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Heart, Lung and Circulation

Validation of the Physician Attitudes toward Cardiac Rehabilitation and Referral (PACRR) Scale

  • Gabriela Lima de Melo Ghisi
    Affiliations
    Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute (TRI), University Health Network (UHN), University of Toronto, Toronto, Canada

    School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Canada
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  • Sherry L. Grace
    Correspondence
    Corresponding author at: York University, Bethune 368, 4700 Keele Street, Toronto, Ontario, M3J 1P3, Canada. Tel: (416) 736-2100 x. 22364; Fax: (416) 736-5774.
    Affiliations
    Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute (TRI), University Health Network (UHN), University of Toronto, Toronto, Canada

    School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Canada
    Search for articles by this author

      Background

      One of the key drivers of cardiac rehabilitation under-utilisation is physician referral failure. The Physician Attitudes toward Cardiac Rehabilitation & Referral (PACRR) scale was developed to understand factors that impact their referral practices, so they can be ultimately reliably be identified and mitigated. The objectives of this study were to assess the reliability, factor structure, and validity of the PACRR.

      Methods

      Data were retrospectively analysed from three cohorts administering the PACRR, a 19-item scale. The first cohort consisted of 185 cardiologists or family physicians; the second of 51 of the same, and the third of 97 cardiologists. Internal consistency was assessed by Cronbach's alpha, factor structure by confirmatory factor analysis, construct validity by significant differences in PACRR scores by physician specialty, and criterion validity by testing for significant differences in PACRR scores by referral.

      Results

      Cronbach’s alpha was 0.81, 0.71, and 0.69 in each of the three cohorts, respectively. Factor analysis in the latter two cohorts revealed four factors: referral norms, preference to manage patients independently of cardiac rehabilitation (CR), perceptions of program quality, and referral processes. Construct validity was established in the first cohort, as significant differences in PACRR scores were found by physician specialty. Criterion validity was supported by significant differences in mean scores by referral in each cohort. Physicians rated bad experiences with CR programs, poor program quality, skepticism of CR benefits and lack of familiarity with local programs as the most important factors that affected their referral to CR.

      Conclusions

      In conclusion, the PACRR scale was demonstrated to have good reliability and validity.

      Keywords

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      References

        • Roth G.A.
        • Johson C.
        • Abajobir A.
        • Abd-Allah F.
        • Abera S.F.
        • Abyu G.
        • et al.
        Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015.
        J Am Coll Cardiol. 2017; 70: 1-25
      1. World Health Organization (WHO). Global health observatory data repository; 2016. http://apps.who.int/gho/data/node.main.

        • Hamm L.F.
        • Sanderson B.K.
        • Ades P.A.
        • Berra K.
        • Kaminsky L.A.
        • Roitman J.L.
        • et al.
        Core competencies for cardiac rehabilitation/secondary prevention professionals: 2010 update: position statement of the American association of cardiovascular and pulmonary rehabilitation.
        J Cardiopulm Rehabil Prev. 2011; 31: 2-10
        • Clark A.M.
        • Haykowsky M.
        • Kryworuchko J.
        • MacClure T.
        • Scott J.
        • DesMeules M.
        • et al.
        A meta-analysis of randomized control trials of home-based secondary prevention programs for coronary artery disease.
        Eur J Cardiovasc Prev Rehabil. 2010; 17: 261-270
        • Davies E.
        • Moxham T.I.
        • Rees K.
        • Singh S.
        • Coats A.J.
        • Ebrahim S.
        • et al.
        Exercise training for systolic heart failure: cochrane systematic review and meta-analysis.
        Eur J Heart Fail. 2010; 12: 706-715
        • Anderson L.
        • Oldridge N.
        • Thompson D.R.
        • Zwisler A.D.
        • Rees K.
        • Martin N.
        • et al.
        Exercise-based cardiac rehabilitation for coronary heart disease.
        J Am Coll Cardiol. 2016; 67: 1-12
        • Wood D.A.
        • Kotseva K.
        • Connolly S.
        • Jennings C.
        • Mead A.
        • Jones J.
        • et al.
        Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial.
        Lancet. 2008; 371: 1999-2012
        • Smith Jr, S.C.
        • Benjamin E.J.
        • Bonow R.O.
        • Braun L.T.
        • Creager M.A.
        • Franklin B.A.
        • et al.
        AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American heart sssociation and American college of cardiology foundation.
        Circulation. 2011; 124: 2458-2473
        • Balady G.J.
        • Ades P.A.
        • Bittner V.A.
        • Franklin B.A.
        • Gordon N.F.
        • Thomas R.J.
        • et al.
        Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American heart association.
        Circulation. 2011; 124: 2951-2960
        • Corra U.
        • Piepoli M.F.
        • Carre F.
        • Heuschmann P.
        • Hoffmann U.
        • Verschuren M.
        • et al.
        Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the cardiac rehabilitation section of the European association of cardiovascular prevention and rehabilitation.
        Eur Heart J. 2010; 31: 1967-1974
        • Piepoli M.F.
        • Corra U.
        • Benzer W.
        • Bjarnason-Wehrens B.
        • Dendale P.
        • Gaita D.
        • et al.
        Secondary prevention through cardiac rehabilitation: from knowledge to implementation: a position paper from the cardiac rehabilitation section of the European association of cardiovascular prevention and rehabilitation.
        Eur J Cardiovasc Prev Rehabil. 2010; 17: 1-17
        • Grace S.L.
        • Turk-Adawi K.
        • Contractor A.
        • Atrey A.
        • Campbell N.
        • Derman W.
        • et al.
        Cardiac rehabilitation delivery model for low-resource settings: an international council of cardiovascular prevention and rehabilitation consensus statement.
        Prog Cardiovasc Dis. 2016; 59: 303-322
        • Chan P.S.
        • Oetgen W.J.
        • Buchanan D.
        • Mitchell K.
        • Fiocchi F.F.
        • Tang F.
        • et al.
        Cardiac performance measure compliance in outpatients: the American college of cardiology and national cardiovascular data registry’s pinnacle (practice innovation and clinical excellence) program.
        J Am Coll Cardiol. 2010; 56: 8-14
        • Ghisi G.L.
        • Polyzotis P.
        • Oh P.
        • Pakosh M.
        • Grace S.L.
        Physician factors affecting cardiac rehabilitation referral and patient enrolment: a systematic review.
        Clin Cardiol. 2013; 36: 323-335
        • Beckstead J.W.
        • Pezzo M.V.
        • Beckie T.M.
        • Shanraki F.
        • Kentner A.C.
        • Grace S.L.
        Physicians’ Tacit and stated policies for determining patient benefit and referral to cardiac rehabilitation.
        Med Decis Making. 2014; 34: 63-74
        • Grace S.L.
        • Evindar A.
        • Abramson B.L.
        • Stewart D.E.
        Physician management preferences for cardiac patients: factors affecting referral to cardiac rehabilitation.
        Can J Cardiol. 2004; 20: 1101-1107
        • Grace S.L.
        • Grewal K.
        • Stewart D.E.
        Factors affecting cardiac rehabilitation referral by physician specialty.
        J Cardiopulm Rehabil Prev. 2008; 28: 248-252
        • Grace S.L.
        • Gravely-Witte S.
        • Brual J.
        • Monette G.
        • Suskin N.
        • Higginson L.
        • et al.
        Contribution of patient and physician factors to CR referral: a prospective multi-level study.
        Nat Clin Pract Cardiovasc Med. 2008; 5: 653-662
        • Ades P.A.
        • Waldmann M.L.
        • McCann W.J.
        • Weaver S.O.
        Predictors of cardiac rehabilitation participation in older coronary patients.
        Arch Intern Med. 1992; 152: 1033-1035
        • Tsui C.K.
        • Shanmugasegaram S.
        • Jamnik V.
        • Wu G.
        • Grace S.L.
        Variation in patient perceptions of healthcare provider endorsement of cardiac rehabilitation.
        J Cardiopulm Rehabil Prev. 2012; 32: 192-197
        • Grace S.L.
        • Gravely-Witte S.
        • Brual J.
        • Monette G.
        • Suskin N.
        • Higginson L.
        • et al.
        Contribution of patient and physician factors to cardiac rehabilitation enrollment: a prospective multilevel study.
        Eur J Cardiovasc Prev Rehabil. 2008; 15: 548-556
        • Dillman D.A.
        Mail and Internet Surveys; The Tailored Design Method.
        John Wiley, New York2000
        • Andersen R.M.
        National health surveys and the behavioral model of health services use.
        Med Care. 2008; 46: 647-653
        • IBM Corp
        IBM SPSS Statistics for Windows, Version 24.0.
        IBM Corp, Armonk, NY2016
        • Mokkink L.B.
        • Terwee C.B.
        • Patrick D.L.
        • Alonso J.
        • Stratford P.W.
        • Knol D.L.
        • et al.
        The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study.
        Qual Life Res. 2010; 19: 539-549
        • Kaiser H.F.
        The application of electronic computers to factor analysis.
        Educ Psychol Meas. 1960; 20: 141-151
        • Hair J.F.
        • Anderson R.E.
        Multivariate data analysis.
        Prentice Hall, New Jersey1998
        • Sarikaya S.
        • Sonel Tur B.
        • Kurtais Y.
        • Uzumcugil Karapolat H.
        • Soyupek F.
        • Hafiz M.
        • et al.
        The awareness of physicians and allied health professionals about cardiopulmonary rehabilitation: a cross-sectional survey study.
        Turk Fiz Tip Rehab D. 2014; 60: S19-S24
        • Suter P.M.
        • Suter W.N.
        • Perkins M.K.
        • Bona S.L.
        • Kendrick P.A.
        Cardiac rehabilitation survey: maintenance of lifestyle changes and perception of program value.
        Rehabil Nurs. 1996; 21: 192-195
        • Vogel H.
        • Faller H.
        • Zimmermann R.
        • Holderied A.
        Physicians’ attitudes regarding medical rehabilitation after acute care in myocardial infarction patients: an empirical investigation in Northern Bavaria.
        Prev Rehabil. 1997; 9: 139-146
        • Bartholomew Eldridge L.K.
        • Markham C.M.
        • Ruiter R.A.C.
        • Kok G.
        • Parcel G.S.
        • et al.
        Planning health promotion programs; an Intervention Mapping approach.
        4th Edition. Jossey-Bass, San Francisco, CA2016