Coronary Heart Diseases Rehabilitation - Essay Example

Critical Review: Cardiac Rehabilitation. Introduction. Coronary Heart Diseases (CHD) and other cardiovascular diseases are known to be the leading cause of death in several industrialised nations, both in men and women (Ades, 2001; Jackson et al, 2004). It is also a major cause of physical disability, especially in the elderly, which happen to be a continuously growing population (Ades, 2001). However, due to increased medical technology, fatalities after cardiac events have been on the downward slide. This has led to the increase of people requiring secondary preventive care (Witt et al, 2004). With this increasing population of coronary event survivors, the prevention of subsequent coronary events and the maintenance of physical functioning in such patients have been a constant challenge in preventive care (Ades, 2001). To further enhance the efficiency of preventive care for post coronary event patients and due to the concern about the safety of unsupervised exercise after discharge from the hospital led to the development of cardiac rehabilitation programmes in the 1960s. The cardiac rehabilitation programme is a highly structured rehabilitation programme, usually supervised by physicians and other healthcare professionals. The programmes typically consist of supervised exercise, dietary and health education and counselling (Ades, 2001; Jackson et al, 2004). The idea behind cardiac rehabilitation is the understanding that by modifying (reducing) risk factors, further acute cardiac events can be curtailed. However, with the reduction in the length of hospital stay for acute coronary syndromes, the possibility of counselling patients about risk reduction and the importance of exercise in preventing future events have been greatly hampered. To this end, clinical guidance from the National Institutes of Health have further broadened the scope of cardiac rehabilitation programmes to include the assessment and modification of risk factors, to enable such programmes further function effectively as secondary prevention centres. Several studies have demonstrated the convincing efficiency and efficacy of cardiac rehabilitation programmes in reducing mortality and morbidity related to cardiovascular diseases (Jackson et al, 2004; Ades, 2001; Witt et al, 2004). This review, therefore, takes a critical look at cardiac rehabilitation with a view to assessing the level of acceptance/attendance, availability of resources and gender and age distribution of participation in the programmes, which are issues that have taken dominance in recent study reports involving cardiac rehabilitation. Topic for Review. The area of focus for this review will be cardiac rehabilitation and personal/patients' factors that have influenced attendance of the programmes. Cardiac rehabilitation was rightly chosen as the topic for review due to its impact in the reduction of cardiac related mortality and morbidity. Comprehensive cardiac rehabilitation programmes have been severally demonstrated to be quite effective as secondary prevention towards forestalling future cardiac events and disabilities due to cardiac events. Unfortunately, only a minute fraction of patients eligible seems to utilise this opportunity, with the participation of women and the elderly, most disappointing. Several reasons have been offered for this disproportionate participation in the programmes. It is therefore, important to look at some of these attributed reasons with a view to analysing how well they attend to the low attendance suffered by cardiac rehabilitation programmes. Background. According to Ades (2001), cardiac rehabilitation is indicated for patients who have suffered or have been diagnosed of acute myocardial infarction, those who have undergone coronary revascularization, cardiac angioplasty or cardiac transplantation. It is also appropriate for patients with chronic stable angina and chronic heart failure (Ades, 2001). By improving exercise capacity, plasma lipids, obesity indexes, behavioural characteristics, healthier lifestyles and quality of life (Lavie and Richard, 2004), formal cardiac rehabilitation programmes are aimed towards preventing disability resulting from coronary diseases, particularly in the elderly, to prevent subsequent coronary events, further hospitalisation or death from cardiac causes (Ades, 2001). Several research studies have exhaustively demonstrated the benefits and efficiency of the rehabilitation programmes at improving quality of life and altering cardiovascular risks. However, an issue that has been on the receiving end of considerable attention is the low participation/attendance of patients in the cardiac rehabilitation programme. The percentage of eligible patients that attend these programmes has been quite disappointing. Thus several studies have been geared towards understanding the reasons or factors responsible for this trend. Lavie and Richard posited that the bias in cardiac rehabilitation participation has been towards the elderly and attributed poor or 'weak' referral from physicians as the main cause (Lavie and Richard, 2004). Witt and his colleagues believe that besides the elderly, women have also been poorly represented in cardiac rehabilitation programmes (Witt et al, 2004). However, Jackson and others took a broader look at the problem of low participation and argued that potential variables that can impact attendance of these programmes include; age, income, distance to the rehabilitation centre and the beliefs and behaviours of physicians towards cardiac rehabilitation (Jackson et al, 2004). It becomes apparent that the problem of low attendance at rehabilitation programmes, despite the established benefits, has been widely researched. Several factors have been researched for their role in this trend, but no single key factor, as yet, can be attributed to this trend of events. Literature Search Method. For the purpose of this review the search for articles was restricted to medical journals and research reports. Medical journals available online were first searched using search engines like Google and Yahoo. Several online medical journals were located, like New England Journal of Medicine, British Medical Journal, Journal of Advanced Nursing and a host of others. Once within these journal databases, the search was narrowed down with 'Cardiac Rehabilitation' as the main keyword, though modifications of the keyword like 'Factors affecting', were used to further narrow down the search results. A lot of research studies on the topic were available from these journals. Two of these articles will be reviewed, while some others were read to form a background understanding of the topic. Critical Review. Two research articles from the Journal of Advanced Nursing would be reviewed for this purpose. The two research studies are: one, "Promoting Participation in Cardiac Rehabilitation: Patient Choices and Experiences" Clark et al (2003), and two, Re-engineering cardiac Rehabilitation Programmes: Considering The Patients' Point of View" Paquet et al (2004). Research one was carried out in a mixed rural-urban settlement in Scotland, in 2001, with participants selected from a district hospital's record that serve the population. The second study, however, was carried out in a Canadian University hospital, in 1999, though participants were also selected based on a rural, semi-rural and urban settlement basis. As evidenced in the research titles, both studies took a look at the problem of low participation/attendance at cardiac rehabilitation programmes from the perspectives of the patients, in a view to assessing how patients' beliefs and self perceived needs, in contrast to what the programmes offer, affect or hinder participation in these programmes. Although, the two studies took varying look at patient's part in the poor performance of cardiac rehabilitation programmes; study one was aimed at examining how patients' beliefs and decision-making affected attendance in rehabilitation programmes, while study two was concerned with patients' expressed/felt needs (3months after a cardiac event induced hospitalisation), in contrast to what the programmes offer and how this affected attendance. However, they both have a common ground. They emphasised the necessity of cardiac rehabilitation programmes to be less stereotyped. "Cardiac rehabilitation services appear to have been conceptualised in a simplistic manner in which programmes are assumed to provide services in a fixed, decontextualised and uniform fashion to passive and inter-changeable subjects", asserts Clark et al (2003). Buttressing this line of argument, Paquet et al (2004) states, "cardiac rehabilitation programmes need to shift their focus of attention from promoting healthier behaviours, to responding to patients' perceived needs" In a way, both studies appear to emphasise that cardiac rehabilitation programmes will record better levels of acceptance and attendance, if the patients, who it is supposed to serve, are but into the right perspective while planning and providing services. This fact is evident from the discussions and conclusions of both research studies. On grounds of ethics, both studies appear to be sound. Both studies were authorised by the relevant local authority. In both studies, the identities and confidentiality of the participants and information they provided were preserved and participants were enabled to make informed decision to participate in the studies, as consent form was signed. However, study one stated that participants were offered reimbursement for transport costs. This could serve as incentive to provide better participation and a more sincere opinion, than where such is absent, as in the case of study two. This brings us to the data collection method and the reliability of these data. Focus groups were the method of data collection in both studies, and the data collated were analysed with qualitative procedures. Clark et al argue that "focus groups are efficient and effective way of gathering data pertaining to a particular topic in a group with common background" (Clark et al, 2003). They also argue that focus group is well suited to such a study because it allows for discussion of factors suggested by participants, in contrast to surveys and other research methods. Paquet et al agreed and stated that focus groups and qualitative research method was more suited to their study, since it is an area where little research work has been carried out (Paquet et al, 2004). Also, inclusion criteria for the studies were similar for both studies. Patients were only eligible for the study due to previous cardiovascular diagnosis or hospitalisation. And participants were properly selected to reflect different settlements - rural, semi-rural and urban, age, sex etc. However, unlike in study one where 50 people were selected from a total sampling pool of 277 people and 44 finally participating in the study, the reliability of study two is not that sacrosanct. Only 30 people were selected out of a sampling pool of 438, with only 20 (13% of the pool) finally participating. This, coupled with the fact that the data collection was done five years (1999) before the report, raises serious credibility issues about this study. The researchers seek to douse such worries by stating "although, the data were collected 5years ago, they remain relevant in today's environment" (Paquet et al, 2004). However, their admittance that "possibly, only people who were doing well, had good support and were interested in group events chose to participate" (Paquet et al, 2004) creates a selection/desirability bias that further deepens the concern about reliability of the research data. The methodology of both studies was also similar. Participants were selected, contacted through mail, and then phone, while focus groups were employed in data collation and the collected data qualitatively analysed for results. With eight focus groups from 44 participants, study one is more likely to generate reliable data and reach a reasonable conclusion, compared to 20 participants in 3 focus groups of study two. Also, both studies appear to exhibit a gender bias in their representation. Only 4 of the 20 participants in study two were females and 11 of the 44 participants in study one were females. Moreover, since study one was aimed at looking into how beliefs and decision making affected attendance at cardiac rehabilitation programmes, one would have expected equal number of focus groups for both the high attendance groups and the non-attendance groups, for a more balanced opinion, instead of the 4:2 focus groups held. The results of both studies portend serious implications for cardiac rehabilitation programmes. Both studies seem to demonstrate that the several available cardiac rehabilitation programmes have been far divorced from patients they are supposed to care for, and until such re-union is achieved, i.e. programmes aligned along patients' expectations, rehabilitation programmes are unlikely to record any remarkable success. Both studies demonstrated that CHD impact highly on patients' self-esteem and self-efficacy. Thus the embarrassment of exercising in groups or in public scares many away. Coupled with the pronounced believe by many participants, that cardiac rehabilitation programme is all about exercising and lifestyle changes, patients appear to have a justifiable reason not to attend. Another issue demonstrated in the studies is the impact the necessity of life style changes, as advised by most programmes, have had on attendance. Clark et al explain that, though, experiencing CHD caused patients to have a re-think on their lifestyles, they were also able to form ideas and views about the causes of CHD and of cardiac rehabilitation that justified the retention of former lifestyles and negated the need to attend rehabilitation programmes. Along this line of argument, Paquet et al asserts, "viewing their heart attack as an acute event, rather than a symptom of a chronic condition has been proposed as an explanation for patients' low motivation for long term life style changes" (Paquet et al, 2004). Finally, though both studies emphasised the need for a more patient-friendly approach to cardiac rehabilitation, they hold different views as to how to achieve this. While in study one, Clark et al explained that, non-attendees in cardiac rehabilitation programmes probably decided not to attend/continue participation because they view others who attended as being "old, illness focused and generally needy" (Clark et al, 2003), and also because they see health professionals as providing inconsistent and poorly timed information or "coercive, overly negative and too intense" (Clark et al, 2003), Paquet et al believe that patients were generally satisfied with the care they receive, and the health professionals caring for them. And they probably did not attend rehabilitation programmes because they felt their needs would not be met. Although, one can attribute this fact to the possibility that only satisfied and interested people participated in study two, as evident in an earlier quote. Also, Clark et al argue that acceptance and attendance would improve in rehabilitation programmes if they were better presented to patients as an all-encompassing health promoting strategy and by providing reassurance prior to and in the early stages of the programmes. Paquet et al, on the other hand, believe that attendance will only improve if programmes attend to stress management and other specific patients' needs, instead of the current health and lifestyle modification approach. Between these two approaches, one is therefore lost, as to which one will better address the low participation in rehabilitation programmes. Maybe further research in this area will shed more light. Implications for Practice. Because of their closer involvement with patients, nurses are better placed to challenge the several misconceptions about cardiac rehabilitation programmes held by patients that has been militating against the success of the programmes. Nurses should be able to discard the beliefs that cardiac rehabilitation is for older, sicker or 'other' types of patients, or that lifestyle modifications are not important in preventing secondary cardiovascular events. In study one, Clark et al demonstrated that non-attenders in rehabilitation programmes hold negative perceptions of health professionals. Nurses should be able to dispel such negative conceptions and portray a better-organised and caring image of health care providers. Also, nurses can reduce the stereotypical nature of cardiac rehabilitation by employing listening skills to elicit patients' reasons for non-attendance and using such information as basis for providing practical support to promote attendance. Future Research Questions. Although, the two research studies reviewed extensively examined the factors impacting attendance of cardiac rehabilitation programmes, from the perspectives of the patients, they cannot be said to be exhaustive. Further research should be geared towards the following areas: The impact of contextual factors, like income, environment etc, on attendance of cardiac rehabilitation programmes How personal beliefs interact with structural and organisational factors to impact on attendance If programmes aimed at stress management improves attendance of rehabilitation programmes Assessing if providing patient-specific programmes improves attendance. Conclusion. Despite the established benefits of cardiac rehabilitation in preventing future events and improving quality of life, the percentage of patients attending these programmes have being disappointingly low. These research studies have demonstrated that the stereotyped and standardised nature of the present cardiac rehabilitation programmes, which does take into account patients' needs and beliefs have played a major role in the failure of the programme. Thus, they have shown that by tailoring cardiac rehabilitation to meet the expectations of patients, and by improving on the presentation of these programmes, as an all-encompassing health promoting strategy, to potential participants, better attendance rates could be achieved. References. Ades, Philip A, 2001, Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease, New England Journal of Medicine, Vol. 345:892-902, No. 12, Accessed 17th Feb. 2006, Available online Clark, Alexander M.Barbour, Rosaline S, White, Myra MacIntyre, Paul D, 2003, Promoting participation in cardiac rehabilitation: patient choices and experiences, Issues And Innovations In Nursing Practice, Journal of Advanced Nursing, Vol47(1), Blackwell Publishing Ltd,p 5-14. Jackson L, J Leclerc, Y Erskine and W Linden, 2004, Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors, Rehabilitation Medicine, BMJ Publishing Group & British Cardiac Society, Accessed 17th Feb. 2006, Available online Lavie, Carl J. and Richard Milani, 2004, Benefits of Cardiac Rehabilitation in the Elderly, American College of Chest Physicians, 126:1010-1012, Accessed 16th Feb. 2006, Available online Pquet, Mariane MSc; Bolduc, Nicole, Xhignesse, Marianne, Vanasse, Alain, 2004, Re-engineering cardiac rehabilitation programmes: considering the patient's point of view, Issues And Innovations In Nursing Practice, Journal of Advanced Nursing, Vol. 51(6),Blackwell Publishing Ltd, p 567-576. Witt, Brandi J, Steven J. Jacobsen, Susan A. Weston, Jill M. Killian, BS, Ryan A. Meverden, BS, Thomas G. Allison, Guy S and V.ronique L. Roger, 2004, Cardiac rehabilitation after myocardial infarction in the community, Acute Myocardial Ischemia/Infarction, American College of Cardiology Foundation, J Am Coll Cardiol,; 44:988-996, doi:10.1016/j.jacc.2004.05.062 Read More