From research to practice: piloting clinical implementation strategies for CRAMS (Cardiovascular Rehabilitation for transient ischaemic Attack and Mild Stroke)

One in three strokes in Australia are repeat events. These repeat strokes are more likely to result in death and are costly, for both individuals and the healthcare system. Cardiac rehabilitation is a well-established, evidenced-based and widely available secondary prevention program that reduces disease risk and death from heart disease and could help prevent repeat strokes as both share similar risk factors, such as physical inactivity, high blood pressure and poor diet. However, our research has found that less than 2% of Australian cardiac rehabilitation programs include people with stroke1. This is despite Australian stroke health professionals and cardiac rehabilitation coordinators agreeing that cardiac rehabilitation is suitable for people after a transient ischaemic attack (TIA) or mild stroke2. Our recent randomized trial has found that a 6-week integrated (TIA, mild stroke, heart disease) traditional cardiac rehabilitation program (Cardiovascular rehabilitation, CVR) is feasible with very few barriers for patients and clinicians but implementation strategies to promote uptake within existing cardiac rehabilitation programs need to be investigated3,4.

Here Canberra Health Services (CHS) will partner with the University of Canberra, supported by the Stroke Foundation, to evaluate the effectiveness of implementation strategies to promote the uptake of CVR programs in one health service considering process measures such as acceptability, adoption, appropriateness, feasibility, fidelity, cost, penetration and sustainability. This 2-year pilot implementation trial will use a pragmatic pre-post trial design and will be conducted within CHS (Canberra and North Canberra Hospitals). The multi-component implementation intervention will first be developed using implementation frameworks, data from our randomized trial and in consultation with stakeholders (stroke and cardiac rehabilitation clinicians, managers, patients). We will then assess the effectiveness of the implementation strategies (e.g. DHR referral, clinician training) for improving clinician referral and provision of cardiac rehabilitation to people who have had a TIA or mild stroke (CVR program) over 12-months. Implementation outcome (i.e. number people with TIA or mild stroke referred, commenced and completed the CVR program) and process measures will be collected using routinely collected administrative data, clinician semi-structured interviews and surveys, and observations of the clinical context. Results will guide the implementation of this novel program on a larger scale, identifying solutions to address the research to practice gap, rarely included in efficacy or effectiveness trials. By making minor adaptations to existing cardiac rehabilitation programs the CVR program will support lifestyle modifications in this population to reduce the risk of recurrent CVD events, aiming to help more Australians live longer and healthier after TIA and mild stroke and avoid hospital readmissions.