REACH-HF (Rehabilitation EnAblement in CHronic Heart Failure) is a facilitated evidence based cardiac rehabilitation (CR) and self-management programme for use at home. It comprises the ‘Heart Failure Manual’, a Relaxation CD, a choice of exercise (walking programme or a chair-based DVD) a ‘Progress Tracker’ for patients, and a ‘Family and Friends Resource’ for caregivers. A video of the intervention can be viewed on:
http://sites.exeter.ac.uk/reach-hf/
To improve the poor uptake and access to CR in heart failure, NICE (NG106) recommendation 66 states that CR ‘should be provided in a format and setting (at home, in the community or in the hospital) that is easily accessible for the person’. However, in the COVID-19 era, centre-based options are limited and there has been an increase in use of home-based programmes.
The REACH-HF Service Delivery Guide captures the learnings from our beacon sites and a delivery pathway for COVID-19.
The REACH-HF programme was developed by a collaboration involving several clinical and academic partners across the UK including the Universities of Birmingham, Dundee, Exeter, Glasgow, Plymouth and York together with the Aneurin Bevan University Health Board, NHS Lothian, Ninewells Hospital & Medical School, Dundee, Royal Cornwall Hospitals NHS Trust, Sandwell and West Birmingham Hospitals NHS Trust ,University Hospitals of Leicester NHS Trust and York Hospitals NHS Foundation Trust. The REACH-HF collaboration has received research and implementation funding past and present from a number of research funders and charities including: the National Institute for Health Research (NIHR), the British Heart Foundation (BHF), Heart Research UK, and the South West Academic Health Sciences Network.
Funding has been from NIHR National Institute of Health Research – Programme Development Grant (2010-11) and Programme Grant (2013-19) to develop and robustly evaluate the intervention. Heart Research UK has also funded the SCOT REACH-HF project.
Example
Aims and objectives
Our mission is to:
Ensure easy access to cost-effective rehabilitation for people with heart failure to enable them to lead healthier and better lives
Our objectives were:
- To develop an affordable evidence-informed, homebased, self-care CR programme for patients with HF and their caregivers (‘the REACH-HF intervention’)
- To assess the short- and long-term effectiveness and cost-effectiveness of the REACH-HF intervention in addition to usual care in patients with HFrEF (heart failure with reduced ejection fraction) and their caregivers
In 2010, NICE (CG108) recommended centre/group-based cardiac rehabilitation for people with heart failure. Women, people living in rural and higher deprivation areas and non-white ethnic groups are less likely to attend centre-based CR. (2018 National Audit of Cardiac Rehabilitation (NACR)) Low uptake has been attributed to various reasons (see The REACH-HF Service Delivery Guide) and how REACH HF is able to overcome some of these barriers.
68,266 patients in England and Wales were admitted to hospital with heart failure in 2017-18 but less than 10% participated in CR. COVID -19 has made this worse with less than 5% receiving CR ( NACR 2020).
Our updated 2019 Cochrane systematic review (44 randomised controlled trials (RCTs), n=5,763) showed that participation in CR results in a reduction in risk of all-cause hospitalisation (RR 0.70 [95% CI 0.60 to 0.83]) and a meaningful improvement in HRQoL (as assessed using the Minnesota Living with Heart Failure Questionnaire –7.1 [95% CI –3.7 to –10.5]).
In our four real world NHS beacon sites (2019-20) the REACH-HF programme was offered as an additional option, which enabled the choice of participation in either the centre-based rehabilitation programme or REACH-HF. This approach has several advantages. Some patients prefer to attend centre-based programmes. For example, they might not feel motivated enough to exercise by themselves at home, have safety concerns, or just enjoy getting out of the house every week and meeting other people with heart failure in a supportive environment. Others may struggle to attend the hospital or rehabilitation centre due to poor mobility, lack of transport or a busy lifestyle. Some feel uncomfortable in group situations and may prefer more individually tailored advice. Since there are many reasons why patients may prefer centre-based or homebased rehabilitation programmes, offering a choice (as per NG106) can improve adherence.
Reasons for implementing your project
In 2010, we designed a two-stage postal questionnaire-based survey to examine why so few patients with heart failure across England, Wales and Northern Ireland take part in CR. Stage 1 included 277 CR centres on the NACR register. Stage 2 comprised of 35 (16%) centres from stage 1 that indicated that they provide a separate CR programme for patients with heart failure.
Full data were available for 224/277 (81%) CR centres. Only 90/224 (40%) routinely offered CR to patients with heart failure. Of these 90 centres that offered CR, 39/90 (43%) did so only when heart failure was secondary to myocardial infarction or coronary revascularisation. Only 35/90 (39%) had a specific CR programme for heart failure. 134/224 (60%) centres not providing for patients with heart failure, considered a lack of resources and exclusion from commissioning contracts as the main reasons for not recruiting patients. Overall, only 35/224 (16%) centres provided a specific CR programme for people with heart failure. See Paper : https://bmjopen.bmj.com/content/bmjopen/2/2/e000787
Patients with heart failure and their caregivers were highly involved in our programme of research since its initial conception and co-developed with REACH-HF team, the patient and care givers materials. The Patient, Public Involvement (PPI) group has met regularly since 2011. The group, was based in Cornwall but subsequently had other members. They met 3–4 times a year to review intervention development and work packages. Advisors provided comments on aspects like the proposed choice of patient- reported outcome measures. Early on in the study, the Group contributed particularly to the development of the REACH-HF intervention (helping to select the core intervention targets, identifying barriers to change and ways to facilitate change, and reviewing the entire content of the intervention as it developed).
The PPI group members were keen to have feedback about how their recommendations were used – for example, they suggested having two types of exercise programmes (chair-based and walking) and they contributed to wording on the patient-facing documents to encourage participants in the control group to continue with the trial. The PPI group have participated in several dissemination events and continue to advise on the rollout of the intervention and in developing modifications, such as a digital version of REACH-HF. Other stakeholders, such as clinicians and commissioners were also consulted.
How did you implement the project
Prior to implementation, we conducted a successful multicentre RCT (see key findings) which showed that when the REACH HF intervention is added to usual care it improves the HRQoL of patients with heart failure. In addition to clinical effectiveness our health economic modelling confirmed cost-effectiveness of REACH HF.Our next step was to pilot the implementation of the REACH HF programme in real-world NHS cardiac rehabilitation settings across the UK.
The aim of this work is to:
- Compare real-world patient outcomes with the results from the REACH HF RCT
- Assess the quality of the real-world REACH HF programme delivery.
- Explore the implementation process to inform a larger scale roll-out of REACH HF across the UK and possibly even internationally.
Initially, we recruited four ‘beacon’ sites: UCLH, Belfast, Gloucester and Wirral cardiac rehabilitation services. Three health professionals from each beacon site attended the 3 day face to face REACH-HF facilitator course in Edinburgh in May 2019.So far, REACH HF has been delivered to over ~130 heart failure patients within the past year. We have recently been awarded funding from Heart Research UK to implement REACH HF across 4 Scottish Health boards and this project is currently underway.
Impact of COVID-19
The COVID-19 pandemic has had a significant impact on provision of cardiac rehabilitation. We received an overwhelming number of requests from health professionals to train as REACH HF facilitators so that the home and evidence-based REACH HF programme could be rolled-out in their area and patients could benefit from rehab from the comfort and safety of their own home. With the support from the SW AHSN, we trained 89 health professionals, including nurses, physiotherapists, occupational therapists and exercise physiologists from across the UK and Republic of Ireland to deliver REACH HF.
A number of adaptions were required to ensure patients could receive rehab during the COVID-19 outbreak, this included cancellation of home and clinic visits and increased telephone support for patients and have been well received by health care professionals (HCPs) and patients. Details are included in the REACH-HF Service Delivery Guide (supporting material).
Key findings
Our primary outcome of our randomised trials of REACH-HF have been health related quality of life (HRQoL) which is acknowledged as an important outcome for heart failure patients. We used the disease specific Minnesota Living with Heart Failure questionnaire (MLHFQ), which is a key outcome indicator for patient well-being that is independently related to survival.
We recruited to target (216) at four centres – Birmingham , Cornwall, Gwent and York; the average age of participants was 70 years, with a mean left ventricular ejection fraction of 34%. Overall, 185 (86%) participants provided data for the primary outcome. At 12 months, there was a significant and clinically meaningful between-group difference in the MLHFQ score of –5.7 points (95% confidence interval –10.6 to –0.7) in favour of the REACH-HF intervention group (p=0.025). With the exception of patient self-care (p < 0.001), there was no significant difference in other secondary outcomes, including clinical events (p > 0.05) at follow-up, compared with usual care.
See Paper (Table 2) for results:
https://journals.sagepub.com/doi/epub/10.1177/2047487318806358
The mean estimated total cost for delivery of the REACH-HF intervention was £418 per patient, within the current NHS tariff for CR of £477 per patient.
The estimated total delivery cost per patient for HF facilitator/staff time was £363. Other resource use and costs: Consumables (1 REACH-HF Manual) £25, DVDs (2 at £7.50) £15.00.Full details published. See Paper : Table S2. REACH-HF intervention contacts and costs: https://journals.sagepub.com/doi/suppl/10.1177/2047487318806358/suppl_file/Supplemental_material.pdf
We also performed a model-based economic evaluation to assess cost-effectiveness over the longer term of the REACH-HF intervention. Over the lifetime of people with heart failure, the REACH-HF intervention was estimated to be cost-effective, with an incremental cost-effectiveness ratio (ICER) of £1,720 per Quality-Adjusted Life Year (QALY) which is well within the NICE willingness to pay threshold of £20,000 per QALY. See Paper:
https://journals.sagepub.com/doi/epub/10.1177/2047487319833507
We estimate that 1,693 QALYs could be gained for every 10% increase in patients with heart failure undergoing CR, nationally.
REACH HF intervention materials are available for the assessors on request.
Key learning points
REACH-HF was well-received. Older, frailer, less technologically-minded patients needed additional time and support to access some programme components like the chair-based exercise DVD so it is important to allow for this in the delivery.
We need to culturally adapt the REACH-HF for ethnic minorities/BAME population where CR uptake is very poor. We will be working with the Heart Manual Department who have translated patient facing materials in Asian languages such as Urdu and Hindi. The REACH-HF Service Delivery Guide will be posted on our website with a view to having this translated to other languages.
Other challenges in intervention delivery are reported in: https://bmjopen.bmj.com/content/9/8/e026039
HCPs who attended the 2019 3-day face-to face training to deliver REACH-HF found it an impressive resource -83% satisfied or very satisfied . Although the ‘training was good’, several facilitators suggested reducing it to 2 days. We implemented this by providing 5x2 day online training in summer 2020 (see section on 'How did you implement the project'). Feedback from the HCPs who attended this training was also positive and we plan to conduct a webinar in 2021 to find out how many participants are actually using REACH HF and their experiences.
Additional reading and resources
In October 2020 we won the BMJ Award for the Stroke and Cardiovascular Team of the year. The judges commended the patient involvement and ‘excellent teamwork producing a real-world solution':
https://vimeopro.com/healthandcarevideos/reach-hf-bmj
The REACH-HF rollout is currently being piloted and evaluated (PhD study) in the ‘real-world’ in: Belfast, Gloucestershire, Wirral and UCLH,
Published protocol for REACH HF Beacons:
https://bmjopen.bmj.com/content/10/6/e036137
Presentation of REACH-HF Beacon Sites study -Implementation Science Conference hosted by NIHR Applied Research Collaboration 2020:
https://www.youtube.com/watch?v=ehxmY1yJ4LU&list=PLKf5MPVrf50yHwgxJm2_RX7kKwuCQHCht&index=5&t=2s
BMJ Awards showcase:
The 2020 BMJ Awards Showcase | Watch our short 5 minute videos
Heart Failure Policy and Practice in Europe:
British Heart Foundation: Heart Failure Blueprint for Change:
https://www.bhf.org.uk/blueprint
REACH-HF Service delivery guide: http://sites.exeter.ac.uk/reach-hf/reach-hf-service-delivery-guide
AHSN Innovation exchange: https://www.ahsninnovationexchange.co.uk/innovations
NICE CVD Impact Report: https://www.nice.org.uk/Media/Default/About/what-we-do/Into-practice/measuring-uptake/cvd-impact-report/nice-impact-cvd-management.pdf
NIHR Journal: Programme Grants for Applied Research: A facilitated home-based cardiac rehabilitation intervention for people with heart failure and their caregivers: a research programme including the REACH-HF RCT (nihr.ac.uk)
REACH-HF website: http://sites.exeter.ac.uk/reach-hf/
REACH HF in the real world – the Wirral experience ( Mar 2021)
https://www.nice.org.uk/sharedlearning/delivering-rehabilitation-enablement-in-chronic-heart-failure-reach-hf-in-wirral
Virtual and in-person cardiac rehabilitation: https://www.bmj.com/content/373/bmj.n1270
Alliance for HF report 2021 (features rehab and REACH HF on p21) https://allianceforheartfailure.org/wp-content/uploads/2021/02/AHF-HF-A-Call-to-Action-FINAL.pdf
Nature Reviews Cardiology The role of cardiac rehabilitation in improving cardiovascular outcomes