Patients

1
Patients perspective of the factors for
non-attendance to and non-completion of a phase
III cardiac rehabilitation programme A
qualitative study.

• Mary Kerins

2
Background

• Part of a mixed method study
• Single site
• 2006-2007
• 267 patients enrolled for a cardiac
  rehabilitation programme, 50 patients did not
  attend and 30 patients did not complete the
  programme. 
• Quantitative study showed that smokers and
  non-skilled manual workers were more likely not
  to attend
• Telephone Survey
• Not interested
• Illness

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Background (continued)

• Benefits of cardiac rehabilitation are well
  documented (Jacob 1999Clarke et al 2004)
• Non-attendance /non-completion - many recent
  studies have examined this phenomenon (Yohannes
  et al 2007 Cooper et al 2007 Sanderson and
  Bittner 2005 Hemmingway 2003)
• Completion rates range from 58-89 (Sanderson
  et al 2003 Jennings et al 2006)
• Non-attendance rates range 4-14 (Turner et al
  2002 Roblin et al 2004Blackburn et al 2000)
• Drop out rates range 30-50 (Carlson et al 2001
  Turner et al 2002 Farley et al 2003 Chan et al
  2005)

4
Purpose

• To examine the factors why patients do not attend
  or do not complete cardiac rehabilitation
  programmes after freely enrolling.
• To enhance quantitative arm of study

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Method

• 50 patients did not attend and 30 patients did
  not complete the programme. Ten were identified
  and invited for interview, of those, seven agreed
  to be interviewed
• Convenience sample
• Semi structured interviews were done

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Method (continued)

• The interviews were an in depth analysis of the
  factors that contributed to their non-attendance
  or non-completion of the programme. An interview
  schedule was developed using apriori themes.
  These themes were derived from the researcher's
  clinical experience and the literature. The
  interviews were transcribed and coded to the
  various themes in NVivo.
• Template analysis

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Method

• Ethics
• - Approval from AMNCH/SJH joint Ethics committee

8
Results
9
 
 
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Results
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Exercise Quotes Anthony The exercise part of
it was boring for my age group. Like I was only
45 and I was exercising with people of 65. I had
no problem with that but with myself I had, I
wanted to give that little bit more, where, when
I felt that, like I mean there was only a certain
limit that the people of sixty were able to do
and it sort of slowed me down in that aspect
(Document Anthony, Section 0, Paragraphs
33-34, 403 characters)
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Exercise Quotes and, my, needs were totally
different, and , I did try to keep up , but I
just felt, it was doing me, it wasnt doing me
good. I was feeling it more, difficult because I
just wasnt able for it (Document Breda,
Section 0, Paragraph 19, 195 characters)
13
Exercise Quotes Peter Some, of the things,
like, were grand, like, and I could have done a
little bit longer, but others, it was a, it was a
strain to get to the final, you
know.. Researcher You know, youre saying
now that you did not finish because the exercise
was too difficult for you. Is that what Im
taking from you? Peter Yes (Section 0,
Paragraph 241, 137 characters.)
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Access and I had more of a workout sitting in
traffic for an hour and a half trying to get here
which was the problem, like you know what I mean,
like I came from the north side of the city all
the way to the south (Document Anthony,
Section 0, Paragraph 51, 205 characters)
15
Access but spending nearly four hours on the
road getting in and out is not good time
management (Document Breda, Section 0,
Paragraph 64, 86 characters) Then its hard
to get parking,.. (Document Peter, Section 0,
Paragraphs 161-162, 64 characters.)
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Health and Risk factors Breda Physically I
was weaker. My autoimmune problem was much more
active. I was sweating profusely, I was feeling
awful, and I felt, you know other than that, I
just felt awful. I felt more and more anxious
(Document Breda, Section 0, Paragraphs 149-150,
335 characters) Researcher How much exercise
do you normally do? Mel None (Document Mel
Section 0, Paragraphs 139-142, 214 characters)
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Results
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Self Anthony Well, I wasnt, I have to say, I
didnt drop out of the cardiac because of the
cardiac. I did not finish mentally (Document
Anthony Section 0, Paragraphs 126-136, 1310
characters) Sean I didnt need, I didnt want
to, I knew I wasnt well enough to do any
programme at the time as well. My mind wasnt
telling me yes, go and do it (Document Sean.
Section 0, Paragraph 37, 148 characters)
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Depression Anthony After the cardiac problem,
I ended up been very, very depressed. And, ah, it
brought a big strain on the household, because
the mood swings were up and down. The first
couple of weeks I had a terrible fear of getting
meself isolated on my own anywhere (Document
Anthony, Section 0, Paragraph 14, 250
characters)
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Stress Sean .but all that stress didnt help
me, didnt help the wife or the family. And I
went through a lot of that (Document Sean,
Section 0, Paragraph 164, 105 characters)
Family Mel.I wouldnt
leave her any longer than an hour, two hours
No, in case she would fall, you know, she
wouldnt be able to get up (Document Mel
Section 0, Paragraphs 113-116, 304 characters)
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Results
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Perceptions of the programme Researcher .What
do you think the cardiac rehab course was all
about? Mel I really thought it was, just, you
go down, and you do exercises. You know. Em, so
much exercises, you know. Thats what I thought
it was, just exercises (Document Mel, Section
0, Paragraphs 200-207, 478 characters.)

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Work Sean I hadnt, as I say I had a lot going
on as well, at home, I had a lot going on after
the operation, feeling down, depressed, the job,
I had, at the time I was doing morning work, I
knew I couldnt do the eight weeks because I had
to be at work at ten o clock at the time
(Document Sean, Section 0, Paragraphs 191-192,
574 characters.)
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The System Breda I was over in the clinic
again, recently and doctor P wasnt there, there
was a student with a supervising doctor, you
actually feel like they could put a cardboard cut
out on the chair and they wouldnt know the
difference. Youre not... .. And a lot of
patients that you meet in the queues and the
cardiac group will say that if you dont fit into
the neat box, then nobody is comfortable with
you. And that would be very much, what I would,
think.. , the patient isnt the focus when you
come to hospital (Document Breda Section 0,
Paragraphs 26-32, 1345 characters.)
26
Noel I went to ah, sixth class.. but I didnt
do well in it now but Researcher Did you
not? Noel Oh no, no (Document Noel,
Section 0, Paragraphs 65-70, 236 characters.)
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Conclusion

• The patients interviewed had mainly issues with
  the exercise regime on the programme,
  depression/stress, work and the programme itself.
  A low level of education was also evident.
• Although Phase III programmes are now mainly menu
  based, with exercise individually prescribed,
  this study has shown that there are still many
  outstanding factors that strongly influence
  patients non attendance/non completion of
  programmes which could be addressed.

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Recommendations

• Further attention is required to individual needs
  within Phase III programmes, thus motivating
  patients and encouraging their choice even more
• Initiating changes that will improve patient
  choice, perhaps shorter more intensive
  programmes, or increasing availability of
  programmes to outside normal working hours,
  different modes of delivery of exercise progamme

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Recommendations

• A more comprehensive recruitment session for
  programmes comprising in depth assessment of
  patients profile, individual needs, readiness
  for change, beliefs, anxiety and depression.
• A more comprehensive programme introduction.
• Coordinator intervention calls

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Thank you
Mary Kerins
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References

• Carlson, J.J. Johnson, J.J. et al (2000)
  Programme Participation, Exercise Adherence,
  Cardiovascular Outcomes, and Program Costs of
  Traditional Versus Modified Cardiac
  Rehabilitation. The American Journal of
  Cardiology 86(1) 17-23.
• Clarke, A. Barbour R, et al (2004) Issues and
  Innovations in Nursing Practice Promoting
  Participation in Cardiac Rehabilitation Patient
  Choices and Experiences. Journal of Advanced
  Nursing 47(1) 5-16.
• Cooper, A. F. Weinman, J. (2007) Assessing
  Patients Beliefs about Cardiac Rehabilitation as
  a Basis for Predicting Attendance after Acute
  Myocardial Infarction Heart 9353-58.
• Farley, R. L. Wade, T. D. et al. (2003) Factors
  Influencing Attendance at Cardiac Rehabilitation
  among Coronary Heart Disease Patients European
  Journal of Cardiovascular Nursing 2(3) 205-212.
• Hemingway, A. (2003) Factors which may Affect
  Attendance at Cardiac Rehabilitation.
  Bournemouth, Institute of Health and Community
  Studies Bournemouth University 1-38.
• Jacob, M. (1999) Building Healthier Hearts
  Report of the Cardiovascular Health Strategy
  Group. G. S. Office. Dublin, Department of Health
  and Children.
• Jennings, S. and D. Carey (2002) Capacity and
  Equity in Cardiac Rehabilitation in the Eastern
  Region Good and Bad News. Irish Journal of
  Medical Science 173(3)
• 151-154.
• Jolly, K. Greenfield, S. M. et al. (2004)
  "Attendance of Ethnic Minority Patients in
  Cardiac Rehabilitation." Journal of
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• Jones, N.L. Schneider, P.L. et al (2007) An
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  Activity of Patients Participating in a Phase III
  Cardiac Rehabilitation Programme. Journal of
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  27(2) 81-85.

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References

• Oldridge, N. B., Donner, A. P. et al (1983)
  Predictors of Dropout from Cardiac Exercise
  Rehabilitation. The American Journal of
  Cardiology 51 70-74.
• Sanderson, B. K. and V. Bittern (2005) Women in
  Cardiac Rehabilitation Outcomes and Identifying
  Risk of Dropout. American Heart Journal 150(5)
  1050-1058.
• Sanderson, B. K. Phillips, M. M. et al (2003)
  Factors Associated with the Failure of Patients
  to Complete Cardiac Rehabilitation for Medical
  and Nonmedical Reasons
• Turner, S. C. Bethell, H. J. N. et al (2002)
  Patient Characteristics and Outcomes of Cardiac
  Rehabilitation Journal of Cardiopulmonary
  Rehabilitation 22 253-260.
• Yohannes, A. M. Yalfani, A. et al (2007)
  Predictors of Drop-out from an Outpatients
  Cardiac Rehabilitation Programme. Clinical
  Rehabilitation 21(3) 22-229.