How best to enable access to rehabilitation for people with heart failure and their families in these challenging times?
MRC/CSO Social and Public Health Sciences Unit's Professor Rod Taylor writes about how the REACH-HF (Rehabilitation EnAblement in CHronic Heart Failure) research programme: how this evidence-based model of care has enabled access to rehabilitation for people with heart failure in from own homes during the COVID-19 pandemic, the ongoing Glasgow-led SCOT:REACH-HF and REACH:HFpEF studies, and plans to take the REACH-HF intervention abroad.
Why and what is the REACH-HF intervention?
Despite robust evidence for the benefits of rehabilitation for people with heart failure (including improvements in health-related quality of life and reduction in risk of costly unplanned hospital admissions) and NICE and SIGN recommendation that all patients with heart failure should receive cardiac rehabilitation, access remains stubbornly poor: <20% of patients diagnosed with heart failure in UK receive rehabilitation. Whilst the reasons for suboptimal access are complex and multifaceted, a key recurring problem is the traditional model of supervised hospital centre delivery and the resulting patient barriers of inconvenience, transport costs, and dislike of group-based sessions: barriers that have been shown to particular the case of subgroups including women, ethnic minorities, those who are elderly, living with complex health conditions or living in rural areas; barriers that become all the more acute during the pandemic (which has seen a 66% decrease in absolute rehabilitation attendance compared to pre-COVID).
With prior National Institute for Health Research (NIHR) Programme Grant funding (2013–2019), the theory-based REACH-HF programme was co-developed with patients, caregivers, clinicians, and healthcare providers by a UK clinical and academic partnership collaboration led by the University of Exeter. In brief, REACH-HF is a 12-week cardiac rehabilitation and self-management programme for use at home supported by trained healthcare professionals. In 2015–2019, through a multicentre randomised controlled trial and post-trial economic modelling, the addition of the REACH-HF programme was shown be to a clinically effective and cost-effective intervention for the management of patients with reduced ejection fraction heart failure. In recognition of the rollout of the REACH-HF programme across NHS England during the COVID-19 pandemic, the REACH-HF team received the BMJ award as Stroke Cardiovascular Team of the Year 2020 and the REACH-HF programme was adopted by NICE.
A Scottish evaluation of implementation
Funded from Heart Research UK, the SCOT:REACH-HF study led by Carrie Purcell and Rod Taylor with support the Robertson Centre for Biostatistics and Glasgow researchers (Profs John Cleland and Claire Murphy, Dr Tracy Ibbotson and Claire Kerr), aims to understand what shapes the implementation of the REACH-HF programme in a real-world setting of the Scottish NHS. This ongoing mixed methods study is being conducted across four "beacon sites" (NHS Ayrshire and Arran, NHS Lanarkshire, NHS Forth Valley, and NHS Highlands/Orkney/Shetland). Due to complete in July 2022, we hope that the results of the SCOT:REACH-HF project can inform the future implementation of this home-based programme for people with heart failure and their caregivers across Scotland.
Extending REACH-HF to those with highest unmet treatment need
Following successful demonstration of the feasibility and acceptability of REACH-HF intervention in patients with preserved ejection fraction (HFpEF) in the single centre setting as part of the previous Programme Grant, the NIHR HTA programme are now funding a full multicentre randomised trial. HFpEF has severe impacts on both patients and healthcare systems, including: a markedly reduced ability to undertake activities of daily living, greatly reduced quality of life, and highly increased risk of unplanned hospital admissions, resulting in high NHS costs. Drug and device therapies shown to work in people with the other type of heart failure (heart failure with reduced ejection fraction) do not work in HFpEF. As a result, the 400,000 patients in the UK who have HFpEF are effectively living with untreated heart failure, with potentially devastating consequences for themselves and their families. The REACH-HFpEF trial is jointly led by Prof Chim Lang (Professor of Cardiology, University of Dundee) and myself with strong Glasgow representation: trials support from Robertson Centre for Biostatistics (Emma Burrell, Claire Brunton, Elizabeth Thomson), PHRF (Kaye Ross), and co-applicants/collaborators (Profs John Cleland, Emma McIntosh, Alex McConnachie, and Mark Petrie and Dr Tracy Ibbotson). Trial funding formally began in March 2021 and seeks to recruit 520 HFpEF patients across 20 UK sites with completion expected in Q3 2024.
In the last 9-months, together with colleagues based at the Institute for Public Health, University of Southern Denmark in Copenhagen we have received research funding from both the Danish Heart Foundation and Trygfonden. Starting in March 2021, this funding supports an ongoing programme of developmental work that includes: (1) national register based analysis of access to cardiac rehabilitation for people with heart failure in Denmark (2) a cultural adaptation of REACH-HF ("DK:REACH-HF" intervention); and (3) a mixed methods feasibility study to assess the implementation of the DK:REACH-HF intervention in the setting of the Danish healthcare and municipalities.
Finally, through the ACROSS collaboration, the Glasgow REACH-HF team have developed a collaboration with clinical and research partners in South Asia (Bangladesh, Pakistan, India) with the aim of improving access and uptake to cardiac rehabilitation in a setting with high cardiovascular disease burden but little or no current rehabilitation provision or capacity. Although unsuccessful, our recent large ACROSS GCRF research funding application was highly rated by the NIHR RIGHT-3 committee. Encouraged by this feedback, we continue to undertake capacity building (including a Glasgow supported PhD studentship to develop one of our LMIC partner clinicians) and foundational research activities that will underpin future funding applications.
Professor Rod Taylor (Professor of Population Health Research)
MRC/CSO Social and Public Health Sciences Unit
First published: 14 March 2018