在资源匮乏的环境下，从医疗保健管理人员、康复服务提供者和心脏病患者的角度来看，心脏康复服务提供面临的障碍。
Barriers to cardiac rehabilitation delivery in a low-resource setting from the perspective of healthcare administrators, rehabilitation providers, and cardiac patients.
机构信息
Rehabilitation Science Graduate Program, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
Cardiovascular Prevention and Rehabilitation Program, University Health Network, University of Toronto, Toronto, Canada.
出版信息
BMC Health Serv Res. 2019 Sep 2;19(1):615. doi: 10.1186/s12913-019-4463-9.
BACKGROUND
Despite clinical practice guideline recommendations that cardiovascular disease patients participate, cardiac rehabilitation (CR) programs are highly unavailable and underutilized. This is particularly true in low-resource settings, where the epidemic is at its' worst. The reasons are complex, and include health system, program and patient-level barriers. This is the first study to assess barriers at all these levels concurrently, and to do so in a low-resource setting.
METHODS
In this cross-sectional study, data from three cohorts (healthcare administrators, CR coordinators and patients) were triangulated. Healthcare administrators from all institutions offering cardiac services, and providers from all CR programs in public and private institutions of Minas Gerais state, Brazil were invited to complete a questionnaire. Patients from a random subsample of 12 outpatient cardiac clinics and 11 CR programs in these institutions completed the CR Barriers Scale.
RESULTS
Thirty-two (35.2%) healthcare administrators, 16 (28.6%) CR providers and 805 cardiac patients (305 [37.9%] attending CR) consented to participate. Administrators recognized the importance of CR, but also the lack of resources to deliver it; CR providers noted referral is lacking. Patients who were not enrolled in CR reported significantly greater barriers related to comorbidities/functional status, perceived need, personal/family issues and access than enrollees, and enrollees reported travel/work conflicts as greater barriers than non-enrollees (all p < 0.01).
CONCLUSIONS
The inter-relationship among barriers at each level is evident; without resources to offer more programs, there are no programs to which physicians can refer (and hence inform and encourage patients to attend), and patients will continue to have barriers related to distance, cost and transport. Advocacy for services is needed.
背景
尽管临床实践指南建议心血管疾病患者参与，但心脏康复（CR）计划的可及性和使用率仍然很低。在资源匮乏的环境中，这种情况尤其如此，因为疾病在这里最为严重。原因很复杂，包括卫生系统、计划和患者层面的障碍。这是第一项在资源匮乏的环境中同时评估所有这些层面障碍的研究。
方法
在这项横断面研究中，对来自三个队列（医疗机构管理人员、CR 协调员和患者）的数据进行了三角测量。邀请来自巴西米纳斯吉拉斯州所有提供心脏服务的机构的医疗机构管理人员，以及来自公立和私立机构所有 CR 项目的提供者完成一份问卷。从这些机构的 12 个门诊心脏诊所和 11 个 CR 项目中随机抽取的一部分患者完成了 CR 障碍量表。
结果
32 名（35.2%）医疗机构管理人员、16 名（28.6%）CR 提供者和 805 名（305[37.9%]正在参加 CR）心脏患者同意参与。管理人员认识到 CR 的重要性，但也认识到提供 CR 的资源不足；CR 提供者指出转诊缺乏。未参加 CR 的患者报告的与合并症/功能状态、感知需求、个人/家庭问题和获得相关的障碍明显大于参加者，而参加者报告的旅行/工作冲突的障碍大于未参加者（均 p<0.01）。
结论
各层面障碍之间的相互关系是明显的；如果没有资源来提供更多的项目，就没有医生可以转诊（从而告知并鼓励患者参加）的项目，患者将继续面临与距离、成本和交通相关的障碍。需要倡导服务。
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