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Table 3 Barriers to and enablers of delivering cardiac rehabilitation to patients with heart failure identified in our thematic analysis

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

Overarching categories Barriers/factors preventing delivery of cardiac rehabilitation
(theme frequency/coverage)
Enablers/factors promoting delivery of cardiac rehabilitation
(theme frequency/coverage)
The origins of CR and previous practices The outdated practise of bed rest [39, 42]  
Evidence-base Poor evidence-base supporting CR for HF [34, 38] Sufficient evidence-base supporting CR for HF [38, 39]
Guidelines Guidelines not tailored to the end-user [32, 34] Better tailoring of guidelines [32, 34]
Volume and complexity of guidelines [32, 42] Translating guidelines into clinical algorithms [32]
Lack of inclusion of CR in local guidelines [42] Guideline endorsement [38, 39]
Cross-institutional guidelines [36]
  Guideline implementation [42]
Education Lack of formal education on exercise training [42] Education programmes on the importance of exercise training [42]
  Knowledge sharing opportunities [36, 38]
Awareness-raising [39, 41]
Medical insurance Lack of medical insurance cover [38] Medical insurance eligibility criteria and sufficient cover [38]
Resources Lack of resources: time, staff, facilities and equipment [32, 34, 41, 42] Adequate resources: time, staff, facilities and equipment [42]
The organisation of healthcare system Lack of commissioning [34, 42] Sufficient commissioning [38, 42]
Blurred professional roles [34, 42] Clear professional roles and responsibilities [38, 42]
Lack of integration between organisations [36, 42] Better integration between organisations [36, 42]
Lack of patient pathways [34, 41, 42] Referral system [39]
Inadequate IT systems [32] Adequate IT systems [32, 42]
Lack of integration between departments [36] Better integration between departments [36, 42]
Lack of care standardisation [42] Care standardisation [36]
Lack of implementation strategies [38]  
Lack of referrals [34, 41]
  Healthcare legislation [38]
Performance and target measures [39]
Use of clinical algorithms [32]
The organisation of CR programmes Lack of different modes of delivery [34, 41] Availability of different modes of delivery [34, 38, 41]
Lack of programmes [42] Availability of programmes (specialised and community-based) [42]
Limiting eligibility criteria [38] Broadened eligibility [42]
Difficult to choose a suitable programme [36]  
Confusing referral procedures [36]
Healthcare professional Poor professional’s knowledge, awareness and attitude [32, 38, 39, 41] Sufficient professional’s knowledge, awareness and attitude [36, 38, 39, 41]
Safety concerns [38, 39, 41]  
  Improving the doctor-patient relationship [42]
  1. CR Cardiac rehabilitation, HF Heart failure