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Introduction: Despite extensive evidence of its benefits and recommendation by guidelines, cardiac rehabilitation (CR) remains highly underused with only 20%-50% of eligible patients participating. We aim to implement and evaluate the Country Heart Attack Prevention (CHAP) model of care to improve CR attendance and completion for rural and remote participants., Methods and Analysis: CHAP will apply the model for large-scale knowledge translation to develop and implement a model of care to CR in rural Australia. Partnering with patients, clinicians and health service managers, we will codevelop new approaches and refine/expand existing ones to address known barriers to CR attendance. CHAP will codesign a web-based CR programme with patients expanding their choices to CR attendance. To increase referral rates, CHAP will promote endorsement of CR among clinicians and develop an electronic system that automatises referrals of in-hospital eligible patients to CR. A business model that includes reimbursement of CR delivered in primary care by Medicare will enable sustainable access to CR. To promote CR quality improvement, professional development interventions and an accreditation programme of CR services and programmes will be developed. To evaluate 12-month CR attendance/completion (primary outcome), clinical and cost-effectiveness (secondary outcomes) between patients exposed (n=1223) and not exposed (n=3669) to CHAP, we will apply a multidesign approach that encompasses a prospective cohort study, a pre-post study and a comprehensive economic evaluation., Ethics and Dissemination: This study was approved by the Southern Adelaide Clinical Human Research Ethics Committee (HREC/20/SAC/78) and by the Department for Health and Wellbeing Human Research Ethics Committee (2021/HRE00270), which approved a waiver of informed consent. Findings and dissemination to patients and clinicians will be through a public website, online educational sessions and scientific publications. Deidentified data will be available from the corresponding author on reasonable request., Trial Registration Number: ACTRN12621000222842., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Evidence-based guidelines recommend cardiac rehabilitation(CR) for secondary prevention of recurrent myocardial infarction(re-MI) and risk factor management, but poor referral and completion rates persist. Regular audit can measure the effectiveness of services. A 2011 audit of public CR services, by the South Australian Department of Health CR Clinical Network showed a 12% program attendance rate. Following development of standardised minimum data and uniform electronic data capture, 24 CR services have contributed within 3 audits. We aimed to link referral and attendance with administrative data to assess characteristics and outcomes of eligible patients. Methods: The CR patient database for 2013-2015 was linked to patients discharged alive with a primary cardiac-related diagnosis and/or interventional procedure, identified through public hospital administrative data. Outcomes were defined as readmission for cardiovascular causes and death captured through the Births Deaths and Marriages database. Patient categories were not referred, referred/declined and attended CR. Associations with cardiovascular readmission and composites of death, new/re-MI, heart failure, atrial fibrillation and stroke over the 12-month follow-up duration were reported using inverse probability weighted survival methods among those who attended and those referred/declined. Results: Of 49,909 eligible cardiac separations, referral rate was 15,089/49,909 (30.2%) and attendance 4,286/15,089 (28.4%). Those referred/declined were older (median: 67.3 vs 65.3 years, P< 0.001), more likely to be female (32.3% vs 26.5%, P< 0.001) with more heart failure (17.1% vs 10.9%, P< 0.001) and arrhythmia (6.1% v 2.1%, P< 0.001) admissions, ≥2 comorbidities (35.3% v 23.3%, P< 0.001), with higher socio-economic disadvantage (median IRSAD: 950.1 vs 960.4, p<0.001). Attending patients had lower cardiovascular readmission, (attended vs not referred: 27.3% vs 34.5% and attended vs referred/declined ; 27.3% vs 41.4%, P< 0.001). After clinical and social factors adjustment there was no difference in composite clinical outcomes to 12-months, but attendance was associated with reduced cardiovascular readmission (HR:0.68, 95% IQR: 0.58-0.81, P = 0.001). Conclusions: This analysis highlights the complexity of factors that influence referral, non-attendance and attendance to CR. Conducting clinical audit and reporting to services is vital for measuring program effectiveness and can be a mechanism for service improvement. [ABSTRACT FROM AUTHOR]