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https://orcid.org/0000-0001-8636-5972
Abstract
Abstract
Background
The COVID-19 pandemic has forced many cardiac rehabilitation centres to focus more on the remote delivery of cardiac rehabilitation (CR) components. This increased focus and the lessons learned from this period could enhance the implementation of telerehabilitation and increase the participation in CR in Belgium.
Methods
We conducted a survey between April and May 2020 about the implementation of telerehabilitation services during the COVID-19 pandemic. The electronic questionnaire was sent via email to the heads of 42 Belgian CR centres. Three reminders via email were sent during the study period.
Results
27 CR centres (64%) returned completed questionnaires after three mailings. 52% of the CR centres provided remote CR services during the lockdown due to the COVID-19 pandemic. All CR centres that provided remote CR services delivered exercise training. The most used medium to deliver the CR components were online videos (71%) followed by online information on the website (64%) and emails (64%).
Conclusion
It is interesting that the COVID-19 pandemic has encouraged many CR centres to implement remote delivery of CR components. This can help to speed up the research and implementation of telerehabilitation in daily clinical practice. The COVID-19 pandemic could be the push for a large multicentre implementation study that could prove that telerehabilitation is feasible and effective in the Belgian setting.
Introduction
Cardiovascular disease (CVD) remains the leading cause of mortality (27%) in Belgium, although the relative importance of CVD mortality in Belgium decreased steadily from 36% in 1998 probably due to better medical care and prevention [1,2]. Both primary prevention and secondary prevention are crucial pillars in reducing the morbidity and mortality of CVD, especially with the rising prevalence of obesity and diabetes and the fact that 40% of major coronary events occur in patients with manifest coronary artery disease (CAD) [3,4]. Comprehensive cardiac rehabilitation (CR) is an important part of the secondary prevention of CVD and therefore a class IA recommendation by the European Society Cardiology [4]. Core components of CR are 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 surge capacity due to the COVID-19 pandemic led to the shutdown of all non-urgent medical services such as CR in Belgium. Therefore, centres had to develop remote and innovative ways to deliver the core components of CR because a delay in 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].
The remote delivery of CR can even remain important after the reopening of the CR centres because many CR centres will have reduced capacity after reopening to enable strict social distancing. Remote delivery of CR and telerehabilitation has 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 [8,9]. Telerehabilitation could possibly play a role in improving the participation rates of CR in Belgium by overcoming frequent barriers such as lack of access to transport and time and scheduling constraints. Yet, the implementation of telerehabilitation remained disappointingly low. The COVID-19 pandemic forced many CR centres to focus more on the remote delivery of CR components. This increased focus and the lesson learned from this period could enhance the implementation of telerehabilitation and increase the participation in CR in Belgium.
Methods
From 26 April 2020 to 19 May 2020, we conducted a survey about the implementation of telerehabilitation services during the COVID-19 pandemic. The electronic questionnaire was sent via email to the heads of 42 Belgian CR centres. Three 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 them that this was an anonymous survey and requesting their participation. The questionnaire was newly developed to assess the remote delivery of CR components during the COVID-19 lockdown. The study was approved by the ethical committee of Hasselt University.
Results
Twenty-seven CR centres (64%) returned completed questionnaires after three mailings. 52% of the CR centres provided remote CR services during the lockdown due to the COVID-19 pandemic. All CR centres that provided remote CR services during the lockdown did this for patients that were already rehabilitating. Only half of the rehabilitation centres that provided remote CR services during the lockdown also included patients who suffered a heart attack during the lockdown. Only 4 (29%) CR centres asked patients to use tracking devices to record physical activity and only 2 (14%) provided real-time synchronous exercise training. All CR centres that provided remote CR services delivered exercise training. 10 (71%) CR centres provided dietary advice. The most frequently used medium to deliver the CR components were online videos (71%) followed by online information on the website (64%) and emails (64%). Physiotherapists contributed to the remote delivery of CR in all CR centres. Furthermore, medical doctors contributed in 71%. Lastly, only 4 (15%) CR centres still organised multidisciplinary meetings. The results are presented in Table 1.
Table 1. Results of the survey about the implementation of telerehabilitation in Belgium.
Discussion
In Belgium, 52% of the CR centres provided remote CR services during the COVID-19 pandemic due to the closure of non-urgent medical services. Strikingly, only half of these CR centres provided CR services to patients who had a heart attack during the lockdown. This is probably due to the fact that initial patient and safety assessment is difficult without a face-to-face meeting. The COVID-19 pandemic forced many centres to start promptly with these services. Therefore, easy formats such as online videos and email correspondence were the most used formats to deliver information about CR. None of the CR centres used a smartphone application. Most CR centres that provided remote CR delivered several components of CR. All centres provided remote exercise training but there were also many centres that provided psychosocial support and dietary advice. This shows that remote delivery of most of the CR components is feasible. It is clear that the COVID-19 pandemic is moving to a direction where self-managed, home-based interventions are being encouraged, and are likely to remain with us beyond the current pandemic (Table 2). The importance of the delivery of remote CR services during the COVID-19 pandemic is evident. The closure of CR centres leads to increased time between the acute coronary syndrome and start of CR which is linked with lower participation and completion rates [6,7]. Moreover, CR is associated with a reduction in morbidity and mortality, so the reduced participation and completion rates lead to less well secondary prevention and a higher risk of recurrent events [10]. Remote delivery of CR components can also have a role beyond the COVID-19 pandemic. The EUROASPIRE surveys revealed that the participation rates in CR remain disappointingly low. Common barriers are transport, vocational or scheduling issues. Telerehabilitation could possibly be used to increase the delivery of CR components. Therefore, it is interesting that many Belgian CR centres started experimenting with telerehabilitation during this current crisis. This can help to speed up the research and implementation of telerehabilitation however cutting corners due to urgency is not recommended. More evidence regarding telerehabilitation in Belgium is needed. The COVID-19 pandemic could be the push for a large multicentre implementation study which could prove that telerehabilitation is feasible and effective in the Belgian setting.
Table 2. Geographical distribution of the implementation of telerehabilitation during COVID-19 pandemic in Belgium (for two responses are no geographical data available).
| Remote CR services for patients that were already rehabilitating (yes) | N = 14 |
|---|---|
| Remote CR services for patients that suffered from a heart attack during the lockdown (yes) | 7 (50%) |
| Which team members take part in providing remote CR | |
| Medical doctor | 10 (71%) |
| Social nurse | 3 (21%) |
| Dietician | 5 (36%) |
| Physiotherapist | 14 (100%) |
| Psychologist | 6 (43%) |
| Do you ask patients to use tracking devices to record physical activity? (yes) | 4 (29%) |
| Do you organise real-time (synchronous) remote exercise training sessions? (yes) | 2 (14%) |
| Which components of cardiac rehabilitation are provided to patients? (yes) | |
| Exercise training | 14 (100%) |
| Dietary advice | 10 (71%) |
| Smoking cessation guidance | 8 (57%) |
| Diabetes management | 5 (36%) |
| Cardiovascular education | 8 (57%) |
| Hypertension management | 4 (29%) |
| Weight management | 6 (43%) |
| Psychosocial support | 12 (86%) |
| How do you provide CR components? | |
| Online videos | 10 (71%) |
| Online information on the website | 9 (64%) |
| Text messages | 2 (14%) |
| Information sent by post | 5 (36%) |
| Social media | 4 (29%) |
| 9 (64%) | |
| Smartphone application | 0 (0%) |
| Telephone | 14 (100%) |
| Video consultation | 3 (21%) |
| What is the frequency of one-to-one contact between a patient and health professional? | |
| Daily | 0 (0%) |
| Several times a week | 3 (21%) |
| Once a week | 4 (29%) |
| Once every two weeks | 3 (21%) |
| Once every month | 2 (14%) |
| Less than once a month | 2 (14%) |
| Flanders | 6 (46%) |
| Wallonia | 6 (66%) |
| Brussels | 1 (33%) |
Acknowledgements
We thank the physicians who participated in this study for sharing their information and experiences.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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