To examine whether the dynamics of patient –HP (Health Professional) communication during cardiac rehabilitation referral predict subsequent cardiac rehabilitation (CR) attendance researchers conducted retrospective qualitative interviews with 31 patients eligible for CR, 12 of whom had attended a CR programme.

 They found four factors that were likely to increase CR attendance.  (1) Illness perceptions:  those attending CR  were more likely to view their illness as serious, controllable, and caused by internal factors such as lifestyle choices rather than external causes such as genetics. (2)  Physician minimising:  Non-attenders were more likely to perceive their physician as minimising their cardiac condition and believing that the patient would not benefit from CR.  Importantly, “the patients’ 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”.  (3) Ease of referral : Attenders were more likely to have had detailed follow-up post-discharge, such as phone calls from CR admin or close follow up with their family physician.  Many non-attenders stated that it was a lack of follow-up and of a single source with responsibility for referrals  that stopped them from enrolling.  (4) Timing of discussion:  Sedatives and post- ACS distress interfered with the patients’ ability to retain and recall information about CR.  This further underscores the importance of post-discharge follow-up.

Reviewer’s comment:  A small study from an under-researched area, worth noting for highlighting the importance of the communication process in cardiac referral. The findings are supported by a range of inter-disciplinary studies.  

To assess whether the inclusion of illustrations in the Dartmouth COOP (standard 1989 version) measure of functional health status (health-related quality of life or HR-QoL) affects the properties of the questionnaire researchers conducted a mail-out survey of the residents of French-speaking Vaud in Switzerland, randomly assigning participants to receive either the illustrated or non-illustrated version of the Dartmouth COOP (French translation).  Scales assessed included Physical Fitness,  Feelings, Daily Activities,  Social Activities, Pain, Change in Health, Overall Health, Social Support and Quality of Life. To assess convergent and concurrent validity all respondents received the SF-36  (French translation), an internationally well-validated HR-Qol measure (N=1250,  representing  a 54% response rate) and the MOS-HIV cognitive function scale.    

They  found that the presence illustrations did not substantially alter the psychometric properties of the Dartmouth COOP.  The illustrated charts had a slightly higher missing-response rate, notably the ‘Physical fitness’ scale (3.6% vs. 11.4%, p<.001) and illustrations did not improve response rate in those with lower education levels.  Missing data was not associated with cognitive function scores. The presence of illustrations also did not influence the distribution of scores, except for the “Feelings” chart, where those with pictureless charts chose more extreme options (p=0.04). Both versions of the Dartmouth COOP demonstrated concurrent and discriminant  validity against the SF-36.  

Reviewer’s Comment:  The finding that pictures in the Dartmouth COOP have no substantial influence on test scores in a normal population is congruent with previous research. As far as can be ascertained, this test of difference has not been carried out in a low-literacy group, which would be one of the populations where illustrations are perhaps most likely to have an impact.  

To test the accuracy of acute myocardial infarction patients’ assessment of future cardiac risk researchers assessed their personal risk-assessment  taken on the day of discharge from Auckland Hospital against standard risk indicators TIMI score and peak troponin T levels (N=79, median period of hospitalisation 7 days ).

They found no relationship between patients’ risk perceptions and thrombolysis in myocardial infarction risk (TIMI) scores or with peak troponin T level, indicating that patients have a very poor understanding of their risk of a future  cardiac event at the time of discharge.  Risk perceptions were not significantly associated with age or sex, nor higher in those who had a history of MI, a family history of CHD, diabetes or who smoked. Higher perceived risk was associated with perceived worse consequences of the MI,  lower beliefs about the benefit of treatment and higher anxiety.  The researchers state that  the accuracy of risk perception impacts on the patient’s ability to make informed choices about  healthcare.  Treatment adherence and risk-reduction behaviours are also implicated.  The researchers propose that patients’ poor risk assessment may come about through the process by which the patient forms ideas about risk and a possible lack of effectiveness in communicating risk to post-MI inpatients.

Reviewer’s comment: A well-designed New Zealand-based study that brings attention to the often- overlooked problem of inaccurate perceptions of risk amongst chronic illness populations.