Exploring the acceptability of current delivery modes and content of cardiac rehabilitation: a qualitative study

Background
Following acute coronary syndrome (ACS) the prevention of further progression of disease is heavily dependent on an individual’s response to lifestyle modification and adherence to drug treatment. An extensive and robust body of evidence exists to support the benefits of completing a comprehensive cardiac rehabilitation (CR) course, but the mode of delivery has been widely debated with evidence indicating comparable outcomes between home-based and centre-based courses. ESC Guidelines encourage practitioners to be flexible with approaches to delivery and to identify innovative approaches to ensure hard-to-reach groups are included. However, uptake and attrition levels remain critical, with less than half of those needing CR completing a programme.

Aim
To explore the acceptability of CR from the perspective of those who left the programme or did not attend.

Methods
A qualitative approach, using focus groups and semi-structured interviews with 26 patients following Acute Coronary Syndrome. The sample was stratified into 3 groups, a) those who completed the programme, b) those who left before completion and c) those who declined or did not attend. The Theoretical Domains framework guided data collection and analysis. Interviews and focus groups were taped and transcribed verbatim, prior to framework analysis procedures.

Results
Recruitment is ongoing, provisional main themes are presented.
Presentation of CR: marketing of the programme, education of staff and patients, emphasis needed on benefit to completing CR, incorporate into discharge prescription, social aspect of CR is valued.
Demographic of participants: age can have influence on attendance, socio-economic factors, family a strong motivator for attendance, co-morbidities limit attendance.
Logistics and resource: transport issues limit attendance, flexibility in class time and location welcomed, preference for longer duration of programme.
Emotional state: acceptance of disease vs denial, severity of condition can positively influence attendance, loss of dignity.
Relationship with Healthcare team: positive interactions, trustworthy and approachable, good access, classes provide accountability, home-based CR attractive if accompanied by healthcare professional input.

Conclusion
Deficits in patients’ understanding of their condition, the rationale for CR and what it entailed were common. Solutions for CR uptake and adherence should better suit the needs of the target population and ideally be developed and co-designed in partnership. All groups enjoyed contact with Healthcare staff but external factors severely limited participants ability to attend. Co-morbidities which limit attendance were prevalent in the Declined/Did not attend group, the current CR programme may not be suitable despite best efforts to modify exercise.