Integrating a mobile application to enhance integrated care for atrial fibrillation: key insights from an implementation study guided by the Consolidated Framework for Implementation Research (CFIR) (Preprint)
Authors: Hewage Sumudu , Kularatna Sanjeewa , Parsonage William , Walters Tomos , McPhail Steven , Brain David , Allen Michelle 
Published: September 2024

BACKGROUND

Despite the rise in the use of mobile health applications, their effective integration into routine healthcare remains challenging due to dynamic and context-specific determinants influencing the implementation.

OBJECTIVE

We aimed to identify the key enablers and challenges of integrating a mobile application for cardiac rehabilitation and healthy lifestyles among atrial fibrillation patients at a cardiology clinic in Australia.

METHODS

We interviewed both clinicians and patients to understand their perspectives about the mobile application and what factors affected the implementation. The two semi-structured interview guides used – one for clinicians and one for patients – were developed based on the Consolidated Framework for Implementation Research (CFIR) and Non-adoption Abandonment, Scale-Up, Spread, and Sustainability - Complexity Assessment Tool (NASSS CAT). All interviews were recorded and transcribed, and the transcripts were analysed inductively to generate codes using a constructionist perspective. These codes were subsequently mapped onto the constructs within the CFIR across its five domains. This framework analysis was followed by examining the interconnections among the constructs to understand their collective impact on the implementation process, thereby identifying key enablers and challenges for the integration efforts.

RESULTS

We interviewed 24 participants including 18 patients, whose mean age was 69 years, and six clinicians, comprising four specialist cardiac electrophysiologists and two nurses. Patient engagement with the application varied: three completed the cardiac rehabilitation plan, one was still actively engaged, two had partial use, ten downloaded but never used the app, and two did not download the app.

We identified a complex interplay between key determinants across all five CFIR domains, collectively impacting two main elements in the implementation process: (1) acceptability and user engagement with the app and (2) the clinic's implementation readiness. The app was more likely to be accepted and used by patients who needed to establish healthy lifestyle habits. Those with established healthy lifestyle habits did not indicate that the app provided sufficient added value to justify adoption. Interoperability with other devices and design issues, for example limited customisation options, also negatively impacted the uptake. The clinic's implementation readiness was limited by various challenges including limited staff availability, insufficient internal communication processes, the absence of an implementation evaluation plan, and lack of clarity around who’s funding the app’s use beyond the initial trial. Despite the clinician’s overall inclination towards technology use, diverse opinions on the evidence for short-term cardiac rehabilitation programs in atrial fibrillation critically reduced their commitment to app integration.

CONCLUSIONS

Mobile health apps have seen rapid expansion and offer clear benefits, yet their integration into complex health systems remains challenging. Whilst our findings are from a single app implementation, they highlight the importance of embedding contextual analysis and proactive strategic planning in the integration process.

CLINICALTRIAL

not applicable.