Uptake Of Cardiac Rehabilitation Research Articles

A Qualitative Study of Barriers and Facilitators to the Uptake of Cardiac Rehabilitation in Octogenarians.

Introduction: Despite an established evidence-base for cardiac rehabilitation (CR) improving functional outcomes and quality of life and reducing re-hospitalisation, there is limited research on CR for older cardiac patients, who require rehabilitation the most, as they are often very deconditioned due to aortic stenosis (AS). CR uptake in the UK is limited to 52% with national variability of provision and accessibility, and it is a national priority to increase uptake to 85%. Frequently, research has excluded older populations as they are deemed to be too frail or generally not suitable for inclusion. This study aimed to explore factors that can impact the uptake of CR in octogenarians. Methods: Qualitative interviews were carried out with 20 AS patients (12 female, 8 male), from a large NHS Trust in the North East of England. Results: Four main themes were identified in the data: Perceptions and Understanding, Delivery and Accessibility, Perceived Impact of Exercise and Health and Life Changes, and Transportation. Discussion: The findings suggested that the major factors were the understanding of the nature, purpose and relevance of CR to older patients, whether CR was offered, and the role of social support. Barriers and facilitators can impact uptake based on the mode of delivery and the individual circumstances identified. Future research could explore how to develop CR programmes that overcome the barriers identified in the research, such as education, monitoring strategies, use of telehealth, and home-based elements to create an acceptable and accessible programme for octogenarians.

Perspectives of Policymakers on Barriers to and Enablers of the Uptake of Cardiac Rehabilitation in Saudi Arabia: A Qualitative Study.

This study aimed to identify the barriers to and enablers of secondary prevention care and cardiac rehabilitation (CR) utilization by patients with coronary heart disease (CHD) following percutaneous coronary intervention (PCI) from the perspective of policymakers. A qualitative study involving an interpretive descriptive design was conducted through recorded semistructured interviews with key decision-makers in cardiology care in Saudi Arabia. The analysis was guided by the updated Consolidated Framework for Implementation Research (CFIR), which informed the resulting themes. Interviews were conducted with nine key decision-makers: four directors of major cardiac centers, four heads of cardiac rehabilitation units, and one president of a specialized cardiac society. Data coding identified 16 CFIR constructs as barriers, with seven prioritized by the participants. The most frequently cited barriers included lack of CR facilities, shortage of trained staff, and insufficient knowledge of CR among cardiologists. Seventeen constructs emerged as enablers to aid in overcoming these challenges, with nine receiving high consensus among policymakers. Key enablers included implementing alternative models, such as home-based programs; enhancing cardiologists' understanding of CR benefits; and involving higher authorities for support. This study highlights the significant barriers to CR utilization and proposes solutions to facilitate the implementation of these programs from the perspective of healthcare leaders. Successful implementation requires improved communication within institutions, collaboration with the broader healthcare system, and engagement with other stakeholders, such as the private sector, to expand access and ensure comprehensive service delivery.

Exercise-Based Telerehabilitation for Heart Failure Patients Declining Outpatient Rehabilitation - A Randomized Controlled Trial.

Purpose: Cardiac rehabilitation participation rates are low despite strong recommendations, and many chronic heart failure patients remain physically inactive. Rural living, long travel distance, costs, age, and frailty might be factors explaining this. To increase cardiac rehabilitation uptake, we designed an exercise-based randomized controlled telerehabilitation trial enabling chronic heart failure patients unable or unwilling to participate in outpatient cardiac rehabilitation to exercise at home. Aim was to evaluate the long-term effects of telerehabilitation on physical activity levels.Methods and results: CHF patients (n = 61) with reduced (≤40%), mildly reduced (41-49%), or preserved ejection fraction (≥50%) were randomized (1:1) to telerehabilitation (n = 31) with an initial 3-month group-based high-intensity exercise telerehabilitation program or control (n = 30), with regular follow-up visits over a 2-year period. All participants attended a "Living with heart failure" course. Outcomes were measures of physical activity, peak oxygen uptake, 6-minute walk test distance, quality of life, morbidity, and mortality. We found no significant differences between groups for long-term changes in moderate to vigorous activity (MVPA) or peak oxygen uptake from baseline to the 2-year follow-up. Nor quality of life differed between groups, but both groups had significant within-group improvements in score on the Minnesota living with heart failure questionnaire (p = 0.000) and improvement in EQ-5D VAS score was significant (p = 0.05) in the telerehabilitation group.Conclusions: Telerehabilitation performed as home-based real-time high-intensity exercise sessions provided by videoconferencing for participants unable or unwilling to participate in standard outpatient cardiac rehabilitation did not affect long-term physical activity levels or physical capacity as expected. Still, a positive effect on health-related quality of life was seen in both groups.

Social Determinants and Patient Characteristics Predict Cardiac Rehabilitation Uptake and Adherence

Social Determinants and Patient Characteristics Predict Cardiac Rehabilitation Uptake and Adherence

Co-designing an information map guiding patients on their journey to cardiac rehabilitation in Austria

Abstract Background Cardiac rehabilitation (CR) is underutilised worldwide. Cardiac patients lack sufficient information about CR, for example, regarding the health benefits of CR and how to obtain a referral. This gap presents a significant barrier to CR uptake. Purpose The purpose of this study was (1) to define patients’ needs during their transition from the acute hospital setting to CR and (2) to design a need-based information map. Methods We conducted three sequential co-design workshops with 17 participants: ten cardiac patients, most of whom had completed a CR programme, six healthcare professionals who worked within the CR pathway, and one who was a healthcare professional with a cardiac condition who had completed a CR programme. Patients’ needs and design suggestions were elicited through generative co-design methods [1], such as paper prototyping, persona scenarios, group discussions and presentations, and card sorting. Data were analysed with thematic analysis. Results Workshop participants identified three "steps" at which orientation is required to guide patients along their journey: (1) during the hospital stay, (2) while at home, and (3) throughout the CR programme. Patients’ needs changed accordingly, prompting us to tailor information and tips to these steps (s. Figure). In the hospital, patients needed orientation about follow-up care. The patients sought facts about CR, enabling them to make an informed decision for or against participation. Particularly, info about programme duration, content and health benefits were appreciated. Information about common symptoms related to the treatment and explanations of the hospital environment were also perceived as helpful. After discharge, the time at home was characterised by a need for calm after the stressful time in the hospital. Patients reflected on their cardiac events. Information on adopting a heart-healthy lifestyle and guidance on preparing for CR were perceived as helpful. Contact details for medical support were appreciated. During the CR programme, patients sought motivational support for programme adherence. They appreciated tips such as making use of the time for bonding and seeking out friendships with other patients. Testimonials sharing experiences and tips presented by fellow patients were considered helpful at any point along the patient journey. Conclusion When transitioning from the acute hospital to CR, cardiac patients’ needs change in distinctive steps, which the settings hospital, home and CR represent. Information and tips should be tailored accordingly. Our information map may support patients’ CR uptake and facilitate cardiac patient pathways in Austria, for example, by developing patient-facing technology.Patients' needs and required information

Communicate, support and integrate: strategies to improve engagement with cardiac rehabilitation

Abstract Background Factors beyond Cardiac Rehabilitation (CR) service continue to negatively impact CR attendance and programme completion. Intrapersonal, socioeconomic, health perception/co-morbidity and logistical factors can have a significant impact on CR uptake. During the COVID-19 pandemic many services reconsidered their approach and utilised novel but more flexible delivery solutions (1). As clinical services remodel post-COVID we sought to incorporate the patient perspective. Purpose To identify and co-design strategies to improve engagement with CR. Methods Experience Based Co-Design (EBCD) is a Codesign methodology that incorporates the experiences of patients, caregivers and service providers (2). The project involved staff, patients and caregivers linked to CR across the region. In an iterative process, a literature review followed by focus groups and co-design workshops were conducted by the research team during 2019-2021. Results The co-design workshops identified numerous multifaceted issues in relation to engagement with CR. These can be described in three distinct themes. Communicate Misunderstandings about CR content and efficacy persist amongst patients and the public. Health Care Professionals must streamline, and focus information provided to patients in order to highlight the multifaceted benefits of CR, a patient-led information video for patients and public was produced and shared through CR networks. Support Patients require additional emotional and social support following a cardiac event. Significant concerns described by patients relate to family, work, socialising and future health. A supportive, facilitated discussion was warranted and a brief cardiac intervention (CABIN) was developed and will be tested in a feasibility trial. Integrate Following COVID-19 patients are more receptive to hybrid approaches to delivering CR. Diverse options for delivery of CR should be integrated into standard practice. Patient suggestions included online learning modules, social exercise, video libraries, online support meetings, text chat facilities, and regionally specific webpages. The study resulted in three key outputs; a short regional information video, a regional webpage and the brief supportive intervention, CABIN. Conclusion Co-designing with staff and patients provides relevant and important information about highlighting the importance of and accessing and delivering a service which can be incorporated into future service changes.

The feasibility of delivering cardiac brief intervention to patients following ST-elevation myocardial infarction: Protocol for a pilot randomised controlled trial.

Patients experience emotional distress and hold cardiac misconceptions following ST-elevation myocardial infarction. These issues informed the co-production of Cardiac Brief Intervention with patients and clinicians. The current study will establish a knowledge base for the feasibility of delivering this intervention to patients following ST-elevation myocardial infarction, with a preliminary exploration of impact on associated outcomes (ClinicalTrials.gov: NCT05848674). A pilot randomised controlled trial incorporating a mixed-methods design will be conducted. Patients with ST-elevation myocardial infarction (number = 40) will be recruited from coronary care units at two hospital centres in Northern Ireland, with participants randomised (1:1) to the intervention or control group. Cardiac Brief Intervention constitutes a nurse-led, short (20 minutes) emotional and educational support discussion with a patient, with a leaflet that serves as a memory-aid. It will be delivered to the intervention group prior to discharge from a coronary care unit. The control group will receive standard care information. Data will be collected at baseline, post-intervention, 4 weeks from diagnosis, and 14 weeks from diagnosis. Feasibility measurements and process evaluation (quantitative and qualitative) will assess the viability of the research design and intervention delivery. Cardiac rehabilitation attendance data will be collected, and participants will complete questionnaires related to associated outcomes. Quantitative data will be reported with descriptive statistics and qualitative data will be analysed using framework analysis, with data integrated to achieve triangulation of findings. Educational and emotional difficulties following ST-elevation myocardial infarction may impede patient outcomes and cardiac rehabilitation participation. These issues informed the co-production of Cardiac Brief Intervention with patients and clinicians. This study will evaluate the feasibility of delivering Cardiac Brief Intervention to patients. These results will inform large-scale definitive testing of the intervention, which may lead to adoption in clinical practice to improve cardiac rehabilitation uptake and patient outcomes.

The acceptability of technology-enabled physical activity feedback in cardiac patients and health care professionals

PurposePhysical activity is a key component of cardiac rehabilitation (CR). Despite the widely reported benefits of CR, uptake in the United Kingdom is still low. Alternative home-based and technology-facilitated delivery models are needed to improve CR uptake and physical activity. This study set out to explore patient and clinician views of personalised, multidimensional physical activity feedback and its potential use within CR.MethodsWe developed graphics for the presentation of personalised multidimensional physical activity feedback from data collected through wrist-worn monitors. Thirteen cardiac patients and nine healthcare professionals recruited from South West England wore research grade physical activity monitors for seven days. Participants then attended semi-structured interviews during which personalised physical activity feedback was provided. Interviews were audio-recorded, transcribed, and analysed thematically.ResultsTwo main themes were derived from the data which covered: 1) the perceived value of multidimensional physical activity feedback, and 2) support needed to facilitate understanding. Within the first theme, participants acknowledged that multidimensional physical activity feedback was useful for monitoring progress, goal setting, and increasing self-awareness of physical activity behaviour among both patients and clinicians. Within theme two, the need for more guidance and support from clinicians to aid patient understanding and reassurance was highlighted, particularly for those with very low physical activity levels.ConclusionsMultidimensional physical activity feedback delivered using a technology-enabled approach was perceived as acceptable among patients and clinicians. This study provides insights into the potential novel use of technology-enabled physical activity feedback to support and expand the delivery of CR.

Targeting behavioral factors with digital health and shared decision-making to promote cardiac rehabilitation-a narrative review.

Cardiac rehabilitation (CR) represents an important steppingstone for many cardiac patients into a more heart-healthy lifestyle to prevent premature death and improve quality of life years. However, CR is underutilized worldwide. In order to support the development of targeted digital health interventions, this narrative review (I) provides understandings of factors influencing CR utilization from a behavioral perspective, (II) discusses the potential of digital health technologies (DHTs) to address barriers and reinforce facilitators to CR, and (III) outlines how DHTs could incorporate shared decision-making to support CR utilization. A narrative search of reviews in Web of Science and PubMed was conducted to summarize evidence on factors influencing CR utilization. The factors were grouped according to the Behaviour Change Wheel. Patients' Capability for participating in CR is influenced by their disease knowledge, awareness of the benefits of CR, information received, and interactions with healthcare professionals (HCP). The Opportunity to attend CR is impacted by healthcare system factors such as referral processes and HCPs' awareness, as well as personal resources including logistical challenges and comorbidities. Patients' Motivation to engage in CR is affected by emotions, factors such as gender, age, self-perception of fitness and control over the cardiac condition, as well as peer comparisons. Based on behavioral factors, this review identified intervention functions that could support an increase of CR uptake: Future DHTs aiming to support CR utilization may benefit from incorporating information for patients and HCP education, enabling disease management and collaboration along the patient pathway, and enhancing social support from relatives and peers. To conclude, considerations are made how future innovations could incorporate such functions.

Understanding adaptive tasks in cardiac rehabilitation among patients with acute myocardial infarction: a qualitative study

Background While Cardiac Rehabilitation (CR) programs have shown effectiveness in improving cardiac outcomes, there is limited understanding of how patients perceive and adapt to these interventions. Furthermore, alternative modes of delivering CR that have received positive evaluations from participants remain underexplored, yet they have the potential to enhance CR uptake. Objectives To explore the patient experience in CR programmes following Acute Myocardial Infarction (AMI) and describe their adaptive processing. Patients and Methods This qualitative study was conducted at a nationally certified centre in China between July 2021 and September 2022, encompassing three stages: in-hospital, centre-based, and home-based CR programs. Purposive sampling was used to select eligible AMI patients for in-depth semi-structured interviews. The interview outline and analytical framework were aligned with the key concepts derived from the middle-range theory of adaptation to chronic illness and the normalization process theory. The findings were reported following the Consolidated Criteria for Reporting Qualitative Research checklist. Results Forty AMI patients were recruited. Four main themes describing the process of AMI patients normalizing CR intervention were identified, including (1) experiencing CR service driving by role’s responsibilities, (2) engaging in collaborative relationship based on interpersonal trust, (3) exploring a personalized rehabilitation plan by complex integration, and (4) expecting a promised outcome to shape decision-making. Conclusion Integrated care interventions for AMI patients could benefit from a collaborative co-designed approach to ensure that CR interventions are normalized and fit into patients’ daily lives. Organizational-level CR services should align with the rehabilitation needs and expectations of patients.

Home- versus clinic-based exercise intervention in patients with heart failure (EXIT-HF trial): a pragmatic randomized controlled trial

Abstract Background The limited accessibility partially explains the low uptake of cardiac rehabilitation (ExCR) for heart failure (HF). Home-based programs might address those obstacles but few data from randomized trials are available. Purpose To compare the effectiveness of a home-based versus clinic-based ExCR intervention in HF patients. Methods Single-center, single-blind, parallel groups, non-inferiority pragmatic randomized control trial (1:1 and after COVID-19 2:1 home- vs clinic-based). Adult HF patients referred to our cardiac rehabilitation (CR) unit were randomized to either a clinic-based (24 supervised sessions at a CR unit of a tertiary hospital over 12 weeks) or home-based (4 supervised ExT sessions to familiarize with the training protocol and the remaining sessions continued at home) over 12 weeks. Exercise training protocol consisted of a combination of endurance (at 60%-80% of peak oxygen uptake [VO2peak] and resistance training (elastic bands). The primary endpoint was the change in VO2peak at the end of the 12-week program. Secondary outcomes included adherence (>80% of sessions attendance) and change of Minnesota Living with HF Questionnaire (MLHFQ) scores. Results 120 patients (mean age 64±11 years; 64% men) were randomized: 44 to clinic- and to 76 home-based intervention. 41% had an ischemic cardiomyopathy, 27% had an ICD/CRT, the mean LVEF was 36±11% (62% had LVEF <40%), 73% were on NYHA class II, and the median NT-proBNP was 361 [IQR 170-1008] ng/mL. Intervention groups were well balanced, including basal VO2peak that was similar between groups (17.8±4.8 vs 18.1±5.2 mL/min/Kg; p=0.75). Adherence was similar between groups (87.5% vs 82.5%; p=0.50). At week 12, on average, patients increased VO2 peak by 0.9±2.5 mL/min/Kg compared to baseline (p<0.001). No significant differences were found between clinic- and home-based interventions (p=0.25). Consistently, the MLHFQ total score decreased significantly overall (-10.3±1.7 points; p<0.001), with no significant differences between groups (p=0.91). The drop-out rate was 14% and 17% in clinic- and home-based groups, respectively. Conclusions The clinical impact of home-based CR program on peakVO2 and health-related quality of life of HF patients was similar to a standard supervised clinic-based one. Our data support the home-based program as an effective alternative way of delivering CR in HF.

Rehabilitation Support via Postcard (RSVP): A Randomised Controlled Trial of a Postcard to Promote Uptake of Cardiac Rehabilitation.

The aim was to increase cardiac rehabilitation (CR) uptake using a novel intervention, Rehabilitation Support Via Postcard (RSVP), among patients with acute myocardial infarction discharged from two major hospitals in Hunter New England Local Health District (HNELHD), New South Wales, Australia. The RSVP trial was evaluated using a two-armed randomised controlled trial design. Participants (N=430) were recruited from the two main hospitals in HNELHD, and enrolled and randomised to either the intervention (n=216) or control (n=214) group over a six-month period. All participants received usual care; however, the intervention group received postcards promoting CR attendance between January and July 2020. The postcard was ostensibly written as an invitation from the patient's admitting medical officer to promote timely and early uptake of CR. The primary outcome was CR attendance at outpatient HNELHD CR services in the 30-days post-discharge. Fifty-four percent (54%) of participants who received RSVP attended CR, compared to 46% in the control group; however this difference was not statistically significant (odds ratio [OR]=1.4, 95% confidence interval [CI]=0.9-2.0, p=0.11). Exploratory post-hoc analysis among four sub-groups (i.e., Indigeneity, gender, age and rurality), found that the intervention significantly increased attendance in males (OR=1.6, 95%CI=1.0-2.6, p=0.03) but had no significant impact on attendance for other sub-groups. While not statistically significant, postcards increased overall CR attendance by 8%. This strategy may be useful to increase attendance, particularly in men. Alternative strategies are necessary to increase CR uptake among women, Indigenous people, older people and people from regional and remote locations.

Barriers and facilitators of cardiac rehabilitation uptake and completion in south Asian minorities: a meta-synthesis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiac rehabilitation is a proven modality to prevent future cardiac events and complications in cardiac patients. However, the uptake and completion rate are suboptimal in cardiac patients and even worse in ethnic minorities and women. South Asian minorities experience several barriers and facilitators to cardiac rehabilitation uptake and completion. Aim To develop a comprehensive understanding of barriers and facilitators to cardiac rehabilitation uptake and completion by South Asian minorities. Methods A meta-synthesis was conducted, and findings were reported using PRISMA guidelines. The following databases: Medline, Embase, APA PsycInfo, Cochrane Database of Systematic Review, CINHAL, Scopus, and Web of Science were searched from inception to July 2022. The inclusion criteria comprised the studies that focused on South Asian adult minorities’ barriers and/or facilitators of a structured cardiac rehabilitation program. Studies were critically appraised using the Mixed Methods Appraisal Tool. Thematic synthesis was used in the analysis. Results A total of 7110 records were retrieved and eight studies from Canada and United Kingdom met the inclusion criteria. There were more identified barriers than facilitators. Communication constraints resulted in inadequate health education, while conservative socio-religious beliefs, negative attitudes about healthcare professionals, and systemic constraints (e.g., transportation problems, and work schedule concerns) were the key barriers themes. Peer and family support and patient-preferred specific mechanisms for cardiac rehabilitation implementation were substantial facilitators. Conclusion South Asian minorities experience multilevel barriers and facilitators to cardiac rehabilitation uptake and completion. Further research with a robust and culturally contextual intervention and methodology can help improve the uptake and cardiac rehabilitation completion in this population. Healthcare professionals and policymakers can utilize these findings to develop tailored cardiac rehabilitation programs for South Asian minorities.

Applying User-Centered Design and Implementation Science to the Early-Stage Development of a Telehealth-Enhanced Hybrid Cardiac Rehabilitation Program: Quality Improvement Study.

Cardiac rehabilitation (CR) is an evidence-based intervention that improves event-free survival in patients with cardiac conditions, yet <27% of all eligible patients use CR in the United States. CR is traditionally delivered in clinic-based settings where implementation barriers abound. Innovative nontraditional program designs and strategies are needed to support widespread CR uptake. This study aimed to demonstrate how user-centered design (UCD) and implementation science (IS) principles and methods can be integrated into the early-stage development of nontraditional CR interventions. As part of a NewYork-Presbyterian Hospital (NYPH) quality improvement initiative (March 2020-February 2022), we combined UCD and IS principles and methods to design a novel home- and clinic-based telehealth-enhanced hybrid CR (THCR) program. We co-designed this program with multilevel stakeholders using an iterative 3-step UCD process to identify user and contextual barriers and facilitators to CR uptake (using semistructured interviews and contextual inquiry [step 1]), design an intervention prototype that targets contextual and user factors and emulates the evidence-based practice (through design workshops and journey mapping [step 2]), and review and refine the prototype (according to real-world usability testing and feedback [step 3]). The UCD process was informed by the Theoretical Domains Framework and Consolidated Framework for Implementation Research. At step 1, we conducted semistructured interviews with 9 provider- and system-level stakeholders (female: n=6, 67%) at 3 geographically diverse academic medical centers, which revealed behavioral (eg, self-efficacy and knowledge) and contextual (eg, social distancing guidelines, physical space, staffing, and reimbursement) barriers to uptake; hybrid delivery was a key facilitator. Step 2 involved conducting 20 design workshops and 3 journey-mapping sessions with multidisciplinary NYPH stakeholders (eg, digital health team, CR clinicians, and creative director) where we identified key design elements (eg, mix of clinic- and home-based CR and synchronous remote patient monitoring), yielding an initial THCR prototype that leveraged NYPH's telehealth infrastructure. At step 3, we conducted usability testing with 2 CR clinicians (both female) administering home-based sessions to 3 CR patients (female: n=1, 33%), which revealed usability themes (eg, ease of using remote patient monitoring devices or a telehealth platform, technology disruptions, and confidence in using the telehealth platform to safely monitor patients) and design solutions (eg, onboarding sessions, safety surveys, and fully supervised remote sessions) to be included in the final THCR prototype. Combining UCD and IS methods while engaging multidisciplinary stakeholders in an iterative process yielded a theory-informed THCR program targeting user and contextual barriers to real-world CR implementation. We provide a detailed summary of the process and guidance for incorporating UCD and IS principles and methods into the early-stage development of a nontraditional CR intervention. The feasibility, acceptability, appropriateness, and usability of the final THCR prototype is being evaluated in an ongoing study.

Availability and trend of dissemination of cardiac rehabilitation in China: report from the multicenter national registration platform between 2012 and 2021.

The study aimed to evaluate the current status of cardiac rehabilitation programs in China by registering and tracking patients undergoing CR programs in the database. Data were extracted from the online registry platform of the China Society of Cardiopulmonary Prevention and Rehabilitation from February 2012 to December 2021. Overall, data on 19,896 patients with cardiovascular diseases (CVDs) from 159 hospitals in 34 provinces of China were extracted. From a time point of view, the number of patients who had undergone CR and institutions that perform CR showed the first decline in 2009 and then increased until 2021. From a geographic point of view, the degree of participation varied greatly among regions, most of which were concentrated in eastern parts of China. A higher population of patients who underwent CR were male, aged less than 60 years, with low-a risk for coronary heart disease (CHD), and tended to choose the hospital-based CR program among all cases registered in the database. The top three diseases in the patients who participated in CR were CHD, hypertension, and metabolic syndrome (MS). Centers with CR were more likely to be tertiary-level hospitals. After adjusting for baseline values, there were significant differences in post-CR exercise capacity among the three groups (home-based CR group, hospital-based CR group, and hybrid CR group), which were in favor of the hybrid CR group compared with other groups. The underutilization of CR is a global issue, not just in China. Despite the number of CR programs showing an increasing trend in the past years, CR in China is still in the preliminary stage of development. Furthermore, the participation of CR in China shows wide diversity across geography, disease, age, sex, risk stratification, and hospital-level factors. These findings reinforce the importance of the implementation of effective measures to improve the participation, enrollment in, and uptake of cardiac rehabilitation.

Uptake of Cardiac Rehabilitation in Te Whatu Ora – Counties Manukau During the Pandemic

Cardiac rehabilitation (CR) is an evidence-based range of interventions to support people with several cardiac issues. The impact of the COVID-19 pandemic created many challenges for health services and communities. Using the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZAC-QI) CR database this study tracked referral, mode, and level of engagement from 2013 to 2023. Over 10 years, 9,134 referrals were identified, with a steadily decreasing number every year (1,040 in 2023 vs 672 in 2022; 35% decrease). The majority (70%) was male; mean age for males was 66 years, for females 67 years; and ethnicity was Māori 12%, Pacific 25%, Indian 12%, others 51%. Attendance of any program was 71%, with a 600% increase in clinics vs group interventions. The average uptake of the exercise program was 24%; Māori compared with Pacific and Euro/others (61% vs 71% vs 73%, p>0.001); and younger people (<60 years, 66% vs older >61 years, 73%, p>0.001) were least likely to attend, with no gender differences (male 71% vs Female 69%, p=NS). There has been a significant decline in CR referrals over the last 10 years, with a shift from group-based education to individualised clinic contacts. Uptake of exercise programs remains low. Novel interventions to support Māori and younger patients have been implemented.

Te Kaahui Ora Māori Health Team Offering Whanau Ora and Secondary Prevention in Te Whatu Ora – Counties Manukau

Cardiac rehabilitation (CR) is an important evidence-based secondary prevention intervention following acute coronary syndrome (ACS). In this catchment, Māori uptake of CR is persistently low. A partnership with the Māori health team was introduced during the COVID pandemic to deliver a Te Kaahui Ora model of care. Using the ACS and CR database, 100 consecutive Māori patients—50 preintervention and 50 postintervention—were retrospectively audited. All patients were discharged alive after ACS with similar characteristics: 78% vs 72%, revascularised, 93% vs 94% discharged on standard ACS medications. Risk factors: smoking 53% vs 56%, mean SBP 145.4 vs 146.3, LDL >2, 86.3% vs 74%, BMI >30 67% vs 63%, and diabetes 34% vs 34%. The majority were male 64% vs 68% and mean age was 54 vs 58.6 years. Cardiac rehabilitation attendance declined 44% vs 28%; however, 96% in the intervention cohort received 20% home visits and 100% telephone support with often multiple contacts. The introduction of a wide-ranging intervention in Māori post-ACS patients resulted in a decrease in traditional CR attendance but also a significant increase in phase 1 and 2 contacts, and addressed a wide range of issues unlikely to be addressed in standard CR interventions.

Achieving cardiac rehabilitation uptake targets: What is the value case for commissioners? A UK case-study

Cardiac Rehabilitation (CR) has become an established intervention to support patient recovery after a cardiac event, with evidence supporting its effectiveness and cost-effectiveness in improving patient health and reducing future burden on healthcare systems. However, this evidence has focussed on the national value case for CR rather than at the point at which it is commissioned. This analysis uses the UK as a case-study to explore variation in current CR engagement and disassemble the value case from a commissioner perspective.Using data collected by the National Audit of CR (NACR), and an existing model of cost-effectiveness, we present details on the current level of CR uptake by commissioning region (Specialist Clinical Networks) in light of the current UK target of achieving 85% uptake. We then interrogate the value case for achieving the target at a commissioner level, highlighting the expected profile of health benefits and healthcare system costs over the long-term. Importantly we consider where this may differ from the national value case.Each commissioning region has a unique level of CR uptake and sociodemographic profile. Concurrently, the value case for commissioning CR relies on the upfront cost of the service being offset by long-term healthcare savings, and health improvements.The shift in the UK and internationally to more localised commissioning necessitates evidence of cost-effectiveness that better reflects the realities of those decision makers. This paper provides vital additional data to facilitate such commissioners to understand the value case in increasing CR uptake in line with national policy.

Overview of Cardiac Rehabilitation following post-acute myocardial infarction in European Society of Cardiology member countries.

Cardiovascular disease (CVD) is still a leading cause of death and morbidity in Europe and must be addressed through approaches beyond therapeutic interventions and pharmacological management. Cardiac rehabilitation (CR) is a comprehensive, individualized, and patient-tailored programme, comprising multidisciplinary interventions. Despite its clinical benefits, cost-effectiveness, and existing guidelines, CR uptake in Europe remains suboptimal and detailed information on its current state is lacking. This centralized pan-European study (Overview of Cardiac Rehabilitation-OCRE) aimed to characterize and advance the knowledge about European Society of Cardiology (ESC) affiliated national CR settings. An online survey about provision and quality indicators from CR was sent to the network of National CVD Prevention Coordinators of ESC member states, whose answers were supported by published evidence and/or national experts. The OCRE study had a high participation rate (82%). Current positive aspects of CR include low dropout rates and short average start time after myocardial infarction, as well as public funding being standard practice. However, the uptake rate and average duration of CR are still suboptimal, and several countries lack CR mandatory rotation in Cardiology training, guidance documents, national accreditation, and electronic database registries. We also found several barriers to CR guideline implementation, at patient, staff, and healthcare levels. This study provides a comprehensive characterization of CR in Europe, generating important insight on the current provision and quality of CR in Europe, highlighting its sucesses and shortcomings, and discussing important strategies to overcome current obstacles.

Home-based cardiac rehabilitation for people with heart failure and their caregivers: a mixed-methods analysis of the roll out an evidence-based programme in Scotland (SCOT:REACH-HF study).

Alternative models of cardiac rehabilitation (CR) are required to improve CR access and uptake. Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) is a comprehensive home-based rehabilitation and self-management programme, facilitated by trained health professionals, for people with heart failure (HF) and their caregivers. REACH-HF was shown to be clinically effective and cost-effective in a multicentre randomised trial. The SCOT:REACH-HF study assessed implementation of REACH-HF in routine clinical practice in NHS Scotland. A mixed-method implementation study was conducted across six regional Health Boards. Of 136 people with HF and 56 caregivers recruited, 101 people with HF and 26 caregivers provided four-month follow-up data, after participating in the 12-week programme. Compared with baseline, REACH-HF participation resulted in substantial gains in the primary outcome of health-related quality of life, as assessed by the Minnesota Living with Heart Failure Questionnaire (mean difference: -9.8, 95% CI: -13.2 to -6.4, P < 0.001). Improvements were also seen in secondary outcomes (PROM-CR+; EQ-5D-5L; Self-Care of Heart Failure Index (SCHFI) domains of maintenance and symptom perception; Caregiver Contribution to Self-Care (CC-SCHFI) domains of symptom perception and management).Twenty qualitative interviews were conducted with 11 REACH-HF facilitators, five supporting clinicians, and four national stakeholders. Interviewees were largely positive about REACH-HF, considering it to have 'filled a gap' where centre-based CR was not an option. Key issues to support future roll-out were also identified. Our findings support wider roll-out of REACH-HF as an alternative to centre-based models, to improve CR access and uptake for people with HF.