Goal setting in cardiac rehabilitation.

Goal setting in cardiac rehabilitation (CR) is an axiomatic process that occurs in both transparent and covert ways. Unfortunately, the specific goals of patients, referring physicians, and CR programs themselves are often not discussed. More than a decade ago, Ades and colleagues documented that one of the most important reasons identified by patients for attending CR is physician recommendation and endorsement. In making a referral to CR, the presumed goal of referring physicians is to improve their patients’ cardiac outcomes. By endorsing these programs as beneficial, referring physicians also increase the likelihood of patient attendance and adherence to prescribed interventions. Although these physician goals are obvious and transparent to those familiar with chronic disease care programs such as CR, they are all too often not specifically communicated to patients. Similarly, patients sometimes fail to clearly identify or articulate their own goals for CR. The purpose of goal setting in CR is to enhance the patient’s health, clinical, educational, and behavioral outcomes. Common goals for patients include an improved sense of well-being, weight loss, and smoking cessation. Based on an initial assessment and cardiovascular risk stratification, referring physicians’ goals for patients usually include cardiovascular disease risk factor modification and participation in a regular exercise program. Cardiac rehabilitation program goals most often reflect the collective goals of patients and referring physicians delivered within a structured multidisciplinary clinical practice environment. Thus, documenting and aligning the goals of the patient, the referring physician, and the CR program would seem a desirable prerequisite to the efficacious delivery and utilization of CR services. In this issue of Journal of Cardiopulmonary Rehabilitation and Prevention, Farin and coworkers present a large cohort of patients participating in CR (n = 2,182) in which the results of a patient questionnaire (Indicators of Rehabilitation Status—IRES) were used to document the patient’s somatic, functional, and psychosocial status. The health status portion of the profile was then forwarded to referring physicians who selected 3 to 7 areas to be pursued as CR goals. The study methodology indicates that this was done in conjunction with the study patients, although specific documentation of this is not presented. In addition, the patient’s motivation to participate in CR was rated by the referring physician and 9 comorbidities were documented for occurrence and severity of disease. The authors used latent class cluster analysis to determine clusters of patients with similar goals. This type of statistical analysis is used to apportion research parameters into like groups when the number of groups or classes and their respective sizes is unknown. The actual effects of CR on IRES responses were determined by comparing the standardized response means at program admission, discharge, and 6 months postdischarge. The investigators found that the most common goals included a reduction in cardiovascular symptoms, modification of risk factors, improvement in mobility, increased physical activity, and a reduction in ‘‘vital exhaustion. ’’ It is interesting that patients chose reduction in cardiovascular symptoms as a major goal. At one time, most patients attending CR