Cardiac prehabilitation: who declines participation and why? a single-centre analysis of recruitment barriers in the PRECOVERY trial

Abstract Background The PRECOVERY trial investigates the effectiveness of a standardised, multimodal prehabilitation programme for older adults prior to elective cardiac procedures, with the long-term aim of integrating this pathway into routine care. Recruiting suitable patients remains challenging. Identifying and understanding barriers to participation are crucial to optimising recruitment strategies and facilitating the wider implementation of multimodal prehabilitation. This single-centre analysis examined the reasons why eligible patients declined participation in the PRECOVERY trial despite potential benefits. Methods PRECOVERY is a randomised, controlled, longitudinal, multicentre trial enrolling patients aged ≥65 years scheduled for elective cardiac procedures. The intervention group receives a two-week multimodal prehabilitation programme. The primary endpoints are quality of life and 12-month mortality. For this analysis, recruitment data from 147 eligible patients were retrospectively evaluated. Initial contact was made via telephone by a member of the study team; interested patients subsequently received written study information by post. Recruitment outcomes were analysed using continuously collected screening data. Reasons for non-participation were recorded and categorised as follows: (1) medical advice against participation; (2) lack of interest; (3) imminent surgery not to be postponed; (4) caregiving or other private commitments; and (5) other reasons. Results Over a 14-month period, the overall recruitment rate was 28% (41 of 147 screened patients). Participation rates did not differ significantly by gender or referring department (p 0.05). The mean age of enrolled patients was 73.1 ± 5.1 years, while the mean age of non-enrolled patients was 75.6 ± 5.8 years. A significant association was observed for age, with participation rates of 39% among patients aged ≤75 years and 16% among those aged 75 years (p = 0.004) (Fig. 1). Logistic regression analysis revealed that patients aged 75 years were significantly more likely to decline participation due to "imminent surgery" (odds ratio OR 4.6; p = 0.04). A further significant association was observed between the category "imminent surgery" and patients referred from cardiac surgery (OR 11.8; p = 0.03) (Fig. 2). Conclusion Recruitment to multimodal prehabilitation programmes is impeded by medical concerns, lack of interest, scheduling constraints, and private obligations, particularly among younger patients and those referred from cardiac surgery. Understanding these barriers is vital to improve recruitment strategies and enable the integration of prehabilitation into routine care. Analysis of participation patterns revealed a significant association with age, with higher enrolment among patients aged ≤75 years. These findings highlight the importance of demographic factors in designing targeted recruitment strategies for prehabilitation programmes.For image description, please refer to the figure legend and surrounding text. For image description, please refer to the figure legend and surrounding text.