Saudi Cultural Missions Theses & Dissertations
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Item Restricted Barriers and Facilitators to Uptake of Cardiac Rehabilitation Following Percutaneous Coronary Intervention in Saudi Arabia(Saudi Digital Library, 2025-06-17) Almoghairi, Ahmed Mohammed A; Duff, Jed; O'Brien, JaneBackground Cardiovascular disease remains the foremost cause of mortality and a major contributor to morbidity globally, with coronary heart disease being particularly prevalent across populations. In the Kingdom of Saudi Arabia, cardiovascular disease accounts for approximately 45% of all deaths, with coronary diseases as the leading cause. Treatment for coronary diseases typically involves lifestyle modifications and medications to manage symptoms. However, when these are insufficient, percutaneous coronary intervention is employed to restore blood flow to the heart muscle. Even with these interventions, patients who do not alter their lifestyle post procedure remain at high risk for recurrent cardiac events and rehospitalisation imposing tremendous burdens on health systems. Thus, effective post-discharge care is crucial, particularly through cardiac rehabilitation programs. Despite their proven benefits and cost-effectiveness, these programs are globally underutilised due to multiple barriers at the patient, clinician, and healthcare system levels. In the Kingdom of Saudi Arabia, the paucity of research further limits understanding of adherence to secondary prevention measures and barriers to the uptake of cardiac rehabilitation among patients with coronary heart disease. This backdrop sets the stage for this study to explore the country’s understudied areas of cardiology care. Aim This research project aims to identify the difficulties and opportunities in providing cardiac rehabilitation services to patients with coronary heart disease following percutaneous coronary intervention in cardiac centres across Saudi Arabia. Methods This PhD thesis employed a multiphase methodological approach beginning with conducting a systematic scoping review using the Joanna Briggs Institute methodology to identify effective interventions to promote uptake of cardiac rehabilitation (objective 1). This review systematically searched seven online databases for English-language articles published in the last decade, extending until October 2024. Reviewers independently assessed eligibility, and data extraction followed the Template for Intervention Description and Replication and PRISMA guidelines. The subsequent phase utilised a cross-sectional survey employing computer-assisted telephone interviews to collect insights from Saudi patients with coronary disease who underwent revascularisation at the Prince Sultan Cardiac Center in Riyadh and were clinically eligible for cardiac rehabilitation (objective 2). The study collected data from patients one-month post-procedure and aimed to evaluate their adherence to secondary prevention behaviours and identify their challenges when enrolling in cardiac rehabilitation programs. The further phase involved an observational cross-sectional study that distributed an online survey to cardiologists and cardiology fellows across Saudi Arabia (objective 3). This questionnaire was disseminated during the Saudi Heart Association's annual conference in October 2023 and extended through various social media platforms. It assessed participants' self-reported knowledge, attitudes, and practices regarding cardiac rehabilitation and determined impediments to their referral practice. Participants were required to have a minimum of six months of clinical experience managing patients with coronary disease post-percutaneous coronary intervention. The final phase involved a qualitative study using an interpretive descriptive approach, featuring recorded semi-structured interviews with key decision-makers in cardiology care within Saudi Arabia (objective 4). It aimed to identify the health system level challenges and potential enablers for the uptake of cardiac rehabilitation in the country. The analysis of these interviews was structured around the updated Consolidated Framework for Implementation Research, which guided the identification of themes. Results The scoping review highlighted that home-based cardiac rehabilitation internationally led to higher patient engagement and adherence to secondary prevention post interventions and effectively overcame several challenges at patient and health system levels. The observational study in phase two included 104 post-procedures Saudi patients with coronary diseases and showed a concerning prevalence of cardiac risk factors and significantly low adherence to secondary prevention measures, with only 10.6% being referred to cardiac rehabilitation. The most-cited barriers to enrolment in cardiac rehabilitation by included patients were inadequate program endorsement by cardiologists, absence of communication with cardiac rehabilitation care providers, and geographic distance to the service site. The subsequent survey involving 106 cardiologists revealed that, while they were knowledgeable about cardiac rehabilitation services and their benefits for patients following interventions, there was notable uncertainty regarding the quality of local services. This ambiguity, combined with unclear patient pathways and the limited availability of programs in practice areas, contributed to the reluctance of cardiac specialists to recommend these programs to their eligible patients. The last research examination interviewed nine policymakers and revealed systemic issues such as insufficient facilities, lack of cardiologists’ knowledge about cardiac rehabilitation, and shortage of qualified staff. This thesis recommends strategic improvements for consideration by the national healthcare system in Saudi Arabia to facilitate broader and successful implementation of cardiac rehabilitation programs. These reforms incorporate revising patient discharge protocols, enhancing the education and training of clinicians on cardiac rehabilitation, implementing effective referral systems, and ensuring equitable expansion of services across all regions. It also advocates for the adoption of innovative models of cardiac rehabilitation such as home-based and telerehabilitation programs, the development of supportive cardiac rehabilitation policies and regulations, and the engagement of higher authorities to drive these transformative changes. Conclusion This PhD thesis thoroughly examines effective interventions for cardiac rehabilitation delivery and identifies home-based models as effective alternatives to the underutilised traditional programs. It reveals critical findings pinpointing low adherence to secondary prevention measures and enrolment in cardiac rehabilitation programs among Saudi patients with coronary heart disease following percutaneous coronary intervention, primarily due to inadequate healthcare professional support and limited program accessibility. It indicates a significant knowledge practice gap in cardiologists within Saudi Arabia which affected the nationwide endorsement of cardiac rehabilitation. It uncovered systemic challenges necessitating urgent national reforms to boost program capacity, enhance healthcare professionals’ understanding of cardiac rehabilitation, and attract qualified personnel to the services. The integrated insights from the conducted studies significantly improve the understanding of cardiac rehabilitation utilisation within Saudi Arabia and similar contexts, laying a foundation for ongoing research to design, refine, test and implement innovative cardiac rehabilitation models, and encourage more international collaborative efforts for comparative studies of these innovative models.19 0