This study has for the first time assessed CR barriers in a sample of HF patients solely. This assessment was undertaken in a low-resource context of insufficient CR capacity, referral and coverage. Results revealed relatively high barriers compared to other cohorts (even considering there were not enrollees), chief among them being lack of energy likely due to HF, that they already exercise (potentially these participants went on to secure a physiotherapist to work with), and lack of awareness of CR. Despite approximately half of patients working with a physiotherapist, about 80% of patients were insufficiently active 30 and 90 days post-discharge. Consistent with previous research, readmission rates were very high, and length of stays long.(20)
IPAQ results suggests where HF patients were exercising, they had brief structured bouts about twice per week, but practically no lifestyle activity and high sedentary time. This is consistent with the low activity in HF samples, (30) and draws attention to the loss of patients’ perception of their health. Other research has suggested that people can be less active on days they have structured exercise. (31) Other HF self-management behaviors were also less than optimal such as daily weighing, again highlighting the need for CR where comprehensive educational process and lifestyle change support is proffered, such as for medication adherence. And more importantly, it makes the patient role of their self-care.
These results underscore the need for CR, particularly in low-resource settings.
We found a high mean score of barriers for HF patients to start the CR program after hospital discharge, even higher than other studies carried out in the same country. (16) Besides that, most patients were in preparation stage (readiness scale) to participate in CR, thus showing that this is the opportune moment to intervene and encourage the patient to engage in the program and highlighting the need to think about actions to maintain the motivation of patients over time. Finally, CR could mitigate these high readmissions rates, and also shorten length of stay.(32)
With only 1 patient accessing CR, the implications of this study are chiefly that systematic CR referral is needed in this setting, (33, 34) in conjunction with advocacy for CR coverage (35) to augment capacity (36) and enable patient participation without financial hardship. (37) We believe that directed educational interventions should be implemented during the hospitalization period, increasing their knowledge about their disease and management, as well as the responsibility for self-care. Suggesting supervised activities can help reduce one of the biggest problems found in this population, hospital readmissions. Controlled studies comparing supervised and unsupervised interventions, as well as their cost-effectiveness, are needed to confirm these findings.
Caution is warranted in interpreting these results. First, with regard to generalizability, these data were collected at a single center. Moreover, the patient profile may not represent the population of patients from non-private hospitals and hence of diverse socioeconomic backgrounds. The proportion of women in the sample was low, considering the burden of HF in that population. Moreover, CR barriers were assessed in a setting where there is little CR coverage. Many other South American countries have two-tier health systems, but the generalizability of these findings outside Brazil is not known.
There are several potential limitations related to measurement. Readmissions or CR enrolment were not verified using medical charts. Furthermore, there could be socially-desirable responding. For example, we also asked participants to self-report daily weighs and exercise. In addition, these assessments were global, so did not capture for instance some missed days, or adherence to medications specifically. Tobacco cessation and diet were not considered. Finally, due to the nature of the design, causal conclusions cannot be drawn.
We can conclude that HF patients have particularly high barriers to CR. Despite half of patients accessing physiotherapy based on coverage, HF patients were insufficiently active and highly sedentary. Systematic CR referral is needed in low-resource settings as well, so patients can not only have formal exercise training but also support to self-manage their condition, thus mitigating the very high readmission rates and long lengths of stay in this setting.