Care of Patients With Cardiopulmonary DisordersPerspectives of cardiac rehabilitation staff on strategies used to assess, monitor and review – a descriptive qualitative study
Introduction
How does cardiac rehabilitation achieve positive effects? The most recent Cochrane review of exercise-based CR (n = 14,000) reported CR reduced cardiovascular mortality (risk ratio 0.74, 95% CI 0.64–0.86) and hospital admissions (risk ratio 0.82, 95% CI 0.70–0.96).1 However, the mechanisms responsible for these benefits have been recently reconsidered. Given rapid advancements in the field and potential alternative delivery methods, it is crucial to understand these mechanisms so that effectiveness is maintained and improved.
CR is a complex intervention, composed of multiple parts, acting separately and in combination to produce the effectiveness or ‘power’ of the intervention.2 The most well-investigated component of CR and arguably its most powerful is exercise-training. Exercise training directly improves endothelial function, ventricular function, remodelling and electrical stability and reduced inflammatory status after myocardial infarction and has indirect effects on lipids.3, 4, 5 When CR programs do not include exercise, and have only psychological or educational components, they may not be as effective.1 However, a recent systematic review of 69 trials of exercise-based CR concluded that beyond adherence, the individual effect of components of exercise, such as dosage, could not be differentiated.6
Behaviour change and social support interventions are also considered to be active agents contributing to the effectiveness of CR. Behaviour change techniques used in CR are diverse but commonly include goal setting, self-monitoring against goals, stress management, social support and providing feedback, used singly and/or in combination. However, a recent systematic review of 22 CR trials demonstrated that while these behaviour change interventions had a small effect on mortality (RR 0.82, 95% CI 0.69, 0.97), no single or combined behaviour change techniques, or method of delivery, was identified as influencing mortality.7 Similarly, there is evidence that adherence and/or length of contact increase effectiveness, rather than the specific techniques being used.8, 9
Dose-dependent relationships between increased attendance at CR and reduced mortality and myocardial infarction are well-known,10 and people who drop-out have worse outcomes in multiple areas.11 Consequently, attendance may enable other important but tacit or hidden mechanisms for the effectiveness of CR in addition to the well-documented exercise training, exposure to behaviour change techniques and receiving social support.
One such potential mechanism are the assessment, monitoring and review processes undertaken by staff,12 a mechanism which may be made most effective through the regular contact with expert staff occurring in CR.13 Such assessment, monitoring and review over time enables early detection of health issues, timely intervention and review of responses to intervention, promoting continuity of care and ultimately contributing to improved patient outcomes.14 However, not all forms of assessment, such as those undertaken for non-urgent health issues, are documented and are thus largely invisible.15, 16, 17
The potential benefit to patient outcomes of assessment, monitoring and treatment activities occurring in CR staff is mentioned briefly in key CR systematic18, 19, 20 and narrative reviews21 and policy guidelines.22 Others refer to the essential role of CR staff evaluation and reporting of patient's health status in optimising medical and pharmacological treatments.21, 23 However, no study has specifically identified the activities undertaken and the indicators used by CR staff in practice in relation to the core component of assessment and review of clinical progress. This study explores these aspects of care in CR with the view to identify additional potentially active ingredients of CR.
Section snippets
Study design
The study used a qualitative design with semi-structured focus group and individual interviews. The study protocol received approval from the University of Sydney Review Board and was undertaken in accordance with the Helsinki Declaration of 1994.
Subjects and setting
In this setting (New South Wales, Australia), eligible patients are referred to CR following admission for coronary heart disease, structural heart disease and dysrhythmia events and interventions. Most CR programs in this context are comprehensive
Participants
Participants' length of experience in CR was an average 13.57 (SD 7.4) years; 44% had post-basic qualifications and 82% were nurses. Most staff worked in metropolitan contexts, either at tertiary (41%) or district hospitals (13%); with 46% working in nonmetropolitan contexts at community hospitals (36%) or health centres (10%). A majority (82%) of programs were served by a multidisciplinary team with a median of 3 staff (range 1–10).
Themes
Our analysis indicates the processes of assessment, monitoring
Discussion
This study is the first to identify the potentially highly influential post-discharge safety net created by assessment, monitoring, review, and actions undertaken by CR staff. Regular contact at CR was important to enabled continuity of care and early detection and timely management of multiple adverse health indicators, which alongside the more well-known exercise training and behaviour change components, is likely to contribute important but to-date unacknowledged benefits. As documentation
Conclusion
Assessment, monitoring, review and intervention activities by CR staff provide a post-discharge safety net for early detection, prevention and timely intervention for adverse health indicators for CR participants. This safety net is another important but unrecognised mechanism of the effectiveness of CR beyond the well-known exercise and behaviour change intervention components. CR staff perceived that multiple adverse health indicators were detected and managed, but these actions were likely
Acknowledgements
We would like to acknowledge the CR staff participants for volunteering their time, the CRA of NSW for email distribution and Patrick Gallagher for manuscript preparation.
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Funding: This work received a seeding grant from the Heart Foundation (NSW).