Original articles
Cardiac rehabilitation for community-based patients with myocardial infarction: Factors predicting discharge recommendation and participation

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Abstract

Although there is substantial evidence that cardiac rehabilitation is beneficial for post myocardial infarction (MI) patients, such programs are currently under utilized. This study examined systematic criteria predicting physician referral to and patients' participation in cardiac rehabilitation programs. Patients discharged for MI were interviewed in-hospital and at 6-12 weeks post discharge to determine referral, participation, and completion. Stepwise logistic regression analyzed factors associated with rehabilitation. Factors associated with referral to rehab were catheterization (p < 0.001), bypass surgery (p < 0.01), cardiologist/cardiac surgeon appointment (p < 0.02), and age (p < 0.01). Participation was increased for those with bypass surgery (p < 0.001), and referral to cardiologist or cardiac surgeon (p < 0.001). Type of provider significantly influences referral to and participation in cardiac rehabilitation. This suggests that encouragement plays a strong role in attendance for rehabilitation. The same strong encouragement should be given to the broader range of MI patients who stand to benefit from cardiac rehabilitation.

Introduction

There is substantial evidence that attending physical exercise programs as part of cardiac rehabilitation is beneficial to post-myocardial infarction (MI) patients. However, participation rates in cardiac rehabilitation programs are generally low, with reported levels ranging from 17% to 21% 1, 2. This pattern even applies to patients who meet all the low-risk criteria outlined in the guidelines of the American Association of the Cardiovascular and Pulmonary Rehabilitation [3]. Yet, little is known about the reasons for the low patient participation in cardiac rehabilitation programs. An emerging literature has focused on patient-centered reasons for non-participation and non-compliance. It shows that affordability of service, possibly insurance coverage, social support from a spouse or other caregiver [4], gender-specific attitudes 5, 6, and patient anxiety 7, 8 all play a role in patient under utilization. Less well studied are physician-specific predictors. Yet, anecdotal evidence suggests that physicians may under-appreciate the importance of physical exercise programs in cardiac rehabilitation. As a result, patient referral and encouragement to participate in cardiac rehabilitation may be less than optimal.

Cardiac rehabilitation has been shown to be effective in improving clinical outcomes for patients following a heart attack event. Patients completing rehabilitation programs with exercise tend to achieve lower blood pressure, decreased weight, improved muscle tone, increased exercise capacity and tolerance, decreases in debilitating symptoms, and general improvement in cardiac functioning 9, 10. Together with dietary or pharmacological therapy, improvements in lipid levels have also been observed [11]. In combination with education and behavioral counseling, exercise increases the likelihood of smoking cessation and enhances measures of psychological functioning [12]. Finally, cardiac rehabilitation has been shown effective as secondary prevention in decreasing the risk of re-infarction and improving survival [13].

Currently, there is little evidence as to what impact physicians' attitudes and decisions have on the willingness of patients to participate and follow through with a rehabilitation program. In a prospective study of 226 MI patients, 62 years and older, after controlling for the effects of demographic, medical, and psycho-social factors, the most powerful predictor of patient participation in a rehabilitation program was the primary physician's recommendation [2]. This effect was strongest among the oldest patients and among women. The latter finding should not be surprising, since many cardiac patients after an MI are fearful and uncertain of the possible negative side effects of physical exercise [6]. Clearly, they will need encouragement and assurance that physical exercise, as a part of a comprehensive rehabilitation program not only has benefits, but also is safe and does not increase the risk of re-infarction.

Other researchers have also shown that women and the elderly are less frequently referred to cardiac rehabilitation programs, even though program benefits have been observed in these groups 14, 15. Thus, available information on referral patterns seems to indicate a certain reluctance on the part of physicians to push for patient participation in physical rehabilitation programs [16]. Existing community studies show that fewer than one-third of MI patients receive information or counseling about cardiac rehabilitation before being discharged from the hospital. Contemporary trends toward shorter hospital stays may further reduce the likelihood of comprehensive counseling in this setting. There is a clear need to examine what systematic criteria, if any, predict referral and participation of MI patients in cardiac rehabilitation programs.

The study of referral and participation patterns is complicated by the fact that different factors may influence: (1) the referral to cardiac rehabilitation by the provider, (2) the actual patient enrollment in a program, and (3) the completion of such a program. Employing data from a community-based study, we focus primarily on two issues: (1) factors that predict referral of MI patients to cardiac rehabilitation programs at hospital discharge, and (2) factors that predict actual participation in cardiac rehabilitation 6 or 12 weeks after the hospital discharge.

Section snippets

Sample

Subjects were 1671 patients, who were diagnosed with acute myocardial infarction (AMI) at admission to one of five hospitals in two mid-Michigan communities. Enrollment in the Michigan State University Inter-institutional Collaborative Heart Study occurred in two different phases, between January 1994 and April 1995 (Phase I: n = 1163) and between February 1 and September 30, 1997 (Phase II: n = 508). The independent Institutional Review Boards of each hospital approved the study and procedures

Results

Table 1 presents descriptive information on all variables used in the analysis for the discharge sample of 1475 MI patients and the subset of 347 patients interviewed about their participation in rehabilitation. There were no significant differences in the distribution of cases according to age groups, gender and bypass surgery. However, patients with follow-up were slightly less likely to be minority (9% vs. 15%, χ2 = 8.5, P < 0.014), and somewhat more likely to have commercial insurance (49%

Discussion

Despite the available evidence and clinical guidelines for MI patients published by such groups as the American Association of the Cardiovascular and Pulmonary Rehabilitation [3], overall participation in exercise-based cardiac rehabilitation programs remains low. Data from our study show only 16% of the MI patients were referred to a cardiac rehabilitation program at discharge, and only 26% of the patients later interviewed in the community actually participated in such a program. However, 54%

Investigators Participating in the Michigan State University Inter-Institutional Collaborative Heart Study

Firas Akhrass MD, Chris Colenda PhD, Francesca Dwamena MD, Hassan El-Tamimi MD, Joseph Gardinei PhD, Ken Gaines MD, Margaret Holmes-Rovner PhD, Jill Kroll PhD, Joel Kupersmith, MD, Raj Nfitra MD, David Rovner MD, Peter Vasilenko PhD, and Ralph Watson MD, (MSU, East Lansing); Aryeh Stein PhD, Emory University, Atlanta. Kimberly Barber MS, Sue Davis RN, Del DeHart MD, (Saginaw Cooperative Hospitals, Inc., Saginaw); Saginaw Cooperative Hospitals, Inc.; Jack Ferlinz MD, Aleda E. Lutz (VAMC,

Acknowledgement of Support

Abin Achrekar MPH, Fawzia Ahmed MS, Usman Alam, Elisa Arfianti, Amy Cairns, Qin Chen, East Lansing; Peter Fattel, Syed Fazal-Ur-Rehman, V. Kandallu, Anton Koinev, Annette McLane BS, Danutta Podgorska, Gennaro Polverino, Manfred Stommel, PhD (MSU, East Lansing). Leslie Franke BS and O. David Tenny, (Saginaw Cooperative Hospitals, Inc., Saginaw). Jeanne Minor, (Rochester). Kathy Sands, (Flint).

Acknowledgements

The Blue Cross/Blue Shield of Michigan Foundation, Michigan State University Foundation-College of Human Medicine at Michigan State University, and all hospitals involved in the study provided funding for this project.

References (18)

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    Two studies (33%) found no significant association between smoking status and referral (Bittner et al., 1999; Kotseva et al., 2013). Additionally, one study (17%) found a significant negative relationship between smoking status and referral (Barber et al., 2001). While more data on this issue are clearly needed, it appears that reporting current smoking may increase a patient's probability of CR referral.

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