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.1 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.2

The purpose of goal setting in CR is to enhance the patient's health, clinical, educational, and behavioral outcomes.3,4 Common goals for patients include an improved sense of well-being, weight loss, and smoking cessation.5 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.6 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 coworkers7 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 experienced angina during their exercise sessions. With the current emphasis on routine myocardial revascularization and the use of multiple classes of medications to prevent or suppress ischemia, most patients rarely experience exercise-induced angina. Indeed, the few that do frequently now end up in emergency departments.8

With respect to the effect of CR on goals, the authors found medium-high effects for the somatic and psychosocial IRES dimensions at program discharge. However, at 6 months postdischarge, these effects were diminished compared with increases in risk factors and restrictions in everyday living. Three clusters of patients with similar CR goals were identified: cluster 1-undefined, cluster 2-patients interested in risk factor modification, and cluster 3-patients with multiple comorbidities who primarily wished to improve mobility and physical activity. Patients within the risk factor cluster were more likely to have experienced a myocardial infarction, whereas those in the multiple comorbidities group were more likely to be older, to have set a greater number of treatment goals, and to have undergone heart valve surgery. Somewhat surprisingly, however, goal setting and patient motivation had no apparent independent influence on the effects of CR. In contrast, the presence of multiple comorbidities had the anticipated negative influence on the long-term success of goal attainment after CR.

The authors concluded that CR goals agreed upon by patients and referring physicians are consistent with those defined by professional associations.4,9Although it would have been very useful to compare the agreement (or lack thereof) between patient goals and physician goals, this was not possible because only a single set of mutually agreed upon goals was evaluated. The authors also concluded that the referring physician's illness perception of the patient had a significant influence on goal setting, as did the medical assessment process itself. This observation alone is of great importance because previous studies have shown that the referring physician's perception of their patient's motivation has a significant effect on the likelihood of a referral to CR being initiated.10,11 The authors quite rightly emphasize that physicians need to adhere to CR guidelines in determining which of their patients are appropriate for referral (in reality, most of them) rather than imposing value judgments of their own.4,9

There are some methodological issues with this study that are worth considering. First, it is not clear to what degree the physicians and patients collaborated on defining the patient goals. In other words, the reader cannot be clear regarding who defined or ultimately determined the goals. Second, the significant measurement overlap between vegetative symptoms and symptoms of vital exhaustion (in addition to how these symptoms may be associated with cardiac symptoms) may have confounded the IRES-generated patient profile such that patients' health status may have been incorrectly assessed.

In considering how this study will impact the process of CR, it is important to keep in mind that the mean age of this population was 68 years and more than 90% of the patients were retired. Consequently, the results of this study may well not apply to younger, actively employed populations. Other considerations that might influence the applicability of results to other regions and patient populations include program duration; the intensity of risk factor intervention, particularly psychosocial interventions; the interaction with the referring physicians during the CR process; and whether the program models used (residence-based spa type programs vs outpatient programs) were similar to those elsewhere.

Setting these qualifiers aside, this important study does remind us of the need for patients and their care providers to ensure that treatment goals are both congruent and attainable. The process of goal setting should take place at the beginning of CR with regular reviews regarding goal attainment, and, when necessary, modification, addition, or deletion of patient goals should be undertaken. Furthermore, CR staff should identify patients' motivation for change, that is, stages of change,12 through goal setting and focus intervention efforts on the goals most important to their patients rather than on goals deemed most important by the referring physicians or the program. Finally, the frequency with which patients, programs, and referring physicians prospectively and overtly identify treatment goals and the frequency with which they achieve those goals should be adopted as another marker of program quality and may ultimately improve long-term outcomes through improved lifestyle and medication adherence.13

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