Affordable Cardiac Rehabilitation: An Outreach Inter-disciplinary Strategic Study (ACROSS)

Research question: Is implementation of a culturally and contextually adapted home-based rehabilitation programme for people with multimorbidity that includes coronary heart disease and/or heart failure with co-existing depression and/or anxiety, clinically effective, cost-effective, sustainable, and scalable in Bangladesh, India, and Pakistan? Background: The multimorbidity of heart disease alongside the mental health disorders of depression and anxiety is a common and profound unmet need for global health systems, especially in low and middle-income country (LMIC) settings. Rehabilitation is a proven model of secondary prevention, shown in high income settings to reduce mortality, hospital admissions (and consequent health care costs), and improve health-related quality of life and mental well-being of people with heart disease and mental health disorders. However, the evidence and infrastructure needed for delivery of rehabilitation services is absent or lacking in LMICs, resulting in a huge loss of potential health and socio-economic benefit. Home-based programmes provide an affordable model of delivery that can leverage a scalable increase in rehabilitation access in LMICs, a key strategic global goal of the World Health Organisation. Aims and objectives: The ACROSS (Affordable Cardiac Rehabilitation: An Outreach Inter-disciplinary Strategic Study) project seeks to co-develop (with patients, caregivers, clinicians, and service commissioners) an applicable and affordable home-based ('ACROSS') rehabilitation programme for people with multimorbidity that includes coronary heart disease and/or heart failure with co-existing depression and/or anxiety and evaluate the acceptability, clinical effectiveness, and cost-effectiveness of its implementation in Bangladesh, India, and Pakistan and to determine its scalability and sustainability. Methods: Four linked work packages (WPs). WP1 (cultural/contextual adaptation and refinement of rehabilitation Intervention): examine rehabilitation implementation barriers/enablers from multiple stakeholder perspectives and co-develop a feasible and acceptable ACROSS rehabilitation programme, extended to take account of co-existing depression and/or anxiety; WP2 (external pilot): assess feasibility/acceptability of the ACROSS rehabilitation programme and study design and processes necessary for a full-scale trial; WP3: (multi-country hybrid effectiveness and implementation randomised trial) to determine the clinical and cost effectiveness of the ACROSS rehabilitation programme for people with coronary heart disease and/or heart failure) and depression and/or anxiety; WP4 (capacity building): build research and rehabilitation delivery capacity. Timelines for delivery: In partnership with CEI/PPIE, the project will be conducted over 60 months with 6-months prefunded preparatory phase when activities of ethics approval, staff recruitment, PhD advertising will begin. Because of their contingencies, WPs 1-3 will be conducted in series: WP1 from months 0-12, WP2 from months 12-30, and WP3 from months 30-60. WP4 (training/capacity building) will take place across the 60 months. Anticipated impact and dissemination: A cost-effective rehabilitation model in low resource settings for people with multimorbidity that includes heart disease and depression and/or anxiety offers huge potential health and socio-economic benefits. The wider implementation of such an affordable intervention model also offers an important strategic opportunity to overcome the problem of suboptimal rehabilitation access experienced in high-income settings. We will disseminate our findings widely, using a variety of approaches, supported by our stakeholder and patient advisory groups.