The evidence shows cardiac rehabilitation reduces premature deaths and improves quality of life, yet half of patients invited still don’t attend. Siobhan Chan investigates why – and looks at what healthcare professionals can do about it.
Imagine you had a heart attack, or needed heart surgery. Imagine afterwards you were offered an intervention to reduce your risk of dying prematurely from a cardiovascular event by 26%, being readmitted to hospital unexpectedly by 18%, and experiencing another heart event. One would imagine you’d say yes.
That intervention is cardiac rehabilitation, a programme of exercise and information sessions to help heart event patients get back on their feet again. Yet, despite many clear benefits, half of all people offered it don’t turn up. More still don’t complete the course.
“Cardiac rehab saves lives,” says Professor Patrick Doherty, Director of the National Audit for Cardiac Rehabilitation (NACR). “People who complete cardiac rehab live longer and have a better quality of life.”
So why are patients not turning up?
Cardiac rehabilitation helps patients feel more confident returning to normal life after a heart event. More than a dozen Cochrane reviews, as well as clinical trials and observational studies, have shown evidence of benefit and NICE recommends that patients are referred to cardiac rehab schemes while in hospital (see: The benefits of cardiac rehabilitation).
Lack of interest is a key reason. In 2015-16, at least 39% of people did not attend cardiac rehab once they’d been discharged from hospital, according to the National Audit of Cardiac Rehabilitation Annual Statistical Report 2017. And a further 13% of patients who don’t take part in programmes signed up for cardiac rehab sessions but did not attend them.
People can think “what’s the point?”, says Cem Hilmi, 44, who had a heart attack in 2011 and now volunteers with his local cardiac rehabilitation service.
“There’s a lot going through your head and you’re not thinking positively. It’s so hard to absorb information [at that stage].
“People might be frightened and not happy with their body image, they’re not feeling positive about what they’re able to do. And for some people where health and exercise aren’t a priority, they were difficult to encourage before [their heart event], so they’ll be even harder to encourage afterwards.”
The benefits of cardiac rehabilitation
- 26% reduced cardiovascular mortality
- 18% reduced hospital admissions
- 13% reduced all-cause mortality
- Reduced risk of further events
- Improved quality of life
Should the onus be on healthcare professionals and clinical leaders to raise patient interest to increase uptake rates?
Yes, according to Professor Doherty. “We can’t blame patients and [just concede that] they’re not interested,” he says.
“[Healthcare professionals] have to think about what we’re offering.”
What should cardiac rehab involve?
- Health behaviour change and education
- Lifestyle risk factor management
- – Physical activity and exercise
- – Diet
- – Smoking cessation
- Psychosocial health
- Medical risk factor management
- Cardioprotective therapies
- Long term management
- Audit and evaluation
- Source: Dalal HM, Doherty P, Taylor RS (2015) Cardiac rehabilitation. BMJ; 351 :h5000. www.bmj.com/content/351/bmj.h5000
Adapting to local needs
One way cardiac rehab professionals have tried to encourage patients to attend is by taking into account the specific needs of local patients. NICE guidance recommends that services “reflect the diversity of the local population”.
Judith Colley is Lead Nurse for Cardiac Rehabilitation at Barts Health NHS Trust in North East London. Improving uptake can be more problematic for services based in areas with high ethnic diversity and deprivation, according to the NACR report 2017 and Judith’s personal experience.
Cardiac rehab programmes can be successful only when they’re tailored to meet local people’s needs, she says.
Judith’s team has made changes to the service as their knowledge of the local population increased. More than half of patients who start the programme are Bengali, so her team set up a Bengali language programme. They’ve also made allowances to encourage patients to come to sessions. “We’ve changed clinic times to accommodate prayer times; we’ve employed Bengali patient advocates to spread awareness of cardiac rehab; and we’ve paused some cardiac rehab programmes during Ramadan,” she says.
Simerjit Thapar, Cardiac Rehab Sister at Bradford Teaching Hospitals NHS Foundation Trust, experienced the same in her area, where many patients are from the South Asian community.
“I found the barriers to be cultural and religious beliefs, and a limited knowledge of cardiac rehabilitation,” she says, adding that many people see their health as being ‘in the hands of God’.
Judith says putting herself in her patients’ shoes and providing lots of options is the key to getting through to patients. “We have to think about how that group of people sees things,” she says. “We want people to come, so that means we have to be as flexible as possible.”
But in areas where the local population changes frequently, such as Tower Hamlets where they are based, their service has to be ready to adapt. “Lots of Italian and Spanish people are moving to the area, so we may need to change the service in future to reflect that,” she says.
Other areas in London, such as Newham, have such a broad range of ethnicities up to six interpreters will need to attend each cardiac rehabilitation session.
“It’s about knowing your population – I don’t think one size fits all,” Judith says. “The people that need to come the most are the hardest to reach.”
Reaching out to patients
Inviting patients onto programmes can also be an issue for busy healthcare professionals. In some areas cardiologists refer patients onto cardiac rehab services, but this isn’t the case everywhere.
In contrast, the cardiac rehab service at Bart’s Health isn’t based on referrals – attendance relies on cardiac rehab nurses speaking to patients directly.
Judith says: “When patients stayed in [hospital] for five days [in the past], we could arrange to see them, but nowadays people are only in for one or two days [after a heart attack], and cardiac rehab isn’t their priority at the time – recovery is.” She chairs the Pan London Cardiac Rehabilitation working group and says the picture is similar across the capital.
Healthcare professionals should recommend cardiac rehabilitation services to their patients, according to NICE, whose quality standard states that “people who are referred to rehabilitation programmes before they are discharged from hospital have better rates of uptake and adherence and improved clinical outcomes”.
Cem was not told about cardiac rehab when he was in hospital (see: “I wasn’t aware of cardiac rehab – I could have slipped through the net”), and has since spoken to other people who were similarly not informed about the programme.
“It needs to be more joined-up, so everyone hears about rehab,” he says. “I would recommend some kind of follow-up, either with a GP, another professional or another healthcare organisation like a charity,” he said. “In the first couple of weeks it all needs to sink in, so you’d probably get a bigger uptake if you gave them the information [about cardiac rehab] again at another stage.”
Additionally, if GPs and practice nurses endorsed cardiac rehab directly to their patients, it could have a big impact on the numbers attending.
People are up to nine times more likely to go to cardiac rehab if their referral comes from primary care rather than acute care, according to a recent small study. “This continuity of care may be driving greater referral and uptake,” says Professor Doherty, who is considering ways of reaching out to the GP community to encourage more referrals to cardiac rehab.
This is only part of the article from the British Heart Foundation. See the complete article here.