AimsAnxiety, depression, and post-traumatic stress symptoms are common in cardiac rehabilitation (CR) patients. Group metacognitive therapy (MCT) alongside CR can significantly improve such symptoms compared to usual care. We aimed to conduct the first implementation study of group-MCT in NHS CR services. The objectives were: 1. Establish sites and assess levels of adoption; 2. Revise and pilot data capture via national auditing systems to assess MCT attendance and uptake; 3. Assess site-level MCT-adherence under roll-out conditions.MethodsA mixed-methods study evaluated implementation of group-MCT in routine care in CR services. Services across England were recruited as early adopters and staff were trained. The National Audit of Cardiac Rehabilitation (NACR) database was modified to collect and assess performance of group-MCT data capture. Five implementation outcomes were assessed; uptake and adherence, data-capture and quality, patient characteristics, site-level of adoption, and treatment adherence.ResultsTwenty-six courses of group-MCT were delivered across six services, with an average of 4.3 courses per site and 131 patients receiving treatment. 82.4% of patients attended at least four sessions. Five services met all outcomes and were classed as green; one failed on one criterion and was rated amber. Data capture worked but with some minor discrepancies. Levels of intervention adherence were excellent, with high consistency across sites and time.ConclusionsWe established six sites meeting our recruitment threshold and demonstrated satisfactory data capture on MCT attendance and uptake via national auditing systems. Five out of six sites met all adoption criteria. Site level adherence and compliance was excellent at 86.7%. Wider-scale adoption could improve access to evidence-based psychological therapy and enhance outcomes across the 188 CR-services in England.

Background This study was designed to explore cardiac rehabilitation (CR) practitioners' experiences and perceptions of group metacognitive therapy training, identifying the facilitators and barriers encountered. Methods A nested qualitative study using reflexive thematic analysis was conducted as part of PATHWAY‐Beacons (National Institute for Health and Care Research 202956), a mixed‐methods study evaluating the implementation of group metacognitive therapy as part of routine care in CR services. Practitioners from 6 CR services in England enrolled in interviews at 3 stages: before training, after training, and after delivering all group sessions. Results Nine practitioners participated in the study, with 7 completing all 4 interviews, 1 completing 2 interviews (pre‐ and posttraining), and another completing just 1 (pretraining). Key enablers for effective training emerged in 3 subthemes: training delivery style, essential training components, and the online training format. These aspects contributed positively to the practitioners' training experiences and improved their understanding of group metacognitive therapy. Conversely, barriers included issues related to training structure, staff skepticism, and specific additional training needs. Conclusion The findings support the positive value of training CR staff in group metacognitive therapy and offer important insights for enhancing the delivery and uptake of training within the National Health Service. Although the study findings represent views of a predominantly female sample, this reflects the composition of the current CR workforce.

Objective:To determine the effectiveness of mobile health augmented cardiac rehabilitation on clinical factors among post-acute coronary syndrome (post-ACS) patients. Method:A randomized controlled trial was conducted at Armed Forces Institute of Cardiology, Rawalpindi. This study was conducted on inpatients post-ACS patients. Patients were randomly allocated into the intervention group (counselling, short text messages, and standard post-ACS care) or the control group (standard post-ACS care). Clinical factors assessed were blood pressure, body mass index, the number of days of hospitalization, no of readmissions, and major adverse clinical events (MACE) within 180 days post-ACS. Data were collected thrice for six months follow-up periods (baseline, 12 and 24 weeks). Result:The mean days of hospitalization were reduced significantly of the intervention group compared to the control group (02.55, 95%CI: 02.13, 02.98 versus 04.07, 95%CI: 02.96, 05.17, p-value=0.033) at 12 weeks follow up. Also, at 24 weeks follow up, the intervention group reduced the number of readmission days compared to the control group (02.62, 95% CI: 02.00, 03.24, versus 03.71, 95%CI: 02.68, 04.74, p-value=0.041). Twenty-nine (43.94%) patients of the control group and 18 (24.32%) of the intervention group developed MACE at 12 weeks follow up (p-value: 0.016). While at 24 weeks follow up, 8 (16.33%) of the control group and 7 (9.86%) of the intervention group suffered MACE (p-value: 0.196). Conclusion:The MCard positively impacts the clinical outcomes. It has significantly decreased the likelihood of readmission and decreased the number of days of hospitalization among the MCard group compared to the usual care group. This trial has found an overall lower incidence of MACE (composite of readmission, myocardial re-infarction, heart failure and death) among the MCard group than usual care. Registration: Australian New Zealand Clinical Trial Registry (ANZCTR) (ACTRN12619001731189).16.

Objective To investigate whether achieving minimum clinically important difference in anxiety and depression is associated with meeting minimum clinically important difference in walking fitness following cardiac rehabilitation.Methods This retrospective observational study analysed routinely collected data from the UK National Audit of Cardiac Rehabilitation. Univariate analyses were employed to investigate the baseline characteristics associated with walking fitness. Then, a logistic regression analysis was conducted to examine whether achieving the minimum clinically important difference in anxiety and depression (defined as >1.7 score improvement in the Hospital Anxiety and Depression Scale) was associated with achieving the minimum clinically important difference in walking fitness (defined as >70 m improvement in the incremental shuttle walk test) following cardiac rehabilitation.Results A total of 4585 acute coronary syndrome patients at the National Audit of Cardiac Rehabilitation underwent valid incremental shuttle walk test and the Hospital Anxiety and Depression Scale assessments before and after cardiac rehabilitation between 1 January 2021 and 30 June 2024. Patients who achieved the minimum clinically important difference for depression had 23% higher odds of meeting the minimum clinically important difference for walking fitness (OR 1.23, 95% CI 1.01 to 1.49). Compared with home-based programmes, centre-based group programmes and hybrid programmes (combining centre-based and home-based components) were associated with higher odds of achieving clinically meaningful improvement in walking fitness. Factors such as older age, female sex, physical inactivity, obesity and longer waiting times to commence cardiac rehabilitation were associated with a lower likelihood of achieving minimum clinically important difference in walking fitness, adjusting for baseline anxiety, depression and incremental shuttle walk test scores.Conclusion Clinically meaningful improvement in depressive symptoms was associated with clinically meaningful improvement in walking fitness, underscoring the relevance of addressing depression within cardiac rehabilitation.

Aim To investigate potential factors that might influence the achievement of the minimum clinically important difference (MCID) in walking fitness following cardiac rehabilitation (CR) in patients with and without new-onset depression. Methods The clinical data from the National Audit of CR (NACR) indicated that between January 1, 2016, and January 31, 2020, 2027 acute coronary syndrome (ACS) patients with new-onset depression (15.5%) and 11,059 without new-onset depression (84.5%) underwent pre- and postincremental shuttle walk test (ISWT) measurements. Patients with new-onset depression had a mean age of 61.7 +/- 10.5 years (27.5% female), compared to 64.8 +/- 10.3 years (20.6% female) among those without. Comparative analyses were conducted to examine differences in walking fitness between these groups. Subsequently, a binary logistic regression analysis was executed to investigate the factors associated with achieving the MCID in walking fitness, defined as > 70 m improvement in ISWT, following CR. Results The multivariate analysis results revealed that having new-onset depression (OR: 0.89, 95% CI: 0.80 and 0.99), older age (OR: 0.96, 95% CI: 0.95 and 0.96), female gender (OR: 0.61, 95% CI: 0.56 and 0.68), physical inactivity (OR: 0.84, 95% CI: 0.78 and 0.91), and obesity (OR: 0.65, 95% CI: 0.60 and 0.71) were all associated with being less likely to achieve MCID in walking fitness adjusting for baseline fitness levels. Patients with new-onset depression had reduced walking fitness at baseline compared to those without, and they were less likely to meet the MCID for ISWT following CR. The study also generated a novel set of walking fitness reference values for patients with new-onset depression.

BACKGROUND:Participation in cardiac rehabilitation (CR) by ethnic minorities is poor, despite evidence supporting its effectiveness. This study evaluated CR participation and completion by South Asian compared to White European service users, and assessed factors associated with non-completion in both groups. METHOD:The National Audit of Cardiac Rehabilitation (NACR) data (January 2014 to February 2023) was used to identify South Asian and White European service users referred for CR following myocardial infarction, percutaneous coronary intervention and coronary artery bypass graft. Logistic regression and backwards selection were used to examine differences in participation and completion between groups and identify associated factors. FINDINGS:From 421,281 service users eligible for CR (383,833 White European, 37,448 South Asian, 115,812 women, median age 67 years), 222,928 participated (53%), of which 171,297 (77%) completed. After adjustment for age, sex, index of multiple deprivation (IMD) and co-morbidities, South Asian service users were 12% more likely to participate in CR than White Europeans (aOR 1.12, 95% CI 1.09 to 1.15), but 22% less likely to complete (aOR 0.78, 95% CI 0.75 to 0.82). In both groups, strongest associations with non-completion were higher deprivation, diabetes and being single. In White European and South Asian men, stroke and depression were also key factors. Non-completion was also associated with respiratory conditions in White Europeans and with rheumatism and family cardiovascular history in South Asian men. INTERPRETATION:South Asians are more likely to participate but less likely to complete CR than White Europeans. Programmes tailored to individual needs are required to reduce disparities in care.

BACKGROUND:Androgen deprivation therapy (ADT) for prostate cancer causes substantial adverse effects. Despite consistent national and international guideline recommendations, supervised exercise is rarely integrated into care. We aimed to determine whether the STAMINA lifestyle intervention, embedded into cancer care, would improve cancer-specific quality of life and fatigue versus behaviourally Optimised Usual Care in men with prostate cancer in England. METHODS:STAMINA was a multicentre, randomised trial done across 15 UK National Health Service (NHS) trusts in England. Men on ADT for prostate cancer were eligible. Participants were randomly assigned (5:4) via computer-generated minimisation, stratified by age, ADT duration, chemotherapy or androgen receptor pathway inhibitor therapy, and radiotherapy, to the STAMINA lifestyle intervention or to Optimised Usual Care. Participants were aware of treatment allocation. The STAMINA lifestyle intervention comprised supervised aerobic and resistance exercise for 12 months, dietary advice, behavioural support, and complimentary gym membership. Optimised Usual Care comprised clinician training, educational materials, behavioural prompts, and safety-to-exercise checks. Primary outcomes were the Functional Assessment of Cancer Therapy-prostate (FACT-P) and the Functional Assessment of Chronic Illness Therapy-fatigue (FACIT-F) subscale at 12 months, analysed by intention to treat (according to randomised treatment). This trial is registered with ISRCTN (ISRCTN46385239), and recruitment is complete. FINDINGS:Between Jan 20, 2022, and June 12, 2023, 700 men were randomly assigned to STAMINA lifestyle intervention (n=389) or Optimised Usual Care (n=311). Median age was 71·6 years (IQR 66·3-76·0), and 680 (97%) of 700 participants were White. Primary outcome data were available for 345 (89%) of 389 participants in the STAMINA lifestyle intervention group and 251 (81%) of 311 in the Optimised Usual Care group. The STAMINA lifestyle intervention was superior to Optimised Usual Care in terms of FACT-P score (adjusted mean difference 4·5, 97·232% CI 1·7-7·2; p=0·0004) and FACIT-F score (1·9, 0·4-3·4; p=0·0068). Three intervention-related serious adverse events occurred in the STAMINA lifestyle intervention group (transient loss of consciousness, leg pain or weakness, and back pain); all participants recovered. No treatment-related deaths occurred. INTERPRETATION:The STAMINA lifestyle intervention meets best practice guidelines, can be implemented in NHS trusts in England, and offers clinicians a clear basis for identification and prescription of a supervised exercise and dietary advice intervention to mitigate negative effects associated with ADT. FUNDING:National Institute for Health Research.

BackgroundMusculoskeletal conditions are leading contributors to global disability and place a significant economic burden on health systems. Optimal physical activity is a key recommended strategy for managing musculoskeletal conditions, yet many individuals struggle to sustain activity levels following the completion of exercise rehabilitation programmes. Identifying and understanding the factors that influence sustained physical activity may aid intervention design and benefit future patients. The aim of the study was therefore to explore the evolving needs of participants completing a joint pain exercise rehabilitation programme and identify factors which influenced sustained physical activity beyond programme completion.MethodThe current study adopted a longitudinal semi-structured interview methodology, building upon our initial study conducted at the end of the supported phase (week 12). Semi-structured interviews were conducted at week 24 (mid-term follow up), and at week 36 (long-term follow-up), during which participants were expected to self-initiate engagement with structured physical activity. Reflexive thematic analysis was employed, and interpretation of findings was guided by the Socio-Ecological Model and Transtheoretical Model, to examine changes in behavior and context over time. Participants were classified as either sustainers or non-sustainers based on their overall behavioral trajectory.ResultsFive overarching themes were identified: (1) From avoidance to approach; (2) Becoming an independent exerciser; (3) Establishing a new routine; (4) Outsourcing willpower; (5) Evidence of self-determined behavior. Individual-level factors such as confidence, motivation, and acceptance of pain were central to sustained engagement, but these were shaped by broader influences including access to facilities and social support.ConclusionSustained physical activity following rehabilitation is a dynamic, context-dependent process. Interventions should prepare individuals for independent physical activity by fostering the development of psychological and self-regulatory skills, whilst also considering community and policy-level influences. Incorporating these elements may enhance sustained engagement in structured physical activity and improve long-term rehabilitation outcomes.

BACKGROUND:Prehypertension (blood pressure (BP) 120-139/80-89 mmHg) affects 40% of UK adults increasing cardiovascular risk. While BP self-monitoring is effective in hypertension, its feasibility in prehypertension is unclear. Concerns include lack of interest, medicalisation, and unintended consequences, despite evidence suggesting it may empower individuals in risk management and prevention. AIM:To determine the feasibility of BP self-monitoring for prehypertension. METHOD:A prospective, non-randomised, mixed-methods, feasibility study across primary care in Lancashire and South Cumbria. People with prehypertension were recruited from five general practices, three pharmacies, and one BP-checking provider. Participants received a BP monitor and training, then self-monitored BP on the first 3 days of each month for 6 months. Participants submitted their results to the research team. Outcome data were collected at baseline, 6-months, and 12-months and analysed mainly using descriptive statistics. RESULTS:Of 162 expressions of interest, 80 were eligible and consented; 78 from general practice, one each from pharmacy and community providers. Of those recruited, 66 (83%) and 33 (41%) completed 6-month and 12-month follow-up, respectively, with minimal missing data. No adverse effects were reported. Illness perception scores significantly decreased (mean 26.6 [SD 8.6] to mean 22.6 [SD 8.7], p=0.002), with no other significant changes. There was only one non-White participant, and limited socioeconomic diversity, limiting generalisability and highlighting the need for targeted outreach. CONCLUSION:BP self-monitoring for prehypertension is feasible in general practice, but requires further exploration with pharmacy, and community providers. These findings need confirming in an effectiveness trial.

Background:Despite strong recommendations for heart failure (HF) rehabilitation, participation (uptake and sustained engagement) remains low. Digital interventions may enhance participation and scalability, yet evidence for feasibility in real-world National Health Service settings remains limited. Rehabilitation Enablement in Chronic Heart Failure (REACH-HF), an effective home-based HF cardiac rehabilitation programme, is currently delivered using paper-based manuals with facilitator support. Objectives:To co-develop and assess the feasibility of a digitally adapted and enhanced version of REACH-HF (D:REACH-HF) with patients, caregivers, and healthcare professionals. Methods:Following the Person-Based Approach, D:REACH-HF was iteratively co-developed with patients and caregivers in a public involvement group (stage 1) and through qualitative research (stages 2A and 2B). Usability and acceptability of content and design iterations were evaluated with patients, caregivers, and healthcare professionals through think-aloud interviews (n = 20 participants) and feasibility of the fully-functional intervention with facilitation, was assessed with semi-structured interviews at 2-4 and 10-12 weeks (n = 10). Results:Participants rated D:REACH-HF highly (mean app quality score: 4.02/5), particularly for information credibility and functionality. Key benefits included flexibility, structured self-monitoring, and healthcare professional support. Remote access to patient data enabled more efficient consultations, allowing healthcare professionals to focus on tailoring their support to patient needs. Challenges included technical issues, digital literacy, and engagement variability. All patients requested continued access to the platform, highlighting perceived long-term value. Conclusion:The D:REACH-HF programme is acceptable to patients and healthcare professionals. Moreover, as indicated by participant reports, it enables and achieves the same perceived benefits as the paper-based REACH-HF. However, evaluation of clinical and cost-effectiveness, implementation, and optimisation of D:REACH-HF for patients from under-researched and underserved communities is needed.

This meta-analysis of published studies was conducted to determine the effectiveness of cardiac rehabilitation (CR) in terms of health-related quality of life (HRQoL) in post-coronary artery disease (CAD) patients in low- and middle-income countries (LMICs). Eighteen studies were identified from six countries (Malaysia, Iran, Brazil, Turkiye, China, and Pakistan) totalling 2,620 study participants with a mean age of 57.43 ± 7.9 years. Significantly higher mean physical (13.48, 95% CI: 7.75 to 19.21, p <0.001) and mental (11.52, 95% CI: 4.44 to 18.60, p <0.001) component scores were observed in the CR group compared to the usual group. The myocardial infarction- specific MacNew QLMI domains also showed significant mean differences (1.59, 95% CI: 0.97 to 2.21, p <0.001). This systematic review and meta-analysis showed significant improvements in physical and mental HRQoL in the CR group compared to the control group among post-CAD patients in LMIC. Furthermore, the myocardial infarction-specific MacNew QLMI global domain shows significant improvement in the CR group compared to the usual care group. Key Words: Acute coronary syndrome, Cardiac rehabilitation, Quality of life, Short-form 36, MacNew quality of life after myocardial infarction.

Abstract Background Identifying clusters of multiple long-term conditions (MLTCs), also known as multimorbidity, and their associated burden may facilitate the development of effective and cost-effective targeted healthcare strategies. This study aimed to identify clusters of MLTCs and their associations with long-term health-related quality of life (HRQoL) in two UK population-based cohorts. Methods Age-stratified clusters of MLTCs were identified at baseline in UK Biobank (n = 502,363, 54.6% female) and UKHLS (n = 49,186, 54.8% female) using latent class analysis (LCA). LCA was applied to people who self-reported ≥ 2 LTCs (from n = 43 LTCs [UK Biobank], n = 13 LTCs [UKHLS]) at baseline, across four age-strata: 18–36, 37–54, 55–73, and 74 + years. Associations between MLTC clusters and HRQoL were investigated using tobit regression and compared to associations between MLTC counts and HRQoL. For HRQoL, we extracted EQ-5D index data from UK Biobank. In UKHLS, SF-12 data were extracted and mapped to EQ-5D index scores using a standard preference-based algorithm. HRQoL data were collected at median 5 (UKHLS) and 10 (UK Biobank) years follow-up. Analyses were adjusted for available sociodemographic and lifestyle covariates. Results LCA identified 9 MLTC clusters in UK Biobank and 15 MLTC clusters in UKHLS. Clusters centred around pulmonary and cardiometabolic LTCs were common across all age groups. Hypertension was prominent across clusters in all ages, while depression featured in younger groups and painful conditions/arthritis were common in clusters from middle-age onwards. MLTC clusters showed different associations with HRQoL. In UK Biobank, clusters with high prevalence of painful conditions were consistently associated with the largest deficits in HRQoL. In UKHLS, clusters of cardiometabolic disease had the lowest HRQoL. Notably, negative associations between MLTC clusters containing painful conditions and HRQoL remained significant even after adjusting for number of LTCs. Conclusions While higher LTC counts remain important, we have shown that MLTC cluster types also have an impact on HRQoL. Health service delivery planning and future intervention design and risk assessment of people with MLTCs should consider both LTC counts and MLTC clusters to better meet the needs of specific populations.

Chronic obstructive pulmonary disease (COPD) is a heterogeneous chronic lung condition often accompanied by comorbidities and systemic manifestations that affect the person’s clinical condition and prognosis and often require specific treatment. Therefore, the management of COPD extends beyond treatment for the lungs per se. Pulmonary rehabilitation (PR) should be considered as part of person-centered management, and supervised exercise training is a core component of this intervention. PR exercise training parameters (e.g., frequency, intensity, time, and type) should be individualized to maximize each individual’s functional gains while targeting systemic manifestations and comorbidities. This manuscript presents evidence-based tailored recommendations for optimizing exercise interventions for people with COPD and comorbidities that significantly affect prognosis (e.g., mortality, hospitalizations) including cardiovascular disease (CVD) (e.g., chronic coronary syndrome, heart failure), CVD risk factors (e.g., type 2 diabetes mellitus [T2DM], hypertension), and sarcopenia. To achieve these goals, existing guidelines and evidence for exercise training in COPD, CVD, CVD risk factors, and sarcopenia have been reviewed to identify synergies between PR and cardiac rehabilitation, as well as the treatment of T2DM and sarcopenia. In addition, we provided clinical cases to illustrate how PR can be adapted to accommodate specific comorbidities. These examples offer practical guidance for tailoring exercise prescriptions within PR programs to address the unique needs of people with COPD and clinically relevant comorbidities, thereby enhancing overall treatment effectiveness and optimizing health outcomes.

Background Cardiac rehabilitation (CR) uptake for heart failure (HF) in the UK remains low at around 15%, with evidence of disparities based on sex, ethnicity, socioeconomic status, availability of staffing and financial constraints. We analysed data from the Pumping Marvellous Foundation online home CR programme to understand who accesses this service and whether inequities persist, to help guide strategies to achieve equitable rehabilitation delivery. Methods The PMF online home CR platform was launched in August 2024 along with an educational booklet available for order (at no cost) by HF or CR teams. We analysed anonymised data (n=673) of registrants from August 2024 to July 2025. Variables analysed included demographics, ethnicity, deprivation index, HF type based on ejection fraction, referral source, time since diagnosis and prior CR participation. We also analysed CR booklet orders and assessed correlation with HF admissions as per national HF audit data. Descriptive statistics summarised distributions. Results 673 participants (median age 62 years; IQR 18 to 90 years, 12% aged >76 years) registered for the online CR classes from August 2024 to July 2025. The majority (63%) were women, and 6% were from minority ethnic communities. 35% of registrants had either mildly reduced (HFmrEF) or preserved (HFpEF) ejection fraction. 30% of referrals were from HF or CR teams, 29% obtained information via social media, and around 25% obtained information directly from PMF groups. There were also direct referrals from GPs (4%) and around 10% obtained referral information via Google search or YouTube. Analysis of the time since HF diagnosis demonstrated late entry to CR: 343 (51%) registered >12 months post-diagnosis, 88 (13%) within 3 months, and 130 (19%) within 6 to 12 months. Only 38 (6%) reported any prior CR participation. We also correlated CR booklet orders from hospitals with National HF Audit HF admissions. Within the limitations of the spread of the scatter, there was a general positive relationship: hospitals with more HF admissions tended to order more booklets. 33% of registrants came from the top 20 most deprived cities in England. Conclusions By providing free lifetime access to online cardiac rehabilitation, widening the access of cardiac rehab to more women and people without access to standard cardiac rehabilitation (due to staffing, cost constraints, accessibility issues) and reaching areas with socio-economic deprivation, the PMF online cardiac rehab platform can help to increase CR uptake and reduce the inequity in access to CR in the UK. ### Competing Interest Statement The production of the Cardiac Rehabilitation Platform, including a digital platform and accompanying booklet, has been funded by a hands-off educational grant by Pharmacosmos UK ### Funding Statement The production of the Cardiac Rehabilitation Platform, including a digital platform and accompanying booklet, has been funded by a hands-off educational grant by Pharmacosmos UK ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Clinical Advisory Board of pumping Marvellous Foundation waived need for ethics application as this was a retrospective service evaluation I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

Background Exercise and self-management support may be clinically effective and cost-effective treatments for a range of individual long-term conditions (LTCs), as they activate multiple beneficial physiological and psychological mechanisms. We aimed to develop a complex intervention to deliver exercise and self-management support for people with multiple LTCs (MLTCs). Methods Following the Person Based Approach to intervention development, we conducted ten co-development workshops with people with MLTCs, family and friends; healthcare providers; service commissioners and policymakers. The workshops iteratively identified the unmet needs of people with MLTCs and informed a programme theory outlining theoretical mechanisms of change and intervention strategies to change the targeted behaviours. They also identified ideas for efficient delivery and service providers’ training needs. Mixed methods feedback from the Personalised Exercise-Rehabilitation FOR people with Multiple long-term conditions (PERFORM) feasibility study (reported elsewhere) informed intervention refinement. Results A diverse group of stakeholders (26 people with MLTCs/supporters, 13 service providers, 16 experts in chronic illness and 14 service commissioners) helped to develop the PERFORM intervention. This included 16 supervised exercise sessions and 16 ‘Health and Wellbeing’ self-management support sessions, delivered in hospital or community settings over eight weeks, plus check-in sessions at four and six months. The self-management sessions covered maintenance of exercise/physical activity, healthy eating and managing common symptoms (pain, fatigue, breathlessness, stress). Conclusion The PERFORM intervention is a comprehensive, evidence-informed, theoretically driven self-management and exercise-based rehabilitation intervention, co-developed with people with MLTCs, service providers and service commissioners. PERFORM is now ready for evaluation regarding clinical effectiveness and cost-effectiveness.

INTRODUCTION:Cardiac rehabilitation (CR) improves cardiovascular health and quality of life after coronary heart disease (CHD). However, it remains uncertain whether patients with diabetes achieve similar gains in exercise capacity as those without diabetes. METHODS:This cohort study included patients discharged from hospital following CHD between February 2019 and December 2022 who completed a 12-week CR programme at 18 community health centres. Exercise capacity was assessed using a symptom-limited bicycle ergometer test and reported as both absolute (mL O₂/min) and relative VO₂peak (mL O₂/kg/min). Differences in improvement were evaluated using multiple regression analyses, and the likelihood of achieving a minimal clinically important difference (MCID) of 3.5 mL O₂/kg/min was examined using binary logistic regression. RESULTS:Of the 2227 patients included, 437 (19.6 %) had diabetes. At both baseline and follow-up, patients with diabetes had significantly lower exercise capacity (p < 0.001). Although both groups improved significantly, gains were smaller among patients with diabetes (2.3 ± 2.4 vs. 2.9 ± 2.6 mL O₂/kg/min; p < 0.001). After adjustment, diabetes remained independently associated with smaller improvement (-0.42 mL O₂/kg/min; 95 % CI: -0.69 to -0.15; p = 0.002). The likelihood of achieving the MCID was also lower in the diabetes group (risk difference: -0.08; 95 % CI: -0.13 to -0.04; p < 0.001). CONCLUSION:Although patients with diabetes demonstrated improvements following CR, their gains in exercise capacity were smaller and less likely to be clinically meaningful compared with those without diabetes. These findings highlight the need for tailored CR strategies to optimise outcomes in this high-risk population.

OBJECTIVE:Existing exercise-based rehabilitation services, such as cardiac and pulmonary rehabilitation, are traditionally commissioned around single long-term conditions (LTCs) and therefore may not meet the complex needs of adults with multiple long-term conditions (MLTCs) or multimorbidity. The aim of this study was to assess the feasibility and acceptability of the newly developed personalised exercise-rehabilitation programme for people with multiple long-term conditions (PERFORM) and the trial methods. DESIGN:A parallel two-group mixed-methods feasibility randomised controlled trial (RCT) with embedded process and economic evaluation. SETTING:Three UK sites (two acute hospital settings, one community-based healthcare setting). PARTICIPANTS:60 adults with MLTCs (defined as the presence of ≥2 LTCs) with at least one known to benefit from exercise therapy were randomised 2:1 to PERFORM intervention plus usual care (PERFORM group) or usual care alone (control group). INTERVENTION:The intervention consisted of 8 weeks of supervised group-based exercise rehabilitation and structured self-care symptom-based support. PRIMARY AND SECONDARY OUTCOME MEASURES:Primary feasibility outcomes included: trial recruitment (percentage of a target of 60 participants recruited within 4.5 months), retention (percentage of participants with complete EuroQol data at 3 months) and intervention adherence (percentage of intervention group attending ≥60% sessions). Other feasibility measures included completion of outcome measures at baseline (pre-randomisation), 3 months post-randomisation (including patient-reported outcomes, exercise capacity and collection of health and social care resource use) and intervention fidelity. RESULTS:Target recruitment (40 PERFORM group, 20 control group) was met within the timeframe. Participants were 57% women with a mean (SD) age of 62 (13) years, body mass index of 30.8 (8.0) kg/m2 and a median of 4 LTCs (most common: diabetes (41.7%), hypertension (38.3%), asthma (36.7%) and a painful condition (35.0%)). We achieved EuroQol outcome retention of 76.7% (95% CI: 65.9% to 87.1%; 46/60 participants) and intervention adherence of 72.5% (95% CI: 56.3% to 84.4%; 29/40 participants). Data completion for attendees was over 90% for 11/18 outcome measures. CONCLUSIONS:Our findings support the feasibility and rationale for delivering the PERFORM comprehensive self-management and exercise-based rehabilitation intervention for people living with MLTCs and progression to a full multicentre RCT to formally assess clinical effectiveness and cost-effectiveness. TRIAL REGISTRATION NUMBER:ISRCTN68786622.

Participation in cardiac rehabilitation (CR) has been shown to reduce mortality and morbidity1; however, it remains unclear whether long-term trends in uptake and completion differ by sociodemographic factors. To investigate 8-year trends in CR uptake and completion by sex, ethnicity and socioeconomic status. Age adjusted Trends were assessed using logistic regression modelling on National Audit of Cardiac Rehabilitation data (2014 to 2022). Of 454,492 individuals referred for CR after an MI (23%), percutaneous coronary intervention (63%) or a bypass graft (15%) (median age of 76 years [IQR 58.0, 76.0], 28% female, 90% white ethnicity, 20% most affluent, 20% most deprived), 251,436 (55%) started CR, of which 195,514 (78%) completed. Both the patients that started and completed CR were younger than those referred (mean age 66 years) and the majority were male (75%), of white ethnicity (90% and 91% respectively) and in the most affluent group (22% and 24%). Males were more likely to start and complete CR than females, but the difference between men and women narrowed in most recent years (start; male, 2014: 54% [95% CI 54, 6] to 2022: 63% [95% CI 63, 65]; female, 2014: 50% [95% CI 49, 51] to 2022: 63% [95% CI 61, 63]; completed; male, 2014: 77% [95% CI 77, 78] to 2022: 79% [95% CI 78, 80]; female, 2014: 74% [95% CI 72, 75] to 2022: 78% [95% CI 77, 79]). Whilst all ethnic groups experienced a slight improvement in uptake and completion rates over time, there were differences by ethnicity. The White group remained the most likely to start and complete CR (start; 2014: 53% [95% CI 53, 55] to 2022: 63% [95% CI 63, 64]; complete; 2014: 77% [ 95% 76, 78] to 2022: 79% [95% CI 79, 80]) and the Black group least likely to start and complete CR (start; 2014: 49% [95% CI 0.44, 0.53] to 2022: 52% [95% CI 48, 56]); complete: 2014: 67% (95% CI 61, 73) to 2022: 71% [95% CI 0.67, 0.76]). White and Asian uptake rates increased the most (by ~10%), with the Black group experiencing the smallest increase (3%). The most affluent group were more likely to start and complete CR than the most deprived group, with an increase in uptake and completion rates in both groups over time (start; most deprived, 2014: 44% [43, 46] to 2022: 53% [95% CI 52,54]; most affluent, 2014: 63% [95% CI 62, 64] to 2022: 68% [95% CI 67, 69]; completion; most deprived, 2014: 65% [63, 66] to 2022: 75% [95% CI 74, 76]; most affluent, 2014: 84% [95% CI 82, 85], to 2022: 81% [95% CI 80, 82]). The gap in uptake rates between most affluent and most deprived groups reduced from 19% to 15% and the gap in completion rates reduced from 19% to 6% over the 8 years. Trends demonstrate consistent inequalities in uptake and completion of CR in females, most derived and ethnic minorities however the gap has reduced overtime. Tailored programmes should promote inclusivity to improve outcomes among these populations.

BACKGROUND:Musculoskeletal (MSK) conditions are a leading cause of pain and disability in adults. Exercise-based rehabilitation programmes are recommended however, sustained behaviour change is often poor. New rehabilitation pathways designed to promote adherence to exercise, can be iteratively developed using behaviour change models. This study explored the experiences of people living with joint pain participating in a Joint Pain Programme (JPP), a unique community-based rehabilitation initiative delivered by exercise professionals, that is offered 'free of charge' to patients and provides supplementary access to a local fitness and well-being centre. The findings are mapped to behaviour change models to inform implementation strategies that enhance exercise adherence in this population. METHODS:A qualitative design, informed by pragmatism, using semi-structured interviews was used to explore participants' experiences of uptake and attendance at a 12-week community-based rehabilitation programme for joint pain. Findings were analysed using inductive thematic analysis. NVivo software was used to facilitate analysis, with models of behaviour change used to interpret the findings. The study is reported in accordance with the consolidated criteria for reporting qualitative (COREQ) research. RESULTS:21 interviews took place online with individuals who attended the programme. Four themes were identified: 1) The programme supports my needs; 2) What motivates me; 3) The 'value add' environment; and 4) What hinders me from exercising. CONCLUSION:The JPP provides a new pathway for MSK rehabilitation that is perceived positively by people living with joint pain. Uptake and attendance in the early stage of exercise adoption is influenced by multiple interventions acting at the policy, community, organisational, interpersonal and intrapersonal level. Recommendations for policy and programme designers are made. The structure of the JPP could act as a potential springboard where programmes for other long-term conditions could be rolled out, reducing the burden on valuable health service resources.