News Release 

Remote cardiac rehabilitation programs are effective alternatives to on-site services

American Heart Association Scientific Sessions 2020, presentation Posters P2365 and P664

American Heart Association

Research News

DALLAS, Nov. 9, 2020 -- Remote or virtual cardiovascular or cardiac rehabilitation programs using tele-counseling with specialists, provided via telephone or mobile apps and web-based technology, were found to be as effective as on-site programs offered in hospitals, according to preliminary research to be presented at the American Heart Association's Scientific Sessions 2020. The meeting will be held virtually, Friday, November 13-Tuesday, November 17, 2020, and is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science for health care worldwide.

Cardiac rehabilitation is a standardized, outpatient program of exercise and education designed to help patients with established vascular disease or heart failure and patients after hospitalization for a heart attack, stroke, heart failure or surgery to treat heart disease. Research has shown that cardiac rehabilitation programs can reduce the risk of death from heart disease, hospital and emergency visits and the risk of future heart problems. However, many people have limited access to these services due to numerous factors including limited availability, transportation challenges and costs.

It has become challenging to provide on-site, outpatient cardiovascular rehab in hospitals or community sites in the advent of the COVID-19 public health emergency this year. Non-essential services closed in some countries as a result of COVID-19, and social distancing requirements prevented group activities, thereby, terminating in-person, on-site cardiac rehabilitation programs. Health care systems have adapted since the initial COVID-19 closures to provide remote delivery, also called telehealth, of rehabilitation services.

Two separate studies recently investigated the participation rates and effectiveness of remote, or virtual, rehabilitation programs for cardiac patients since the COVID-19 pandemic.

Health Care System Design and Virtual Delivery System: Cardiovascular Rehabilitation Access and Participation Rates During Covid19 Public Health Emergency (P2365)

Central East Cardiovascular Rehabilitation in the Eastern Greater Toronto area, Ontario, launched a region-wide, community-based cardiovascular rehabilitation service in 2011. The program includes region-wide referral criteria, centralized referral acceptance and standardized delivery of quality care by a regional workforce. The evidence-based, cardiac rehabilitation program serves patients at 17 community sites across a large region of Ontario and includes weekly visits for six months. More than 3,600 people participate in the program annually, with 70% acceptance rates and 60% completion rates.

When the Canadian and provincial governments implemented a nationwide lockdown on March 17 to limit the spread of COVID-19, the centrally managed, regional health care team of Central East Cardiac Rehabilitation Program rapidly transitioned from in-person, on-site to virtual content within one week. The virtual cardiovascular rehabilitation program included e-visits by telephone and email, as well as interactive technology such as web-based video support and mobile apps.

"We anticipated that the pandemic response would negatively impact referral, acceptance and completion rates," said Joseph A. Ricci, M.D., medical director of the Central East Cardiovascular Rehabilitation Program in Toronto, and lead author of this study. "Our centralized processes allowed uninterrupted referrals, and although office closures reduced community referrals, inpatient referrals increased."

In addition, patient acceptance and adherence were not significantly reduced compared to traditional cardiac rehabilitation services.

Compared to the same six-week period in 2019, after implementing the virtual rehab program since late March 2020:

  • Total referrals increased by 33%;
  • Patient acceptance exceeded 90%; and
  • Attendance rate vs. scheduled was 85%.

"We understood that virtual rehab may not be equivalent to the in-person, on-site community interaction patients were accustomed to, so we were pleasantly surprised that the virtual program was just as effective and that patient satisfaction did not decline," said Ricci. "The data confirm that virtual cardiac rehabilitation offers a viable solution as a result of the COVID pandemic, and also for patients in rural areas or those who have limited access to transportation."

However, one disadvantage of virtual cardiac rehab could be the higher cost in comparison to on-site delivery. In this study, the cost per patient was approximately double, due to staff costs related to more frequent one-on-one patient consultation and smaller group interactions.

Ricci added, "Based on this experience, modern technologies should be integrated into traditional delivery models beyond the pandemic period, including exploration of hybrid in-person, on-site and virtual rehabilitation programs. These programs are essential to improving outcomes for cardiovascular patients."

Co-authors are Riyad Akbarali, R. Kin., M.H.Sc.; Courtney Tsui, M.S.F.C., R.Kin.; Adam Pierce, B.A.Sc.; Stephanie Bennett, M.F.Sc., R.Kin.; Michael Wilson, B.Sc.; Kristen Doucette, B.H.Sc.; Thiru Appasamy, M.Com., Neville Suskin, M.B.Ch.B.; Trixie Williams, R.N., B.Sc.N., M.H.S.; and Stephanie Frisbee, Ph.D. Author disclosures are in the abstract.

The study was conducted by the program's CE Cardiovascular Rehabilitation Outcomes Research without funding from external sources.

Note: Session: EP.APS.18 - Role of Healthcare Systems and Care Delivery in Modifying CVD Epidemiology and Epidemiology of Atrial Fibrillation

Remote Cardiac Rehabilitation is a Good Alternative of Outpatient Cardiac Rehabilitation in the Covid-19 Era (P664)

In 2019, the University of Tokyo Hospital established a remote cardiovascular rehabilitation program for patients with heart failure. Patients who participated in the remote program received telephone support from cardiologists and nurses specializing in heart failure every two weeks for five months after hospital discharge. Each patient received a DVD of the cardiac rehab program, used their own medical devices at home and tracked their daily steps using a mobile app.

"Since our hospital has a large heart transplantation center in Japan, with many patients suffering from severe heart failure, we needed to perform remote cardiac rehabilitation before the COVID-19 era," said Atsuko Nakayama, M.D., Ph.D., a cardiologist at the University of Tokyo Hospital. "As the pandemic rapidly spread throughout the world, people needed to social distance, and on-site cardiac rehab services were temporarily suspended. During stressful times, the risk of cardiovascular events in patients with heart failure increases, and we wanted to evaluate if remote cardiac rehabilitation might be an effective alternative."

Researchers investigated patients hospitalized for heart failure from January 2019 to April 2020. This prospective study assessed patients' cardiac function including blood pressure, heart rate and shortness of breath. Emergency readmission rate within 30 days after hospital discharge was compared among groups receiving outpatient, remote or no cardiac rehabilitation. Quality of life scores were also compared between the outpatient and remote groups.

The results showed that remote cardiac rehabilitation is as effective as outpatient rehab for improvements in short-term prognosis after hospital discharge for patients hospitalized with heart failure. The emergency readmission rate within 30 days after discharge was lower in both the outpatient and remote groups as compared with patients who did not receive any rehabilitation services. In addition, patients' quality of life scores one month after discharge were higher in the remote group than the patients in the outpatient group.

"We were surprised by the better quality of life scores in the remote rehab group compared to the outpatient group," said Nakayama. "Our team speculated that talking to health care professionals on the phone instead of in person helped patients feel more comfortable discussing their medical problems, leading to better management of their heart problems. These findings suggest that remote rehab programs are a good alternative for in-person, outpatient programs."

The study also found that the participation rate in the remote cardiac rehabilitation program was higher during the COVID-19 pandemic:

  • Prior to COVID, more than 50% of patients did not complete any type of rehab after discharge, and 3% received remote rehab.
  • After in-person, outpatient programs closed, 69% of patients participated in a remote rehabilitation program.
  • During the COVID pandemic, only 20% of patients did not receive any cardiovascular rehabilitation services after discharge.

Nakayama added, "Most hospitals in the world can easily start a remote cardiac rehab service, which can help many cardiac patients during the COVID-19 pandemic. Our remote program required minimal expenses except for DVDs, booklets and phone costs, and patients did not need any special medical devices. In the future, remote cardiac rehabilitation may help resolve disadvantages due to regional disparities and access to medical specialists, which would especially benefit elderly patients and people living far away from a hospital."

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Co-authors are Naoko Takayama, R.N.; Hiroyuki Morita, M.D., Ph.D.; and Issei Komuro, M.D., Ph.D. Author disclosures are in the abstract.

The Yuumi Memorial Foundation for Home Health Care funded the study.

Note: Session: NR.APS.02 - Moving and Grooving: Physical Activity and CVD Health

Additional Resources:

Multimedia, including a perspective video interview with Barry A. Franklin, Ph.D., chair of the writing committee for the Scientific Statement "Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training: Placing the Risks Into Perspective-An Update from the American Heart Association, (February 2020), may be downloaded from the right column of the release link https://newsroom.heart.org/news/remote-cardiac-rehabilitation-programs-are-effective-alternatives-to-on-site-services?preview=41c3d8f97d8525502acc8dcd5e836eae

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AHA COVID-19 Newsroom

For more news at AHA Scientific Sessions 2020, follow us on @HeartNews #AHA20.

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