Elsevier

Heart & Lung

Volume 47, Issue 5, September–October 2018, Pages 471-476
Heart & Lung

Care of Patients With Cardiopulmonary Disorders
Perspectives of cardiac rehabilitation staff on strategies used to assess, monitor and review – a descriptive qualitative study

https://doi.org/10.1016/j.hrtlng.2018.06.001Get rights and content

Abstract

Background

The mechanisms contributing to the success of cardiac rehabilitation (CR) are poorly understood and may include assessment, monitoring and review activities enabled by continuity of care and this is investigated in this study.

Objectives

To identify active assessment components of CR.

Methods

A qualitative study using focus groups and individual interviews. CR staff (n = 39) were recruited via professional association email and network contacts and organised into major themes.

Results

CR staff assessment strategies and timely actions undertaken provided a sophisticated post-discharge safety net for patients. Continuity of care enabled detection of adverse health indicators, of which medication issues were prominent. Interventions were timely and personalised and therefore likely to impact outcomes, but seldom documented or reported and thus invisible to audit.

Conclusion

CR staff assessment and intervention activities provide an unrecognised safety net of activities enabled by continuity of care, potentially contributing to the effectiveness of CR.

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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  • Cited by (4)

    Funding: This work received a seeding grant from the Heart Foundation (NSW).

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