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

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The outdated practise of bed rest [39, 42]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]