Adopting adaptation in REACH-HF

This invited commentary refers to ‘Adapting an evidence-based, home cardiac rehabilitation programme for people with heart failure and their caregivers to the Danish context: DK:REACH-HF study’, by M. Eghøj et al., https://doi.org/10.1093/eurjcn/zvae037. Cardiac rehabilitation is a well-established and effective intervention recommended for people with cardiovascular disease, but referral, access, enrolment, and completion rates vary markedly across the world, with many people likely to benefit not being offered or receiving it.1,2 For example, in the UK, national guidelines and clinical standards produced nearly 30 years ago recommended that cardiac rehabilitation be offered to all who are likely to benefit; start simultaneously with the process of medical diagnosis and management; components, such as exercise or psychological support, be tailored to individual need and context (i.e. not all patients require every component of a comprehensive rehabilitation programme); involve the partner or caregiver; and be delivered in the hospital, home, or community.3 However, most cardiac patients do not receive rehabilitation; service provision varies markedly; and many programmes are focused on select populations, predominantly those with acute coronary syndrome, often operate in an inflexible manner, and fail to add potential value.4 Despite exhortations5 and international guidelines6–8 recommending participation in cardiac rehabilitation as part of heart failure management, many people with heart failure do not receive rehabilitation, and a more holistic approach, rather than the predominant focus on exercise, is likely needed to increase uptake. An individualized, needs-led approach exploiting the latest digital technologies when appropriate has the potential to fill existing gaps; improve access, uptake, and completion; and ensure optimal health and well-being for people with heart failure and their families. The core elements of education, exercise, lifestyle change, and psychosocial support should, unless contraindicated due to medical reasons, be offered routinely to people with heart failure, but tailored to individual needs and circumstances, such as age and frailty, and possibly for recipients of cardiac implantable electronic devices or left ventricular assist devices.9,10 It is against this background that the paper ‘Adapting an evidence-based, home cardiac rehabilitation programme for people with heart failure and their caregivers to the Danish context: DK:REACH-HF study’11 is a timely contribution. Rehabilitation EnAblement in Chronic Heart Failure (REACH-HF) is a novel home-based, health professional-facilitated, self-management programme for people with heart failure and their caregivers.12 It comprises a manual-based structured exercise training programme, education modules, and psychological support facilitated by trained healthcare professionals over a 12-week period. Developed and evaluated in the UK, the REACH-HF intervention has been shown to improve health-related quality of life and be an affordable alternative to traditional centre-based programmes,13 to improve the self-confidence of self-management among caregivers,14 and likely be cost-effective.15 Based on such evidence, REACH-HF is being implemented as a cardiac rehabilitation service for patients with heart failure in the UK National Health Service. As the authors of the accompanying paper11 note, adapting an existing evidence-based intervention (REACH-HF) to another context—in this case, a Danish healthcare setting (DK-REACH-HF)—is potentially much more efficient for healthcare systems than designing a completely new intervention. This paper describes the process of adaptation—the intentional modification(s) of an evidence-informed intervention to achieve a better fit between an intervention and a new context—in accordance with ADAPT guidance,16 a four-step process for adapting interventions to new contexts: assess rationale for intervention and intervention-context fit of existing intervention; plan for and undertake adaptations; plan for and undertake piloting and evaluation; and implement and maintain adapted intervention at scale. This paper reports the first two steps, i.e. the development of the Danish version of the REACH-HF intervention, which will inform steps three (piloting) and four (implementation). The authors undertook, for over nearly 2 years, a systematic approach comprising guideline and policy analysis, stakeholder (patient, caregiver, and healthcare professional) consultations, mapping of the Danish policy (political, organizational, and sociocultural) context, and drafting and finalizing of the DK-HEART-HF intervention, including a digital version, and external review. The authors report that they were able to adapt the original REACH-HF intervention to the Danish health and cultural context, maintain core components, and develop manual and digital versions of the DK-REACH-HF programme. Study findings revealed an important difference in informal caregiver roles and responsibilities between the UK and Denmark and identified key areas of adaptation for the Danish context, including reducing the word count of the intervention’s resources by linking to existing publicly available cardiac rehabilitation materials. The paper highlights the complexity of achieving a good fit between an intervention and a context. As the authors point out, a strength of this study is that it was designed in accordance with ADAPT guidance for the methodological process for intervention adaptation.16 Another strength is the co-production of the adapted intervention with Danish patients with heart failure, their caregivers, and healthcare professionals. The study findings accord with the need to consider more creative, flexible, patient-responsive, and cost-effective approaches to rehabilitation for people with heart failure that are easily accessible.9,10 Home-based approaches made possible through digital technologies, such as REACH-HF, are an attractive option, but whatever approach is adopted, the core elements should, depending on an assessment of individual needs, circumstances, and choice, consist of education, lifestyle change, exercise, and psychosocial support, unless contraindicated due to medical reasons.9 Provision of rehabilitation that is flexible and individualized, with easy access, may help improve uptake and adherence to help optimize health and well-being for people with heart failure. As this study demonstrates, contextual factors, such as the setting in which rehabilitation is delivered, and the resources and support available, are important considerations.17 Moreover, the mechanisms by which such interventions work, for whom, when, and why remain unclear, and more nuanced approaches are needed for this to be elucidated.18 The authors are to be commended on the co-design, conduct, and reporting of this study, which is high on novelty, rigour, and significance and makes an important contribution to the literature pertaining to cardiac rehabilitation, heart failure, and adaptation science. Particularly noteworthy is the insight into how adaptation methodology can be applied to other cardiovascular interventions in a political, sociocultural, and organizational context, with an added benefit of increasing their sustainability and scalability potential.