULATIONAHA.109.876383 [8] Suaya, J.A., Shepard, D.S., Normand, S.L., Ades, P.A., Prottas, J. and Stason, W.B. ( 2007) Use of Cardiac Rehabilitation by Medicare Beneficiaries after Myocardial Infarction or Coronary Bypass Surgery. Circulation, 116, 1653-1662.
http://dx.doi.org/10.1161/CIRCULATIONAHA.107.701466 [9] Leon, A.S., Chair, M.S. Franklin, B.A., Costa, F., Balady, G.J., Berra, K.A., et al. (2005) An American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention); Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation. Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease. Circulation, 111, 369-376.
http://dx.doi.org/10.1161/01.CIR.0000151788.08740.5C [10] Yohannes, A.M., Yalfani, A., Doherty, P. and Bundy, C. (2007) Predictors of Drop-Out from an Outpatient Cardiac Rehabilitation Programme. Clinical Rehabilitation, 21, 222-229.
http://dx.doi.org/10.1177/0269215506070771 [11] Santibáñez, C., Pérez-Terzic, C., López-Jiménez, F., Cortés-Bergoderi, M., Araya M.V. and Burdiat, G. (2012) Situación actual de la rehabilitación cardiaca en Chile. Revista médica de Chile, 140, 561-568.
http://dx.doi.org/10.4067/S0034-98872012000500002 [12] Scott, L.A., Ben-Or, K. and Allen J.K. (2002) Why Are Women Missing from Outpatient Cardiac Rehabilitation Programs? A Review of Multilevel Factors Affecting Referral, Enrollment, and Completion. Journal of Women’s Health, 11, 773-791.
http://dx.doi.org/10.1089/15409990260430927 [13] Todaro, J.F., Shen, B.J., Niaura, R., Tilkemeier, P.L. and Roberts, B.H. (2005) Do Men and Women Achieve Similar Benefits from Cardiac Rehabilitation? Journal of Cardiopulmonary Rehabilitation, 24, 45-51. [14] Jackson, L., Leclerc, J., Erskine, Y. and Linden, W. (2005) Getting the Most Out of Cardiac Rehabilitation: A Review of Referral and Adherence Predictors. Heart, 91, 10-14.
http://dx.doi.org/10.1136/hrt.2004.045559 [15] Grundy, S.M., Brewer Jr., H.B., Cleeman, J.I., Smith Jr., S.C. and Lenfant, C. (2004) Definition of Metabolic Syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on Scientific Issues Related to Definition. Circulation, 109, 433-438.
http://dx.doi.org/10.1161/01.CIR.0000111245.75752.C6 [16] Alberti, K.G.M.M., Eckel, R.H., Grundy, S.M., Zimmet, P.Z., Cleeman, J.I., Donato, K.A., et al. (2009) Harmonizing the Metabolic Syndrome: A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation, 120, 1640-1645.
http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192644 [17] Ministerio de Salud, Pontificia Universidad Católica y Universidad Alberto Hurtado (2011) Encuesta Nacional de Salud. Chile 2009-2010.
http://www.redsalud.gov.cl/portal/url/item/99c12b89738d80d5e04001011e0113f8.pdf [18] Krämer, V., Acevedo, M., Orellana, L., Chamorro, G., Corbalán, R., Bustamante, M.J., et al. (2009) Actividad física y potencia aeróbica: Cómo influyen sobre los factores de riesgo cardiovascular clásicos y emergentes? Revista Médica de Chile, 137, 737-745.
http://dx.doi.org/10.4067/S0034-98872009000600002 [19] (1998) U.S. Population Norms. United States of America.
http://www.sf-36.org/research/sf98norms.pdf [20] Perk, J., De Backer, G., Gohlke, H., Graham, I., Reiner, Z., Verschuren, M., et al. (2012) European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (Version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (Constituted by Representatives of Nine Societies and by Invited Experts). European Heart Journal, 33, 1635-1701.
http://dx.doi.org/10.1093/eurheartj/ehs092 [21] Corrá, U., Piepoli, M.F., Carré, F., Heuschmann, P., Hoffmann, U., Verschuren, M., et al. (2010) Secondary Prevention through Cardiac Rehabilitation: Physical Activity Counseling and Exercise Training: Key Components of the Position Paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. European Heart Journal, 31, 1967-1974.
http://dx.doi.org/10.1093/eurheartj/ehq236 [22] Turk-Adawi, K.I., Oldridge, N.B., Tarima, S.S., Stason, W.B. and Shepard, D.S. (2013) Cardiac Rehabilitation Patient and Organizational Factors: What Keeps Patients in Programs? Journal of the American Heart Association, 2, e000418.
http://dx.doi.org/10.1161/JAHA.113.000418 [23] Worcester, M.U., Murphy, B.M., Mee, V.K., Roberts, S.B. and Goble, A.J. (2004) Cardiac Rehabilitation Programmes: Predictors of Non-Attendance and Drop-Out. European Journal of Cardiovascular Prevention and Rehabilitation, 11, 328-335.
http://dx.doi.org/10.1097/01.hjr.0000137083.20844.54 [24] Oldridge, N.B. and Streiner, D.L. (1990) The Health Belief Model: Predicting Compliance and Dropout in Cardiac Rehabilitation. Medicine & Science in Sports & Exercise, 22, 678-683.
http://dx.doi.org/10.1249/00005768-199010000-00020 [25] Wakefield, M., Roberts, L. and Rosenfeld, E. (1997) Smoking Cessation among People with Diabetes: Beliefs and Barriers. Health Promotion Journal of Australia, 7, 46-51. [26] McGee, H.M. and Horgan, J.H. (1992) Cardiac Rehabilitation Programmes: Are Women Less Likely to Attend? British Medical Journal, 305, 283-284.
http://dx.doi.org/10.1136/bmj.305.6848.283-a [27] Jones, M., Jolly, K., Raftery, J., Lip, G.Y., Greenfield, S. and BRUM Steering Committee (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.
http://dx.doi.org/10.1093/fampra/cmm021 [28] Dunlay, S.M., Witt, B.J., Allison, T.G., Hayes, S.N., Weston, S.A., Koepsell, E., et al. (2009) Barriers to Participation in Cardiac Rehabilitation. American Heart Journal, 158, 852-859.
http://dx.doi.org/10.1016/j.ahj.2009.08.010