Community health service center-based cardiac rehabilitation in patients with coronary heart disease: a prospective study

In this study, we investigated the effectiveness of CR program in the setting of CHSC. Among the eligible patients, 65.3% agreed to participate in the CHSC-based program and only 5.3% did withdraw themselves during follow up. CR patients displayed important improvement in the psychological and physical status between baseline and 6-months follow-up, including a significant decrease in HADS anxiety score and HADS depression score, marked increase in SF-12 PCS and SF-12 MCS scores as well as in exercise capacity as measured by 6MWT. These findings suggested that incorporation of CHSC-based delivery of CR program in the management of CHD patients was probably feasible.

Although the benefits of CR had been well established in patients with CHD, the reported proportions of participation in previous hospital or center-based CR programs were far less than optimal. According to data from the European Cardiac Rehabilitation Inventory Survey [24], fewer than half of eligible cardiovascular patients benefitted from CR in most European countries. In the United States, a health survey by the Behavioral Risk Factor Surveillance System (BRFSS) indicated that less than one third of eligible patients participated in CR programs [25]. Similarly, in a retrospective cohort study in Australia [26], Scott et al. reported that only 29% were referred to an outpatient cardiac rehabilitation (OCR) program, and fewer than a third of all referred patients actually attended the OCR programs. Compared to these reports regarding participation in hospital or center-based CR programs, our data showed a much higher proportion of participation (62.3%) and lower drop out (5.3%), suggesting that CR program might be more attractive to CHD patients in the setting of CHSC compared to hospitals. These perceived benefits of CHSC-based CR programs might include some well-known advantages of community-based programs like the close proximity, perceived convenience and easy access, as indicated by the previous studies [14, 27] and they could possibly explain our results to some extent. Potential explanations might also include the fact that some disadvantaged subgroups such as older patients, those having multiple-complications or with lower educations were more likely to prefer the CHSC-based programs as opposed to the hospital-based ones for simple logistic reasons.

Psychological intervention, as indicated previously [28], was pivotal for any successful rehabilitation programs, as the burden of psychological problems like anxiety and depression, were found to be considerably high among CHD patients [29], and these problems were found to be negatively associated with motivation, adherence, maintenance and prognosis [29]. A variety of psychological intervention techniques, including stress management [30], relaxation and meditation practices [31], were applied in previous CR programs and shown favorable effects in terms of reduction in anxiety and depression scores as well as HRQoL score. In the present study, psychological intervention was also one of the key components of rehabilitation program and might be the explanation for the substantial changes of HADS anxiety and depression scores as well as SF-12 PCS and SF-12 MCS scores. However, given the study setting, we anticipated, some further reasons underlying the results might also be important and therefore were needed to be pointed out. In this CHSC-based CR program, patients could receive education and guidance from the same team members who were easily available locally at the time of requirement. Moreover, the multidisciplinary management team could bridge the gap between primary and tertiary care thus minimizing the worries of the patients regarding availability of treatment at the time of emergency. The appreciation of these advantages could have helped the patients to gain confidence on health service providers, to participate in CHSC based programs actively and thus to enhance their health related quality of life.

Previous studies consistently confirmed the role of CR in improving the exercise capability of CHD patients [4, 32]. Results from the current study also showed a significant increase of 57.42 m in the distance walked by the patients participating in the CR program, suggesting that the CHSC-based CR program could also improve the capacity of physical exercise among the CHD patients. In addition, the results revealed a marked reduction of several modifying risk factors like smoking and improvements in adherence to medication among patients in both groups. However, there was no significant difference between two groups at 6 month regarding these. Potential explanations might include the fact that CHD patients, as the core population for chronic disease management in CHSC, were well educated on these issues and thus the potential for differences in these factors diminished across the groups.

In the present study, patients were recruited and allocated in a non-random way. The potential healthy volunteer effect might have resulted in an overestimation of the actual effects of CHSC-based CR program. Although randomized approach would have been ideal, it was not used in this study, considering the difficulty of randomization of patients in the setting of CHSCs. The patients, practitioners and community nurses were residing in the same community for years. Prior acquaintance and familiarity would result in inevitable crossing over between study arms through regular communication and mutual learning between participants and nonparticipants about skills on CR, which in all possibilities would have reduced the exposure contrast between the study groups. On the other hand, by virtue of recruiting all intervention recipients from the same CHSC, it was easier for the patients and their caregivers to get involved in mutual communication and group discussion. These events cumulatively facilitated better delivery of information regarding potential benefits of CR and enhanced their motivation to participate, which was just what we expected and might well be considered as one of the main advantages of CHSC-based CR programs. Unlike other studies, we did not set a hospital-based CR program as the control for comparison. So it remained unclear whether the present program could achieve benefits equivalent or more than the hospital-based CR program. However, in China, owing to the lack of prioritization and consequent underinvestment, CR services were mainly provided by university-based centers or a few private hospitals. Patients recruited in these programs were highly selective and inappropriate to be served as the control. [33]. But we expect, with passage of time, as CR programs will become more common, future studies will have the opportunity to provide further evidences regarding the efficacy of CHSC-based CR program with better comparison.