Published: 10 August 2021
Dr Hasnain Dalal and Prof Rod Taylor describe how they’ve used several consecutive funding awards from the NIHR to develop, test and implement a new home-based approach to rehabilitation that is now improving lives for people with heart failure.
Heart failure is a condition that means that the heart is unable to pump blood around the body properly. For the more than 900,000 people in the UK living with heart failure, cardiac rehabilitation, where people are offered exercise and information sessions, is a key way they can get their lives back on track.
More than two decades ago a patient who was discharged after a heart attack attended our GP surgery for a review. He was not keen to attend the group-based rehabilitation offered by the local hospital. Another patient of mine discharged with heart failure was also not keen on attending group-based rehab classes in hospital, although he lived less than a mile away from the hospital! This inspired me to look at alternatives to centre based cardiac rehabilitation.
A first step on our NIHR funding journey
Our ambition was to develop a home-based intervention to allow patients a choice and overcome some of the barriers to attend centre based classes.
In 2010 we applied for our first Programme Development Grant (PDG) from the NIHR to begin looking into home-based rehabilitation for heart failure. The first PDG helped us to conduct a survey to examine why so few patients with heart failure take part in cardiac rehab and their attitudes, beliefs and expectations. We reviewed the evidence of exercise training in patients with heart failure.
Moving on up to a Programme Grant
Following this first PDG, we then secured a £2 million funding award from Programme Grants for Applied Research (PGfAR) for the Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) study. The published findings from the PDG were instrumental in making a robust case for our PGfAR application.
The REACH-HF programme is a facilitated home-based rehabilitation programme for people with heart failure and their caregivers, allowing patients to benefit from rehabilitation from the comfort and safety of their own home. The programme, designed to make rehabilitation more accessible, includes tailored exercise and wellbeing interventions.
We used this PGfAR award to develop, pilot and trial the REACH-HF intervention and develop an evidence-informed, home-based, self-care cardiac rehabilitation programme for patients with heart failure and their caregivers. We conducted a pilot randomised controlled trial to assess the feasibility of a full trial of the clinical effectiveness and cost-effectiveness of the REACH-HF in patients.
Successes and challenges
This research found adding on the rehabilitation programme to usual care in patients with heart failure improved quality of life at 12 months compared with usual care alone, and that was cost effective.
Following the success of this research, the REACH-HF programme was rolled out as an additional option for patients diagnosed with chronic heart failure, in four real world NHS beacon sites.
However, a major challenge at the end of this research was to bridge the gap between evidence generation and full implementation, through refining the REACH-HF programme and its training course to make it ‘NHS ready’.
Taking rehabilitation into practice
This year we successfully applied for a new PDG to fund developing a digital version of the REACH-HF training programme, to maximise accessibility and minimise the cost of rollout.
Before the pandemic, the REACH-HF facilitator training programme was a three-day, face-to-face course, which was time-consuming and costly. In our PDG we will offer a two-day online course to allow busy NHS staff to access the training when it is convenient for them and avoid the travel and other associated costs. This project is a crucial step in scaling up REACH-HF for national delivery - it will allow more staff to be trained so more patients with heart failure can be offered rehab.
We have also started another NIHR-funded randomised controlled trial to evaluate the effectiveness and cost effectiveness of REACH HF in patients with heart failure with preserved ejection.
In the future, patients with heart failure are likely to be offered alternatives to centre based cardiac rehabilitation, including home based models, which will provide patient choice and should increase overall uptake. We discussed this trend in a recent BMJ article.
Delivering impact after a decade of research
The REACH-HF intervention is extending the availability and uptake of cardiac rehabilitation for people with heart failure – a key objective of the NHS Long Term Plan. Patients have told us how the programme has helped them manage their condition and improve their day-to-day lives. We have also found that REACH HF can help patients’ access cardiac rehab during the current pandemic.
Having spent over a decade developing and evaluating REACH-HF with a dedicated team of patients, caregivers, clinicians, and academics, we are delighted to see how well this evidence-based programme has been received. The positive feedback from patients, their families, and practitioners coupled with the wider implementation across the NHS is most gratifying – makes us want to do more of the same!
There has been no doubt that the NIHR funding we received via PDG and PGfAR has been central to our ability to develop a cost-effective home-based rehabilitation programme and take it through to adoption by the NHS.
Dr Hasnain Dalal, Associate Professor in Primary Care at the University of Exeter Medical School and Clinical Researcher, Royal Cornwall Hospitals NHS Trust
Prof Rod Taylor, Professor of Population Health Research, University of Glasgow and Honorary Professor Health Service Research, University of Exeter