Adapting cardiac telerehabilitation from research evidence to real-world implementation: engaging stakeholders

This invited commentary refers to ‘Stakeholder perceptions of factors contributing to effective implementation of exercise cardiac telerehabilitation in clinical practice’, by J.C. Rawstorn et al., https://doi.org/10.1093/eurjcn/zvae127. Although compelling evidence indicates the benefits of cardiac rehabilitation (CR) in reducing hospitalization and mortality and improving health-related quality of life for patients with ischaemic heart disease (IHD), the path from treatment to rehabilitation and beyond is rarely straightforward.1 Patients with IHD are required to attend in structured sessions lasting 12 weeks or more, which focus on exercise training, risk factor management, and psychosocial counselling, provided by a team of multidisciplinary CR professionals. Barriers along the way include a lack of resources and infrastructure, fragmented care systems with inadequate referral processes, and challenges related to awareness, time, and geography. These challenges are further compounded by persistent disparities in participation based on sex, ethnicity, age, and socio-economic status, as well as the increasing burden of comorbidities in the aging population.2,3 In this complex care context, harnessing the advantages of technology and involving all stakeholders in CR implementation becomes both promising and time sensitive. Health technology-driven delivery models, such as telerehabilitation, enable connections between patients and CR professionals through mobile phones, apps, instant messaging, and wearable devices.4 The telerehabilitation model has three key advantages that make it an effective alternative: it allows for real-time monitoring and feedback, empowers patients to make health choices based on their personal preferences, and has a low incidence of major exercise-related adverse events.5 However, this approach necessitates a new type of partnership between patients and professionals, requiring different levels of commitment from the healthcare system, healthcare professionals, and patients themselves.6 Additionally, the current body of knowledge is primarily derived from research studies rather than real-world practice, making it essential to involve stakeholders’ perspectives to effectively translate this knowledge into practical application.7,8 In a recent study published by Rawstorn et al.,9 patients, healthcare professionals, and health service managers from four healthcare settings offering CR programmes were interviewed. Three of these settings provide in-person CR, while one offers eHealth education. The data were analysed thematically using two frameworks: the Spread and Sustainability framework and the Consolidated Framework for Implementation Research. The importance of this study lies in offering insights into adapting complex interventions into real-world implementation. The intricacies of this topic are rooted in the nature and suitability of the intervention, attitudes towards change and innovation, resource availability, expertise, competing priorities, and time constraints. Additionally, the same intervention can be performed differently across various organizations due to the mentality and characteristics of the people involved. Without considering stakeholders’ perspectives, the adaptation of research evidence to clinical practice can be delayed or obstructed. Moreover, such dialogue can provide insights into how the intervention should be tailored or modified for real-world practice without compromising the effectiveness demonstrated in clinical trials.10 Consistent with existing evidence, stakeholders from this study considered the clinical implementation of telerehabilitation to have multiple strengths and potentials in terms of cost, effectiveness, safety, and enhancing health equity.5,11 This knowledge provides reassurance for researchers and practitioners who are actively promoting and advancing cardiac telerehabilitation, affirming that the potential for real-world implementation is tangible and well recognized. The work of Rawstorn et al. expands the concept from cost to value, as telerehabilitation is considered to deliver significant value for both patients and the healthcare system. It achieves this by providing patient-centred, autonomy-enabled care that can augment traditional CR in a sustainable manner. Recognizing this full value can contribute to fundraising and lobbying for societal and governmental support for telerehabilitation implementation. Thus, the potentials and intrinsic advantages of telerehabilitation make its implementation worthwhile despite the complexities and difficulties associated with facilitating the transition. The collective wisdom from the stakeholders generated possible solutions to resolve the challenges of implementation, particularly in soliciting resources and facilitating changes. Resource constraints were widely reported and discussed, including a lack of funding support, Internet accessibility and stability, local medical support for safety and risk management, and tele-care resource at smaller sites. The proposed suggestions emphasize resolving these barriers through optimizing and integrating existing resources, such as increasing activity-based funding opportunities, taking advantage of the rapid development of mobile network infrastructure, and promoting regional partnerships by referring patients from smaller sites to attend telerehabilitation at larger-scale centres. Another widely reported challenge is preparing staff to shift from one-to-one healthcare provision to a one-to-many model. Facilitator-led training can help with staff preparation for this transition. It is worth noting that participants in this study also recognized stereotypes towards older persons and emphasized that they should not be excluded. The technology should be developed inclusively to ensure accessibility for all age groups. Successful implementation of cardiac telerehabilitation requires a tailored approach that considers the specific characteristics of each healthcare organization.12 Organizational culture, patient demographics, and available resources can significantly influence the feasibility and effectiveness of these programmes. Factors such as the existing infrastructure, staff expertise, and patient preferences should be carefully assessed to identify potential challenges and opportunities.13 By customizing implementation strategies to meet the unique needs of each setting, healthcare organizations can maximize the benefits of telerehabilitation and improve patient outcomes. A critical consideration in the implementation of cardiac telerehabilitation is the protection of patient data.14 The sensitive nature of health information, coupled with the remote delivery of care, necessitates robust data governance and security measures. Adherence to relevant regulations is essential to safeguard patient privacy and maintain public trust. Encryption, access controls, and regular audits of security protocols are among the key strategies to mitigate data breaches and ensure the confidentiality, integrity, and availability of patient data. Though scepticism arose in this study regarding whether the current safety approaches adopted by several rehabilitation institutions were suitable. In summary, the study explored and discussed the resources, change management, knowledge, and intervention design among stakeholders of cardiac telerehabilitation, offering insights into crucial elements to be considered before clinical implementation. It underscores the importance of context, resources, people, and values in understanding the complexity of implementation research and transitioning telerehabilitation evidence into practice. By addressing and mobilizing these elements, different cardiovascular clinics can leverage their own strengths and advantages to provide better care. Jing Jing Su (Conceptualization [lead], Writing—original draft [lead]), Garyfallia Pepera (Conceptualization [supporting], Visualization [supporting], Writing—original draft [supporting]), Varsamo Antoniou (Conceptualization [supporting], Visualization [supporting], Writing—original draft [supporting]), and Ladislav Batalik (Conceptualization [supporting], Visualization [supporting], Writing—review & editing [lead]) This research was funded by the Ministry of Health, Czech Republic, conceptual development of research organization (FNBr, 65269705). No new data were generated or analysed in support of this research.