Improving the uptake of cardiac rehabilitation in invited patients: a multi-method evaluation

Cardiac rehabilitation (CR) can reduce mortality and morbidity through assisting patients in regaining physical and psychosocial well-being. CR is effective yet uptake rates are 44%. Of non-attenders, 30% expressed a ‘lack of interest’; the focus of this thesis’ question ‘What strategy would improve uptake of CR in invited patients.’ A sequential, multi-method approach was used. Literature reviews, assessing strategies to increase CR uptake and participation in other health services, found similar intervention designs, such as peers or health behaviour theory-based (HBT). An e-survey explored invitation strategies in CR practice and confirmed letters are used and low-cost. An advancement of theory-based letters is valuable but little is known about the operationalisation of HBT. Telephone interviews were conducted to explore the latter through patients’ viewpoints. A quasi-experiment evaluated the amended letters. One review found six RCTs testing peer support, professional support (or combined) and letters, the latter two increased attendance. Twenty-three reviews on strategies promoting participation support access-enhancing methods, organisational changes, letters and calls. 190 CRPs indicated that multiple invitation strategies including in- hospital (70%), telephone (70%), letters (50%) are used; variations exist. Feasibility considerations supported the development of existing HBT letters. Interviews revealed a preference for less authoritative content outlining positive effects. Of 6 sites, with different organisational structure, 1 increased CR uptake using the new letter. The amended theory-based letter had limited impact in CR uptake perhaps due to extrinsic factors, the letter itself or methodological issues. CR is a fragmented service and results highlight the importance of context-sensitive policies.