The complexities of implementing cardiac rehabilitation for heart failure

Daw, Paulina ORCID: 0000-0002-0942-3953 (2022). The complexities of implementing cardiac rehabilitation for heart failure. University of Birmingham. Ph.D.

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Abstract

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.

Type of Work:

Thesis (Doctorates > Ph.D.)

Award Type:

Doctorates > Ph.D.

Supervisor(s):