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Purcell C, Purvis A, Cleland JGF, Cowie A, Dalal HM, Ibbotson T, Murphy C, Taylor RS. 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). Eur J Cardiovasc Nurs 2023; 22:804-813. [PMID: 36617216 DOI: 10.1093/eurjcn/zvad004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/29/2022] [Accepted: 01/04/2023] [Indexed: 01/09/2023]
Abstract
AIMS 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 multi-centre randomized trial. The SCOT:REACH-HF study assessed implementation of REACH-HF in routine clinical practice in NHS Scotland. METHODS AND RESULTS 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 4-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 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. CONCLUSION 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.
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Affiliation(s)
- Carrie Purcell
- Faculty of Wellbeing, Education and Language Studies, The Open University in Scotland, 10 Drumsheugh Gardens, Edinburgh EH3 7QJ, UK
| | - Anthony Purvis
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Berkeley Square, 99 Berkeley St, Glasgow G3 7HR, UK
| | - John G F Cleland
- Robertson Centre for Biostatistics, University of Glasgow, Level 11, Boyd Orr Building, University Avenue, Glasgow G12 8QQ, UK
| | - Aynsley Cowie
- NHS Ayrshire and Arran, University Hospital Crosshouse, Kilmarnock Rd, Crosshouse, Kilmarnock KA2 0BE, UK
| | - Hasnain M Dalal
- Primary Care Research Group, University of Exeter Medical School, St Luke's Campus, Exeter EX1 2LU, UK
| | - Tracy Ibbotson
- General Practice & Primary Care, University of Glasgow, 1 Horselethill Road, Glasgow G12 9LX, UK
| | - Clare Murphy
- NHS Forth Valley, Forth Valley Royal Hospital, Stirling Road, Larbert FK5 4WR, UK
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Berkeley Square, 99 Berkeley St, Glasgow G3 7HR, UK
- Robertson Centre for Biostatistics, University of Glasgow, Level 11, Boyd Orr Building, University Avenue, Glasgow G12 8QQ, UK
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Agbo ECU, Ifeanyichukwu H. Comment on: Analysis of Action Planning, Achievement, and Life Purpose Statements in an Intervention to Support Caregivers of Persons With Heart Failure. Curr Probl Cardiol 2023; 48:101896. [PMID: 37394204 DOI: 10.1016/j.cpcardiol.2023.101896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 06/27/2023] [Indexed: 07/04/2023]
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Ifeanyichukwu H, Agbo E. Comment on: Risk Factors for Inspiratory Muscle Weakness in Coronary Heart Disease. Curr Probl Cardiol 2023; 48:101895. [PMID: 37399859 DOI: 10.1016/j.cpcardiol.2023.101895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 06/27/2023] [Indexed: 07/05/2023]
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Loureiro M, Parola V, Duarte J, Mendes E, Oliveira I, Coutinho G, Martins MM, Novo A. Interventions for Caregivers of Heart Disease Patients in Rehabilitation: Scoping Review. NURSING REPORTS 2023; 13:1016-1029. [PMID: 37606457 PMCID: PMC10443275 DOI: 10.3390/nursrep13030089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/29/2023] [Accepted: 07/24/2023] [Indexed: 08/23/2023] Open
Abstract
Map the interventions/components directed to the caregivers of heart disease patients in cardiac rehabilitation programs that promote their role and health. METHODS The Joanna Briggs Institute method was used to guide this scoping review. Two independent reviewers assessed articles for relevance and extracted and synthesized data. Inclusion criteria comprised articles published in English, Spanish, and Portuguese since 1950. The following databases were searched: CINAHL Complete (Via EBSCO), Medline (via PubMed), Scopus, PEDro, and Repositórios Científicos de Acesso Aberto de Portugal (RCAAP). RESULTS From 351 articles retrieved, 10 were included in the review. The interventions identified directed to the caregiver were: educational interventions and lifestyle changes; physical exercise; psychological interventions/stress management; and a category "Other" with training interventions in basic life support, elaboration of guidelines/recommendations, and training for the role of caregiver. CONCLUSIONS It was found that most of the related cardiac rehabilitation interventions are aimed at the dyad heart failure patient and their caregivers/family. Including specific interventions targeting caregivers improves the caregiver's health and empowers them. Patient care planning should include interventions specifically aimed at them that result in health gains for caregivers and patients, striving to improve the quality of care. This study was not registered.
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Affiliation(s)
- Maria Loureiro
- Instituto Ciências Biomédicas Abel Salazar, Cintesis-NursID, Centro Hospitalar e Universitário de Coimbra, 3000-602 Coimbra, Portugal
| | - Vítor Parola
- Nursing School of Coimbra (ESEnfC), The Health Sciences Research Unit: Nursing (UICISA:E), Portugal Centre for Evidence-Based Practice: A Joanna Briggs Institute Centre of Excellence, 3004-011 Coimbra, Portugal
| | - João Duarte
- Instituto Ciências Biomédicas Abel Salazar, Cintesis-NursID, Centro Hospitalar e Universitário de Coimbra, 3000-602 Coimbra, Portugal
| | - Eugénia Mendes
- Instituto Politécnico de Bragança-Escola Superior de Saúde, Cintesis-NursID, 5300-121 Bragança, Portugal
| | - Isabel Oliveira
- Escola Superior de Saúde Norte Cruz Vermelha Portuguesa Oliveira de Azeméis, Center for Health Studies and Research of the University of Coimbra, 3040-156 Coimbra, Portugal
| | - Gonçalo Coutinho
- Faculdade de Medicina de Coimbra, Centro Hospitalar e Universitário de Coimbra, 3000-602 Coimbra, Portugal
| | | | - André Novo
- Instituto Politécnico de Bragança-Escola Superior de Saúde, Cintesis-NursID, 5300-121 Bragança, Portugal
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Daw P, Wood GER, Harrison A, Doherty PJ, Veldhuijzen van Zanten JJCS, Dalal HM, Taylor RS, van Beurden SB, McDonagh STJ, Greaves CJ. Barriers and facilitators to implementation of a home-based cardiac rehabilitation programme for patients with heart failure in the NHS: a mixed-methods study. BMJ Open 2022; 12:e060221. [PMID: 35831041 PMCID: PMC9280226 DOI: 10.1136/bmjopen-2021-060221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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).
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Affiliation(s)
- Paulina Daw
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Grace E R Wood
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | | | | | | | - Hasnain M Dalal
- Royal Cornwall Hospital, University of Exeter Medical School, Truro, UK
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, University of Glasgow, Institute of Health and Well Being, Glasgow, UK
| | | | - Sinead T J McDonagh
- Primary Care Research Group, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Colin J Greaves
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, UK
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Daw P, Harrison A, Doherty PJ, van Zanten JJCSV, Dalal HM, Taylor RS, van Beurden SB, McDonagh STJ, Greaves CJ. A pragmatic effectiveness-implementation study comparing trial evidence with routinely collected outcome data for patients receiving the REACH-HF home-based cardiac rehabilitation programme. BMC Cardiovasc Disord 2022; 22:270. [PMID: 35710336 PMCID: PMC9202968 DOI: 10.1186/s12872-022-02707-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 06/02/2022] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Paulina Daw
- grid.6572.60000 0004 1936 7486School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, B15 2TT UK
| | - Alexander Harrison
- grid.5685.e0000 0004 1936 9668Health Sciences, University of York, York, UK
| | - Patrick J. Doherty
- grid.5685.e0000 0004 1936 9668Health Sciences, University of York, York, UK
| | | | - Hasnain M. Dalal
- grid.416116.50000 0004 0391 2873University of Exeter Medical School, Royal Cornwall Hospital, Truro, UK
- grid.8391.30000 0004 1936 8024Primary Care Research Group, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Rod S. Taylor
- grid.8756.c0000 0001 2193 314XMRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
| | - Samantha B. van Beurden
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter, Exeter, UK
| | - Sinéad T. J. McDonagh
- grid.8391.30000 0004 1936 8024Primary Care Research Group, College of Medicine and Health, University of Exeter, St Luke’s Campus, Exeter, UK
| | - Colin J. Greaves
- grid.6572.60000 0004 1936 7486School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, B15 2TT UK
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Mone P, Izzo R, Marazzi G, Manzi MV, Gallo P, Campolongo G, Cacciotti L, Tartaglia D, Caminiti G, Varzideh F, Santulli G, Trimarco V. L-Arginine Enhances the Effects of Cardiac Rehabilitation on Physical Performance: New Insights for Managing Cardiovascular Patients During the COVID-19 Pandemic. J Pharmacol Exp Ther 2022; 381:197-203. [PMID: 35339987 DOI: 10.1124/jpet.122.001149] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/21/2022] [Indexed: 11/22/2022] Open
Abstract
Cardiac rehabilitation (CR) following acute myocardial infarction (AMI) improves physical capacities and decreases hospitalizations and cardiovascular mortality. L-Arginine is the substrate used by nitric oxide (NO) synthase (NOS) to generate NO and it has been shown to exert its beneficial effects on endothelium driving vasodilatation, reducing inflammation, and ameliorating physical function. We hypothesized that L-Arginine could enhance physical capacities in patients who underwent CR after AMI. We designed a study aimed to assess the effects of L-arginine administration on the physical capacity of patients who underwent coronary revascularization after AMI. The trial was carried out amid the COVID-19 pandemic. Patients were assigned, with a 2:1 ratio, to add to their standard therapy 1 bottle containing 1.66 g of L-arginine or 1 bottle of identical aspect apart from not containing L-arginine, twice a day orally for 3 weeks. Patients performed a 6-minute walking test (6MWT) and were assessed their Borg modified 0-10 rating of perceived exertion (BRPE) before starting and at the end of the treatment. Seventy-five patients receiving L-Arginine, and thirty-five receiving placebo successfully completed the study. The 6MWT distance increased significantly in the L-Arginine group compared to both baseline and placebo (p<0.0001). Additionally, we observed a significant improvement in the BRPE in patients treated with L-arginine but not in the placebo group. Taken together, our data indicate that L-arginine potentiates the response to CR, independently of age, sex, baseline functional capacity, and comorbid conditions. Significance Statement This study shows for the first time that oral supplementation of L-arginine potentiates the response to cardiac rehabilitation after myocardial infarction and cardiac revascularization. Indeed, we observed a significant improvement in two fundamental parameters, namely, the 6-minute walking test and the Borg modified 0-10 rating of perceived exertion. Strikingly, the beneficial effects of L-arginine were independent from age, sex, comorbid conditions, and baseline functional capacity.
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Abstract
Cardiac rehabilitation is a complex intervention that seeks to improve the functional capacity, wellbeing and health-related quality of life of patients with heart disease. A substantive evidence base supports cardiac rehabilitation as a clinically effective and cost-effective intervention for patients with acute coronary syndrome or heart failure with reduced ejection fraction and after coronary revascularization. In this Review, we discuss the major contemporary challenges that face cardiac rehabilitation. Despite the strong recommendation in current clinical guidelines for the referral of these patient groups, global access to cardiac rehabilitation remains poor. The COVID-19 pandemic has contributed to a further reduction in access to cardiac rehabilitation. An increasing body of evidence supports home-based and technology-based models of cardiac rehabilitation as alternatives or adjuncts to traditional centre-based programmes, especially in low-income and middle-income countries, in which cardiac rehabilitation services are scarce, and scalable and affordable models are much needed. Future approaches to the delivery of cardiac rehabilitation need to align with the growing multimorbidity of an ageing population and cater to the needs of the increasing numbers of patients with cardiac disease who present with two or more chronic diseases. Future research priorities include strengthening the evidence base for cardiac rehabilitation in other indications, including heart failure with preserved ejection fraction, atrial fibrillation and congenital heart disease and after valve surgery or heart transplantation, and evaluation of the implementation of sustainable and affordable models of delivery that can improve access to cardiac rehabilitation in all income settings.
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Affiliation(s)
- Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health & Well Being, University of Glasgow, Glasgow, UK.
- College of Medicine and Health, University of Exeter, Exeter, UK.
| | - Hasnain M Dalal
- University of Exeter Medical School (Primary Care), Smeall Building, St Luke's Campus, Exeter, UK
| | - Sinéad T J McDonagh
- University of Exeter Medical School (Primary Care), Smeall Building, St Luke's Campus, Exeter, UK
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Dalal HM, Taylor RS, Wingham J, Greaves CJ, Jolly K, Lang CC, Davis RC, Smith KM, Doherty PJ, Miles J, van Lingen R, Warren FC, Sadler S, Abraham C, Britten N, Frost J, Hillsdon M, Singh S, Hayward C, Eyre V, Paul K. A facilitated home-based cardiac rehabilitation intervention for people with heart failure and their caregivers: a research programme including the REACH-HF RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background
Rates of participation in centre (hospital)-cardiac rehabilitation by patients with heart failure are suboptimal. Heart failure has two main phenotypes differing in underlying pathophysiology: heart failure with reduced ejection fraction is characterised by depressed left ventricular systolic function (‘reduced ejection fraction’), whereas heart failure with preserved ejection fraction is diagnosed after excluding other causes of dyspnoea with normal ejection fraction. This programme aimed to develop and evaluate a facilitated home-based cardiac rehabilitation intervention that could increase the uptake of cardiac rehabilitation while delivering the clinical benefits of centre-based cardiac rehabilitation.
Objectives
To develop an evidence-informed, home-based, self-care cardiac rehabilitation programme for patients with heart failure and their caregivers [the REACH-HF (Rehabilitation Enablement in Chronic Heart Failure) intervention]. To conduct a pilot randomised controlled trial to assess the feasibility of a full trial of the clinical effectiveness and cost-effectiveness of the REACH-HF intervention in addition to usual care in patients with heart failure with preserved ejection fraction. To assess the short- and long-term clinical effectiveness and cost-effectiveness of the REACH-HF intervention in addition to usual care in patients with heart failure with reduced ejection fraction and their caregivers.
Design
Intervention mapping to develop the REACH-HF intervention; uncontrolled feasibility study; pilot randomised controlled trial in those with heart failure with preserved ejection fraction; randomised controlled trial with a trial-based cost-effectiveness analysis in those with heart failure with reduced ejection fraction; qualitative studies including process evaluation; systematic review of cardiac rehabilitation in heart failure; and modelling to assess long-term cost-effectiveness (in those with heart failure with reduced ejection fraction).
Setting
Four centres in England and Wales (Birmingham, Cornwall, Gwent and York); one centre in Scotland (Dundee) for a pilot randomised controlled trial.
Participants
Adults aged ≥ 18 years with heart failure with reduced ejection fraction (left ventricular ejection fraction < 45%) for the main randomised controlled trial (n = 216), and those with heart failure with preserved ejection fraction (left ventricular ejection fraction ≥ 45%) for the pilot randomised controlled trial (n = 50).
Intervention
A self-care, facilitated cardiac rehabilitation manual was offered to patients (and participating caregivers) at home over 12 weeks by trained health-care professionals in addition to usual care or usual care alone.
Main outcome measures
The primary outcome was disease-specific health-related quality of life measured using the Minnesota Living with Heart Failure Questionnaire at 12 months. Secondary outcomes included deaths and hospitalisations.
Results
The main randomised controlled trial recruited 216 participants with heart failure with reduced ejection fraction and 97 caregivers. A significant and clinically meaningful between-group difference in the Minnesota Living with Heart Failure Questionnaire score (primary outcome) at 12 months (–5.7 points, 95% confidence interval –10.6 to –0.7 points) favoured the REACH-HF intervention (p = 0.025). Eight (4%) patients (four in each group) had died at 12 months. There was no significant difference in hospital admissions, at 12 months, with 19 participants in the REACH-HF intervention group having at least one hospital admission, compared with 24 participants in the control group (odds ratio 0.72, 95% confidence interval 0.35 to 1.51; p = 0.386). The mean cost of the intervention was £418 per participant with heart failure with reduced ejection fraction. The costs at 12 months were, on average, £401 higher in the intervention group than in the usual care alone group. Model-based economic evaluation, extrapolating from the main randomised controlled trial in those with heart failure with reduced ejection fraction over 4 years, found that adding the REACH-HF intervention to usual care had an estimated mean cost per participant of £15,452 (95% confidence interval £14,240 to £16,780) and a mean quality-adjusted life-year gain of 4.47 (95% confidence interval 3.83 to 4.91) years, compared with £15,051 (95% confidence interval £13,844 to £16,289) and 4.24 (95% confidence interval 4.05 to 4.43) years, respectively, for usual care alone. This gave an incremental cost per quality-adjusted life-year of £1721. The probabilistic sensitivity analysis indicated 78% probability that the intervention plus usual care versus usual care alone has a cost-effectiveness below the willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained. The intervention was well received by participants with heart failure with reduced ejection fraction and those with heart failure with preserved ejection fraction, as well as their caregivers. Both randomised controlled trials recruited to target, with > 85% retention at follow-up.
Limitations
Key limitations included (1) lack of blinding – given the nature of the intervention and the control we could not mask participants to treatments, so our results may reflect participant expectation bias; (2) that we were not able to capture consistent participant-level data on level of intervention adherence; (3) that there may be an impact on the generalisability of findings due to the demographics of the trial patients, as most were male (78%) and we recruited only seven people from ethnic minorities.
Conclusions
Evaluation of the comprehensive, facilitated, home-based REACH-HF intervention for participants with heart failure with reduced ejection fraction and caregivers indicated clinical effectiveness in terms of health-related quality of life and patient self-care but no other secondary outcomes. Although the economic analysis conducted alongside the full randomised controlled trial did not produce significant differences on the EuroQol-5 Dimensions or in quality-adjusted life-years, economic modelling suggested greater cost-effectiveness of the intervention than usual care. Our REACH-HF intervention offers a new evidence-based cardiac rehabilitation option that could increase uptake of cardiac rehabilitation in patients with heart failure not attracted to or able to access hospital-based programmes.
Future work
Systematic collection of real-world data would track future changes in uptake of and adherence to alternative cardiac rehabilitation interventions in heart failure with reduced ejection fraction and increase understanding of how changes in service delivery might affect clinical and health economic outcomes. The findings of our pilot randomised controlled trial in patients with heart failure with preserved ejection fraction support progression to a full multicentre randomised controlled trial.
Trial registration
Current Controlled Trials ISRCTN86234930 and ISRCTN78539530.
Funding details
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 1. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hasnain M Dalal
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
- Research and Development, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Rod S Taylor
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
- Professor of Population, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Jennifer Wingham
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Colin J Greaves
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Chim C Lang
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Russell C Davis
- Cardiology Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Karen M Smith
- Cardiac Rehabilitation Office, Ninewells Hospital, Dundee, UK
| | | | - Jackie Miles
- Research and Development, Aneurin Bevan University Health Board, St Woolos Hospital, Newport, UK
| | | | - Fiona C Warren
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Susannah Sadler
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Charles Abraham
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
- School of Psychological Sciences, University of Melbourne, Victoria, VIC, Australia
| | - Nicky Britten
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Julia Frost
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | | | - Sally Singh
- Centre for Exercise and Rehabilitation Science, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| | | | | | - Kevin Paul
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
- Research and Development, Royal Cornwall Hospitals NHS Trust, Truro, UK
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Daw P, van Beurden SB, Greaves C, Veldhuijzen van Zanten JJCS, Harrison A, Dalal H, McDonagh STJ, Doherty PJ, Taylor RS. Getting evidence into clinical practice: protocol for evaluation of the implementation of a home-based cardiac rehabilitation programme for patients with heart failure. BMJ Open 2020; 10:e036137. [PMID: 32565467 PMCID: PMC7307528 DOI: 10.1136/bmjopen-2019-036137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/28/2020] [Accepted: 05/11/2020] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Paulina Daw
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Samantha B van Beurden
- Psychology, University of Exeter, Exeter, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Colin Greaves
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | | | | | - Hasnain Dalal
- College of Medicine and Health, University of Exeter, Exeter, UK
- Royal Cornwall Hospitals NHS Trust, Cornwall, UK
| | | | | | - Rod S Taylor
- College of Medicine and Health, University of Exeter, Exeter, UK
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
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