Piloting Implementation Strategies for Clinicians: Cardiovascular Rehabilitation for transient ischemic Attack and Mild Stroke

This study will evaluate the potential effectiveness of implementation strategies targeted at improving uptake (clinician referral and delivery) of cardiac rehabilitation programs that include people with TIA or mild stroke, alongside people with Coronary Heart Disease (CHD), within one health service (Canberra Health Services) (North Canberra Hospital and The Canberra Hospital). Phase II cardiac rehabilitation in Australia is multidisciplinary, time-limited (e.g. 6-weeks), conducted in groups, health service-based, and has educational and supervised exercise components. The aim of the individually tailored exercise sessions is to increase exercise capacity, and education sessions aim to increase the patient’s knowledge of their cardiovascular disease condition and increase risk factor self-management skills. In this study, people with TIA and mild stroke will be referred to, and included in the delivery of existing outpatient cardiac rehabilitation programs at two sites, The Canberra Hospital (TCH) and North Canberra Hospital (NCH). No modifications to existing cardiac rehabilitation exercise sessions are required for this study, however the inclusion of the above brain, ischemic stroke and TIA education as part of existing education sessions will be encouraged to promote integration A multi-component implementation strategy intervention will be developed to increase the number of people with TIA or mild stroke who have been referred, commenced and completed cardiac rehabilitation. To achieve this, this study will be conducted in three phases over 12 months. • Phase 1 (3-months): The ‘Experience based co-design toolkit for Australia’ five-step methodology will be used to develop and refine the implementation strategies: 5-10 stroke and cardiac rehabilitation clinicians, managers and TIA or mild stroke patients will be recruited to participate in 3-4 workshop to develop the implementation strategy intervention and provide feedback. Workshops will be facilitated by an experienced qualitative researcher and audio recorded and will occur approximately 2 weeks apart over a 2 month period. Workshop 1 will outline the project aims, providing background information before breaking into smaller groups for brainstorming and discussion to explore factors influencing the uptake (referral and delivery) of cardiac rehabilitation for people with TIA or mild stroke. The group will return together to summarize ideas and themes. Workshop 2, and 3 if needed, will begin with a summary of key themes and ideas from the previous workshop. Participants will be asked to identify feasible strategies to address the factors identified in workshop 1 that could increase the uptake (referral and delivery) of cardiac rehabilitation among people with TIA and mild stroke in existing services. Researchers will facilitate discussions and encourage stakeholders to problem-solve to reach agreement, utilizing information gathered from previous research. The Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF) will be used to underpin the development and refinement of the implementation intervention and identify factors influencing potential implementation during the co-design process. A final workshop will be held once implementation strategies and resources have been developed by researchers, to provide feedback and finalize the overall implementation intervention. • Phase 2 (the 3-months following phase 1): The multi-component implementation intervention will be delivered by the research team to stroke and cardiac rehabilitation clinicians, supporting cardiac rehabilitation uptake by people with TIA or mild stroke in their routine practice. The delivery of the implementation intervention will be largely contingent on the outcomes of phase 1 and hence further specifics cannot be provided at this time, however based on prior research this may include establishment of clear referral pathways and eligibility criteria, delivery of education to stroke or cardiac rehabilitation clinicians or increasing program awareness. • Phase 3 (the 12-months following phase 2): The stroke and cardiac rehabilitation clinicians will be encouraged to utilise the implementation intervention over 12-months to support referral to and delivery of cardiac rehabilitation for people with TIA or mild stroke. We will then evaluate the effectiveness of the implementation strategy intervention at mid and end time-points of implementation strategy intervention rollout, over the 12 month period. With informed consent, participants in this study will participate in co-design workshops (phase 1, first 3 months), interviews with research staff (phase 3, final 12 months), and an online survey (phase 3, final 12 months). Semi-covert observations of clinical settings to observe the use of implementation strategies will also be conducted by research staff in phase 3 (12 months). A resources and training log will be kept to log details on clinician training provided during delivery of the implementation strategy intervention (phase 2), and associated costs of the delivery. For the pre-post implementation comparison component of the study, hospital administrative data will be collected at the start and end of the 12-month implementation strategy intervention roll-out period, and will include number people with TIA or mild stroke referred, commenced and completed the cardiac rehabilitation program. No identifiable patient data will be collected.