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Home > RNJ > 2005 > July/August > Patient-Provider Communication Regarding Referral to Cardiac Rehabilitation

Patient-Provider Communication Regarding Referral to Cardiac Rehabilitation
Peter R. Mitoff, BSc • Marta Wesolowski, BSc • Beth L. Abramson, MD FRCP(C) FACC • Sherry L. Grace, PhD

This study investigated the dynamics of patient-provider communication in the cardiac rehabilitation (CR) referral process, to identify which aspects lead to CR participation. Semi-structured individual interviews were conducted with 31 patients eligible for CR. Questions probed the content and perception of the discussion that patients had with healthcare providers (HCP) regarding CR attendance. The interviews were audiotaped, transcribed, and imported into N6 software for grounded analyses. Key emerging themes were identified: illness perceptions; HCP encouragement; timing of discussion; and ease of referral. CR attenders were apt to self-advocate to ensure their enrollment in CR, whereas nonattenders were more likely to minimize the seriousness of their disease, and less likely to persevere to overcome obstacles in enrolling in a CR program. Surprisingly, the strength of the HCP referral did not influence the decision to attend CR as strongly when compared to the HCP’s ability to facilitate enrollment in a CR program.

Substantial health risks continue following coronary events and procedures (Law, Watt, & Wald, 2002), and cardiac rehabilitation (CR) improves subsequent prognosis (Brown, Taylor, Noorani, Stone, & Skidmore, 2003; Jolliffe et al., 2001; Taylor et al., 2004). Despite the proven health benefits associated with participation in CR, most research shows low rates of utilization, and inequality in access to CR (Bittner, Sanderson, Breland, & Green, 1999; Bunker & Goble, 2003; Grace et al., 2002; Pell, Pell, Morrison, Blatchford, & Dargie, 1996; Thomas et al., 1996).

Studies have cited patient factors, such as age, gender, ethnicity, and social support, and clinical characteristics, such as comorbidities and cardiovascular disease (CVD) risk factors, to explain low rates of participation in CR (Grace, Evindar, Kung, Scholey, & Stewart, 2004; Wyer, Joseph, & Earll, 2001). Healthcare system and provider factors also have been shown to play a role in the low rates of CR utilization (Grace, Evindar, Abramson, & Stewart, 2004). In particular, the strength of physician endorsement or encouragement has been shown to be integral to patient enrollment in CR (Barber, Stommel, Kroll, Holmes-Rovner, & McIntosh, 2001; King, Humen, Smith, Phan, & Teo, 2001; Lieberman, Meana, & Stewart, 1998). Rates of attendance were significantly higher for patients who perceived their physician to recommend strongly participation in CR (Ades, Waldmann, Polk, & Coflesky, 1992).

These findings raise questions about the nature of patient-provider referral discussions and how they may influence patient participation patterns. While previous research has examined patient factors and provider factors that may affect CR participation, to our knowledge, none has examined the interaction between the two. There is a need to identify how the referral discussion can be improved to increase participation in CR among eligible patients. The objective of this study was to qualitatively explore the dynamics of patient-provider communication in the CR referral process and its impact on patient decision making regarding participation in CR.

Methods

Design and Procedure

A qualitative design was used, and data were analyzed using Grounded Theory (Bartlett & Payne, 1997; Glaser & Strauss, 1967; Strauss & Corbin, 1990). Following informed consent, semistructured individual patient interviews were conducted by the first two authors by telephone. Interviews were approximately 30 minutes in length. The interviewer probed patient perceptions of communication with healthcare professionals (HCP), specifically regarding CR referral discussions. Probes were used to establish which benefits and drawbacks participants weighed in their decision-making process ().

Qualitative Analysis

The interviews were audiotaped, transcribed verbatim except for omitting information that would violate anonymity, and imported into the software package N6 (NUD*IST software series) by Qualitative Solutions & Research (QSR; QSR International Pty Ltd, 2003). The N6 software was used to facilitate coding and grounded analysis of the interviews, searching and retrieving of related segments and subthemes, and theorizing. Data transcription and analysis were concurrent with data collection, and involved inductively documenting emerging themes. After the first few interviews, open coding was performed, and the coauthors met regularly to discuss emergent themes. A codebook, with definitions of each code, was then produced and used for subsequent coding.

Concurrent data analysis facilitated generation of new questions for subsequent participants. Themes were coded and analyzed through grounded analyses (Bartlett & Payne, 1997; Glaser & Strauss, 1967; Strauss & Corbin, 1990). When all interviews were complete, the data were reindexed independently and together. Disagreements were resolved through consensus. Saturation was achieved.

Participants

Following approval from the research ethics board, acute coronary syndrome (ACS) patients were recruited from the general cardiology and cardiac surgery wards of an urban teaching hospital. All patients were eligible for CR based on the Canadian Association for Cardiac Rehabilitation guidelines (Stone et al., 2001) at the time of their hospitalization. The insurance status of the participants was not a consideration because universal coverage applied to all. Thirty-one participants were interviewed from four groups, as summarized in Table 1.

Following the interview, demographic data were obtained. With each patient’s consent, medical information, such as dates and reason for hospitalization, medications, and risk factors, such as diabetes, family history of heart disease, hypertension, and lipid levels, were obtained from patient charts. Participants were asked to self-report their marital and work status, highest level of education attained, and gross family income. These quantitative demographic data were entered into SPSS (SPSS for Windows, 2001). Descriptive statistics were computed to describe the nature of the sample, and differences between groups were analyzed using Kruskal-Wallis and chi-square tests as appropriate.

Results

Participant Characteristics

Participant characteristics are summarized in Table 2. A Kruskal-Wallis Test was used to compare all continuous variables, and chi-square tests were performed to compare categorical variables between the four groups. No significant differences between the groups were found for any variable except work status and length of time between the patient’s hospitalization and the study interview. Attenders (Group 3) had a significantly longer interval than others, which reflects the time involved in being referred to and enrolling in a CR program. Nonattenders (Group 2) were more likely to be working full-time.

Key Themes

Qualitative analysis of interviews resulted in the emergence of four key themes: illness perceptions; strength of HCP referral endorsement; timing of conversation; and ease of referral/enrollment.

Theme #1—Illness Perceptions

Patients differed in how they perceived their health condition, and these differences clearly affected their receptiveness to—and likely their perception of—CR referral discussions. Similar to Wyer et al. (2001b), illness perceptions outlined in Leventhal’s Self-Regulation Model (1997) served as a unifying theme reflecting participant responses. For instance, participants discussed the causes of their CVD, described the severity of or minimized their CVD, and outlined the perceived controllability of their illness as internal or external. These perceptions influenced their coping and appraisal processes.

Causal attribution. The perception of the factors (e.g., genetic, lifestyle) that lead to CVD differed among the groups. Attenders were more likely to perceive that aspects of their lifestyle contributed to the development of CVD. They also perceived that participating in a CR program could modify these risk factors.

3/M (group/gender): “Well, I had hypertension and cholesterol … It was just a matter of time when it caught up to me.”

Nonattenders did not attribute their health condition to any of their behaviors and tended to cite external causes, over which they have little control.

2/M: “My mother died from heart disease, so it was the genetic thing.”

Perceived severity. Attenders were more likely to perceive their illness as being very serious and see themselves at imminent risk of death without intervention. They were very eager to improve their health status by making changes to their lifestyle and participating in CR.

3/M: “So when someone says you’re having a mild heart attack, well, I took it pretty seriously in terms of, well, I may be doing pretty well, but there have to be other things I could be doing.”

3/M: “I know that I’m not going to get many more chances. So you know, it (CR) is something that I’ve got to do.”

Perceived control. With respect to perceived control, two groups were identified: patients with internal control, who saw their illness as something that they could change; and patients with external control, who viewed their illness as something that was beyond their control. Attenders tended to catastrophize, and viewed their recent hospitalization as giving them strong motivation to adopt a healthier lifestyle.

3/M: “If I want to die, if I want to have another heart attack, I go back to my normal life.”

3/M: ”It was then recognizing that I was very lucky this time, that I’d better smarten up.”

Nonattenders did not believe that they had control over their health problem, and tended to have lower expectations with respect to their overall recovery.

1/M: “They told me is that my body isn’t going to be as good as an 18 year old.”

Coping. Attenders were more likely to self-advocate to obtain information about participating in a CR program.

3/F: “That’s one of the hardest things. I’ve been asking for cardiac rehab information since before I went into surgery, and it’s been very difficult to come by. …I would have gone into a weight loss, exercise program before I had the surgery if I could have found one and if I could have found somebody that would have taken me.”

Nonattenders were more likely to minimize the need to obtain additional information about their recovery, and instead, relied more heavily on printed material they received from the hospital.

Theme #2—Strength of HCP referral endorsement

HCP factors, such as the ability to show concern or empathize, did not appear to affect the decision to attend CR. Of those patients who attended CR, there was a subset who had already made the decision to attend prior to their hospitalization or procedure and did not seem to require any encouragement from HCPs.

3/M: “I didn’t need any encouragement. I’m very disciplined myself, and I just figured if that’s needed, I have to do it, you know.”

3/M: “ Well, in fact, I didn’t need any encouragement when it came to rehab. I was pretty keen when Dr. X mentioned it to me. There wasn’t really much of a conversation about the merits of the rehab clinic. I think he said, ‘Are you interested in attending the rehab clinic,’ and I said ‘Yes,’ and that was pretty much the extent of it.”

Others weighted the recommendation from the physician so strongly that it overrode their capacity to make an informed personal decision.

3/M: “Well, I didn’t think that I had any decision in the matter at all. I was told that I was going.”

One participant related this concept to a sense of gratitude he felt to the physician.

3/M: “I didn’t have second thoughts about it because I took it for granted that they go to all this trouble of repairing the damage you’ve done through your life, I think that you should be obligated to do it [attend CR].”

Another subset considered the physician recommendation realistically, and weighed the benefits and drawbacks of attending in the context of their own values and expectations of their recovery.

3/M: “They said that after I recovered, I have to definitely do this because it would sort of help me to recover faster and not to have a relapse.”

Physician minimizing. The perceived HCP reaction to the severity of their health condition influenced the participants’ attitude towards their recovery. Nonattenders were more likely to perceive their physician as minimizing their cardiac condition and believing that the patient would not benefit from CR.

1/M: “The reason why they did it [triple bypass surgery] on me is I’ve never smoked in my life. And Dr. X said my heart is in very good shape.”

Diffusion of responsibility. The perception that the physician did not believe that CR was necessary was manifested in the diffusion of responsibility for enrolling patients in CR once they were discharged.

1/M: “Well not very much. They said, ‘Well you’ll be going to rehab’ or something, but I think they left that to my own family doctor.”

Theme #3—Timing of the Discussion

Because decisions to attend CR usually are made during a patient’s hospitalization, interventions at this time are crucial (McSweeney & Crane, 2001). Recognition of the need for an appropriate time for the conversation about attending CR is extremely important. Hospitalized participants who had family members with them at the time of the CR discussion were likely to recall that the topic was raised, but none of the details. Participants who were aware of CR before surgery and were interested in enrolling were more likely to recall that the CR conversation occurred at an inappropriate time, and made a point of revisiting the topic later with their HCP.

1/F: “You know, when they come in to talk to you, you’re still a little bit out of it. They should give you a little bit more time, and make sure that you’re with it when they come in to talk to you.”

1/F: “Well, I was totally out of it. I’m serious, I was totally out of it most of the time because I had had to have two surgeries within a day or two of each other. So, I have no memories at all of when I was in the hospital because seriously, as I say, I was really quite ill.”

Theme #4—Ease of Referral

Enrollment in CR programs is highly dependent on the mechanics and timing of the referral. One of the major barriers to enrolling was lack of follow-up with interested patients. Many participants mentioned that they were interested in enrolling in a CR program, but once they were discharged they did not know where to turn for information.

Attenders were more likely to have had more detailed follow-up postdischarge, such as phone calls from an administrative assistant at the CR clinic and close follow-up with a family physician.

3/M: “Yes, the secretary called me, and she set up the time. She called and confirmed the time and date, and I talked to her a couple of times on the phone. And that was good. And she said if I had any questions to please call her. So that was good.”

For many nonattenders—some who may have initially expressed an interest in attending CR—it was the lack of follow-up and the the lack of a single source with responsibility for referrals that prevented them from enrolling in a program.

Discussion

This is the first study to our knowledge to assess the dynamics of patient-HCP communication during CR referral. While there has been some research on patient decision making in CR enrollment (Wyer, Earll et al., 2001), literature on cardiac-related patient-provider communication generally has only focused on diagnostic testing and treatment decisions (Collins, Clark, Petersen, & Kressin, 2001; Seils, Friedman, & Schulman, 2001). Because physician endorsement is so integral to CR enrollment (Ades et al., 1992), this study examined the dynamics of patient-HCP communication during the referral process and how it affected patients’ decision to attend CR. Nurses also play an integral role in the recruitment and referral of patients to CR, both as sources of information and as patient advocates in the referral process.

Illness Perceptions

The way patients perceive their illness appeared to significantly influence their choice of recovery strategies. Importantly, the cognitive representation of their illness appeared to affect their perception of the communication they received regarding their recovery, and subsequently, their decision to attend CR (Leventhal et al., 1997; Petrie, Weinman, & Sharpe, 1996; Weinman, Petrie, Sharpe, & Walker, 2000). This finding supports findings by Wyer, Joseph, and Earl, et al. (2001). In the current study, CR attenders were more likely to have a realistic illness perception, recognize that certain aspects of their lifestyle contributed to the development of CVD, and feel as though they could influence their recovery by making changes to their lifestyle. Patients who were not interested in CR tended to downplay the severity of their health condition, blame external causes (such as genetics) for their poor health, and believe they had little control over their recovery. These results are consistent with findings presented by Petrie et al. (1996) showing that CR participation was related to the patient’s sense that the illness could be controlled. Taken together, the research highlights the need for physicians to understand patients’ cognitive misconceptions about their illness and recognize that these misrepresentations influence future health behaviors and healthcare utilization. HCPs should address the patient’s illness perceptions by probing into the perceived causes, severity, and sense of control and tailor the discussion about healthy lifestyle modification and CR participation accordingly (Petrie, Cameron, Ellis, Buick, & Weinman, 2002).

Strength of HCP Referral

Unfortunately, many participants in the current study were not referred to CR. When patients were referred, results suggest that the influence of physician recommendation differed. Few CR attenders considered their physician’s encouragement to be important in their decision to attend CR, but some made their decision to participate in CR based solely on their physician’s orders (but not physician encouragement per se). HCPs should refer all eligible patients to CR, but also should attempt to tailor advice based on patient’s receptiveness and focus follow-up efforts on those who may be less conscientious about following through on the advice.

Timing

The time at which patients are particularly receptive to health advice is immediately after a cardiac event or procedure. Patient teaching at this point is particularly important for patients with CVD, as lifestyle modification can diminish the risk of subsequent events (Taylor et al., 2004). Unfortunately, this also is a time when most patients’ emotional distress may interfere with their understanding and retention of information. Shuster et al. (1999) demonstrated that patients under the influence of sedatives were unable to remember whether health information was discussed with them. This finding is significant because with improved treatments and use of day revascularization procedures, the length of time patients are hospitalized is decreasing; thus the time to discuss interventions to prevent secondary events is limited. HCPs must take advantage of “teachable” moments, but also must be cognizant of the patient’s mental state to ensure maximal impact of the discussion. Providing patients with written material they can take home to read at a more appropriate time is a teaching strategy that can be used in the absence of proper inpatient teaching time. However, even after reading handouts and pamphlets describing CR, some patients may still be unaware of its benefits. Follow-up by CR staff appeared to be most effective in ensuring patient participation.

This study illustrated that a discussion about CR before hospitalization for surgery may be an effective strategy to overcome inappropriately timed teaching. If patients have a basic knowledge of CR programs from the start, they may be more attentive to the discussion while they are hospitalized and thus retain more of the information presented. These findings point out the need to develop new strategies for recruiting patients for CR, but also highlight the need for detailed follow-up posthospitalization.

Ease of Referral

Confusion and misinformation regarding enrollment in CR programs was extremely common, and has been found to result from a disorganized referral process and the diffusion of responsibility between potential referrers (Grace, Evindar, Abrahamson et al., 2004). When patients perceived that physicians had referral support and relationships with CR programs, the referral was more likely to occur. This ease of referral seemed to be more important to patients’ willingness to attend CR than was physician endorsement. Patient contact with nursing staff both on the wards and at the CR program positively affected patient enrollment. A potential strategy to facilitate participation in CR is to make follow-up calls to remind patients of CR, a finding supported in a study by DeBusk et al. (1994). System mechanisms, such as automatic referral, also may be useful to ensure the referral of all eligible patients (Grace, Evindar, Kung et al., 2004).

The main limitation of this study was the exclusion of physician perceptions of patient-provider CR discussions. Directions for future research include interviewing physicians regarding their perceptions of CR referral discussions, and observing and coding live or videotaped CR referral discussions.

Conclusions

CR programs have been shown to improve significantly the health of ACS patients, but they are drastically underutilized. By qualitatively examining the interface between patients and providers, this study has produced several recommendations that may lead to improved CR enrollment. Illness perceptions influenced participants’ perceptions of their communication with HCPs, with participants who perceived their ACS as serious, controllable, and caused by internal factors being more likely to adopt a coping strategy of attending CR when such a referral was discussed.

Some participants reported that physicians downplayed the importance of CR or diffused responsibility of referral to other HCPs. Ease of the referral and enrollment process, often facilitated by nurses, generally was more important in encouraging CR participation than the strength of the physician recommendation. Timing of the discussion was crucial: sedatives and the post-ACS distress interfered with patients’ ability to retain and recall information about CR. Procedures should be in place to ensure referral to a CR center is systematic for all eligible patients, and follow-up telephone contact would encourage participation when timing of the referral discussion was inappropriate.

Acknowledgments

The authors would like to thank Michelle Santos, Rita Tungcol, and the staff of the Cardiac Prevention Centre of St. Michael’s Hospital for their assistance in participant recruitment. We also acknowledge postdoctoral support from the Canadian Institutes of Health Research for Dr. S. Grace, which supported this work.

About the Authors

Peter R. Mitoff, BSc, is a medical student at the University of Toronto, Toronto, ON.

Marta Wesolowski, BSc, is a health psychology graduate from the University of Toronto.

Beth L. Abramson, MD FRCP(C) FACC, is the director of the Cardiac Prevention and Rehab Centre & Women’s Cardiovascular Health in the Division of Cardiology at St. Michael’s Hospital and an assistant professor of the Department of Medicine at University of Toronto.

Sherry L. Grace, PhD, is an affiliate scientist at the University Health Network Women’s Health Program and an assistant professor at York University, Toronto, ON.

Address correspondence to Sherry L. Grace, PhD, affiliated scientist, University Health Network Women’s Health Program, Toronto General Research Institute, Behavioural Sciences and Health Division, Assistant Professor, York University, Kinesiology and Health Science, 368 Bethune, 4700 Keele Street, Toronto, ON M3J 1P3, or via e-mail at sgrace@yorku.ca.

References

Ades, P. A., Waldmann, M. L., Polk, D. M., & Coflesky, J. T. (1992). Referral patterns and exercise response in the rehabilitation of female coronary patients aged greater than or equal to 62 years. American Journal of Cardiology, 69, 1422–1425.

Barber, K., Stommel, M., Kroll, J., Holmes-Rovner, M., & McIntosh, B. (2001). Cardiac rehabilitation for community-based patients with myocardial infarction: Factors predicting discharge recommendation and participation. Journal of Clinical Epidemiology, 54, 1025–1030.

Bartlett, D. & Payne, S. (1997). Grounded theory—its basis, rational and procedures. In G. McKensie, J. Powell, & R. Usher (Eds.). Understanding social research: Perspectives on methodology and practice. London: Falmer Press.

Bittner, V., Sanderson, B., Breland, J., & Green, D. (1999). Referral patterns to a University-based cardiac rehabilitation program. American Journal of Cardiology, 83, 252–255, A5.

Brown, A., Taylor, R., Noorani, H., Stone, J., & Skidmore, B. (2003). Exercise-based cardiac rehabilitation programs for coronary artery disease: A systematic clinical and economic review (Rep. No. Technology report number 34). Ottawa, ON: Canadian Coordinating Office for Health Technology Assessment.

Bunker, S. & Goble, A. (2003). Cardiac rehabilitation: Under-referral and underutilisation. Medical Journal of Australia, 179, 332–333.

Collins, T. C., Clark, J. A., Petersen, L. A., & Kressin, N. R. (2001). Racial differences in how patients perceive physician communication regarding cardiac testing. Medical Care, 40, 27–34.

DeBusk, R. F., Miller, N. H., Superko, H. R., Dennis, C. A., Thomas, R. J., Lew, H. T. et al. (1994). A case-management system for coronary risk factor modification after acute myocardial infarction. Annals of Internal Medicine, 120, 721–729.

Glaser, B. & Strauss, A. (1967). The discovery of grounded theory: Strategies for qualitative research. New York: Aldine de Gruyter.

Grace, S. L., Abbey, S., Shnek, Z., Irvine, J., Franche, R. L., & Stewart, D. (2002). Cardiac rehabilitation II: Referral and participation. General Hospital Psychiatry, 24, 127–134.

Grace, S. L., Evindar, A., Abramson, B., & Stewart, D. (2004). Physician management preferences for cardiac patients: Factors affecting referral to cardiac rehabilitation. Canadian Journal of Cardiology, 20, 1101–1107.

Grace, S. L., Evindar, A., Kung, T., Scholey, P., & Stewart, D. (2004). Automatic referral to cardiac rehabilitation. Medical Care, 42, 661–669.

Grace, S., Krepostman, S., Abramson, B., Scholey, P., Brooks, D., Jaglal, S. et al. Referral to and discharge from cardiac rehabilitation: Key informant views on continuity of care. Journal of Evaluation in Clinical Practice, (in press).

Jolliffe, J. A., Rees, K., Taylor, R. S., Thompson, D., Oldridge, N., & Ebrahim, S. (2001). Exercise-based rehabilitation for coronary heart disease. Cochrane Database Systematic Reviews.

King, K. M., Humen, D. P., Smith, H. L., Phan, C. L., & Teo, K. K. (2001). Predicting and explaining cardiac rehabilitation attendance. Canadian Journal of Cardiology, 17, 291–296.

Law, M. R., Watt, H. C., & Wald, N. J. (2002). The underlying risk of death after myocardial infarction in the absence of treatment. Archives of Internal Medicine, 162, 2405–2410.

Leventhal, H., Benyamini, Y., Brownlee, S., Diefenbach, M., LEventhal, E., Patrick-Miller, L. et al. (1997). Illness representations: Theoretical foundations. In K. J. Petrie & J. Weinman (Eds.). Perceptions of health and illness: Current research and applications (pp. 19–45). Amsterdam: Harwood Academic Publishers.

Lieberman, L., Meana, M., & Stewart, D. (1998). Cardiac rehabilitation: Gender differences in factors influencing participation. Journal of Women’s Health, 7, 717–723.

McSweeney, J. & Crane, P. (2001). An act of courage: Women’s decision making processes regarding outpatient cardiac rehabilitation attendance. Rehabilitation Nursing, 26, 132–140.

Pell, J., Pell, A., Morrison, C., Blatchford, O., & Dargie, H. (1996). Retrospective study of influence of deprivation on uptake of cardiac rehabilitation. British Medical Journal, 313, 267–268.

Petrie, K., Cameron, L., Ellis, C., Buick, D., & Weinman, J. (2002). Changing illness perceptions after myocardial infarction: An early intervention randomized controlled trial. Psychosomatic Medicine, 64, 580–586.

Petrie, K., Weinman, J., & Sharpe, N. (1996). Role of patients’ view of their illness in predicting return to work and functioning after myocardial infarction: Longitudinal study. British Medical Journal, 312, 1191–1194.

QSR International Pty. Ltd. (2003). NUD*IST (Version 6) [Computer software]. Melbourne, Australia: QSR International.

Schuster, M., McCauley, K., Kutalek, K., Hessen, S., Marchlinski, F., & Baessler, C. (1999). Learning retention in patients receiving midazolam during permanent pacemaker implantation. Journal of Cardiovascular Nursing, 14, 27–34.

Seils, D. M., Friedman, J. Y., & Schulman, K. A. (2001). Sex differences in the referral process for invasive cardiac procedures. Journal of the American Medical Women’s Association, 56, 151–154, 160.

SPSS for Windows (2001). Rel. 11.0.1. [Computer software]. Chicago: SPSS Inc.

Stone, J. A., Cyr, C., Friesen, M., Kennedy-Symonds, H., Stene, R., & Smilovitch, M. (2001). Canadian guidelines for cardiac rehabilitation and atherosclerotic heart disease prevention: A summary. Canadian Journal of Cardiology, 17 Suppl B, 3B–30B.

Strauss, A. & Corbin, J. (1990). Basics of qualitative research: Techniques and procedures for developing grounded theory. Thousand Oaks, CA: Sage Publications.

Taylor, R. S., Brown, A., Ebrahim, S., Jolliffe, J. A., Noorani, H., Rees, K. et al. (2004). Exercise-based rehabilitation for patients with coronary heart disease: Systematic review and meta-analysis of randomized controlled trials. American Journal of Medicine, 116, 682–692.

Thomas, R. J., Miller, N. H., Lamendola, C., Berra, K., Hedback, B., Durstine, J. L. et al. (1996). National survey on gender differences in cardiac rehabilitation programs: Patient characteristics and enrollment patterns. Journal of Cardiopulmonary Rehabilitation, 16, 402–412.

Weinman, J., Petrie, K. J., Sharpe, N., & Walker, S. (2000). Causal attributions in patients and spouses following a heart attack and subsequent lifstyle changes. British Journal of Health Psychology, 5, 263–273.

Wyer, S., Earll, L., Joseph, S., & Harrison, J. (2001). Deciding whether to attend a cardiac rehabilitation programme: An interpretative phenomenological analysis. Coronary Health Care, 5, 178-188.

Wyer, S., Joseph, S., & Earll, L. (2001). Predicting attendance at cardiac rehabilitation: A review and recommendations. Coronary Health Care, 5, 171-177.