Understanding implementation outcomes of cardiovascular rehabilitation for transient ischaemic attack and mild stroke: a process evaluation

AIMS: Despite evidence supporting the inclusion of people with transient ischaemic attack (TIA) or mild stroke in cardiac rehabilitation, no process evaluations have investigated the implementation of integrated [TIA, mild stroke, coronary heart disease (CHD)] cardiovascular rehabilitation (CVR). We aimed to identify factors influencing CVR implementation success or failure, and evaluate CVR implementation outcomes, considering reach, effectiveness, adoption, implementation, and maintenance, from clinician perspectives. METHODS AND RESULTS: This mixed-methods process evaluation was guided by the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. Quantitative patient process-level data were collected throughout CVR implementation. Qualitative data (semi-structured interviews, field notes, observations) were collected and deductively coded to the Consolidated Framework for Implementation Research. Quantitative and qualitative data were mapped to the RE-AIM dimensions. Reach was 44% (140/315) of the eligible patient population, with referral adoption highest at site 1 (74%), influenced by larger referral teams and greater programme awareness. Clinicians viewed CVR as effective based on international recommendations, but more evidence is needed. Cardiovascular rehabilitation was delivered as intended, with fidelity linked to adequate staffing and clinician confidence in delivery. Sixty-six per cent (46/70) of patients completed ≥5 of 6 CVR sessions. Clear referral pathways and access to resources are necessary for CVR maintenance. CONCLUSION: Cardiovascular rehabilitation was delivered as intended, and clinicians reported people with TIA, mild stroke, and CHD demonstrate similar needs. However, greater programme awareness and aligning referral pathways with existing services are indicated. Access to CVR programme resources and clinicians' confidence in CVR delivery enabled implementation and are essential for maintenance. REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN 12621 00158 6808.