Senior Methodologist Ottawa Hospital Research Institute Toronto, Ontario, Canada
Background: Despite clear guideline recommendations for secondary prevention following ST-elevation myocardial infarction (STEMI), adherence to these measures remains suboptimal. Fragmented transitions in care contribute to poor long-term medication adherence and low participation in cardiac rehabilitation, particularly in regional systems lacking standardized follow-up processes. This study aimed to identify key barriers and enablers to effective post-STEMI care transitions using a theory-based qualitative approach.
METHODS AND RESULTS: We conducted semi-structured virtual interviews with STEMI patients (n=14), healthcare providers (n=8), and healthcare leaders (n=4) from a regional cardiac network. Patients were enrolled from the cardiac care unit and the STEMI follow-up clinic at a regional cardiac centre in Hamilton, Ontario. Healthcare providers and leaders were recruited using a snowball sampling technique. Guided by two implementation science frameworks, the Theoretical Domains Framework (TDF) and the Consolidated Framework for Implementation Research (CFIR), data were analyzed using deductive directed content analysis. The TDF was used to explore behavioural influences across all participant groups, while the CFIR was applied to provider and leader interviews to examine implementation-specific factors. Key barriers reported by patients included knowledge gaps about symptoms and treatment (TDF domain: Knowledge), difficulty sustaining behavioural routines (TDF: Behavioural regulation), and logistical barriers to accessing cardiac services (TDF: Environmental context and resources). Healthcare providers and leaders highlighted poor communication across care settings (CFIR domain: Networks and communication), limited follow-up planning (CFIR: Planning), and the absence of long-term funding models to support implementation efforts (CFIR: Available resources). Enablers included strong social support for patients (TDF: Social influences), expanded roles for nurse practitioners and pharmacists (TDF: Social/professional role and identity), and openness to virtual follow-up models (CFIR: Adaptability). Options to address these challenges include strengthening patient education, enhancing interdisciplinary collaboration, addressing financial and structural barriers to care, standardizing follow-up systems, expanding nurse/pharmacist-led roles, and fostering a system-wide culture supporting implementation efforts.
Conclusion: Applying behavioural and implementation frameworks such as TDF and CFIR offers a comprehensive approach to addressing multi-level determinants of care. Our theory-based approach identified a range of patient-, provider-, and system-level barriers and enablers to optimal post-STEMI care. These findings can guide the development of targeted, evidence-based initiatives - such as structured education after discharge, interdisciplinary collaboration, and improved care coordination - to support adherence to secondary prevention and improve patient outcomes.
