A mixed methods study to identify and refine implementation strategies to increase use of cardiac rehabilitation for patients with heart failure

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PROJECT SUMMARY More than 6.5 million American adults have HF, which results in approximately 1 million hospital admissions per year in patients 65 year and older. Cardiac rehabilitation (CR), a multidisciplinary structured secondary prevention program that applies effective lifestyle therapies to reduce the risk of secondary cardiac events and improve functional status, has demonstrated improved outcomes in patients with HF and reduced ejection fraction (HFrEF). The American Heart Association and the American College of Cardiology recommend exercise training for patients with HF, and, in 2014, the Centers for Medicare and Medicaid Services began to reimburse CR for patients with HFrEF. However, national data suggest that only 2% of patients with HF attend CR after a hospitalization, and our preliminary data suggest that little improvement has occurred since 2014. Our long-term goal is to improve the health and outcomes of patients with HF. The objective of the parent proposal is to identify implementation strategies that increase participation in CR among patients with HF. We are working to complete parent proposal Aim 1 (analysis of Medicare claims among recently hospitalized patients with HF) and Aim 2 (to conduct qualitative interviews to identify facilitators and barriers to CR participation and implementation strategies). We will then, in Aim 3, present our findings to a panel of stakeholders who will prioritize strategies. Aim 4 is a pilot of selected strategies in a subset of CR practices and then development of recommendations to increase implementation of CR in patients with HF. As we began to prepare for the Delphi panel that will prioritize strategies, we realized that barriers to CR for HF and strategies to address those barriers are tightly linked. This has implications for Aim 4: pilot sites will struggle to choose from possible strategies if they do not identify the local barriers to CR within their program. Therefore, we propose four supplemental aims to ensure the success of Aim 4. These aims will be led by an outstanding post-baccalaureate researcher (Alexis Stewart) who is also a member of an under-represented minority group. With support from her mentors and the entire study team, she will: 1) Identify pilot site-specific barriers to referral, enrollment, and participation among patients with HF; 2) Assist pilot sites in pairing the list of identified implementation strategies to site-specific barriers; 3) Facilitate creation of a learning community that allows pilot sites to support each other as they put implementation strategies into practice; 4) Collect qualitative feedback on the acceptability and appropriateness of strategies piloted in Aim 4. These aims will help Ms. Stewart to become a competitive PhD applicant and, eventually, independent researcher. They are also consistent with National Heart, Lung, and Blood Institute’s Strategic Goals and Objectives, specifically objective 6, which aims to “optimize translational, clinical, and implementation research to improve health and reduce disease.”