The complexities of implementing cardiac rehabilitation for heart failure

Background There is a global underutilisation of cardiac rehabilitation in heart failure. Many patient-level factors contribute to this phenomenon (e.g., work obligations, caring responsibilities and travel costs). Less is known about wider system influences pertaining to how cardiac rehabilitation programmes are set up (e.g., commissioning structures) and run (e.g., providing group centre-based sessions only). Offering alternative modes of delivery, such as home-based programmes, can lead to an increase in the uptake of cardiac rehabilitation in this clinical population. In 2019, four ‘Beacon Sites’ were set up in the United Kingdom’s National Health Service to deliver the home-based Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) programme to 50 patients at each site. Data generated at the Beacon Sites were used to evaluate the process of implementation in real-world clinical practice. The conducted project builds on prior research studies which led to the creation of the REACH-HF intervention (systematic review and intervention development study) and confirmed its efficacy (feasibility study, pilot trial, randomised controlled trial and process evaluation) and its cost-effectiveness (in-trial cost-effectiveness study with statistical modelling of long-term cost-effectiveness). Methods The projects undertaken in this thesis consisted of a systematic review and a mixed methods implementation evaluation study. The mixed methods study consisted of a qualitative study (semi-structured interviews with REACH-HF practitioners in the Beacon Sites and an online survey with healthcare professionals who attended the REACH-HF remote training during the COVID-19 pandemic) and a quantitative study (quantitative analysis of routinely collected audit data).The systematic review used narrative synthesis and a triangulation protocol and aimed to identify and qualitatively describe provider- and system-level barriers and enablers influencing the delivery of cardiac rehabilitation for patients with heart failure. Results Seven articles met the inclusion criteria for the systematic review. A narrative synthesis of the data uncovered multi-level factors affecting the delivery of cardiac rehabilitation for heart failure. The mesosystem influence of the ‘organisation of healthcare system’ was the most prevalent category both in terms of barriers and enablers. The mixed methods study used data from 17 interviews, 17 survey responses and pre-post outcome measures for 132 patients. There were large variations in how the Beacon Sites delivered the programme and some of the adaptations were inconsistent with the intervention delivery protocol, potentially reducing intervention effectiveness. Substantial differences in implementation patterns (magnified by the COVID-19 pandemic) and patient characteristics between the Beacon Sites and the REACH-HF trial impacted the ability to establish the real-world effectiveness of the programme. Nonetheless, the study identified a complex interacting matrix of factors affecting the implementation of REACH-HF. Discussion The project uncovered different factors that have the potential to influence (both positively and negatively) the general delivery of cardiac rehabilitation for heart failure and the specific implementation of REACH-HF. Where possible, the identified barriers were matched with enablers and translated into practical solutions for improving the general and home-based cardiac rehabilitation provision for heath failure patients. The project’s main output is an implementation guide – the REACH-HF Service Delivery Guide, which is published on the National Institute for Health and Care Excellence Shared Learning website. Conclusions My thesis generated knowledge that could help to improve the availability and delivery of cardiac rehabilitation (in particular home-based provision) for patients with heart failure (in particular patients with heart failure with reduced ejection fraction). It may also help to bridge the gap between research findings and clinical practice

Getting evidence into clinical practice: protocol for evaluation of the implementation of a home-based cardiac rehabilitation programme for patients with heart failure

INTRODUCTION: Cardiac rehabilitation (CR) improves health-related quality of life and reduces hospital admissions. However, patients with heart failure (HF) often fail to attend centre-based CR programmes. Novel ways of delivering healthcare, such as home-based CR programmes, may improve uptake of CR. Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) is a new, effective and cost-effective home-based CR programme for people with HF. The aim of this prospective mixed-method implementation evaluation study is to assess the implementation of the REACH-HF CR programme in the UK National Health Service (NHS). The specific objectives are to (1) explore NHS staff perceptions of the barriers and facilitators to the implementation of REACH-HF, (2) assess the quality of delivery of the programme in real-life clinical settings, (3) consider the nature of any adaptation(s) made and how they might impact on intervention effectiveness and (4) compare real-world patient outcomes to those seen in a prior clinical trial. METHODS AND ANALYSIS: REACH-HF will be rolled out in four NHS CR centres across the UK. Three healthcare professionals from each site will be trained to deliver the 12-week programme. In-depth qualitative interviews and focus groups will be conducted with approximately 24 NHS professionals involved in delivering or commissioning the programme. Consultations for 48 patients (12 per site) will be audio recorded and scored using an intervention fidelity checklist. Outcomes routinely recorded in the National Audit of Cardiac Rehabilitation will be analysed and compared with outcomes from a recent randomised controlled trial: the Minnesota Living with HF Questionnaire and exercise capacity (Incremental Shuttle Walk Test). Qualitative research findings will be mapped onto the Normalisation Process Theory framework and presented in the form of a narrative synthesis. Results of the study will inform national roll-out of REACH-HF. ETHICS AND DISSEMINATION: The study (IRAS 261723) has received ethics approval from the South Central (Hampshire B) Research Ethics Committee (19/SC/0304). Written informed consent will be obtained from all health professionals and patients participating in the study. The research team will ensure that the study is conducted in accordance with the Declaration of Helsinki, the Data Protection Act 2018, General Data Protection Regulations and in accordance with the Research Governance Framework for Health and Social Care (2005). Findings will be published in scientific peer-reviewed journals and presented at local, national and international meetings to publicise and explain the research methods and findings to key audiences to facilitate the further uptake of the REACH-HF intervention. TRIAL REGISTRATION: ISRCTN86234930

A systematic review of provider-and system-level factors influencing the delivery of cardiac rehabilitation for heart failure

BACKGROUND: There is a longstanding research-to-practice gap in the delivery of cardiac rehabilitation for patients with heart failure. Despite adequate evidence confirming that comprehensive cardiac rehabilitation can improve quality of life and decrease morbidity and mortality in heart failure patients, only a fraction of eligible patients receives it. Many studies and reviews have identified patient-level barriers that might contribute to this disparity, yet little is known about provider- and system-level influences. METHODS: A systematic review using narrative synthesis. The aims of the systematic review were to a) determine provider- and system-level barriers and enablers that affect the delivery of cardiac rehabilitation for heart failure and b) juxtapose identified barriers with possible solutions reported in the literature. A comprehensive search strategy was applied to the MEDLINE, Embase, PsycINFO, CINAHL Plus, EThoS and ProQuest databases. Articles were included if they were empirical, peer-reviewed, conducted in any setting, using any study design and describing factors influencing the delivery of cardiac rehabilitation for heart failure patients. Data were synthesised using inductive thematic analysis and a triangulation protocol to identify convergence/contradiction between different data sources. RESULTS: Seven eligible studies were identified. Thematic analysis identified nine overarching categories of barriers and enablers which were classified into 24 and 26 themes respectively. The most prevalent categories were 'the organisation of healthcare system', 'the organisation of cardiac rehabilitation programmes', 'healthcare professional' factors and 'guidelines'. The most frequent themes included 'lack of resources: time, staff, facilities and equipment' and 'professional's knowledge, awareness and attitude'. CONCLUSIONS: Our systematic review identified a wide range of provider- and system-level barriers impacting the delivery of cardiac rehabilitation for heart failure, along with a range of potential solutions. This information may be useful for healthcare professionals to deliver, plan or commission cardiac rehabilitation services, as well as future research

A pragmatic effectiveness-implementation study comparing trial evidence with routinely collected outcome data for patients receiving the REACH-HF home-based cardiac rehabilitation programme

BACKGROUND: Cardiac rehabilitation for heart failure continues to be greatly underused worldwide despite being a Class I recommendation in international clinical guidelines and uptake is low in women and patients with mental health comorbidities. METHODS: Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) programme was implemented in four UK National Health Service early adopter sites ('Beacon Sites') between June 2019 and June 2020. Implementation and patient-reported outcome data were collected across sites as part of the National Audit of Cardiac Rehabilitation. The change in key outcomes before and after the supervised period of REACH-HF intervention across the Beacon Sites was assessed and compared to those of the intervention arm of the REACH-HF multicentre trial. RESULTS: Compared to the REACH-HF multicentre trial, patients treated at the Beacon Site were more likely to be female (33.8% vs 22.9%), older (75.6 vs 70.1), had a more severe classification of heart failure (26.5% vs 17.7%), had poorer baseline health-related quality of life (MLHFQ score 36.1 vs 31.4), were more depressed (HADS score 6.4 vs 4.1) and anxious (HADS score 7.2 vs 4.7), and had lower exercise capacity (ISWT distance 190 m vs 274.7 m). There appeared to be a substantial heterogeneity in the implementation process across the four Beacon Sites as evidenced by the variation in levels of patient recruitment, operationalisation of the REACH-HF intervention and patient outcomes. Overall lower improvements in patient-reported outcomes at the Beacon Sites compared to the trial may reflect differences in the population studied (having higher morbidity at baseline) as well as the marked challenges in intervention delivery during the COVID-19 pandemic. CONCLUSION: The results of this study illustrate the challenges in consistently implementing an intervention (shown to be clinically effective and cost-effective in a multicentre trial) into real-world practice, especially in the midst of a global pandemic. Further research is needed to establish the real-world effectiveness of the REACH-HF intervention in different populations

Personalised Exercise-Rehabilitation FOR people with Multiple long-term conditions (PERFORM): protocol for a randomised feasibility trial

Introduction: Personalised Exercise-Rehabilitation FOR people with Multiple long-term conditions (PERFORM) is a research programme that seeks to develop and evaluate a comprehensive exercise-based rehabilitation intervention designed for people with multimorbidity, the presence of multiple long-term conditions (MLTCs). This paper describes the protocol for a randomised trial to assess the feasibility and acceptability of the PERFORM intervention, study design and processes. Methods and analysis: A multicentre, parallel two-group randomised trial with individual 2:1 allocation to the PERFORM exercise-based intervention plus usual care (intervention) or usual care alone (control). The primary outcome of this feasibility trial will be to assess whether prespecified progression criteria (recruitment, retention, intervention adherence) are met to progress to the full randomised trial. The trial will be conducted across three UK sites and 60 people with MLTCs, defined as two or more LTCs, with at least one having evidence of the beneficial effect of exercise. The PERFORM intervention comprises an 8-week (twice a week for 6 weeks and once a week for 2 weeks) supervised rehabilitation programme of personalised exercise training and self-management education delivered by trained healthcare professionals followed by two maintenance sessions. Trial participants will be recruited over a 4.5-month period, and outcomes assessed at baseline (prerandomisation) and 3 months postrandomisation and include health-related quality of life, psychological well-being, symptom burden, frailty, exercise capacity, physical activity, sleep, cognition and serious adverse events. A mixed-methods process evaluation will assess acceptability, feasibility and fidelity of intervention delivery and feasibility of trial processes. An economic evaluation will assess the feasibility of data collection and estimate the costs of the PERFORM intervention. Ethics and dissemination: The trial has been given favourable opinion by the West Midlands, Edgbaston Research Ethics Service (Ref: 23/WM/0057). Participants will be asked to give full, written consent to take part by trained researchers. Findings will be disseminated via journals, presentations and targeted communications to clinicians, commissioners, service users and patients and the public. Trial registration number: ISRCTN68786622. Protocol version 2.0 (16 May 2023)

The role of urban environments in promoting active and healthy aging:a systematic scoping review of citizen science approaches

Promoting active and healthy aging in urban spaces requires environments with diverse, age-friendly characteristics. This scoping review investigated the associations between urban characteristics and active and healthy aging as identified by citizen science (CS) and other participatory approaches. Using a systematic scoping review procedure, 23 articles employing a CS or participatory approach (participant age range: 54–98 years) were reviewed. An inductive and deductive thematic analysis was completed to (a) identify local urban barriers and facilitators and (b) map them against the World Health Organization (WHO) Checklist of Essential Features of Age-Friendly Cities. A new Citizen Science Appraisal Tool (CSAT) was developed to evaluate the quality of CS and other participatory approaches included in the reviewed articles. A range of interconnected urban barriers and facilitators was generated by residents across the personal (e.g. perceived safety), environmental (e.g. unmaintained infrastructure), socio-cultural (e.g. cross-cultural activities), economic (e.g. affordable housing) and political (e.g. governmental support to migrant communities) domains. Mapping the barriers and facilitators to the WHO age-friendly checklist underscored the checklist’s relevance and elucidated the need to explore barriers for migrant and cross-cultural communities and neighborhood development and alterations. The CSAT demonstrated strengths related to active engagement of residents and study outcomes leading to real-world implications. To advance the potential of CS to enrich our understanding of age-friendly environments, employing co-production to enhance relevance and sustainability of outcomes is an important strategy. Overall, employing CS highlighted the value of systematically capturing the experiences of older adults within studies aimed at promoting active and healthy aging. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11524-022-00622-w

Barriers and facilitators to implementation of a home-based cardiac rehabilitation programme for patients with heart failure in the NHS : a mixed-methods study

OBJECTIVES: This study aimed to identify barriers to, and facilitators of, implementation of the Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) programme within existing cardiac rehabilitation services, and develop and refine the REACH-HF Service Delivery Guide (an implementation guide cocreated with healthcare professionals). REACH-HF is an effective and cost-effective 12-week home-based cardiac rehabilitation programme for patients with heart failure. SETTING/PARTICIPANTS: In 2019, four early adopter 'Beacon Sites' were set up to deliver REACH-HF to 200 patients. In 2020, 5 online REACH-HF training events were attended by 85 healthcare professionals from 45 National Health Service (NHS) teams across the UK and Ireland. DESIGN: Our mixed-methods study used in-depth semi-structured interviews and an online survey. Interviews were conducted with staff trained specifically for the Beacon Site project, identified by opportunity and snowball sampling. The online survey was later offered to subsequent NHS staff who took part in the online REACH-HF training. Normalisation Process Theory was used as a theoretical framework to guide data collection/analysis. RESULTS: Seventeen healthcare professionals working at the Beacon Sites were interviewed and 17 survey responses were received (20% response rate). The identified barriers and enablers included, among many, a lack of resources/commissioning, having interest in heart failure and working closely with the clinical heart failure team. Different implementation contexts (urban/rural), timing (during the COVID-19 pandemic) and factors outside the healthcare team/system (quality of the REACH-HF training) were observed to negatively or positively impact the implementation process. CONCLUSIONS: The findings are highly relevant to healthcare professionals involved in planning, delivering and commissioning of cardiac rehabilitation for patients with heart failure. The study's main output, a refined version of the REACH-HF Service Delivery Guide, can guide the implementation process (eg, designing new care pathways) and provide practical solutions to overcoming common implementation barriers (eg, through early identification of implementation champions)