Coronary heart disease (CHD) remains a major cause of morbidity and mortality worldwide; annual estimates indicate that 7.4 million deaths globally and 1.8 million deaths in Europe are attributable to CHD [1, 2]. In the UK, an estimated 2.3 million people have CHD, with approximately 492,000 hospitalisations (324,000 men; 168,000 women) and 69,000 deaths (41,000 men; 28,000 women) attributable to CHD in 2013/14 [3]. Cardiac rehabilitation (CR) is an important component of medical management for CHD, improving longer-term patient outcomes, including readmissions, cardiovascular mortality and quality of life [4‐7]. However, despite clear evidence demonstrating beneficial effects, and recommendations for CR in clinical guidelines [8‐11], uptake of CR services globally is poor [12‐15]. In the UK, the National Audit of Cardiac Rehabilitation (NACR) estimated an overall uptake of CR of 45% in 2013 and 47% in 2014 [12, 16]. Areas identified as requiring action included: low referral rates, uptake and completion rates; prolonged times from index event/discharge to commencement of core CR; inadequate duration of CR programmes; and inadequate pre- and post-CR assessments [12]. NACR emphasised the importance of service review, re-design and innovation to ensure CR programmes meet national recommendations [10‐12].

Buckinghamshire Healthcare NHS Trust (BHT) identified the need for a CR service redesign due to poor CR recruitment and completion rates (only 47% of all enrolled patients completed CR and only 5 patients with chronic heart failure were referred for CR annually), and use of paper-based records impaired data-sharing across the CR team. Janssen Healthcare Innovation, a division of Janssen-Cilag UK, supported the patient-centric CR service redesign at BHT with a programme, Care4Today® Heart Health Solutions. The service redesign included development of a web-enabled secure platform designed for healthcare professionals to facilitate patient management along a standardised care pathway, and a patient portal with educational content to increase patient and carer engagement. The novel CR service, implemented in 2013, was aimed at optimising patient recruitment and retention, decreasing readmissions and increasing patient and staff satisfaction. The key characteristics of the pre- and post-service redesign CR programmes are summarised on Table 1.

In order to evaluate the impact of the new CR model on service delivery and patient outcomes, a single centre observational study was carried out in conjunction with a local service evaluation. This was carried out by (i) comparing the 12 month periods pre- and post-implementation of the novel CR service in terms of: emergency cardiac-related readmissions within 30 days, 6 months and 12 months of discharge; CR entry, participation and completion; and (ii) assessing patient and staff satisfaction with the new CR service.

The observational study and service evaluation were conducted at BHT following implementation of the novel CR service on the 1st October 2013. The observational study and service evaluation involved retrospective data collection for the 12-month pre-implementation period and prospective data collection for the 12-month post-implementation period. The observational study was established to formally evaluate the impact of the service change by comparing pre-implementation (Cohort 1) and post-implementation (Cohort 2) patients (350 patients in each cohort). The service evaluation was carried out in parallel to enable BHT to assess the impact of the service change on an ongoing basis in the interim, and ultimately to collect information in larger groups of patients beyond the scope of the research study.

For the observational study, patients referred for CR in cohorts 1 and 2 were closely matched for age, sex and time from index event to discharge, as shown in Table 2. A higher proportion of patients in Cohort 2 had HF (5.7%) compared with Cohort 1 (1.7%, adjusted P = 0.036; see Table 2). Similarly, in the service evaluation, patients referred for CR in Cohorts 1 and 2 were well matched except for a significantly higher proportion of patients with HF in Cohort 2 (6.5%) compared with Cohort 1 (1.8%, adjusted P < 0.001; see Table 3).

In the UK, CR is considered an important component of integrated cardiology services, with the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) emphasising that referral of eligible patients for CR is as important as prescription of cardioprotective medication [10]. While exercise is a core component of all CR programmes, guidelines recommend more comprehensive programmes, which additionally include a range of educational activities and psychological and social support. However the nature and frequency of different interventions and the overall duration and intensity of CR programmes vary considerably [7, 18]. There is evidence to suggest that differences in the design and implementation of CR programmes, including factors such as supervised exercise, development of individualised programmes, and use of information technology, can influence patient outcomes [19, 20]. Based on the results of the present observational study and service evaluation, introduction of the novel CR service model was associated with short-term improvements in emergency readmissions and increases in: monthly patient referrals to CR, the proportion of patients with HF referred for CR, the proportions of referred patients entering and completing CR, and the duration of CR.

More Cohort 2 patients were referred for CR compared with Cohort 1, suggesting introduction of the new service model increased identification of patients suitable for CR by clinicians. However, we cannot exclude that there was an increase in the number of patients with cardiac events post-implementation of the novel CR model. In both cohorts of the observational study and service evaluation, women represented approximately 25% of all referred patients, with no difference in the proportion of women entering or declining CR. Based on recent UK data, women comprise approximately 34% of all CHD-related hospitalisations [3], suggesting that women were under-represented amongst those referred for CR pre- and post-implementation of the new CR service model. These results are consistent with the results of systematic reviews and meta-analyses of CR clinical trials and recent NACR data indicating under-representation of women in CR programmes is widespread as is the under-representation of older people and people with HF [5‐7, 12, 16]. The proportion of patients with HF was significantly higher in Cohort 2 than Cohort 1 of both the observational study and service evaluation. The proportions of patients with HF referred and entering CR in Cohort 2 were higher than those recently reported in the NACR 2014 and 2015 audit data for England (2.8% and 4.4% respectively) [12, 16]. Overall, the proportion of referred patients entering CR was significantly higher in Cohort 2 compared with Cohort 1. Taken together these results support a beneficial effect of the CR service redesign in increasing referral and entry of patients into CR, and increasing recruitment to CR of patients with HF. The mean age of patients referred for CR was similar in cohorts 1 and 2 and similar in patients entering and declining CR in Cohort 1, however, in Cohort 2 those entering CR were approximately 5 years younger than those who declined CR. The results in Cohort 2 are broadly consistent with recent NACR reports indicating that patients entering CR were 8–9 years younger than the overall patient population eligible for CR [12, 16].

Systematic reviews and meta analyses of CR clinical trials indicate that significant reductions in readmissions in patients participating in CR, compared with those not participating in CR, tend to be observed only in the short-term, up to 12 months of follow-up [5‐7]. The observed reduction in patients with ≥1 cardiac-related emergency hospital readmissions within 6 months of discharge and trend towards a reduction in 12-month readmissions in Cohort 2 (overall and in the sub-group of patients entering CR) in this study is therefore encouraging, demonstrating an incremental benefit of the new CR model. These findings may suggest that the short term reduction in emergency readmissions associated with CR may reflect, at least in part, an influence of contemporaneous active participation in CR and the associated contact with healthcare professionals, which may encourage and motivate beneficial lifestyle changes in the short term. These benefits may be lost once regular interactions cease and patients are discharged to long term management. However, given the substantial improvement in patient outcomes over the past three decades due to major advances in medical management and availability of exercise-based CR programmes, the demonstration of an incremental benefit of the novel CR service model highlights the importance of CR service review, re-design and innovation and the results that can be achieved within a single centre.

For patients who entered CR, the absolute proportion completing CR, defined as patients completing an end of programme assessment consistent with BACPR recommendations [10], increased by more than 28% following introduction of the new CR service model, mirroring improvements in CR completion reported in the NACR 2015 audit compared with the 2014 audit [12, 16]. The median time from discharge to CR entry in Cohort 2 was 35 days, representing an improvement of 11 days compared with Cohort 1. Given the mixed patient population included in the present study, the time to CR entry for patients in Cohort 2 is broadly consistent with national guidance that CR should begin within 4 weeks of discharge for patients with MI and PCI and within 6 weeks for patients with CABG [4, 16, 21]. For patients completing CR, the median duration of CR in Cohort 2 was 80 days, significantly longer than in Cohort 1, and consistent with National guidelines indicating an ideal programme duration of 12 weeks [4, 10, 16]. Taken together, these data indicate that the CR service redesign led to a substantial increase in patient engagement with CR. This is reflected in the high levels of patient satisfaction with the information provided in preparation for CR and with the overall CR programme upon completion.

Implementation of the novel CR service including a comprehensive programme tailored to individual patient needs and with a more patient-centric focus resulted in a short-term reduction in emergency cardiac-related readmissions and sustained improvements in patient referral, CR entry and patient engagement. This study highlights the benefits that can be achieved within a single centre through CR service review and re-design, including the use of innovative technologies to facilitate patient management and increase patient and carer engagement.