Running Head: CARDIOVASCULAR REHABILITATION PARTICIPATION

Cardiovascular Rehabilitation and the Influencing Factors on Patient Participation

Ashley A. Bilbo
Northeastern University

CARDIOVASCULAR REHABILITATION PARTICIPATION

Abstract
Cardiovascular disease is a major health concern as it is the leading cause of death in the United
States. Healthcare providers work to decrease the progression and symptomatology of disease
through the use of pharmacotherapy and surgical procedures. Lifestyle changes have been shown
to be highly effective in slowing the progression of disease, and have been shown to decrease
blood pressure, cholesterol, and obesity. Patients recovering from cardiac events may quickly
become overwhelmed by recommended lifestyle changes which leads to noncompliance and
decreased patient outcomes. Cardiovascular rehabilitation is a structured exercise and lifestyle
program which supports patients in recovery. Participation in this type of program has been
shown to decrease mortality and increase quality of life, yet participation is extremely low (14
percent). The research focused on the reasons for poor participation, in hopes that awareness of
obstacles would allow healthcare providers to make changes. It was found that the main
influencing factors on a patients decision were physician endorsement, knowledge of disease,
and socioeconomic issues such as transportation, finances, and support systems. Through
knowledge of these factors nurses and physicians can provide assistance and increase
participation in this valuable program.

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Cardiovascular Rehabilitation and the Influencing Factors on Patient Participation

Cardiovascular disease is the leading cause of death in the United States, claiming the
lives of nearly 600,000 people each year (Centers for Disease Control, 2014). The term is used to
describe multiple cardiovascular conditions including heart failure, coronary artery disease,
myocardial infarction, and valvular disease (American Heart Association, 2014). Treatment of
these conditions generally consists of a combination between pharmacotherapy, medical
procedures, and lifestyle education. Though genetic predisposition plays a major role, lifestyle
choices have been shown to both prevent and slow the progression of cardiovascular disease.
Lifestyle changes have also been shown to decrease mortality after cardiovascular events and
surgical procedures such as revascularization and coronary stenting (American Heart
Association, 2014). Thus it is recommended that eligible patients attend cardiovascular
rehabilitation programs upon discharge from the hospital. Rehabilitation programs combine
physical, emotional, and spiritual support to the recovering cardiovascular patient. Participation
in a structured and supervised rehabilitation program has been shown to decrease mortality by
20-30 percent after a cardiac event or procedure. Surprisingly, however, participation is quite
low and approximately 14 percent of patients attend (American Heart Association, 2014). There
are a multitude of reasons for poor participation, many of which the healthcare provider can
change. Through knowledge of these factors the healthcare provider can plan accordingly and
ensure that each patient has access to this valuable and life changing program.
Cardiovascular Rehabilitation
Cardiovascular rehabilitation is an exercise and lifestyle training program specifically
designed for patients with heart disease. The American Heart Association (2014) defines this

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specialized program as a professionally supervised program to help people recover from heart
attacks, heart surgery, and percutaneous coronary intervention (PCI) procedures such as stenting
and angioplasty. The challenges facing patients recovering from cardiovascular events often
become overwhelming, leading to decreased compliance and increased complications.
Cardiovascular rehabilitation ensures that each patient has the resources to make necessary
lifestyle changes. The program is divided into 3 phases which are to be followed sequentially
by the patient. Phase one of cardiovascular rehabilitation occurs during the hospitalization
period. During this phase the patient is assisted in performing light physical and self-care
activities. The next phase begins upon discharge from the hospital and consists of outpatient
visits to a rehabilitation center. This phase generally lasts three months and requires multiple
sessions per week. The final phase of cardiovascular rehabilitation is a lifetime commitment to
cardiovascular health, requiring the patient to incorporate dietary and lifestyle changes into their
daily routines (American Heart Association, 2014). Each program is supervised and structured
by healthcare providers including nurses, dietitians, and physical therapists. In this way
exercising is done safely and patient anxiety is decreased.
Benefits of Cardiovascular Rehabilitation
The benefits of cardiovascular rehabilitation are numerous and have been researched
extensively. Patients who attend structured rehabilitation programs are at a decreased risk for
complications, and have an increased quality of life. According to Lindsey Getz (2010) the most
important benefit of cardiovascular rehabilitation is that patients live longer (p.8). In fact,
participation has been shown to decrease the mortality rate by up to 30 percent (American Heart
Association, 2014). Not only are patients living longer but they are emotionally and spiritually
more satisfied. The holistic nature of cardiovascular rehabilitation programs allows patients to

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improve in all areas of life (Getz, 2010). Healthcare providers stress the importance of lifestyle
changes in an attempt to decrease complications and rehospitalizations. Once the patient is
discharged, however, the much needed support disappears. Opponents of cardiovascular
rehabilitation often state that the same benefits could be achieved through the use of a local gym
and simple dietary changes. However, this argument does not take into account the psychological
impact of a cardiac event. Though patients may be able to attend exercise programs on their own,
many lack the confidence and motivation to exercise and make changes. They are battling
depression, anxiety, and stress on top of the physical challenges of recovery. The environment of
cardiovascular rehabilitation allows for physical, emotional, and spiritually healing after a
cardiovascular event. A study on this supportive environment found that patients thrive in it, as
one patient stated here, we all have same kind of problems, same concerns and same
worldhere I see other participants are like me, and I feel I m like themwhen I exercise
alone, I easily give up (Shahsavari, Shahriari, and Alimohammadi, 2012, p.7). Patients often
gain friendships through attending rehabilitation as each patient is fighting the same battle.
Cardiovascular rehabilitation ensures that patents have the physical ability, emotional stability,
and knowledge to remain compliant. Its benefits far surpass those which could be achieved
through at home exercise regimens.
Participation
Despite the great benefits of cardiovascular rehabilitation, research has shown that it is
vastly underutilized and often overlooked. Out of those eligible to attend a mere 14 percent of
patients participate (American Heart Association, 2014). Healthcare providers express concern
when compliance towards pharmacotherapy and other treatments is low, and yet there seems to
be little action made to increase rehabilitation participation across the board. As the leading

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cause of death in the United States, cardiovascular disease is a major health concern.
Cardiovascular rehabilitation must be used in the treatment of patients, and must be seen as
important as pharmacotherapy. Its importance is so great that increasing physician referrals and
patient participation should be a priority for professionals (Lindsey Getz, 2010, p.8). Healthcare
providers not only need to be aware of the factors involved in low participation, but prepare to
combat them.
Influencing Factors on Participation
Perhaps one of the most influential factors on a patients decision to attend cardiac
rehabilitation is physician endorsement. Patients typically base their decisions on physician
provided information. They are a well trusted resource and are believed to have the best interests
of their patients in mind. The problem arises when the physician does not see the benefits of
cardiovascular rehabilitation. Without knowledge of the great benefits the physician simply
cannot advise the patient to attend, and certainly cannot persuade them. The American Heart
Association (2012) emphasizes that due to time constraints and lack of awareness of its value,
physicians have generally not been as strong an advocate for cardiovascular rehabilitation as
other allied health professionals. Nurses are also influential in the patients decision to attend
cardiovascular rehabilitation. Nurses have the unique opportunity to provide hands on care and
spend a great deal of time with each patient. They are in the perfect position to educate patients
on the benefits of cardiovascular rehabilitation. Arena and Forman (2012) emphasize this point
as they state that nurses frequently have immediate and direct contact with the patient and
therefore have a pivotal role following a cardiac event or procedure (p. 1322). It has also been
suggested that nurses must advocate for their patients and obtain a referral for rehabilitation

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when they are originally not given one. Thus, participation rates are greatly impacted by nurse
and physician recommendations.
Other factors which influence participation include perceptions of the program itself. In
one study it was shown that the largest predictor of participation was whether the patient
perceived it as beneficial (McKee, Biddle, ODonnell, Mooney, OBrien, & Moser, 2013).
Patients are generally motivated to make behavioral changes if they can truly see the ways in
which they will benefit from it. Furthermore, patients have increase motivation when they
perceive themselves to be at risk. Shahsavari, et al. (2012) stress this point, stating that a patients
belief in cardiac rehabilitation results in this belief that non-attendance and non- adherence to
such programs is equal to being at risk (p.6). If the benefits of structured exercise and lifestyle
programs are not discussed with patients they likely will not make arrangements to attend, even
if they are referred to one.
A patients education surrounding the topic of cardiovascular disease has also been
shown to influence their decision. Lifestyle changes have been shown to decrease the
progression of cardiovascular disease by decreasing blood pressure, cholesterol, and obesity
(NIH, 2011). Thus a patient can reduce further progression of disease after a cardiovascular
event by making lifestyle changes. If a patient has a false perception of their illness they may feel
helpless and take a passive role in their health. Due to their lack of education they may not see
the importance of cardiovascular rehabilitation. A study published in Heart, a journal of the
British Cardiovascular Society, showed that individuals who did not attend cardiovascular
rehabilitation were unaware of their own role in the disease progression. The authors suggested
that the perception of illness plays a key role in attendance and that those with a stronger belief
that their condition is controllable will subsequently take appropriate action such as attendance at

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cardiac rehabilitation (Cooper, Weinman, & Jackson, 1999). Healthcare providers must take the
time to educate their patients on the changes they can make to live a healthier, longer life.
The decision to attend a structured cardiovascular rehabilitation program also involves
many social and economic aspects. Though a lack of knowledge and physician endorsement
decrease participation rates, there are many patients that desire to participate and find themselves
facing other barriers. First, there are transportation issues. Patients recovering from
revascularization procedures have strict activity limitations, including a restriction from driving
for 3 to 4 weeks after surgery. Patients who do not have a large support system may not be able
to find transportation to rehabilitation programs, even if they do understand its importance.
Furthermore, the amount of rehabilitation programs in some areas is relatively small which
forces patients to travel long distances to attend. A study on the socioeconomic barriers involved
in attendance found that those living approximately 30 miles away from the nearest rehabilitation
center were 71% less likely to participate (Shanmugasegaram, Oh, & Grace, 2013). The same
study explored the effect of socioeconomic class on participation. The study found that patients
of lower subjective socioeconomic class were significantly less likely to be referred, enroll, and
participate in cardiovascular rehab, and reported significantly greater barriers than patients from
higher socioeconomic classes (Shanmugasegaram, et al. 2013). Other barriers include financial
issues and the lack of health insurance coverage. Many health insurance plans do cover the costs
of rehabilitation; however others only cover a portion. The average cost of a traditional cardiac
rehabilitation program may be up to 2,000 dollars (Shepard & Lee, 2009). This expense is quite
large for patients who have not been able to work due to illness and hospitalizations. Healthcare
providers need to ensure that referrals to rehabilitation programs are given to all patients,
regardless of class. Each patient deserves the opportunity to participate in structured exercise

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programs as they have been shown to decrease mortality and increase quality of life. Just as there
are assistance programs to cover the costs of medications, there is a great need for programs that
will assist patients in accessing this resource. Nurses and other healthcare providers must
advocate for patients who are unable to access cardiac rehabilitation programs. Social workers
and community volunteers may be able to assist patients in overcoming transportation barriers
and financial issues.
Conclusion
Cardiovascular rehabilitation has been shown to be beneficial for patients recovering
from cardiac events and procedures. Extensive research has shown that it leads to decreased
mortality and overall better patient outcomes. Unfortunately, despite its many benefits,
participation is extremely low. Research has also shown that poor participation is likely due to a
combination of factors, many of which the healthcare provider can change. Not only should
healthcare providers be aware of the benefits of rehabilitation, but they must be prepared to
tackle obstacles facing patients. Healthcare providers must regard cardiovascular rehabilitation
as important as medications in treating cardiovascular disease. There needs to be assistance
programs set in place to help patients gain access to this invaluable resource. As the leading
cause of death in the United States, cardiovascular disease must be treated at many different
levels and patients must begin to take charge of their heart health. Through cardiac rehabilitation
programs patients are given the necessary resources to make heart healthy choices.

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Reflective Note: I hope to use this piece as part of my professional portfolio. I learned a
great deal from this project, and believe this information will truly benefit the healthcare
provider and cardiovascular patients.

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Resources
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