How can we increase the participation of patients in cardiac rehabilitation programmes?

Cardiac rehabilitation has long been proved to be efficient in improving secondary prevention. It is highly recommended for cardiac patients, but remains underutilized worldwide, including in Europe.1,2 This could be considered as a loss of opportunity for both patients (a demonstrated reduction in cardiovascular mortality and morbidity) and health care systems (a demonstrated reduction in rates of re-hospitalization and, ultimately, improved cost-effectiveness). The potential causes of this underutilization include physicians’ lack of awareness of its benefits and various barriers at the patient level. The organization of this important therapeutic intervention probably shares some responsibility for this underutilization and should be questioned to better adapt to patients’ needs. Cardiac rehabilitation is a special and dedicated occasion on which to help patients become aware of their risk factors, to learn how to improve their long-term health and to start (or restart) a personalized, adjusted physical training programme. Such awareness and effort should be sustained by patients in the long term to capitalize the full health benefits. Two different organizations of cardiac rehabilitation have been proposed: residential (in dedicated rehabilitation centres) or home-based (supervised or unsupervised). European quality criteria have been set, which include the presence of cardiologists, nurses and physical activity professionals, with strong contributions from dieticians, psychologists, occupational therapists and social workers.3 A meta-analysis of 2172 patients has shown that home- and centre-based forms of cardiac rehabilitation seem to be equally effective in improving clinical and health-related quality of life and outcomes in low-risk patients after myocardial infarction, revascularization or in patients with heart failure.4 In this context, the conclusions of Harrison and Doherthy5 in their paper ‘Does the mode of delivery in routine cardiac rehabilitation have an association with cardiovascular risk factor outcomes?’ are encouraging. These researchers found similar benefits on cardiovascular risk factors when comparing two modes of ambulatory cardiac rehabilitation: supervised or facilitated self-management. Using data from the National Audit of Cardiac Rehabilitation in >80,000 patients, 15% of whom had facilitated self-management (either home- or web-based), they found comparable effects on decreased rates of obesity, smoking and hypertension after the programme. Gains in physical activity were 5% greater in the supervised mode. Data from the same register also showed similar results in exercise capacity, with a gain of 60 m in the six minute walking test (<1 MET),6 although these researchers acknowledged that various modes of delivering cardiac rehabilitation may reduce inequalities in accessing rehabilitation programmes. This mode of care seems to favour older patients, women and patients with socioeconomic deprivation. A shorter time delay in implementing this approach, a longer follow-up period, a more sustained investment by patients in their health and, presumably, a better integration of healthy behaviours into their daily life may improve the sustained benefit of these results in the long term. It should be noted, however, that the study population mainly consisted of patients with stable coronary disease and that there was some heterogeneity in the structure and delivery of the two modes of rehabilitation, corresponding to a specific national British model of care. These results contribute to fostering current reflections on scenarios of the delivery of cardiac rehabilitation to better adapt to patients’ needs, wills and possibilities, with a high quality of care according to European guidelines.3,7 To avoid a dilemma in choosing between high quality care for a few patients versus low quality care for all patients, and taking in account limited resources, we propose a more tailored organization of cardiac rehabilitation with the main objective of reaching targeted goals for each patient. A rigorous evaluation of the medical and psychosocial severity and complexity of each patient, together with a thorough knowledge of the means and resources adapted to various profiles, are, in this context, mandatory to optimize referral and participation, both at the patient and population level, so that the chosen solution is the most adapted and safe approach. Residential cardiac rehabilitation should be proposed for the most seriously ill patients, who require close monitoring, as early as possible in the evolution of their cardiac disease. Supervised ambulatory rehabilitation can be adapted to patients with specific surveillance or care requirements as a result of their cardiac disease, comorbidities, risk factors or psychological status. Home-based programmes should be favoured in stable and low-risk patients, or for patients in whom their distance from home, personal circumstances or work demands are incompatible with cardiac rehabilitation in dedicated centres. These patients should be volunteers and able to handle the physical sessions on their own. Depending on their progress, a patient may, of course, benefit from these different modes offered in succession according to the health care coverage available. The main objective is to help every patient to improve their health, exercise capacity and ability to care for themselves, and to sustain this gain over time, with appropriate guidance from specialized practitioners (e.g. physiotherapists and nurses), with the best efficiency and cost-effectiveness. Tools are currently available to facilitate rehabilitation programme settings and customization, including smartphone-based applications, assistance with prescribing and monitoring physical training,8 as well as tele-rehabilitation solutions, which will develop rapidly and offer increasingly fine-tuned solutions in the near future.9,10 However, whatever type of organization is proposed, personal contact between patients and the multidisciplinary cardiac rehabilitation team is required to tailor, encourage and maximize the results of preventive cardiology. Cardiologists should be aware of their limited ability to conduct efficient preventive strategies and should rely more on the expertise of the cardiac rehabilitation team to help their patients recover and sustain good health in the long term. The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author received no financial support for the research, authorship, and/or publication of this article.