Title: Implementing Group Metacognitive Therapy in Cardiac Rehabilitation Services (PATHWAY-Beacons)
Funder: Department of Health and Social Care

Abstract: Research Question: We will address: 1) what are cardiac rehabilitation (CR) staff views of training in group MCT, it s delivery and the enablers and barriers, 2) what is the acceptability and feasibility of roll-out at commissioner level and what are the barriers and enablers. We have principal objectives of: 1) developing beacon sites to support a future study of roll-out in the NHS; 2) introducing data capture using the CR national audit to capture psychological outcomes when group MCT is implemented. Background: CR services aim to improve heart disease patients health, quality of life, and reduce risk of further cardiac events. Depression and anxiety are common among CR patients (27.6% of patients experience anxiety and 19% experience depression [1]). Current psychological treatments for cardiac patients have small effects. However, the NIHR funded PATHWAY trial (RP-PG-1211-20011), found that group Metacognitive Therapy (MCT) is effective at treating anxiety and depression when added to CR, and was more effective than usual CR alone. Group-MCT also appeared to prevent anxiety and depression. These favourable results mean that the next step should explore factors that facilitate and impede wider service uptake and establish structures that can support implementation. Specifically, establishing beacon sites and piloting additions to the NACR data capture mechanism to include an MCT data field. Aims and Objectives: We aim to assess practitioner and commissioners views of delivering group-MCT alongside CR to identify barriers and facilitating factors, and to prepare the stage for a large-scale trial of roll-out supported by beacon sites. The study will allow us to develop and geographically extend beacon sites and data capture in preparation for wider implementation. Method: We will deliver training in group-MCT to CR staff from three new leading CR services across the UK. We will conduct qualitative interviews with CR staff being trained in Group-MCT pre training, mid training, and after training to assess views on the training program including successes and barriers to implementation of training and delivery of Group-MCT. We will interview 8-10 CR managers, clinicians, and health care professionals from local clinical commissioning groups to identify any barriers to implementation and how these might be resolved. We will add new data lines to the national audit of cardiac rehabilitation (NACR) data-base and examine the reliability of data reporting. We will also collect pilot data on uptake of group-MCT in the new CR services which along with the qualitative interviews will help to inform a future PGfAR grant application. Timeline: The study will take 24 months: 6 months set-up, including training, 12 months conducting the pilot delivery of Group-MCT and qualitative interviews, and 6 months for analysis and dissemination. Impact and Dissemination: The study will support the implementation of a roll-out strategy and routine collection of data that can be used to evaluate wide-scale implementation. The study can provide immediate benefit to service users by improving patient s mental health outcomes and CR practitioner s clinical skills. Results will be disseminated via peer-reviewed journals, national and international conferences and service user/voluntary sector organisations and networks.

Lay abstract: Background: Cardiac rehabilitation (CR) services aim to reduce the risk of patients experiencing more cardiac events and improve their health and quality of life. Depression and anxiety are common in cardiac patients with approximately 1 in 4 experiencing symptoms of anxiety and 1 in 20 experience symptoms of depression, but talking based therapies have little success in improving symptoms of anxiety and depression. However, a National Institute for Health Research funded trial called PATHWAY, found that a group-based talking therapy called Metacognitive Therapy (MCT) is helpful at treating anxiety and depression and more helpful than cardiac rehabilitation alone. We now need to understand the factors that will help services include MCT, so that we can make MCT available across all CR services in the NHS. To do this we need to add MCT to more CR services, and check that data on MCT is being collected in the right way by the National Audit of Cardiac Rehabilitation (NACR). This will help us to understand how many patients are taking part in MCT in CR services. Aim: To add MCT to more CR services in the UK to check that routine data on MCT is being collected correctly by services, understand what factors help or prevent CR staff from including MCT in services, and understand what CR staff think of delivering group MCT in CR. Understanding these factors will help us prepare for making MCT available across the NHS. Methods: We will train CR staff to deliver group-MCT in three CR services across the UK. We will interview staff before, during, and after they have completed training to see how training might be improved for future roll-out. The three services will also deliver group-MCT and collect data on how many patients choose to take part. We will interview 8-10 service managers, clinicians, and health care professionals to find out what factors will prevent or encourage them from including group-MCT and how we can overcome any difficulties. We will also make changes to the data collected as part of the national CR database, so that it includes measures on group-MCT. Patient and Public Involvement and Engagement (PPIE): The PATHWAY PPIE group has helped to develop the research aim, lay abstract and project design. We will recruit a PPIE group made up of new and current PATHWAY PPIE group members to co-develop study materials, advise, and participate in promotion of group-MCT within services and help in dissemination of study findings. Impact: The study benefits patients, staff, and clinicians by improving CR staff skills and patient s mental health. Findings will be publicised in various ways including conferences (local, international), peer-review publications, social media, and workshops for clinicians, patients and carers delivered within the community.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH;CARDIOVASCULAR