CR4ALL- Cardiac Rehabilitation for All: A telehealth cardiac rehabilitation care pathway tailored to the needs and preferences of disadvantaged populations living with cardiovascular diseases in rural and remote Australia

Project Details


Cardiac rehabilitation (CR) is a well-established and effective but under-used intervention. CR is a multidisciplinary program which aims to support successful risk factor management and re-integrate patients with cardiovascular (CV) diseases into their former family, social and work-related lives after an acute CV event(1). CR reduces mortality and hospital readmission at 12 months post-discharge(2) and is recommended as a Class I, Level of Evidence A secondary prevention approach for patients after a heart attack by national and international guidelines(3-5). However, only 30-46% of eligible patients are referred and only 28% attend a CR program(6, 7).
Patients of low socioeconomic status (SES) are at highest risk of poor cardiovascular outcomes but are least likely to access cardiac rehabilitation. Patients with both low income and low education surviving a heart attack are particularly at risk of premature mortality. Also, compared to the highest socioeconomic areas of Australia, CV death rate in the lowest socioeconomic areas is 1.3 times higher for males and 1.5 times for females.7 (8) Psychosocial risk factors of CV diseases (e.g., low SES, low social support, depression, anxiety) tend to cluster together and co-occur with traditional risk factors (e.g. smoking, obesity)(1). Biological and behavioural mechanisms explain this link(1, 9). Lower SES is associated with low-grade inflammation and autonomic dysfunction(10), decreased adherence to medical treatment regimens and unhealthy lifestyle behaviours, as well as with social isolation and depression. Whilst some components of SES are not modifiable, CR can address some of the correlates, such as functional recovery and traditional CV risk factors which account for much of the association between low SES and CV mortality(11, 12). However, there is evidence, including from the South Australian audit (6), that patients from low-income areas are less likely to attend and complete CR after hospitalization for a heart attack (13-15)and are less likely to be informed about CR while in hospital (16). This highlights the gap in translation of the evidence around CR into practice which is partly explained by access barriers to CR.
Telehealth offers a solution to access barriers to CR(17, 18). The Integrated Cardiovascular Clinical Network (iCCnet) is a network of over 70 hospitals, health centres and GP surgeries providing evidence-based cardiac care for ~700,000 people in regional, rural and remote South Australia (SA) since 2008 (19). iCCnet delivers telehealth CR programs and has demonstrated a significant reduction in the gap in myocardial infarction mortality between rural and metropolitan areas of SA(20).
The iCCnet telehealth service comprises a telephone-based and a web-based program. The telephone-based CR program is delivered across the six local health networks (LHNs) in regional, rural and remote SA since 2012 as a stand-alone intervention and also as part of a hybrid program in which patients are managed face-to-face by the GP and by a CR nurse via telephone(20). The web-based CR program delivered through iCCnet since July 2021 was developed in partnership with Flinders University and funded by the “Country Heart Attack Prevention (CHAP)” Project, an NHMRC Partnership Project (GNT1169893). The project also brought together Heart Foundation, the Royal Australian College of General Practitioners (RACGP), the Country SA Primary Health Network and Health Translation SA.
Our aim is to develop and implement CR4ALL, a new care pathway within the iCCnet telehealth service to increase attendance and completion of CR among patients with a low SES living in regional, rural and remote areas of Australia. In this proposal, we aim to initiate the co-design of CR4ALL with patients with a low SES and professionals working in CR telehealth in SA.
The potential of telehealth remains unfulfilled. Despite a radical increase in telehealth in response to COVID-19, only 14% of patients referred to telehealth CR completed their program in Australia (21). This indicates that CR telehealth services need to be re-designed to meet the needs of patients at high risk of non-attendance. Co-design of health services is a collaborative change process driven by a patient-centred approach to participatory design that seeks to actively involve all stakeholders (e.g., staff, patients, families) to increase services usability and the potential of meeting users’ needs. Consumers have a unique position and perspective that can help to identify opportunities for improvement at an individual and organisational level. Data from the Australian Commission on Safety and Quality in Health Care(22) shows that co-design can improve patient experience and patient–provider communication, and result in services that are more accessible and appropriate for users.(22, 23)
There is evidence that tailored CR programs informed by patients can improve participation and outcomes. For example, a Danish study found improved participation and risk factor control among patients referred to a CR program tailored for the ‘socially vulnerable’(11, 24, 25). At the 10 year follow-up, all-cause mortality for this group was similar to that of non-socially vulnerable patients(24, 25).

H1:Compared to the usual approach to health services design, co-designing a care pathway within an existing telehealth service with patients with low SES living in country areas will improve patient-centredness, tailor the service to their needs and preferences, increase CR uptake, and, ultimately, improve CR clinical outcomes, patient-reported outcomes and experience measures.

Study design: Qualitative study using individual interviews and workshops.
Methodology: We will apply the Experience Based Co-Design – A toolkit for Australia(26) to engage with patients and professionals and co-design CR4ALL. This methodology suits our project because it provides guidance on how to use data from interviews/workshops with stakeholders to explore their experiences with the current service and map the patient journey. It also provides guidance and tools on how to create accessible, tangible ways (e.g., visual communication, scenarios, personas) to help people with low literacy levels convey ideas and design better service experiences(26).
We will also apply a Social Return on Investment methodology to understand the economic impact of the CR4ALL for patients, services and the system(27). This approach promotes organisational learning and is increasingly used as an economic evaluation methodology(27) in healthcare including CV models of care(28). It relies on strong engagement with stakeholders to capture and analyse: outcomes that matter for patients and are often not monetised in traditional forms of economic analysis; deadweight (i.e., what would have happened if the patients did not receive the intervention); displacement (i.e., whether any other outcomes were displaced by the intervention); attribution (i.e., whether any other services contribute to the outcome); and whether the outcomes drop off over time. This will allow, in the later phases of the larger project in which this proposal is embedded, to estimate the cost of the new pathway compared to the current service(27).

Participants will be patients and professionals.
Eligible patients will be identified through the South Australian CR database managed by iCCnet and be recruited by a clinical nurse. Inclusion criteria: age>=18 years; referred to the telephone-based or web-based cardiac rehabilitation programs; low SES defined as being unemployed or living in a postcode with an Australian Bureau of Statistics Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD)(8) within the first 2 quintiles. Exclusion criteria: cognitive impairment (Mini-mental short scale<20).
Eligible professional participants will be identified through iCCnet registries and invited via email to participate in the workshops. Inclusion criteria: clinicians (e.g., psychologists, pharmacists, cardiologists, physicians, general practitioners, nurses) and non-health professionals (e.g., social workers, administrative staff, managers) involved in the referral processes to cardiac rehabilitation across the six local health networks in regional, rural and remote SA (Barossa Hills Fleurieu LHN, Flinders and Upper North LHN, Yorke LHN, Limestone Coast LHN, Eyre and Far North LHN, Riverland Mallee Coorong LHN) or working in the CATCH program. Exclusion criteria: less than 12 months working in theses settings.
Interviews over phone/zoom with 5 patients with low SES referred to CR will explore the patient journey from hospital discharge/referral to (non) attendance/completion of CR and perceived positives and negatives of the current processes. The research questions and target groups in this phase are very specific so this sample size will generate sufficient information for in-depth analysis of the narratives(29). The interviews will help to generate “patient stories” which are central in the Experience Based Co-Design and have the purpose of exploring and understanding patient experiences of their condition and of health services over time. Patient stories can be used to map the patient journey and also to construct reference case studies, scenarios and personas to help patients in the workshops make sense of their experiences.

Five workshops with patients who were referred to telehealth CR and (a) attended telephone-based CR; (b) attended web-based CR; or (c) did not attend either (N=6-10 per workshop), and professionals to explore:
1.Potential changes to referral processes regarding in-hospital professional liaison, family involvement, follow-up of the referrals after hospital discharge.
2.Potential changes to the content delivered in the telehealth CR programs to meet the patients’ health (30)and technology literacy(31), address their psychosocial risk factors and meet their needs and preferences regarding their social environment (e.g., work stress).
3.Potential changes to processes of CR delivery such as the time of the day calls are made, duration of calls, communication style and language used in the calls, social support (e.g., family and professionals involvement), data requirements of the web portal for patients according to their financial conditions.
4.Changes in work and organisational processes, capacity building and resources needed to implement the changes suggested by patient, important outcomes for these professionals and the willingness of managers to pay for these outcomes.
5.Assessing the impact of CR4ALL: identification of outcomes that matter for the patients and their families (patient-reported outcomes and experiences); developing a theory of change based on reconfiguring the service in alignment with patient and professional feedback. Estimating the costs of delivered the proposed services compared to the existing service.
To increase patient engagement in the interviews and workshops, we will offer options of out of hours participation, in-person or virtual attendance.

Analysis: Data from workshops and interviews will be transcribed verbatim and thematic analysis will be performed. Data for the Social Return on Investment analysis will be added to the impact map, including financial inputs to the current service and outcomes identified by the stakeholder groups. This will allow future comparisons of the new pathway versus the current service costs, which is a vital aspect for service implementation.

Milestones and timeframe:
The total duration of the project will be 12 months.
•Milestone 1- Ethics approval (Month 0-2): We will seek Ethics and governance approval from the announcement of the grants results.
•Milestone 2- Completion of the construction of reference case studies, scenarios and personas and of the map of the patient journey to guide the workshops (Month 3-4). This will involve completion of the interviews with patients and analysis of the data collected.
•Milestone 3 – Completion of the five workshops (Month 5-7).
•Milestone 4 – Development of the CR4ALL care pathway (Month 8-12). The integration of thematic analysis and social return on investment analysis of the workshops will allow us to develop CR4ALL.
•Milestone 5- Dissemination of the findings (Month 12): Meeting with and report to the stakeholders at iCCnet, SA Health and consumers representatives, and completion of a scientific paper to be submitted to a Q1 journal with a focus on health services research (e.g., BMC Public Health). Dissemination will also occur through the iCCnet website and social media.

Layman's description

Cardiac rehabilitation (CR) is a well established intervention to prevent recurrent heart attacks. However, only about 30-50% of the patients with an indication attend and complete CR. People with low SES are less likely to attend. We aim to co-design with patients with cardiovascular diseases living in rural areas a telehealth-based CR program tailored to their needs.

Key findings

Short titleCardiac Rehabilitation for All
Effective start/end date31/01/2230/06/23


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