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Abstract

Background

The first surge of the ongoing COVID-19 pandemic led to a shutdown of all non-urgent medical services such as cardiac rehabilitation. Therefore, centres had to develop remote and innovative ways to deliver the core components of CR during this shutdown. This increase in usage of remote rehabilitation services provides a chance to assess patients' experiences and willingness-to-pay of remote CR sessions.

Methods

This was a prospective single-centre study. From 17 July 2020, to 19 August 2020, we conducted an anonymous survey about the patient experiences of the cardiac telerehabilitation services provided at Jessa Hospital Hasselt during the COVID-19 pandemic. A link to an electronic questionnaire was sent via email to 155 patients who were invited to participate in the cardiac telerehabilitation sessions during the closure of the rehabilitation centre due to COVID-19.

Results

Fifty-five patients (35% of all invited patients) did participate in remote CR and completed the questionnaire. The mean age of the respondents was 65.4鈥壜扁10.5鈥墆ears, 63% were male and 70% of the participants were retired. A total of 91% possessed a smartphone and all those patients used their smartphone regularly to send text messages. Ninety-four per cent of the participants were satisfied with the provided telerehabilitation sessions and 70% of the participants would be prepared to pay for these sessions like for centre-based CR sessions. Twenty per cent of patients would even prefer the telerehabilitation sessions above centre-based CR sessions.

Conclusion

Most patients believed that remote CR could be an option after the COVID-19 pandemic when it is combined with centre-based CR sessions. Patients are willing to pay the same amount for a telerehabilitation session as a centre-based CR session. This demonstrates that highly motivated patients are open to shift certain parts of CR from face-to-face interactions to digital interactions.

Introduction

Comprehensive cardiac rehabilitation (CR) is the first and essential part of the secondary prevention of cardiovascular disease (CVD) and is therefore a class IA recommendation by the European Society of Cardiology [1,5]. Multiple studies already demonstrated the clinical effectiveness and cost-effectiveness of providing CR for coronary artery disease and heart failure patients [2鈥4]. CR is typically a multidisciplinary centre-based programme which consists of the following core components: patient assessment, management and control of cardiovascular risk factors, physical activity counselling, prescription of exercise training, dietary advice, psychosocial management and vocational support [5]. The first surge of the ongoing COVID-19 pandemic had a significant impact on the daily lives of many. In many countries, a shutdown of all non-urgent medical services such as cardiac rehabilitation was issued to lower the surge capacity due to COVID-19. It is well established that a delay of the start of CR after a cardiac event is associated with less improvement in cardiopulmonary fitness and poorer uptake, attendance and completion rates of CR programmes [6,7]. Therefore, centres had to develop remote and innovative ways to deliver the core components of CR during this shutdown. The remote delivery of CR will also remain important after the reopening of the CR centres because many CR centres will have reduced capacity after reopening to enable strict social distancing. A recent study showed that approximately 50% of Belgian CR centres provided a form of remote CR sessions during COVID-19 [8]. Recent advances in information and communication technologies have facilitated the provision, monitoring and guidance of home-based CR. The use of these technologies to deliver CR from a distance is called telerehabilitation [9].

Remote delivery of CR and telerehabilitation have already been studied in small- and medium-sized studies and most of these papers concluded that home-based CR or telerehabilitation was equally effective in improving clinical and health-related quality of life outcomes [10,11]. Telerehabilitation could possibly play a role in improving the participation rates of CR by overcoming frequent barriers such as lack of access to transport and time and scheduling constraints. Yet, the implementation of telerehabilitation remains remarkably low [12]. The COVID-19 pandemic forces many CR centres to focus more on the remote delivery of CR components [9]. The rationale of this study is to take advantage of the increased usage of remote rehabilitation to assess patients' experiences of remote CR sessions. The hypothesis is that the majority of patients are willing to shift components of CR from centre-based to telerehabilitation.

Methods

From 17 July 2020, to 19 August 2020, an anonymous survey was conducted about patient experiences of the cardiac telerehabilitation services provided at Jessa Hospital Hasselt during the COVID-19 pandemic. The electronic questionnaire was developed with Qualtrics software.

The link to the electronic questionnaire was sent via email to 155 patients who were invited to participate in the cardiac telerehabilitation sessions. No reminders via email were sent during the study period. The questionnaires were sent with a brief cover letter and informed consent describing the study, assuring the patients that this was an anonymous survey and requesting their participation. The questionnaire was newly developed to assess the patient experiences and willingness-to-pay for cardiac telerehabilitation. The study was approved by the ethical committee of Jessa Hospital. Cardiac telerehabilitation sessions was defined as all sessions via telephone, videoconsultation or live exercise sessions with a member of the multidisciplinary CR team.

Study population

The cardiac rehabilitation content was provided to all patients participating in the CR program at Jessa Hospital. Furthermore, the content was also provided to patients that had a new indication for CR during the shutdown of the CR centre. Possible indications for CR are acute coronary syndromes, cardiac surgery or PCI, serious concomitant diseases at high risk of cardiovascular events, clinically stable patients with advanced CHF and a recent heart transplantation [5].

Cardiac telerehabilitation

The cardiac rehabilitation sessions in Jessa Hospital were provided by a multidisciplinary team consisting of physiotherapists, dietitians, social nurses, psychologists, and cardiologists. Patient鈥檚 preferences about frequency of contacts and content were assessed during the first call. The medical questions of patients were collected by the multidisciplinary team and discussed with a cardiologist in a multidisciplinary meeting which were still organised as a face-to-face meeting although taking social distancing measures in account. A cardiologist contacted the patients to answer their medical questions via telephone or video consultation.

The dieticians organised interactive live group sessions where they provided educational content via Jitsi (an open-source video conferencing platform). They also provided educational content and tips and tricks on the website of the rehabilitation centre, on Facebook and LinkedIn. The educational content were for example tips to prevent too much snacking during the lockdown and recipes with healthy alternatives and dietary advice for patients with COVID-19. Furthermore, patients could fill in nutrition diaries and self-reflection exercises on the website. The results of the diaries and self-reflections were discussed in individual consultations via telephone or Jitsi.

The psychologists also organised interactive live group sessions but also organised individual consultations to discuss personal issues or barriers and to provide smoking cessation counselling. Patients could also find educational content about smoking cessation and the link between smoking and CVD or COVID-19 on the website of the rehabilitation centre. They also developed a video about depressive symptoms and loneliness with as important message to talk with loved ones about your feelings or to contact the psychologist of the CR centre when feeling down.

The remote exercise training consisted of different exercise programmes. The physiotherapist developed a light-intensive and moderate-intensive training program for cardiac patients which was demonstrated in videos on the website of the rehabilitation centre.

Offline videos with exercises for flexibility and balance were also shared on the website of the rehabilitation centre. The physiotherapists also provided live group sessions with maximal eight patients where patients could train together with the physiotherapists and other patients. Lastly, the physiotherapists also provided advice on how to make the exercises easier or harder during weekly phone calls. Patient could also find four podcasts on the website of the rehabilitation centre. The topics of these podcasts were aerobic exercise training, resistance training, healthy lifestyle and being resilience.

Results

A total of 93 patients (60%) responded to the email. Thirty-eight patients responded that they did not participate in any remote CR session during the COVID-19 pandemic; these patients were excluded from the analysis. Fifty-five patients (35% of the patients invited) did participate in remote CR and completed the questionnaire. The mean age was 65.4鈥壜扁10.5鈥墆ears, 63% were male and 70% of the participants were retired. A total of 91% possessed a smartphone and all those patients used their smartphone regularly to send text messages. All patients had at least participated in one centre-based CR session before and 42% had already participated in more than 10 centre-based CR sessions. Table 1 gives an overview of the baseline demographics of the patients. The response rate demonstrates the percentage of patients responded on that question.

Table 1. Baseline demographics from the respondents.

The average duration of a remote CR session was 20鈥塵in. Most patients (71%) received less than two remote CR sessions per week. However, 38% of the patients preferred two sessions per week and even more patients (54%) trusted the health professionals to determine the adequate frequency. Most patients (54%) believed that remote CR could be an option after the COVID-19 pandemic if it was combined with centre-based CR sessions, 10% of the participants preferred not to receive remote CR at all after the COVID-19 and 36% believed that remote CR could be an option even if it was not combined with centre-based CR sessions. 94% of the participants were satisfied with the provided telerehabilitation sessions and 70% of the participants would be prepared to pay for these sessions like for centre-based CR sessions. 20% of patients would prefer the telerehabilitation sessions above centre-based CR sessions. Most patients (82%) felt sufficiently supported during the telerehabilitation sessions. Patients reported time saving and the fact that they did not have to come to the rehabilitation centre as the main advantages of the telerehabilitation sessions. The feeling of being monitored less intensively by the rehabilitation team, the feeling that the rehabilitation team has less insight in your clinical status and the absence of social contact were the main disadvantages that were reported by the patients. The complete list of results are presented in Table 2.

Table 2. Results of the survey about the experiences of telerehabilitation during COVID-19.

Discussion

The COVID-19 pandemic forced our centre to quickly adapt the standard centre-based CR services to a remote service as remote CR is not routinely offered in our centre. A telerehabilitation service had to be rapidly set up for patients that were already participating in CR. Still, 94% of the participants indicated that they were satisfied with the provided telerehabilitation sessions. An important note is that only 35% procent of the patients that were invited to the remote CR sessions participated in the questionnaire. Therefore, the respondents are highly motivated patients which can influence the results of the survey. This survey learned us several important lessons for future telerehabilitation projects. Most patients responded that they believed that remote CR could be an option even after the COVID-19 pandemic when it is combined with centre-based CR sessions. This could demonstrate that there is more research needed to telerehabilitation intervention as an add-on to standard centre-based CR programmes, such as for example the study of Frederix et聽al. [12]. The survey confirmed that many patients believe that common barriers for CR participation such as transportation and time scheduling issues could be resolved with a telerehabilitation intervention. This could suggest that telerehabilitation services could improve the delivery of CR components in patients experiencing these barriers. Strikingly, most of the patients (70%) were willing to pay the same amount for a telerehabilitation session as a centre-based CR session. This demonstrated that highly motivated patients are open to shift certain parts of CR from face-to-face interactions to digital interactions. Many patients are clearly ready for or even prefer telerehabilitation services. These insights can help to accelerate the implementation process of telerehabilitation.

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Disclosure statement

In accordance with Taylor & Francis policy and our ethical obligation as researchers, we are reporting that we have no financial and/or business interests or we are no consultant to a company that may be affected by the research reported in the enclosed paper. We have disclosed those interests fully to Taylor & Francis.

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Appendix Appendix questionnaire

Q1 What is your age?

_______________________________________________

Q2 What is your gender?

  • Male (1)

  • Female (2)

Q3 Do you currently have paid work?

  • Yes, and I carry out my job as usual, taking into account the social distancing in the workplace (1)

  • Yes, and I do my job as usual, but from home (2)

  • No, I am partially technical unemployed (3)

  • No, I am completely technically unemployed (4)

  • No, I am on sick leave (5)

  • No, I am disabled (6)

  • No, I am retired (7)

  • No, I am unemployed (8)

Q4 Do you own a smartphone?

  • Yes (1)

  • No (2)

Q5 Do you use your smartphone for text messages?

  • Yes (1)

  • No (2)

Q6 Do you have an email address and how often do you check your email?

  • No (1)

  • Yes, Daily (2)

  • Yes, a few times a week (3)

  • Once a week (4)

  • Once a month

  • Rarely (6)

Q7 How many sessions have you already done in the rehabilitation centre for your current complaint (s) BEFORE the corona crisis?

  • 1 session (1)

  • Between 1 and 5 sessions (2)

  • Between 6 and 10 sessions (3)

  • Between 11 and 18 sessions (4)

  • More than 18 sessions (5)

Q8聽How often did you follow phone and / or video consultations as part of your cardiac rehabilitation DURING the corona crisis (average number of sessions per week)?

  • Two times per week (1)

  • More than two times per week (2)

  • Less than two times per week (3)

Q9 What is the average duration of the telephone and / or video consultations in the context of your cardiac rehabilitation followed DURING the corona crisis (average number of sessions per week)?

______________________________________________

Q10 To guarantee continuity in care during the corona crisis, the government has recently started providing temporary reimbursement for remote cardiac rehabilitation (physiotherapy telephone and video consultations). The condition is that there is at least 2x / week contact with the patient by telephone or video.

If these regulations for remote cardiac rehabilitation sessions are maintained after the corona crisis, what should be the minimum frequency for you?

  • Must be two times per week (1)

  • More than two times per week (2)

  • Less than two times per week (3)

  • I rely on the knowledge of my physiotherapist to determine the frequency according to my needs (4)

Q11 If reimbursement for remote cardiac rehabilitation is maintained AFTER the corona crisis, what is your view?

  • Remote cardiac rehabilitation is only possible if the cardiac rehabilitation sessions are a combination of sessions in the REGO and remote cardiac rehabilitation (telephone and / or video consultations (1)

  • Remote cardiac rehabilitation sessions are always possible, even without sessions in the rehabilitation centre (2)

  • Remote cardiac rehabilitation sessions are never possible (3)

Q12 If these regulations for remote cardiac rehabilitation are maintained AFTER the corona crisis, are you as a patient willing to pay part of the cost for 'remote cardiac rehabilitation' yourself (REM money), just like with the physical consultations in the rehabilitation centre itself

  • Yes (1)

  • No (2)

Q13 What is the maximum price you would pay for 1 session (+ -30min) of "remote cardiac rehabilitation"?

_______________________________________________

Q14 Are/were you satisfied with the remote cardiac rehabilitation sessions that you received during the COVID-19 period?

  • Yes (1)

  • No (2)

Q15 Would you prefer cardiac rehabilitation from a distance over cardiac rehabilitation that requires you to come to the rehabilitation centre?

  • Yes (1)

  • No (2)

Q16 Did you find it easy to participate in the video consultations for the training sessions?

  • Yes (1)

  • No (2)

Q17聽I am 鈥. motivated for cardiac rehab by phone or video.

  • More (1)

  • Equally (2)

  • Less (3)

Q18聽I find cardiac rehabilitation interviews with dietitians or psychologists via phone or video 鈥.. useful as a meeting in the rehabilitation centre itself.

  • More (1)

  • Equally (2)

  • Less (3)

Q19 I receive 鈥︹︹ support and trust from my physiotherapist via telephone and / or video consultations then via cardiac rehabilitation sessions in the rehabilitation centre itself.

  • More (1)

  • Equal (2)

  • Less (3)

Q20 There is 鈥. time for consultation and explanation during telephone and / or video consultations than during cardiac rehabilitation sessions in the rehabilitation centre itself.

  • More (1)

  • Equally (2)

  • Less (3)

Q21 Did you feel that you were adequately guided and supported by the rehabilitation team during the remote cardiac rehabilitation?

  • Yes (1)

  • No (2)

Q22 Which components of cardiac rehabilitation do you think can always be delivered remotely? (Multiple answers possible)

  • Physical training (1)

  • Follow-up by cardiologist (2)

  • Conversations with dietician (3)

  • Consultation with psychologist (4)

  • Smoking cessation guidance (5)

  • Conversations with social nurse (6)

Q23聽Which things are currently preventing you from (more often) doing VIDEO consultations with physical exercises with your physiotherapist? (Multiple answers possible)

  • Nothing is stopping me right now (1)

  • Insufficient facilities (computer, internet, closed room) to allow video consultations to take place (2)

  • Insufficient knowledge of the platforms to allow video consultations to take place (3)

  • No belief in the effectiveness of video consultations (4)

  • No time for video consultations to take place (5)

  • Other:鈥 (7) _____________________________________

Q24聽Which things are currently preventing you from having (more) TELEPHONE consultations with psychologists, dieticians or social nurses? (multiple answers possible)

  • Nothing is stopping me right now (1)

  • No telephone, computer, internet to allow telephone consultations to continue (2)

  • Insufficient knowledge of the platforms to allow telephone consultations to proceed (3)

  • No belief in the effectiveness of telephone consultations (4)

  • No time to continue telephone consultations (5)

  • Other:鈥 (6) ____________________________________

Q25 What are the biggest advantages for you of telephone and video consultation, even after the corona crisis, when a visit to the REGO is possible again? (multiple answers possible)

  • I don't see any advantage over a physical consultation (1)

  • No transport necessary (2)

  • Time savings (3)

  • No vehicle needed (4)

  • No childcare required (5)

  • Greater flexibility to schedule an appointment (6)

  • More frequent follow-up (7)

  • Physiotherapist has a better view of the home situation (8)

  • Advice and exercises can be adapted to my specific (home and / or work) situation (9)

  • Partner or other loved one can be involved (10)

  • Other:鈥 (11) ____________________________________

Q26聽What are the biggest disadvantages for you of telephone and video consultations, even after the corona crisis, when a visit to the rehabilitation centre is possible again? (multiple answers possible)

  • The rehabilitation team has insight into the home situation (1)

  • The rehabilitation team does not have a complete overview of the problem, as a physical examination is not possible (2)

  • The absence of social contact (3)

  • The feeling of being less well monitored by the rehabilitation team (4)

  • Other:鈥 (5) ______________________________________

Q27 As a patient, are you willing to share data with your physiotherapist or cardiologist that you have obtained through certain devices (e.g. data collected via pedometer, activity tracker, sports watch, ..)

  • Yes, I want to share this data during a physical consultation (1)

  • Yes, I want to share this data via a digital way whereby data is forwarded to my physiotherapist when I give permission (2)

  • Yes, I want to share this data automatically in a digital way (3)

  • No and give a reason why not (4)

Q28 As a patient, are you willing to participate in cardiac rehabilitation through forms of consultation other than telephone and video, e.g. via an internet platform, via a smartphone application, via text messages

  • Yes (1)

  • No (2)

Q29 What are thresholds for other forms of remote cardiac rehabilitation, e.g. via an internet platform, via a smartphone application, via text messages? (Multiple answers possible)

  • Nothing is stopping me right now (1)

  • Don't have a smartphone (2)

  • Insufficient knowledge of these platforms (3)

  • No need to do this (4)

  • Other: (5)