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patient compliance, adherence, session attendance, cardiac rehabilitation



  1. Sanderson, Bonnie K. PhD, RN
  2. Phillips, Martha M. PhD
  3. Gerald, Lynn PhD, MSPH
  4. DiLillo, Vicki PhD
  5. Bittner, Vera MD, MSPH


PURPOSE: Cardiac rehabilitation (CR) provides effective secondary prevention services, but many patients fail to complete the recommended program. The purposes of this study were to describe completion rates in a hospital-based outpatient CR program, and to identify factors associated with patients failing to complete CR because of nonmedical and medical reasons.


METHODS: Data used for the analyses were from a hospital-based CR program involving 526 discharged patients between January 1996 and February 2002. Patient discharge status was classified into three categories: complete, noncomplete-medical reasons, and noncomplete-nonmedical reasons. Logistic regression modeling identified factors associated with the groups failing to complete CR.


RESULTS: The rate of CR completion was 58% (304/526). Among the 222 patients who did not complete CR, 139 (63%) had nonmedical reasons. As compared with the patients who completed CR, the adjusted odds ratio (AOR) for those who did not complete CR because of nonmedical reasons were more likely to be employed (AOR 2.2), to be obese (AOR 2.5), to be smokers (AOR 2.1), and to have shorter 6-minute walk distances (AOR 1.7). They were less likely to be women (AOR 0.6) or have diabetes (AOR 0.5). Patients not completing CR for medical reasons were more likely to be categorized as being at high clinical risk (AOR 4.2) and having shorter 6-minute walk distances (AOR 1.9).


CONCLUSION: Except for low functional capacity, baseline factors associated with patients failing to complete CR differed on the basis of medical or nonmedical reasons. The development of interventions that address the special needs of patients with low functional capacity may be especially important in attempts to retain this high-risk group in CR therapy.


Cardiac rehabilitation (CR), which includes exercise training, education, counseling, and behavioral interventions, is effective in the management of patients with known coronary heart disease. 1,2 However, the extent to which the services are effective may depend on a patient's willingness or ability to attend the program and adhere to the recommended strategies necessary to achieve the desired benefits. 3-5 Estimates of patient adherence to the completion of CR range from 40% to 60%, 6-8 and are comparable with adherence rates for other cardiovascular risk-reduction interventions. 3


A high dropout rate and poor attendance patterns for CR have been attributed to factors related to clinical, psychological, health behavior, and demographic patient characteristics. The existence of comorbidities 9 and risk factors among patients in CR such as higher body mass index, 6,10 low physical activity levels, 6,7 depression, 10,11 and smoking 12-14 have been associated with poor attendance. Personality tendencies 15 and psychological factors 12,16 also have been shown to affect regular session attendance. Younger participants are reported to have poorer attendance than older participants. 17 Similar CR completion rate comparisons are reported between black and white participants. 18,19 When studies compared program completion rates between men and women 12,16,17 and by sources of reimbursement 17,20,21 results were inconsistent. Logistic barriers such as inconvenient session schedules or the need to drive long distances have been associated with higher dropout rates among CR patients. 17,22 The results from a survey of program directors showed that they perceived conflicts in work schedules, financial issues, and low motivation among patients to be frequent reasons for patient dropout from CR. 23


In clinical care settings, adherence to recommended treatment is a critical element ensuring that the therapy produces the intended effect. 24 Identifying patient characteristics as predictors of poor adherence has not proved to be of much use in improving adherence, but changing treatment strategies may be more effective. 25 Designing effective interventions that address the special needs of patients who may be at higher risk for dropout is important. However, the development of such interventions requires a better understanding of the reasons patients discontinue therapy, exploration of the factors associated with the reasons, and determination whether an intervention will be effective for subgroups of patients who may be more likely to drop out. Because there is an increasing medical acuity of patients referred to CR that may lead to unavoidable dropout, it is important to distinguish medically related reasons from other nonmedical reasons.


The purposes of this study were to describe completion rates in a hospital-based outpatient CR program, and to identify factors associated with the failure of patients to complete CR because of nonmedical and medical reasons. The findings will contribute to the planning of interventions designed to improve program completion rates by targeting patients who may be more likely to discontinue participation before achieving the expected benefits.