Table 1 Selected coding from think-aloud protocol and subsequent interviews, with corresponding changes made to course

1: Details about CR delivery

Over approximately 5 months, patients participate in sessions approximately 2 times per week covering guideline-based “core components”, including: education, exercise and counselling.

“I think when providers and patients think of CR they often think they’re just going to exercise. So, I liked that this breaks down that you’re also going to get counseling and you’re also going to get education on your condition. So that’s good (HCP 3).”

Factors that should not impact referral to CR. Ambulation: These patients can still benefit from other components of CR, such as patient education, dietary counseling and stress management.

“So I think that’s big because I know that I have a bias in my mind if a patient isn’t able to exercise or isn’t able to ambulate well. I often think of the benefit of rehab being minimal, but again, that’s the bias of me thinking about it more as exercise as opposed to the other components. So, I like that (HCP 3).”

Recognizing patients who are indicated for cardiac rehab or who meet indications for Cardiac Rehab and understand how they are referred at UHN.

“Referral is a big part because even though we know CR exists, sometimes the referral process is a little bit like, well, how do we get patients there?... It’s important we understand how that is done (HCP 3).”

First language spoken- interpretation services are available.

“I did not know that. I like that it shows it’s really an all-inclusive process and that, as a rehab center we really try and accommodate people’s different levels of abilities. So, I liked that (HCP 3).”

Patients will be triaged closest to home.

“So, the actual CR here, will figure out where they live and figure out where is the best rehab center for them? Okay, great (HCP 3).”

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2: Good and not good candidates for CR

Poor Candidates for CR – serious mental illness.

“Serious mental illness… I don’t really classify depression as serious (HCP1).”

Poor Candidates for CR section.

“I think most of these (not good candidates) should be obvious, but I think it’s helpful to reiterate to us, as clinical practitioners, you don’t want to send someone to rehab that it’s going to be a dangerous process for them (HCP 3).”

Added pop-up detail: Serious mental illness, not including depression or anxiety

3: CR model

What is CR? CR is an outpatient chronic disease management program, addressing all guideline recommendations for secondary prevention. Recommendations that you provide inpatients are reinforced.

“I think in this section about what CR is, the thing that comes up clinically a lot is how flexible is it? What times of day is it? Like if they’re working, is it still an option or that sort of thing…These are the questions that I don’t always have the answers to (HCP 2).”

Barrier #3: Patient is returning to work, lives out of town, or has no way to get to CR. Explain to the patient: Most CR programs offer “home-based” models.

“Home-based models? Is this where like they would give an exercise prescription so that they could come in less often? I think like that would play well into what we were talking about before too, with like how flexible it is versus, like do you have to come in two times a week and what hours of the day it is and that sort of thing... Because that does come up a lot, especially for younger patients (HCP 2).”

“Oh, okay… Like over the internet or something like videos? I actually didn’t know that education support can be provided over the phone. Very nice! (HCP 5).”

“I didn’t know that there was a home-based model from the get-go. I always thought they had to do the five months in rehab. Like in the physical place and then they could have their exercise prescription and be supported with their home-based? So, that’s good to know (HCP 3).”

Added text: Patients participate in sessions, in-person or on the phone, covering guideline-based “core components”, including education, exercise and counseling. The number of sessions or calls varies by program (on average twice per week over 5 months) and are offered when convenient to the patient. Family members are welcome to attend as well.

Theme 4: Patient safety concerns

How patients are referred at UHN.

“The biggest issue with my team is that the interventionalists are not highly convinced that patients should exercise and what length of time after their event they should start to exercise. Is every rehab supervised differently? Do they all have physicians? Who is responsible for the patient? (HCP 1).”

Added phrase: The patient will not undergo any exercise stress testing until they have been pre-screened and only under the supervision of a physician. Safety should not be a concern.

Theme 5: CR discussion – provider type

Nurses are primarily responsible for initiating this discussion.

“I think that’s great that nurses are responsible, but I also think that we as residents and physicians when discharging the patient should put a positive vote in for the program as well. We have evidence that shows patients are more likely to get engaged in things that physicians recommend. So, I think, we need to do a better job of promoting it as well (HCP 3).”

“Is it that we’re saying that nurses should be the first point of contact in this discussion? Is it that they should start this discussion before a physician thinks that it is appropriate? (HCP 4).”

“I think primarily nurses might not feel comfortable having that initial discussion with someone, let’s say with heart failure, who doesn’t fit the criteria or someone who’s being admitted with some rhythm abnormalities. When is it safe to have that discussion? So, I almost feel like the first person should be the most responsible physician or clinician should have that initial conversation and nurses certainly can help (HCP 4).”

Nurses sentence was removed, and sentence was added:

Often, providers are not sure who is going to discuss CR with patients, so no one does. Ideally, the physician should inform the team and patient that the referral is being made and nurses and allied HCP should reinforce this message by informing patients more fully about getting started.

Theme 6: CR participation barriers

Key points for discussion: discuss how to overcome any raised barriers to entering the program

“I was always kind of under the impression that, you know, if I say to a patient that the CR will call them. If there are any barriers they can be addressed with the person over the phone. I don’t know exactly what their capabilities are… I usually just encourage them to work at it with the CR. Maybe that’s wrong what I’ve been doing. Because I don’t think I’m very well equipped to overcome some of the barriers (HCP 2).”

“A big barrier for patients is the language and cultural. You know in some cultures, women traveling long distances alone and things like that…or I don’t think my mother would benefit from that because she doesn’t really speak English that well or we can’t get her there and that type of thing (HCP 4).”

“I think the barriers are good barriers that were identified that our patients would have (HCP 5).”

Theme 7: Request for additional information

Benefits of CR include: Reducing cardiovascular death and re-hospitalization by 20%

“It’d be nice to see some of this data. Reducing death and rehospitalization... It would be good to see some of the data (HCP 2).”

“So, I think these last two points (Reducing cardiovascular death and re-hospitalization by 20% and significantly improving the patient’s quality of life), um, I think a lot of healthcare providers will be impressed by the statistics. Does that mean it needs to go at the top?... I think maybe putting the point about and cardiovascular death and re-hospitalization higher up or maybe bolded. I think that could reinforce (HCP 3).”

Figure with forest plot and manuscript citation was added, and the phrase “Reducing cardiovascular death and re-hospitalization by 20%” was bolded.

Theme 8: eLearning module feedback

Tools to support your discussion. Click the resources to the right for tools to support your discussion with the patient regarding CR.

“Oh, so this is like a pamphlet you can give to the patient to help them understand in writing what it is you’ve talked about? I like this because often I find when we give patients information at the bedside, they retain maybe 10 or 20% of it. I liked that they have option for something to take with them (HCP 3).”

Summary: You have reached the end of the Promoting Patient Participation in CR eLearning course.

“The course length is fine, it’s good, it’s not too much (HCP 1).”

“The course was very good (HCP 1).”

“Can I add that I really liked the length. Like I think that it’s important that it’s not too, too long. With the addition of a couple of slides maximum, like a little bit extra information that I think is high yield, I wouldn’t change it very much (HCP 2).”

“I thought it was concise. It wasn’t too verbose. I thought it was really well done (HCP 3).”

“I think it was decent. It was good. I think appropriate. Ten to 15 min is fair. (HCP 4).”

“The course length wasn’t bad at all. It was pretty fast (HCP 5).”

Theme 9: Course improvement

What suggestions do you have for us to improve the course? How can we better support providers such as yourself to promote CR to your patients?

“I think the biggest thing is giving them (providers) tools. They need a lot of education about the importance of CR (HCP 5).”

“I think more and more today people are doing or using those tools electronically. So, you know, like the little pocketbooks, the little, ACLS resuscitation cards that we use, and I just have those on my phone and I saved them as different files on my phone. But even if you had a pocket card, I think certainly the older generations would like that. And then if you don’t want it in physical form and you only want in digital form, you could always just take a picture and have it as a file on your phone. So, I like that. (HCP 3).”

“I think most people are very used to just having brochures in front of them and using that as a method for ensuring that they’re getting everything that they’re actually capturing everything. Something visual is important when we’re talking about, especially if it’s nurses, clinicians, that you just want to have that in front of you... To make sure you don’t miss anything important (HCP 4).”

Do you think you will remember the points to discuss with patients? (referring to the Points to Discuss slide)

“Well, I guess it’s not standing out to me from the presentation which are key points for discussion, I know what I’ll usually tell patients, but I’m not sure… There’s something about it that’s not very memorable. Maybe create a handout… You know, what I think works well is things like little cards that people can attach to their badge… easy to carry around and keep on you or like in a lab coat. You know what I mean, like really small and portable.

Or do a handout, but you know what, but a handout is always tricky. Like we’ll just throw them out. You know, what I think works well is things like little cards that people can attach to their badge. I’ve gotten like stroke handouts and things like that are actually easy to carry around and keep on you. Or like in a lab coat. But if it’s this size and it says like, you know, it’s like 12 words, but it says like, what is CR, benefits? You know what I mean, like really small and portable. Then I think that it works better, but truly this slide was not memorable to me (HCP 2).”

“What you could do instead of creating a handout it could be a pocket card that you give out to people? When you complete the course, you can enter your email address and then you email the recipient a PDF of that pocket card? (HCP 3).”

A PDF tool with key points for discussion was created, which learners could download, and keep it in their phones.