{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T18:48:48Z","timestamp":1793213328991,"version":"4.5.0"},"reference-count":46,"publisher":"National Institute for Health and Care Research","license":[{"start":{"date-parts":[[2025,5,6]],"date-time":"2025-05-06T00:00:00Z","timestamp":1746489600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"National Institute for Health Research (NIHR) Research and Innovation for Global Health Transformation (RIGHT) Programme","award":["NIHR205540"],"award-info":[{"award-number":["NIHR205540"]}]}],"content-domain":{"domain":["openresearch.nihr.ac.uk"],"crossmark-restriction":false},"short-container-title":["NIHR Open Res"],"abstract":"<ns3:p>Background The evidence and infrastructure needed to access and deliver cardiac rehabilitation (CR) services are absent or lacking in low and middle-income countries (LMICs), resulting in a substantial loss of potential health and socio-economic benefits. Home-based programmes provide an affordable model of delivery that can leverage a scalable increase in CR access in LMICs. ACROSS (Affordable Cardiac Rehabilitation: An Outreach Inter-disciplinary Strategic Study) seeks to co-develop (with patients, caregivers, clinicians, and service commissioners) a culturally and contextually applicable and affordable home-based programme for people with the multimorbidity of coronary heart disease and\/or heart failure with co-existing depression and\/or anxiety and evaluate the acceptability, clinical effectiveness, and cost-effectiveness of its implementation in Bangladesh, India, and Pakistan and to determine its scalability and sustainability. Methods Four linked work packages (WPs). WP1 (cultural adaptation\/refinement of home-based rehabilitation): examine rehabilitation implementation barriers\/enablers from multiple stakeholder perspectives and co-develop a feasible and acceptable culturally &amp; contextually adapted home-based programme, extended to take account of co-existing depression and\/or anxiety; WP2 (external pilot): assess feasibility\/acceptability of the co-developed rehabilitation intervention and study design and processes necessary for a full-scale trial; WP3: (multicentre\/multi-country hybrid effectiveness and implementation randomised trial) determine the clinical and cost-effectiveness of a culturally adapted home-based rehabilitation intervention for people with coronary heart disease and\/or heart failure and depression and\/or anxiety; WP4 (capacity building): build research and rehabilitation delivery capacity. Conclusions The ACROSS programme overarching goal is to develop a clinically and cost-effective CR model in low-resource settings for people in Bangladesh, India, and Pakistan with a multimorbidity of heart disease and depression and\/or anxiety with the potential for substantial health and socio-economic benefits.<\/ns3:p>","DOI":"10.3310\/nihropenres.13957.1","type":"journal-article","created":{"date-parts":[[2025,5,6]],"date-time":"2025-05-06T06:30:09Z","timestamp":1746513009000},"page":"41","update-policy":"https:\/\/doi.org\/10.3310\/nihropenres.crossmark-policy","source":"Crossref","is-referenced-by-count":3,"title":["Affordable Cardiac Rehabilitation An Outreach Inter-Disciplinary Strategic Study (ACROSS) \u2013 Research Programme Protocol"],"prefix":"10.3310","volume":"5","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3043-6011","authenticated-orcid":false,"given":"Rod S","family":"Taylor","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Imran Bashir","family":"Chaudhry","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mithila","family":"Faraque","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Panniyammakal","family":"Jeemon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amy","family":"Blakemore","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karina","family":"Lovell","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nusrat","family":"Husain","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tahir","family":"Saghir","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7892-798X","authenticated-orcid":false,"given":"Saidur Rahman","family":"Mashreky","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sivadasanpillai","family":"Harikrishnan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chaudhury Meshkat","family":"Ahmed","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abraham","family":"Samuel Babu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7262-7000","authenticated-orcid":false,"given":"Alex","family":"McConnachie","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6340-3083","authenticated-orcid":false,"given":"Emma","family":"McIntosh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rakhshi","family":"Memon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sally","family":"Singh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alastair","family":"Leyland","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bhautesh","family":"Jani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Walter","family":"Flores","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"ACROSS Collaborative Group","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"6221","published-online":{"date-parts":[[2025,5,6]]},"reference":[{"key":"ref-1","doi-asserted-by":"publisher","first-page":"2361-2371","DOI":"10.1016\/j.jacc.2022.11.005","article-title":"The global burden of cardiovascular diseases and risk: a compass for future health.","volume":"80","author":"M Vaduganathan","year":"2022","journal-title":"J Am Coll Cardiol."},{"key":"ref-2","doi-asserted-by":"publisher","first-page":"2982-3021","DOI":"10.1016\/j.jacc.2020.11.010","article-title":"Global burden of cardiovascular diseases writing group. Global burden of cardiovascular diseases and risk factors, 1990\u20132019: update from the GBD 2019 study.","volume":"76","author":"G Roth","year":"2020","journal-title":"J Am Coll Cardiol."},{"key":"ref-3","article-title":"World health association global status report on noncommunicable diseases 2010","year":"2011"},{"key":"ref-4","doi-asserted-by":"publisher","first-page":"518-23","DOI":"10.1136\/pgmj.2007.066381","article-title":"Cardiovascular risk in South Asians.","volume":"84","author":"R Ramaraj","year":"2008","journal-title":"Postgrad Med J."},{"key":"ref-5","doi-asserted-by":"publisher","first-page":"1929-38","DOI":"10.1016\/S0140-6736(07)61696-1","article-title":"The burden and costs of chronic diseases in low-income and middle-income countries.","volume":"370","author":"D Abegunde","year":"2007","journal-title":"Lancet."},{"key":"ref-6","article-title":"Multimorbidity: a priority for global health research","year":"2018"},{"key":"ref-7","doi-asserted-by":"publisher","first-page":"1663-1665","DOI":"10.1093\/eurheartj\/ehad173","article-title":"Successful psychological treatment of depression and subsequent reduction in CVD events.","volume":"44","author":"D Hare","year":"2023","journal-title":"Eur Heart J."},{"key":"ref-8","doi-asserted-by":"publisher","DOI":"10.1016\/j.cpcardiol.2021.100848","article-title":"Global prevalence of depression among Heart Failure patients: a systematic review and meta-analysis.","volume":"47","author":"M Moradi","year":"2022","journal-title":"Curr Probl Cardiol."},{"key":"ref-9","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpsychores.2022.111141","article-title":"Co-prevalence and incidence of myocardial infarction and\/or stroke in patients with depression and\/or anxiety: a systematic review and meta-analysis.","volume":"165","author":"P Aw","year":"2023","journal-title":"J Psychosom 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infarction: a systematic review and meta-analysis.","volume":"48","author":"X Zheng","year":"2019","journal-title":"Heart Lung."},{"key":"ref-17","doi-asserted-by":"publisher","first-page":"2515-2525","DOI":"10.1093\/eurheartj\/ehad225","article-title":"Global perspectives on heart disease rehabilitation and secondary prevention: a scientific statement from the association of cardiovascular nursing and allied professions, European association of preventive cardiology, and international council of cardiovascular prevention and rehabilitation.","volume":"44","author":"R Taylor","year":"2023","journal-title":"Eur Heart J."},{"key":"ref-18","doi-asserted-by":"publisher","first-page":"31-45","DOI":"10.1016\/j.eclinm.2019.06.007","article-title":"Cardiac Rehabilitation availability and density around the globe.","volume":"13","author":"K Turk-Adawi","year":"2019","journal-title":"EClinicalMedicine."},{"key":"ref-19","doi-asserted-by":"publisher","first-page":"143-144","DOI":"10.1097\/HCR.0000000000000774","article-title":"Factors hindering Cardiac Rehabilitation in low- and middle-income countries, by level and setting.","volume":"43","author":"G de Melo Ghisi","year":"2023","journal-title":"J Cardiopulm Rehabil Prev."},{"key":"ref-20","doi-asserted-by":"publisher","first-page":"57-65","DOI":"10.4103\/WHO-SEAJPH.WHO-SEAJPH_62_21","article-title":"Availability and delivery of Cardiac Rehabilitation in South-East Asia: how does it compare globally?","volume":"10","author":"M Chowdhury","year":"2021","journal-title":"WHO South East Asia J Public Health."},{"key":"ref-21","doi-asserted-by":"publisher","first-page":"1449-1455","DOI":"10.1136\/heartjnl-2015-309209","article-title":"Cardiac Rehabilitation delivery model for low-resource settings.","volume":"102","author":"S Grace","year":"2016","journal-title":"Heart."},{"key":"ref-22","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD007130.pub5","article-title":"Home-based versus centre-based Cardiac Rehabilitation.","volume":"10","author":"S McDonagh","year":"2023","journal-title":"Cochrane Database Syst Rev."},{"key":"ref-23","doi-asserted-by":"publisher","first-page":"262-272","DOI":"10.1177\/2047487318806358","article-title":"The effects and costs of home-based rehabilitation for heart failure with reduced ejection fraction: the REACH-HF multicentre randomized controlled trial.","volume":"26","author":"H Dalal","year":"2019","journal-title":"Eur J Prev Cardiol."},{"key":"ref-24","doi-asserted-by":"publisher","first-page":"1252-1261","DOI":"10.1177\/2047487319833507","article-title":"The cost effectiveness of REACH-HF and home-based Cardiac Rehabilitation compared with the usual medical care for heart failure with reduced ejection fraction: a decision model-based 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study).","volume":"22","author":"C Purcell","year":"2023","journal-title":"Eur J Cardiovasc Nurs."},{"key":"ref-28","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.n1679","article-title":"Adapting interventions to new contexts-the ADAPT guidance.","volume":"374","author":"G Moore","year":"2021","journal-title":"BMJ."},{"key":"ref-29","doi-asserted-by":"publisher","first-page":"202-11","DOI":"10.1016\/j.ijcard.2006.11.018","article-title":"Home-based versus hospital-based rehabilitation after myocardial infarction: a randomized trial with preference arms\u2013\u2013Cornwall Heart Attack Rehabilitation Management Study (CHARMS).","volume":"119","author":"H Dalal","year":"2007","journal-title":"Int J Cardiol."},{"key":"ref-30","doi-asserted-by":"publisher","first-page":"1036-40","DOI":"10.1016\/0140-6736(92)90547-g","article-title":"Effects of self help post-myocardial-infarction rehabilitation on psychological adjustment and use of health services.","volume":"339","author":"B Lewin","year":"1992","journal-title":"Lancet."},{"key":"ref-31","doi-asserted-by":"publisher","first-page":"29-34","DOI":"10.1097\/HCR.0000000000000471","article-title":"Effect of home-based Cardiac Rehabilitation in a lower-middle income country: results from a controlled trial.","volume":"40","author":"J Uddin","year":"2020","journal-title":"J Cardiopulm Rehabil Prev."},{"key":"ref-32","doi-asserted-by":"publisher","DOI":"10.1186\/1748-5908-4-50","article-title":"Fostering implementation of health services research findings into practice: a Consolidated Framework for Advancing Implementation Science.","volume":"4","author":"L Damschroder","year":"2009","journal-title":"Implement Sci."},{"key":"ref-33","doi-asserted-by":"publisher","first-page":"77-101","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology.","volume":"3","author":"V Braun","year":"2006","journal-title":"Qual Res Psychol."},{"key":"ref-34","doi-asserted-by":"publisher","DOI":"10.1186\/s40814-016-0105-8","article-title":"CONSORT 2010 statement: extension to randomised pilot and feasibility trials.","volume":"2","author":"S Eldridge","year":"2016","journal-title":"Pilot Feasibility Stud."},{"key":"ref-35","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.h1258","article-title":"Process evaluation of complex interventions: Medical Research Council guidance.","volume":"350","author":"G Moore","year":"2015","journal-title":"BMJ."},{"key":"ref-36","doi-asserted-by":"publisher","DOI":"10.1186\/s40814-023-01291-5","article-title":"Recommendations for progression criteria during external randomised pilot trial design, conduct, analysis and reporting.","volume":"9","author":"K Mellor","year":"2023","journal-title":"Pilot Feasibility Stud."},{"key":"ref-37","doi-asserted-by":"publisher","DOI":"10.1186\/1741-7015-8-63","article-title":"Normalisation process theory: a framework for developing, evaluating and implementing complex interventions.","volume":"8","author":"E Murray","year":"2010","journal-title":"BMC Med."},{"key":"ref-38","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.m3721","article-title":"Designing and undertaking randomised implementation trials: guide for researchers.","volume":"372","author":"L Wolfenden","year":"2021","journal-title":"BMJ."},{"key":"ref-39","doi-asserted-by":"publisher","first-page":"606-13","DOI":"10.1046\/j.1525-1497.2001.016009606.x","article-title":"The Patient Health Questionnaire-9: validity of a brief depression severity measure.","volume":"16","author":"K Kroenke","year":"2001","journal-title":"J Gen Intern Med."},{"key":"ref-40","doi-asserted-by":"publisher","first-page":"395-401","DOI":"10.1016\/j.jad.2020.01.032","article-title":"Sensitivity to change and minimal clinically important difference of the 7\u2013item Generalized Anxiety Disorder Questionnaire (GAD-7).","volume":"265","author":"A Toussaint","year":"2020","journal-title":"J Affect Disord."},{"key":"ref-41","doi-asserted-by":"publisher","first-page":"176-82","DOI":"10.1093\/eurheartj\/ehr352","article-title":"The win ratio: a new approach to the analysis of composite endpoints in clinical trials based on clinical priorities.","volume":"33","author":"S Pocock","year":"2012","journal-title":"Eur Heart J."},{"key":"ref-42","doi-asserted-by":"publisher","first-page":"4391-4399","DOI":"10.1093\/eurheartj\/ehaa665","article-title":"The win ratio approach for composite endpoints: practical guidance based on previous experience.","volume":"41","author":"B Redfors","year":"2020","journal-title":"Eur Heart J."},{"key":"ref-43","doi-asserted-by":"publisher","first-page":"779-87","DOI":"10.1002\/hec.635","article-title":"Representing uncertainty: the role of cost-effectiveness acceptability curves.","volume":"10","author":"E Fenwick","year":"2001","journal-title":"Health Econ."},{"key":"ref-44","article-title":"Bill and Melinda Gates Foundation","year":"2014"},{"key":"ref-45","doi-asserted-by":"publisher","DOI":"10.1186\/1478-7547-11-6","article-title":"Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.","volume":"11","author":"D Husereau","year":"2013","journal-title":"Cost Eff Resour Alloc."},{"key":"ref-46","article-title":"ESSENCE on health research","year":"2020"}],"container-title":["NIHR Open Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-41\/v1\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-41\/v1\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-41\/v1\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,21]],"date-time":"2025-11-21T01:15:11Z","timestamp":1763687711000},"score":1,"resource":{"primary":{"URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-41\/v1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,6]]},"references-count":46,"URL":"https:\/\/doi.org\/10.3310\/nihropenres.13957.1","relation":{"has-review":[{"id-type":"doi","id":"10.3310\/nihropenres.15169.r35712","asserted-by":"subject"},{"id-type":"doi","id":"10.3310\/nihropenres.15169.r35708","asserted-by":"subject"},{"id-type":"doi","id":"10.3310\/nihropenres.15169.r35547","asserted-by":"subject"},{"id-type":"doi","id":"10.3310\/nihropenres.15169.r35708","asserted-by":"object"},{"id-type":"doi","id":"10.3310\/nihropenres.15169.r35547","asserted-by":"object"},{"id-type":"doi","id":"10.3310\/nihropenres.15169.r35712","asserted-by":"object"}]},"ISSN":["2633-4402"],"issn-type":[{"value":"2633-4402","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,5,6]]},"assertion":[{"value":"Indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-41\/v1#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.3310\/nihropenres.15169.r35547, Maria Teresa La Rovere, Istituti Clinici Scientifici Maugeri IRCCS, Montescano, 03 Jun 2025, version 1, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-41\/v1#referee-response-35547","order":0,"name":"referee-response-35547","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.15169.r35708, Porkodi Arjunan, King Faisal University, Al Hofuf, 09 Jun 2025, version 1, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-41\/v1#referee-response-35708","order":1,"name":"referee-response-35708","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Rod Taylor<\/b>; \n<i>Posted: 01 Jul 2025<\/i>; We thank the reviewer #2 for their positive feedback on our ACROSS research programme protocol publication. We provide a response to each of their specific queries below. \n<b>Details &amp; rationale of multimorbidity<\/b> \u2013 as we present in the Introduction section of our paper, the ACROSS programme the rationale for targeting people with a combined diagnosis of heart disease (coronary artery disease and\/or heart failure) plus a mental health disorder (anxiety and\/or depression) is because of their particularly poor health outcomes (i.e. reduced survival, high risk of morbidity, and marked loss of health-related of quality of life). The co-diagnosis of heart disease and a mental health disorder is also a common one [1]. \n<b>Timing of home-based CR<\/b> \u2013 for hospitalised patients, they will receive home-based CR following discharge. Additionally, patients, who may not have been acutely hospitalised, but attending for hospital outpatient management visits will also be eligible for home-based CR. \n<b>Further details of each work package<\/b> - the dual purpose of this present protocol paper was to provide a detailed description of the rationale and research aims of the ACROSS programme together with a high-level summary of methods of each work package. We will separately develop and publish a (master \u2013 cross country ) detailed protocol for each work package (WP 1, 2 and 3). For WP2 and WP3, this will include details of the trial population inclusion and exclusion criteria, patient screening and recuitment procedure, intervention and control condition description (including the health professionals who will deliver the home-based CR programme) and outcome collection. \n<b>Protocol approval<\/b> \u2013 the detailed protocol and participant facing documents (e.g. participant information sheet, consent form) for each work package will be submitted for assessment and approval by R&amp;D teams and ethics committees in each of the participating countries and their relevant institutions. \n<b>Timepoints of outcome assessment<\/b> \u2013 as outlined in our paper, outcomes will be assessed in WP3 trial participants at baseline (prior to randomisation) and 4 and 12-months post randomisation.  References 1. Farmer C, Fenu E, O'Flynn N, Guthrie B. Clinical assessment and management of multimorbidity: summary of NICE guidance. BMJ. 2016;354:i4843.","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-41\/v1#referee-comment-3456","order":2,"name":"referee-comment-3456","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.15169.r35712, Niamh A Merriman, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Leinster, 16 Jun 2025, version 1, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-41\/v1#referee-response-35712","order":3,"name":"referee-response-35712","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"This project is funded by the National Institute for Health Research (NIHR) under its Research and Innovation for Global Health Transformation (RIGHT) Programme (Grant reference - NIHR205540). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":4,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}