The evidence for exercise interventions for cardiovascular risk reduction has been provided in the preceding pages. However, the extent to which exercise is effective may depend in large part on adherence.27 Burke and colleagues,27 in their comprehensive review on adherence, further concluded that non-adherence, whether it occurs early or late in the treatment course, is one mediator of clinical outcomes. Hence, specific attention is given to adherence here. Barriers to exercise are twofold: the lack of physicians' exercise prescription and patient non-adherence. Since physicians have had limited clear evidence on reduction of "hard events" until recently, coronary patients have not consistently received physician recommendations regarding exercise or have received suggestions that were too general to be beneficial. Cardiac rehabilitation programs are available for referral by the physician in virtually every major city throughout the USA.
Much of the information on adherence is derived from multifactorial cardiac rehabilitation studies that were designed not to evaluate or enhance adherence but to determine the effects of rehabilitation services on other outcomes. These studies demonstrate a progressive decline with longer treatment duration, with 20-25% of patients dropping out within the first 3 months, 40-50% between 6 and 12 months, and little further change occurring during the next 3-4 years.28 Although not confirmed, this trend for high early dropout rates may relate to several factors: cost of the exercise program, insurance reimbursement, convenience associated with program scheduling and facility location, return to work or family demands or simply poor motivation. Alternatively, patients may have mastered their skills and dropped out because of adequate self-care. There are differences in adherence with different modes of delivery of exercise services; what is known about adherence to cardiac rehabilitation is based largely on studies conducted when cardiac rehabilitation content, duration, delivery, and goals were considerably different from what they are at present.
Adherence may be enhanced if the physician understands the factors that affect exercise behavior and accordingly devises an exercise program that is tailored to the needs, preferences, and health status of a given person.29 Patients, in general, wish to be partners in healthcare decisions that affect them or their families and improving communication may be a potent adherence enhancing strategy. Attention to the interpersonal relationships between patient and provider can result in greater cooperation and greater patient and provider satisfaction, as well as improved adher-ence.30 For example, increased involvement by the patient in clinical decision making has been shown to improve patient satisfaction,27 patient adherence, and patient out-comes.28 In addition, limited evidence supports the importance of involving family members in promoting adherence to cardiac rehabilitation services.35 If the objective of patient counseling is to permit the patient to make informed decisions about treatments, then a patient may decide to disregard some or all professional advice. This suggests that what is inappropriate behavior from the clinician's perspective (that is, not following recommendations) may in fact be rational decision making from the patient's perspective. Many patients make the best decisions they can without considering the importance or even the implications of adherence and carry out their own risk-benefit analysis for each treatment they are offered.36
Other factors that may influence patient adherence include: emotional support; understanding the patient's (and family's) values, viewpoints, and preferences; integration of the intervention into the patient's lifestyle, as well as patient characteristics and demographic characteristics; aspects of treatment regimens including complexity, duration, and convenience (such as cost, facility location, time of day); and disease factors such as severity of symptoms, among others. Patient perceptions, as well as personal and social circumstances, determine patient decisions about following recommendations.
Adherence to exercise is in general lower than that for pharmacologic interventions; Burke et al27 suggest that the increased behavioral requirements for maintaining an exercise program may account for this. In general, adherence to the exercise program was better in the home exercise programs than the community-based rehabilitation programs.27 Most likely, the convenience factor can account for these improved rates of adherence.27
Improving patient-provider communication with more information about CVD and its treatments would likely result in more informed decision making by the patient; providing culturally sensitive care may also improve adherence and perhaps patient outcomes and is likely to improve patient and clinician satisfaction.37,38 Successful strategies for adherence include:
• Clear communication between patient (family) and provider.
• Emotional support and alleviation of fears and anxieties.
• Understandable and practical explanations about regimens that are compatible with the patient's values, preferences, and expressed needs, acknowledging the patient's social and cultural needs.
• Integration and coordination of patient care to provide continuity of care between transitions.6
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