For patients with established coronary artery disease, lifestyle changes such as dietary modification, smoking cessation, stress management and regular exercise, can help to reduce, or perhaps stop, the progression of their cardiovascular disease, reduce their chance of having another cardiac event, and improve their quality of life. Cardiac rehabilitation can accelerate physical and psychological recovery and reduce mortality after acute cardiac events by 10–25% according to systematic reviews of randomised trials.1-3 Cardiac rehabilitation programmes can also reduce risk factors, improve health-related quality of life, and increase the likelihood of return to work.3-6 Despite this evidence, however, typically fewer than 35% of eligible patients take part in cardiac rehabilitation worldwide, with a recent UK audit reporting figures in line with this.(7-10)
Numerous studies have demonstrated and explored the complex factors associated with low attendance at cardiac rehabilitation. Non-participants tend to be older, female, and more socially deprived, and to live further from the rehabilitation centre.11-13 Organisational factors comprise part of the reason for this. Unsurprisingly, access problems, including long travelling distances, poor public transport and poor parking facilities, discourage participation.14 Women and older people may be less likely to be invited or encouraged to take part. The task of organising programmes, to ensure that everyone eligible is invited and places are available for all who wish to attend, is challenging, especially when resources are limited.11,15-19
However, organisational factors are not the whole story. Older people may be less likely to be invited, but even when they are, they are less likely to attend.16,18 Non-attenders may lack interest, hold misconceptions about heart disease and rehabilitation, or prioritise other activities.20,21 They may have poor social support and work demands or other time conflicts.18
There have been plenty of suggestions on how to improve participation at cardiac rehabilitation. At organisational level, more enthusiastic physician endorsement, partly through education of health professionals,22 provision of information early, social support23 and more accessible rehabilitation, based at home or in the community,24,25 may all help. Other suggestions include following up non-attenders, transport grants, better parking, audiotapes about educational sessions, and tailoring of programmes according to patients’ needs, age, sex and ethnic group.26,27 There have been fewer suggestions at the patient level, but some include ideas such as clearing up of misconceptions about cardiac disease and the rehabilitation programme.20
Unfortunately, few studies have evaluated whether these suggestions are effective. A systematic review in 2004 found only six studies reporting interventions designed directly to improve the uptake of cardiac rehabilitation, of which three were evaluated robustly through randomised controlled trials.28 One intervention involved patient counselling and organisational support. A liaison nurse was responsible for co-ordinating follow-up care after discharge between the hospital and general practice, providing support for practice nurses, encouraging them to attend training courses and to discuss any problems by phone.29 Attendance at cardiac rehabilitation increased by 18% (p<0.005) compared with the control group. A second intervention attempted to improve long-term (phase 4) participation, by enrolling patients in four separate open-discussion sessions, and following them up with two telephone calls and a home visit over the next six months.30 Attendance was 57% in the intervention group compared with 27% in the control group (p<0.005). Results from both these interventions are encouraging, but cash-strapped programme co-ordinators may wonder where to find the necessary resources.
The final intervention, however, appears remarkably simple, involving only rewording of invitation letters. Two letters were developed, one to influence acceptance and the second to influence attendance.31 For both, the Theory of Planned Behaviour was used to develop wording that, it was hoped, would increase attendance at cardiac rehabilitation. And it did, with attendance 86% among those receiving the reworded letters compared with 59% in the control group (p<0.002). The idea that something as simple as a change in wording could have such a dramatic effect may appear too good to be true. It does, however, have some support from another, albeit non-randomised, study, where a motivation message via a pamphlet containing information about heart disease and cardiac rehabilitation also increased participation in cardiac rehabilitation.32
Why does this work?
Perhaps we should not be surprised that a theoretically-based invitation should be effective. It is, after all, a behavioural intervention, and it is now widely accepted that these are more likely to be effective if theoretically based.33 Constructs (elements) from the Theory of Planned Behaviour have been found to be predictive of cardiac rehabilitation attendance in several studies.34 The effective invitation letters tackled these by promoting the benefits of cardiac rehabilitation, letting the recipients know that influential people (especially their doctors) were keen for them to attend, and emphasising the ease of taking part. It also helped them to plan their attendance.Elements from another theory, the Common Sense Model,35 have also been found to be predictive of cardiac rehabilitation attendance, with higher participation rates among those with a better understanding of the disease and believing that it is serious but controllable.36 Promoting these beliefs may also help to increase attendance, but this has yet to be evaluated.
More good evaluations of interventions that seek to increase participation in cardiac rehabilitation would be helpful, and further interventions involving service redesign and face-to-face or telephone counselling may, if properly developed, also be beneficial. However, such interventions will be labour intensive and will take time to evaluate. In the meantime, at the very least, we should be carefully wording letters of invitation – there seems little to lose and much to gain.
Conflict of interest
An article on the long-term benefits of cardiac rehabilitation by Willmer et al. can be found on pages 73–7 of this issue.
- Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. JAMA 1988;7:945–50.
- Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2001;(1):CD001800.
- Taylor RS, Brown A, Ebrahim S et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med2004;116:682–92.
- Dugmore LD, Tipson RJ, Phillips MH et al. Changes in cardiorespiratory fitness, psychological wellbeing, quality of life, and vocational status following a 12 month cardiac exercise rehabilitation programme. Heart 1999;81:359–66.
- Lindsay GM, Hanlon WP, Smith LN, Belcher PR. Experience of cardiac rehabilitation after coronary artery surgery: effects on health and risk factors. Int J Cardiol 2003;87:67–73.
- Yu C-M, Lau CP, Chau J et al. A short course of cardiac rehabilitation programme is highly cost effective in improving long-term quality of life in patients with recent myocardial infarction or percutaneous coronary intervention. Arch Phys Med Rehabil 2004;85:1915–22.
- Bethell H. The BACR database of cardiac rehabilitation units in the UK. Coronary Health Care 2000;4:92–5.
- Bunker S, McBurney H, Cox H, Jelinek M. Identifying participation rates at outpatient cardiac rehabilitation programs in Victoria, Australia. J Cardiopulm Rehabil 1999;19:334–8.
- McAlister F, Lawson F, Teo KK, Armstrong PW. Randomised trials of secondary prevention programs in coronary heart disease: systematic review. BMJ 2001;323:957–62.
- British Heart Foundation Database (2007). Available from: http://www.heartstats.org/homepage.asp
- Aikman H, McBurney H, Bunker S. Cardiac rehabilitation: the extent, reasons and predictors of patient non-attendance. VI World Congress of Cardiac Rehabilitation, Buenos Aires, 1996.
- Marchionni N, Fattirolli F, Fumagalli S et al. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial. Circulation 2003;107:2201–06.
- Yohannes AM, Yalfani A, Doherty P, Bundy C. Predictors of drop-out from an outpatient cardiac rehabilitation programme. Clin Rehabil 2007;21:222–9.
- Evenson KR, Fleury J. Barriers to outpatient cardiac rehabilitation participation and adherence. J Cardiopulm Rehabil 2000;20:241–6.
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- Cottin Y, Cambou JP, Casillas JM, Ferrieeres J, Cantet C, Danchin N. Specific profile and referral bias of rehabilitated patients after an acute coronary syndrome. J Cardiopulm Rehabil2004;24:38–44.
- Lieberman L, Meana M, Stewart D. Cardiac rehabilitation: gender differences in factors influencing participation. J Women’s Health 1998;7:717–23.
- Jackson L, Leclerc J, Erskine Y, Linden W. Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors. Heart 2005;91:10–14.
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- Clark AM, Barbour RS, White M, MacIntyre PD. Promoting participation in cardiac rehabilitation: patient choices and experiences. J Adv Nurs 2004;47:5–14.
- Caulin-Glaser T, Schmeizel R. Impact of educational initiatives on gender referrals to cardiac rehabilitation. J Cardiac Rehabil 2000;20:302.
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- Lewin B, Robertson IH, Cay EL, Irving JB, Campbell M. Effects of self-help post-myocardial-infarction rehabilitation on psychological adjustment and use of health services. Lancet 1992;339: 1036–40.
- Pell JP, Morrison CE. Factors associated with low attendance at cardiac rehabilitation. Br J Cardiol 1998;5:152–5.
- Bethell HJN, Turner SC, Evans JA, Rose L. Cardiac rehabilitation in the United Kingdom: how complete is the provision? J Cardiopulm Rehabil 2001;21:111–15.
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- Jolly K, Bradley F, Sharp S et al. Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). BMJ 1999;318:706–11.
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- Wyer SJ, Earll L, Joseph S, Harrison J, Giles M, Johnston M. Increasing attendance at a cardiac rehabilitation programme: an intervention study using the Theory of Planned Behaviour.Coronary Health Care 2001;5:154–9.
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- Johnston M, Earll L, Pollard B, Giles M, Johnston D. Attendance at cardiac rehabilitation: predictive value of the theory of planned behaviour. BPS Division of Health Psychology Conference, Leeds, 1999.
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