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

Background Part of a mixed method study Single site 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

Background (continued) Benefits of cardiac rehabilitation are well documented (Jacob 1999;Clarke 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 2004;Blackburn 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)

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

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

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

Method Ethics - Approval from AMNCH/SJH joint Ethics committee

Results

Reasons &Factors Physical Reasons Psychological Reasons Health Access Depression Co-morbidity Oneself Risk factors Organization Reasons Schooling Programme Issues The health System Work Exercise Stress Too Hard Not hard enough Family Emotions Programme Dislikes Miscon- ceptions of programme

Results Physical Health Co- morbidities Risk Factors AccessExercise Too hard Not hard enough

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)

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)

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.)

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)

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 , 64 characters.)

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 , 335 characters) Researcher: How much exercise do you normally do? Mel: None (Document Mel Section 0, Paragraphs , 214 characters)

Reasons &Factors Physical Reasons Psychological Reasons Health Access Depression Co-morbidity Oneself Risk factors Organization Reasons Schooling Programme Issues The health System Work Exercise Stress Too Hard Not hard enough Family Emotions Programme Dislikes Miscon- ceptions of programme

Psychological DepressionOneself FamilyEmotions Stress Results

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 , 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)

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)

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 , 304 characters)

Organizational Schooling Programme issues DislikesMisconceptions The health System Work Results

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 , 478 characters.)

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 , 574 characters.)

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.)

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.)

Reasons &Factors Physical Reasons Psychological Reasons Health Access Depression Co-morbidity Oneself Risk factors Organization Reasons Schooling Programme Issues The health System Work Exercise Stress Too Hard Not hard enough Family Emotions Programme Dislikes Miscon- ceptions of programme

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.

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

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

Thank you Mary Kerins

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): 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): Cooper, A. F. Weinman, J. (2007) Assessing Patients Beliefs about Cardiac Rehabilitation as a Basis for Predicting Attendance after Acute Myocardial Infarction: Heart 93: 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): Hemingway, A. (2003) Factors which may Affect Attendance at Cardiac Rehabilitation. Bournemouth, Institute of Health and Community Studies Bournemouth University: 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): Jolly, K. Greenfield, S. M. et al. (2004) "Attendance of Ethnic Minority Patients in Cardiac Rehabilitation." Journal of Cardiopulmonary Rehabilitation 24(5): Jones, N.L. Schneider, P.L. et al (2007) An Assessment of the Total Amount of Physical Activity of Patients Participating in a Phase III Cardiac Rehabilitation Programme. Journal of Cardiopulmonary rehabilitation and Prevention. 27(2):

References Oldridge, N. B., Donner, A. P. et al (1983) Predictors of Dropout from Cardiac Exercise Rehabilitation. The American Journal of Cardiology 51: Sanderson, B. K. and V. Bittern (2005) Women in Cardiac Rehabilitation: Outcomes and Identifying Risk of Dropout. American Heart Journal 150(5): 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: Yohannes, A. M. Yalfani, A. et al (2007) Predictors of Drop-out from an Outpatients Cardiac Rehabilitation Programme. Clinical Rehabilitation 21(3):