A systematic review of provider-and system-level factors influencing the delivery of cardiac rehabilitation for heart failure

Paulina Daw, Thomas M Withers, Jet J C S Veldhuijzen van Zanten, Alexander Harrison, Colin J Greaves

Research output: Contribution to journalArticlepeer-review


BACKGROUND: There is a longstanding research-to-practice gap in the delivery of cardiac rehabilitation for patients with heart failure. Despite adequate evidence confirming that comprehensive cardiac rehabilitation can improve quality of life and decrease morbidity and mortality in heart failure patients, only a fraction of eligible patients receives it. Many studies and reviews have identified patient-level barriers that might contribute to this disparity, yet little is known about provider- and system-level influences.

METHODS: A systematic review using narrative synthesis. The aims of the systematic review were to a) determine provider- and system-level barriers and enablers that affect the delivery of cardiac rehabilitation for heart failure and b) juxtapose identified barriers with possible solutions reported in the literature. A comprehensive search strategy was applied to the MEDLINE, Embase, PsycINFO, CINAHL Plus, EThoS and ProQuest databases. Articles were included if they were empirical, peer-reviewed, conducted in any setting, using any study design and describing factors influencing the delivery of cardiac rehabilitation for heart failure patients. Data were synthesised using inductive thematic analysis and a triangulation protocol to identify convergence/contradiction between different data sources.

RESULTS: Seven eligible studies were identified. Thematic analysis identified nine overarching categories of barriers and enablers which were classified into 24 and 26 themes respectively. The most prevalent categories were 'the organisation of healthcare system', 'the organisation of cardiac rehabilitation programmes', 'healthcare professional' factors and 'guidelines'. The most frequent themes included 'lack of resources: time, staff, facilities and equipment' and 'professional's knowledge, awareness and attitude'.

CONCLUSIONS: Our systematic review identified a wide range of provider- and system-level barriers impacting the delivery of cardiac rehabilitation for heart failure, along with a range of potential solutions. This information may be useful for healthcare professionals to deliver, plan or commission cardiac rehabilitation services, as well as future research.

Original languageEnglish
Article number1267
Number of pages13
JournalBMC Health Services Research
Issue number1
Publication statusPublished - 24 Nov 2021

Bibliographical note

© 2021. The Author(s).


  • Cardiac Rehabilitation
  • Health Personnel
  • Heart Failure
  • Humans
  • Quality of Life

Cite this