Introduction
The burden associated with cardiovascular diseases globally is considerable; it is the leading cause of mortality and a key cause of disability.1 The burden is increasing, with prevalent cases of cardiovascular disease doubling between 1990 (271 million cases) and 2019 (523 million).1 Subsequently, there is a need for effective and cost-effectiveness healthcare interventions for affected populations. Cardiac rehabilitation (CR) is a supervised programme offered to people following a cardiac event and comprising of exercises, education and psychological care.2 Evidence suggests that CR reduces morbidity and improves quality of life, and is often cost-effective.2 3
In the UK, around 90 000 people start CR annually (2019 figures).4 Three-quarters of CR participants in the UK access group-based supervised CR at a healthcare centre.4 Though there is evidence to suggest centre-based and home-based delivery modes have equivalent outcomes, a minority of participants have home-based CR (8.8%).4 5 On entry to CR around 30% of people have symptoms of anxiety and around 20% have symptoms of depression.4 Therefore, CR programmes are uniquely placed to provide vital psychological interventions. A meta-analysis identified that psychological interventions added to exercise-based CR were associated with a reduction in symptoms of depressions and cardiac morbidity.6 As centre-based and home-based CR are available, psychological intervention is needed across delivery modes.
Discrete choice experiments (DCE) are increasingly used to elicit preferences for healthcare interventions and services.7 8 Within a DCE, participants make choices between hypothetical scenarios that are summarised using key attributes. Each attribute has several levels that account for how the attribute can vary. Stated preference methods are based on the assumption that healthcare interventions and services can be described by a number of attributes and that an individual’s valuation of that intervention/service will vary according to their preferences for levels of those attributes.9 Responses allow researchers to quantifiably elicit stated preferences.
The current evidence base for preferences in CR is methodologically heterogeneous and focuses on exercise and education activities. Boyde et al, found preferences were strongest for centre-based programmes providing timely group exercise sessions and one-to-one educational sessions.10 While the results indicated that technology delivered exercise and educational sessions would be less popular, preference heterogeneity was noted, and authors discussed that a one-size-fits-all approach may be unsuitable. Kjaer and Gyrd-Hansen reported preference heterogeneity when they focused on preferences for CR activities.11 12 Activities included physical exercises, personal meetings with a nurse, group counselling, diet guidance and smoking cessation. The authors found that personal meetings were preferred, followed by physical exercise, and nutritional counselling. Preferences differed by gender, and older people (especially men) did not value the offer of CR highly. Whitty et al, found home-based chronic heart failure management plans were preferred by older people, those with a lower income and people living alone.13 Tang et al, found people who preferred a home-based setting for CR reported better physical health and exercise capacity.14 Overall, the existing evidence suggests preferences for home-based CR is heterogeneous.
There has been a significant increase in home-based CR mode of delivery (23%–59%) due to COVID-19 service adaptation.15 Given the growing focus on home-based CR formats and the lack of evidence on preferences for psychological care in CR, there is a clear need to investigate patients’ preferences for the design of home-based CR to inform future research and intervention design. The present study is part of an National Institute for Health Research-funded programme called PATHWAY aimed at improving psychological outcomes in CR patients using group-based or home-based metacognitive therapy.16–18
The PATHWAY Home-MCT feasibility single-blind randomised controlled trial (RCT) investigated the acceptability of delivering metacognitive therapy (MCT) in a home-based format for CR participants with symptoms of anxiety and depression.16 The trial recruited people referred to UK National Health Service (NHS) CR programmes with a score of ≥8 in the anxiety and/or depression subscales of the Hospital Anxiety and Depression Scale. Further details on the design and delivery of Home-MCT are available in the trial protocol.16 Results of the trial, which will be published separately, will provide evidence on the acceptability and feasibility of delivering the home-based format for metacognitive therapy for a sample of CR participants. The current study is an extension of the feasibility study; a pilot discrete choice experiment recruited from trial participants to investigate preferences for the delivery of psychological therapy in CR.
Aims and objectives
The primary aim of this study was to explore the preferences of participants in the Home-MCT feasibility study, who have experienced a cardiac event and have symptoms of anxiety and/or depression, for attributes of a psychological therapy intervention in patients. Specific objectives were to:
Identify which attributes were most important to patients.
Evaluate the feasibility of recruiting from a trial sample.
Estimate the sample size needed for a full study.
The results of this pilot DCE will help to inform the design of future studies to explore the preferences of patients for psychological interventions.