Uptake and implementation of cardiac telerehabilitation: A systematic review of provider and system barriers and enablers

BACKGROUND

Cardiac telerehabilitation has demonstrated effectiveness for patient health outcomes, but uptake and implementation into practice have been limited and variable. While patient-level influences on uptake have been identified, little is known about provider- and system-level factors.

AIMS

To identify provider and system barriers and enablers to uptake and implementation of cardiac telerehabilitation.

METHODS

A systematic review was conducted, including a search of six databases (MEDLINE, Embase, CINAHL, Scopus, Web of Science, and PsycINFO) from 2000 to March 2023. Two reviewers independently screened eligible articles. Study quality was evaluated according to study design by the Critical Appraisal Skills Programme (CASP) checklist for qualitative data, the Appraisal Tool for Cross-sectional Studies (AXIS), and the Mixed Methods Appraisal Tool (MMAT) for mixed methods. Data were analysed using narrative synthesis.

RESULTS

Twenty eligible studies (total 1674 participants) were included. Perceived provider-level barriers included that cardiac telerehabilitation is resource intensive, inferior to centre-based delivery, and lack of staff preparation. Whereas provider-level enablers were having access to resources, adequate staff preparation, positive staff beliefs regarding cardiac telerehabilitation and positive team dynamics. System-level barriers related to unaligned policy, healthcare system and insurance structures, technology issues, lack of plans for implementation, and inadequate resources. System-level enablers included cost-effectiveness, technology availability, reliability, and adaptability, and adequate program development, implementation planning and leadership support.

CONCLUSIONS

Barriers and enablers at both provider and system levels must be recognised and addressed at the local context to ensure better uptake of cardiac telerehabilitation programs.

Effectiveness of Telehealth Cardiac Rehabilitation Programs on Health Outcomes of Patients With Coronary Heart Diseases: An Umbrella Review

PURPOSE

The aim of this study was to conduct an umbrella review summarizing the evidence from existing systematic reviews of telehealth cardiac rehabilitation (CR) on health outcomes of patients with coronary heart disease (CHD).

REVIEW METHODS

An umbrella review of systematic reviews was undertaken in accordance with the PRISMA and JBI guidelines. A systematic search was conducted in Medline, APA PsycINFO, Embase, CINAHL, Web of Science, Cochrane database of systematic reviews, JBI evidence synthesis, Epistemonikos, and PROSPERO, searching for systematic reviews published from 1990 to current and was limited to the language source of English and Chinese. Outcomes of interest were health behaviors and modifiable CHD risk factors, psychosocial outcomes, and other secondary outcomes. Study quality was appraised using the JBI checklist for systematic reviews. A narrative analysis was conducted, and meta-analysis results were synthesized.

SUMMARY

From 1301 identified reviews, 13 systematic reviews (10 meta-analyses) comprised 132 primary studies conducted in 28 countries. All the included reviews have high quality, with scores ranging 73-100%. Findings to the health outcomes remained inconclusive, except solid evidence was found in the significant improvement in physical activity (PA) levels and behaviors from telehealth interventions, exercise capacity from mobile health (m-health) only and web-based only interventions, and medication adherence from m-health interventions. Telehealth CR programs, work adjunct or in addition to traditional CR and standard care, are effective in improving health behaviors and modifiable CHD risk factors, particularly in PA. In addition, it does not increase the incidence in terms of mortality, adverse events, hospital readmission, and revascularization.

A Motivational Telephone Intervention to Reduce Early Dropouts in Cardiac Rehabilitation: A FEASIBILITY PILOT STUDY

PURPOSE

Cardiac rehabilitation (CR) improves outcomes, yet early dropout is common. The purpose of the study was to determine whether a motivational telephone intervention among patients at risk for nonadherence would reduce early dropouts.

METHODS

We performed a randomized double-blind pilot study with the intervention group receiving the telephone intervention 1 to 3 d after outpatient CR orientation. The control group received the standard of care, which did not routinely monitor attendance until 2 wk after orientation. The primary outcome was the percentage of patients who attended their second exercise session as scheduled. Secondary outcomes included attendance at the second CR session at any point and total number of sessions attended. Because not everyone randomized to the intervention was able to be contacted, we also conducted a per-protocol analysis.

RESULTS

One hundred patients were randomized to 2 groups (age 62 ± 15 yr, 46% male, 40% with myocardial infarction) with 49 in the intervention group. Patients who received the intervention were more likely to attend their second session as scheduled compared with the standard of care (80% vs 49%; relative risk = 1.62; 95% CI, 1.18-2.22). Although there was no difference in total number of sessions between groups, there was a statistically significant improvement in overall return rate among the per-protocol group (87% vs 66%; relative risk = 1.31; 95% CI, 1.05-1.63).

CONCLUSIONS

A nursing-based telephone intervention targeted to patients at risk for early dropout shortly after their CR orientation improved both on-time and eventual return rates. This straightforward strategy represents an attractive adjunct to improve adherence to outpatient CR.

A qualitative study exploring why people do not participate in cardiac rehabilitation and coronary heart disease self-help groups, and their rehabilitation experience without these resources

BACKGROUND

Secondary prevention and self-management of coronary heart disease (CHD) are of major importance to people who survive myocardial infarction (MI). This can be facilitated by cardiac rehabilitation (CR; the formal health service programme) and informal CHD self-help groups. Non-participation is an important issue, yet it is poorly understood. Rehabilitation difficulties and prevention challenges have been identified among people following MI, but the particular experience and perspective of CR and CHD group non-participants are largely unknown.

AIM

The study aimed to understand non-participation in CR and CHD self-help groups from the perspectives of the non-participants and to provide insight into their experience and that of their 'significant others' in rehabilitating in the absence of these resources.

METHODS

In-depth interviews were conducted with 27 people who had not participated in either hospital-based CR or a CHD group, 6-14 months post-MI, and 17 'significant others' in Lothian, Scotland.

FINDINGS

Factors influencing non-participation fell into three broad themes 'No need/no point', 'Not worth it', and 'Not possible'. In the latter two categories, non-participation in these resources was often considered a 'missed opportunity' and needs had remained unmet. Shifts between categories could occur over time. Non-participation was linked to rehabilitation difficulties for some people and family members. Recommendations to enhance post-MI support are made.