There is robust evidence supporting cardiac rehabilitation (CR) and its benefits.1 However, the utilization of CR is suboptimal. There are a large number of studies related to improving CR initiation rates.2,3 However, there are a limited number of studies that have explored factors associated with CR completion and potential solutions to increase completion rates (40-60%).3–5 These studies have generally lacked patient-level details about the underlying challenges patients face in completing a course of CR. We conducted a qualitative study to identify barriers to completion of a CR program and identify factors that help facilitate CR completion.

METHODS

In this qualitative study, we conducted interviews with two focus groups of patients who had participated in the Mayo Clinic CR program. One group included those who completed the program (≥36 sessions), and the other group included those who did not complete the program (<36 sessions). The study was approved by the Mayo Clinic Institutional Review Board.

PARTICIPANTS

A purposive sampling of the patients who enrolled in the Mayo Clinic CR program between October 1, 2015, and March 1, 2016, was done with the purpose of including a diverse group of patients in our sample based on sex and work status. Up to three telephone calls were attempted per patient until a sample goal of 12 patients was achieved who had completed their CR program (completers) and 12 patients were recruited who had not completed their CR program (noncompleters). While 12 completers agreed during the recruitment telephone call to attend a focus group meeting, only six of them attended.

Because of the difficulty recruiting, noncompleters were recruited to participate in a brief telephone-based interview that explored the same questions as were explored with the participants in focus group meeting. Seven of the 12 noncompleters who were contacted agreed to participate in the telephone interview. Written consent was obtained from all participants.

The in-person focus group was conducted by two of the investigators (K.V.D., J.H.), who were both experienced in carrying out semistructured patient interviews for qualitative research purposes. The telephone interviews of the noncompleters group were conducted by one of the investigators (J.H.). An interview guide was developed and used (see Supplemental Digital Content 1, available at: https://links.lww.com/JCRP/A404).

The interview data were recorded, transcribed, and coded by a qualified audio typist and analyst according to a standard qualitative analysis approach. A qualitative software analysis program, NVivo9 (QSR International), was used to facilitate data coding and sorting. Descriptive codes by constant comparison methods were merged to thematic categories and conceptual frameworks to provide insight to further the enhancement of both CR modalities and barriers towards achieving ideal cardiovascular health. To ensure rigor and accuracy, separate transcription and coding were conducted by independent analysts from the study team (K.V.D. and M.S.P.).

RESULTS

Six patients in the completers group participated in the in-person focus group, and seven patients in the noncompleters group completed the telephone interview. The mean age among all the participants was 60.9 ± 8.9 yr. Of the 13 patients who participated in the completers and noncompleters groups, four (31%) were women and six (46%) were employed.

We found that the primary types of barriers, along with solutions identified by participants, differed in the completers and noncompleters groups (Figure). In the completers group, the most common barrier identified was emotional barriers, such as a perception of feeling being overwhelmed with the myriad of issues facing the patients after their cardiovascular event. In the noncompleters group, the most common barrier identified was logistical barriers (eg, scheduling issues etc). Despite not completing CR, it is interesting to note that noncompleters reported receiving benefits from CR participation.

Figure.:

Patient-reported barriers to cardiac rehabilitation participation. Abbreviation: CR, cardiac rehabilitation.

Participants also identified some strategies with the potential to facilitate completion to CR. The first involved the need to better inform and educate patients about the importance of attending CR while in the hospital. Participants were aware of the paradox between their need for information and the tendency toward information overload that is commonly experienced before hospital discharge. A second potential solution was to develop a more tailored CR program that includes more guidance than usual to help tailor the program to patient specific needs and goals. A third potential solution was to increase the level of support to patients, such as a group exercise option that would allow patients to support each other during exercise sessions, or specific individual or group support sessions with CR staff members.

DISCUSSION

In this qualitative study, we identified challenges to CR program attendance among completers and noncompleters. Some of these challenges include barriers that have been previously reported such as transportation and scheduling issues.6–8 However, we also identified other more novel barriers that are less well known, including a perceived lack of interaction with CR staff and patients; a feeling of anxiety related to exercise participation; and a feeling of being overwhelmed by medical appointments and other responsibilities, all of which lead the patient to view CR participation at a relatively low priority level. These findings suggest the importance of patient education and psychosocial support to help identify and overcome potential barriers to CR participation.

This study was limited by the small sample size and by differing data collection strategies for completers and noncompleters. However, we used a standardized interview guide. A minority of women and employed individuals participated in the study. This may have weakened our ability to collect information from these populations, which along with ethnic minorities and lower income and education attainment, have been shown to be significant disparities in CR utilization.9,10

CONCLUSION

Our study identified psychological and emotional barriers to CR participation for some individuals that have been missed in previous studies. These barriers include a perceived lack of interpersonal interaction with CR staff and patients and a sense of emotional exhaustion when confronting the myriad of health conditions in individuals who have suffered a recent cardiovascular disease event. Future studies should address these barriers through the use of personalized support tools that help identify and manage the various social and emotional determinants of health that exist for CR patients.

Marta Supervia, MD, MSc
Gregorio Marañón Health Research Institute, Gregorio
Marañón General University Hospital, Madrid, Spain
Division of Preventive Cardiology, Department of
Cardiovascular Medicine, Mayo Clinic,
Rochester, Minnesota
Jose Medina-Inojosa, MD, MSc
Department of Cardiovascular Medicine, Mayo Clinic,
Rochester, Minnesota
Begoña Martinez-Jarreta, MD, PhD
Consolidated Scientific Research Group GIIS063, Aragon
Health Research Institute (IIS-Aragón), Zaragoza, Spain
Francisco Lopez-Jimenez, MD, MSc, MBA
Department of Cardiovascular Medicine, Mayo Clinic,
Rochester, Minnesota
Kristen Vickers, PhD
Department of Psychiatry and Psychology, Mayo Clinic,
Rochester, Minnesota
Carmen M. Terzic, MD, PhD
Department of Physical Medicine and Rehabilitation, Mayo Clinic,
Rochester, Minnesota
Randal J. Thomas, MD, MS

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