| Abstract|| |
Objective: To assess the roles of demographic factors, actual and perceived risk factors, and perceived control in the referral to cardiac rehabilitation (CR) after coronary artery bypass graft (CABG). Methods: In this cross-sectional study, data related to 312 CABG patients in a hospital of the Western part of Iran, gathered through demographics and actual risk factors' checklist, open single item of perceived heart risk factors, life stressful events scale, and perceived control questionnaire. Data analyzed by binary logistic regression. Results: The results showed that only 8.3% of CABG patients refer to CR. The facilitators of this referral included official employment (P < 0.05), coronary history (P = 0.016), and hyperlipidemia (P = 0.030) but more distance to the CR center (P = 0.042) and perceived physiological risk factor (P = 0.025) are concerned as the barriers for the referral to CR. Conclusion: Providing appropriate awareness about the benefits of CR for patients with regard to their job status, coronary history, and perception about the illness risk factors can be effective in referral to CR. In addition, the presence of CR centers in towns and facilitated achievement to these centers can play a significant role in patients' participation.
Keywords: Cardiovascular diseases, referral, rehabilitation, risk factors, surgery
|How to cite this article:|
Soroush A, Heydarpour B, Komasi S, Saeidi M, Ezzati P. Barriers for the referral to outpatient cardiac rehabilitation: A predictive model including actual and perceived risk factors and perceived control. Ann Card Anaesth 2018;21:249-54
|How to cite this URL:|
Soroush A, Heydarpour B, Komasi S, Saeidi M, Ezzati P. Barriers for the referral to outpatient cardiac rehabilitation: A predictive model including actual and perceived risk factors and perceived control. Ann Card Anaesth [serial online] 2018 [cited 2020 Feb 20];21:249-54. Available from: http://www.annals.in/text.asp?2018/21/3/249/237459
| Introduction|| |
Despite nowadays cardiovascular diseases (CVDs) concerned as the main factor of mortality among the USA and industrial countries and approximately one-third of adults die because of CVDs, the development of cardiac rehabilitation (CR) has not been noticeable compared to the developments in treatment and cardiac intensive care programs in the recent decades. The CR is one of the most important interventions which recommended after a cardiac event or surgery for reduction of complications. It includes activities such as comprehensive medical evaluation, exercise, training, and modification of the risk factors. CR can reduce the cardiac mortality rate about 25% with goals focused on exercise, lipid and hypertension control, and quit smoking.,
Despite to efficacy and advantages of CR program, the result of different studies reported the referral rate to CR after a cardiac event as 36.2%–64%.,,, In Iran, only 15% of patients refer to CR. Hence, it is clear that there are barriers and problems to beginning CR. Different studies suggested problems such as gender, higher age, low level of education, job, poor socioeconomic status, poor family support, distance and cost, comorbidities, cardiac history, risk factors such as hyperlipidemia, hypertension, body mass index, and smoking.,,,,,
Although clinical and demographic variables are the progressive factors that probably affect the participation behavior in CR, it seems that behaviors affected by thoughts, beliefs, and attitudes. It is clear that patients; cognitions are superior to their behaviors, and naturally, any type of behavior derivates from patients' thoughts and attitudes. Patients' attitudes about risk factors are effective in increasing anxiety and depression, poor physical function, and health-related behaviors. Based on a report, patients' knowledge and perception of symptoms in all stages of the disease, finding a cause for symptoms and change of individual behaviors, have an important role in the progression of disease. The patients' etiological attitudes included 5 categories of biological, environmental, physiological, behavioral, and psychological perceived risk factors  directly affect on patients' health behavior. Despite this issue, in the past studies, patients' beliefs and attitudes as prior behavior have been less concerned in the field of referral to CR. Thus, regarding the necessity of patients' participation in CR to benefit from its advantages, it is necessary that the role of other psychological barriers identified. Hence, the study aimed to assess the role of demographic factors, actual and perceived risk factors, and perceived control in coronary artery bypass graft (CABG) patients' referral to CR.
| Methods|| |
Design and context
In this cross-sectional study, patients (June–September 2015) after CABG and before discharge admitted to CR Center of Imam Ali Hospital of Kermanshah city (Iran). In this phase, the aim of invitation is to make patients' knowledge about CR and provide adequate motivation to the following treatment. The members of CR team explain the process and benefits of this program, and they provide a time schedule for patients in the introduction session. Furthermore, patients fulfilled the questionnaires and their demographics and actual risk factors registered by the CR team.
Inclusion and exclusion criteria
Inclusion criteria included (1) 30–80 year age, (2) appropriate perception and emotional-physical abilities, and (3) lack of physical limitation for participation in an exercise program. Exclusion criteria included (1) fatigue and lack of tendency for participation, (2) defects in questionnaires, and (3) nonperfect medical records.
Among 357 CABG patients who admitted to the department of cardiac surgery (during June–September 2015), 312 patients had inclusion criteria participated in this research. According to the formula (N > 50 + 8 m), the sample size is appropriate.
According to the routine program, the CR team presented in men and women surgery wards of the hospital, and they informed patients daily about the date of CR program before discharge. At first, this team carried a short interview with patients for control of inclusion criteria. The written consent form, demographics, actual and perceived risk factors were registered. Furthermore, the psychologist reads the questions of inventories and registered answers for patients with age of higher than 50 years and illiterate patients. In addition, the team referred to the medical records to gain more accuracy. In the later phase, approximately 2 months after initial assessment (1 month after presented schedule for exercise), the list of all participants obtained from the CR statistics unit. Hence, the patients were coded in two groups (without refer = 1, referred = 2).
Sociodemographics and actual risk factors checklist
This checklist fulfilled through cardiologist's interview with each patient, and it includes information about sociodemographic variables (age, gender, education level, job, medical insurance, and distance to CR) and actual risk factors (diabetes, hypertension, hyperlipidemia, body mass index, smoking, opiates, drinking, coronary, and family history). Body mass index was measured by the CR nutritionist.
Perceived risk factors
According to the new category in Iran ,, about the perceived risk factors for CVDs, we applied open single item that the “Which item you know as the main factor for your disease?” Based on the mentioned method, the responses were divided into five categories including biological (gender, age, and genetic), environmental (smoke and toxic substances, polluted weather, and passive smoking), physiological (hypertension, diabetes, hyperlipidemia, and obesity), behavioral (malnutrition, smoking and substance abuse, and lack of exercise), and psychological (stress, anxiety, depression, anger, and hostility) risk factors.,,,,,
Perceived control questionnaire
The scale of control attitudes that designed by Moser and Dracup evaluates the control on disease among cardiac patients through four questions which two of them related to personal control and other two questions related to familial control. These items are scored based on the Likert system from zero (absence of control) to seven (complete control). In addition, the scoring of two items is indirectly. A higher score indicates more personal and familial control on cardiac disease.
Holmes and Rahe scale of life events stress
This questionnaire was made in 1963 for the evaluation of 41 stressful events. Based on this scale, the life changes in the past 6–12 months were evaluated and the total score obtains through the sum of the scores. The total score in a range of 150–200 means that the probability of disease in the future year estimated as 37% while this probability increases to 50% or 80% in scores in the ranges of 200–300 or higher than 300. The Iranian version validity and reliability of this scale reported acceptable.
For assessment of effective variables in referring to CR, data analyzed through Chi-square, t-test, and binary logistic regression analysis. At baseline, Chi-square and independent t-test were used for comparison between notcontinuous and continuous variables, respectively. In main analysis, binary logistic regression analysis was used for identification of barriers to lack of referral to the CR. All variables together entered into the analysis. SPSS ver. 20.0 for Windows (IBM SPSS, Armonk, NY, USA) software was used for analysis and P < 0.05 concerned as the significance level. Before analysis, the lack of overruns from assumptions was assessed and approved.
| Results|| |
Among the total of 312 patients (male: 63.8%) who entered to analysis, 26 persons (8.3%) referred to CR. The barriers related to the referral to CR were presented in [Table 1]. According to the results, hyperlipidemia is a facilitator for participating in the program (P = 0.049). Although, the higher level of stress is one of the barriers for the referral to CR (P = 0.048).
|Table 1: Baseline data in the overall population and in those referral and nonreferral to cardiac rehabilitation|
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About the regression model, Hosmer–Lemeshow test indicated that this model is acceptable (P = 0.307). The indexes of power effect size have an appropriate explanative ability in patients referrals (Cox and Snell R2 = 0.183; Nagelkerke R2 = 0.419), so it is suggested that our model can explain 18.3%–41.9% of the variance of referral to CR. [Table 2] includes the portion of modified chance (confidence interval: 95%) and significance level for each covariate in the model. [Table 2] indicates the predictor role of variables after control of demographics in the lack of referral to CR. According to the results, occupation, distance to CR, coronary history, hyperlipidemia, and physiologically perceived risk factor can predict the referral to CR. It means that there is a fewer probability that patients with a personal job (P = 0.001), emeriti (P = 0.020), or jobless patients (P = 0.006) refer to CR compared to the employees. Coronary history (P = 0.016) and hyperlipidemia (P = 0.030) are concerned as the facilitating factors in referral to CR. Finally, longer distance to CR (P = 0.042) and physiological perceived risk factors (P = 0.025) are barriers of referral to CR.
|Table 2: Predictors of referral to cardiac rehabilitation in the overall population|
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| Discussion|| |
The study aimed to assess the role of demographic factors, actual and perceived risk factors, and perceived control in CABG patients' referral to CR. In confirmation of the results of a study in Iran which suggested the rate of referral to CR lower than 15%, the results of our study indicated that only 8.3% of CABG patients refer to CR. Whereas the numerous studies ,, have referred the importance of CR, they have mentioned that most health benefits of CR are related to the patients' commitment and participation for at least 12 weeks. In this regard, nearly 80% of Iranian cardiologists suggested that the main cause of this problem is the lack of awareness about the benefits of CR. Furthermore, physicians noted that factors such as the lack of medical insurance, high costs, and the lack of access to CR.
Based on the results, employment, coronary history, and hyperlipidemia are concerned as the facilitating factors in referral to CR. While longer distance and physiologically perceived risk factors are barriers of referral to CR. Sanderson et al. suggested that the nonmedical problems are the causes for lack of referrals among 63% who did not refer, and one of the major problems is patients' occupational status. The employees generally have a higher educational level and health literacy. Based on the theory of accumulative advantage in the health field, more educated people have more health sources (such as more ability to avoidance of chronic stressors and healthier lifestyle) that each of sources is advantageous, and they accumulatively have positive effects on person's health. Among the positive effects, more cooperation in treatment, appropriate physical function, higher quality of life, more control of cardiac signs, and active and continuous participation in sessions of CR can be mentioned.
Regarding the role of coronary history in referral to CR, it may be suggested that uncontrollability aspect of biologic and hereditary nature of disease among patients with coronary artery diseases lead to these patients believe that they are more at risk for future cardiac events  and they have higher perceived risk. This may also be true about patients with hyperlipidemia. However, some studies suggest that hyperlipidemia is a barrier for the referral to CR;, it seems that patients with hyperlipidemia and coronary disease have more perceived risk compared to other patients, and it is more probability that these patients predict the cardiac event. Hence, they try to control these high-risk conditions through referral to the CR. The results of a study introduced hyperlipidemia as one of the facilitating factors in referral to CR.
Concordant to some studies,, we found that longer distance to CR center is one of the main barriers of referral. Patients who live in villages and faraway regions usually confront with transporting problems, and their traffic requires significant time and cost so that in some cases, the time and cost of traffic are more than the time and cost expense in the registration of CR. In addition, the routine exercise begins at 8:30 AM and long distance can convince patients that it is not possible for on time presence in CR.
Finally, it is indicated that the physiologically perceived risk factor is one of the barriers for the referral to CR. According to health beliefs model, the patient's attitudes  and their cognitive and emotional reactions to disease and treatment  can predict health behaviors independently. It seems that patients, who believe that one physiological risk factor such as diabetes or hypertension as the cause of their disease, do not worry about possible consequences of these risk factors because they relate their cardiac disease to these risk factors  and perception of controlling them by medication, diet, and appropriate exercise after CABG. These patients have a sense of control on the main cause of their disease, so this sense decreases the worry. Michie et al. suggested the concept of sense of mastery on health consequences, and the increase of this sense on cardiac conditions can decrease the worry. Lack of worry about negative future outcomes and self-efficacy  can confront referral to CR with the challenge.
| Conclusion|| |
According to Iranian physicians' research which suggested the rate of referral to CR lower than 15%, the results of the present study indicated that only 8.3% of CABG patients refer to CR. Based on the results, employment, coronary history, and hyperlipidemia are concerned as the facilitating factors for a referral, but the longer distance to CR and perceived physiological risk factor are the barriers for the referral to CR. Providing appropriate awareness, about the benefits of CR for patients with regard to their job status, coronary history, and perception about the illness risk factors can be effective in referral to CR. In addition, the launch of CR centers in cities and facilitate access to CR can play a significant role in increasing patients participation.
Financial support and sponsorship
This project was supported by the Kermanshah University of Medical Sciences (ID: 96335).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Heydarpour B, Saeidi M, Ezzati P, Soroush A, Komasi S. Socio-demographic predictors in failure to complete the outpatient cardiac rehabilitation. Ann Rehabil Med 2015;39:872-9.
Bath J, Bohin G, Jones C, Scarle E. Cardiac Rehabilitation. Chichester: Wiley-Blackwell; 2009.
Zand S, Koohestani H, Baghcheghi N, Shah Mirzai R. Assessing effectiveness of a cardiac rehabilitation program on outcomes of myocardial infarction. Nurs Res 2012;6:24-30.
Jackson L, Leclerc J, Erskine Y, Linden W. Getting the most out of cardiac rehabilitation: A review of referral and adherence predictors. Heart 2005;91:10-4.
Brady S, Purdham D, Oh P, Grace S. Clinical and sociodemographic correlates of referral for cardiac rehabilitation following cardiac revascularization in Ontario. Heart Lung 2013;42:320-5.
Brown TM, Hernandez AF, Bittner V, Cannon CP, Ellrodt G, Liang L, et al.
Predictors of cardiac rehabilitation referral in coronary artery disease patients: Findings from the American Heart Association's Get with the Guidelines Program. J Am Coll Cardiol 2009;54:515-21.
Aragam KG, Moscucci M, Smith DE, Riba AL, Zainea M, Chambers JL, et al.
Trends and disparities in referral to cardiac rehabilitation after percutaneous coronary intervention. Am Heart J 2011;161:544-51.e2.
Ali M, Qadir F, Javed S, Khan ZN, Asad S, Hanif B. Factors affecting outpatient cardiac rehabilitation attendance after acute myocardial infarction and coronary revascularization – A local experience. J Pak Med Assoc 2012;62:347-51.
Moradi B, Maleki M, Esmaeilzadeh M, Abkenar HB. Physician-related factors affecting cardiac rehabilitation referral. J Tehran Heart Cent 2011;6:187-92.
Ramm C, Robinson S, Sharpe N. Factors determining non-attendance at a cardiac rehabilitation programme following myocardial infarction. N
Z Med J 2001;114:227-9.
Krisko-Hagel KN. Predictors for Participation in a Cardiac Rehabilitation Program Feasibility Study. (Dissertation). Minnesota: The University of Minnesota; 2009.
Bahremand M, Saeidi M, Komasi S. Non-coronary patients with severe chest pain show more irrational beliefs compared to patients with mild pain. Korean J Fam Med 2015;36:180-5.
Saeidi M, Komasi S, Heydarpour B, Momeni K, Zakiei A. Those who perceive their disease as a physiological or psychological risk factor experience more anxiety at the beginning of the cardiac rehabilitation program. Res Cardiovasc Med 2016;5:e29291. [Full text]
Furze G, Lewin RJ, Murberg T, Bull P, Thompson DR. Does it matter what patients think? The relationship between changes in patients' beliefs about angina and their psychological and functional status. J Psychosom Res 2005;59:323-9.
Lau-Walker M. Importance of illness beliefs and self-efficacy for patients with coronary heart disease. J Adv Nurs 2007;60:187-98.
Hirani SP, Newman SP. Patients' beliefs about their cardiovascular disease. Heart 2005;91:1235-9.
Saeidi M, Soroush A, Komasi S, Moemeni K, Heydarpour B. Attitudes toward cardiovascular disease risk factors among patients referred to a cardiac rehabilitation center: Importance of psychological attitudes. Shiraz E Med J 2015:16:e22281.
Pallant J. SPSS Survival Manual: A Step by Step Guide to Data Analysis Using SPSS for Windows. 2nd
ed., Ver. 12. Australia: Allen & Unwin; 2005. p. 142-152.
Saeidi M, Komasi S, Soroush A, Zakiei A, Shakeri J. Gender differences in patients' beliefs about biological, environmental, behavioral, and psychological risk factors in a cardiac rehabilitation program. J Cardiothorac Med 2014;2:215-20.
Komasi S, Saeidi M. Aging is an important cause for a lack of understanding of the main risk factor in cardiac rehabilitation patients. Thrita 2015;4:e32751.
Komasi S, Saeidi M. Screening for depressive symptoms at the beginning of outpatient cardiac rehabilitation by assessed perceived risk factors by patients. Clin Med Rev Case Rep 2015;2:1-8.
Komasi S, Saeidi M. A perceived risk factor may lead to increased anxiety and depression in cardiovascular patients. Jundishapur J Chronic Dis Care 2016;5:e34159.
Moser DK, Dracup K. Psychosocial recovery from a cardiac event: The influence of perceived control. Heart Lung 1995;24:273-80.
Holmes TH, Rahe RH. The social readjustment rating scale. J Psychosom Res 1967;11:213-8.
Vafaii B. Evaluation of the relation between life stresses and blood neoplastic diseases in males and females aged between 30 and 50. Tabriz Med J 2000;34:47-54.
Karami J, Komasi S, Maesoomi M, Saeedi M. Comparing the effects of two methods of relaxation and interpersonal cognitive problem solving (ICPS) on decreasing anxiety and depression in cardiac rehabilitation patients. Urmia Med J 2014;25:298-308.
Sanderson BK, Phillips MM, Gerald L, DiLillo V, Bittner V. Factors associated with the failure of patients to complete cardiac rehabilitation for medical and nonmedical reasons. J Cardiopulm Rehabil 2003;23:281-9.
Miech RA, Shanahan MJ. Socioeconomic status and depression over the life course. J Health Soc Behav 2000;41:162-76.
King KM, Norris CM, Knudtson ML, Ghali WA. Risk-taking attitudes and their association with process and outcomes of cardiac care: A cohort study. BMC Cardiovasc Disord 2009;9:36.
Acheson LS, Wang C, Zyzanski SJ, Lynn A, Ruffin MT 4th
, Gramling R, et al.
Family history and perceptions about risk and prevention for chronic diseases in primary care: A report from the family healthware impact trial. Genet Med 2010;12:212-8.
Worcester MU, Stojcevski Z, Murphy B, Goble AJ. Factors associated with non-attendance at a secondary prevention clinic for cardiac patients. Eur J Cardiovasc Nurs 2003;2:151-7.
Hajali Akbari Z, Hosseini MA, Nourozi K, Rahgozar M. Comparing barriers and facilitators of attending to cardiac rehabilitation programs from patients with coronary artery bypass graft surgery and rehabilitation specialists' viewpoints. Iran J Rehabil Res Nurs 2014;1:62-73.
van der Wal MH, Jaarsma T, Moser DK, Veeger NJ, van Gilst WH, van Veldhuisen DJ. Compliance in heart failure patients: The importance of knowledge and beliefs. Eur Heart J 2006;27:434-40.
Phillips LA, Diefenbach MA, Abrams J, Horowitz CR. Stroke and TIA survivors' cognitive beliefs and affective responses regarding treatment and future stroke risk differentially predict medication adherence and categorised stroke risk. Psychol Health 2015;30:218-32.
Saeidi M, Komasi S, Heydarpour B, Karim H, Nalini M, Ezzati P. Predictors of clinical anxiety aggravation at the end of a cardiac rehabilitation program. Res Cardiovasc Med 2015;5:e30091.
Michie S, O '
Connor D, Bath J, Giles M, Earll L. Cardiac rehabilitation: The psychological changes that predict health outcome and healthy behavior. Psychol Health Med 2005;10:88-95.
Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Shahid Beheshti Boulevard, Kermanshah
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]