Delivering healthcare remotely to cardiovascular patients during COVID-19 : A rapid review of the evidence

Impacts of the COVID-19 Pandemic on Cardiac Rehabilitation Delivery around the World

Background

We investigated impacts of COVID-19 on cardiac rehabilitation (CR) delivery around the globe, including virtual delivery, as well as effects on providers and patients.

Methods

In this cross-sectional study, a piloted survey was administered to CR programs globally via REDCap from April to June 2020. The 50 members of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) and personal contacts facilitated program identification.

Results

Overall, 1062 (18.3% program response rate) responses were received from 70/111 (63.1% country response rate) countries in the world with existent CR programs. Of these, 367 (49.1%) programs reported they had stopped CR delivery, and 203 (27.1%) stopped temporarily (mean = 8.3 ± 2.8 weeks). Alternative models were delivered in 322 (39.7%) programs, primarily through low-tech modes (n = 226,19.3%). Furthermore, 353 (30.2%) respondents were re-deployed, and 276 (37.3%) felt the need to work due to fear of losing their job, despite the perceived risk of contracting COVID-19 (mean = 30.0% ± 27.4/100). Also, 266 (22.5%) reported anxiety, 241(20.4%) were concerned about exposing their family, 113 (9.7%) reported increased workload to transition to remote delivery, and 105 (9.0%) were juggling caregiving responsibilities during business hours. Patients were often contacting staff regarding grocery shopping for heart-healthy foods (n = 333, 28.4%), how to use technology to interact with the program (n = 329, 27.9%), having to stop their exercise because they have no place to exercise (n = 303, 25.7%), and their risk of death from COVID-19 due to pre-existing cardiovascular disease (n = 249, 21.2%). Respondents perceived staff (n = 488, 41.3%) and patient (n = 453, 38.6%) personal protective equipment, as well as COVID-19 screening (n = 414, 35.2%), and testing (n = 411, 35.0%) as paramount to in-person service resumption.

Conclusion

Given the estimated number of CR programs globally, these results suggest approximately 4400 CR programs globally have ceased or temporarily stopped service delivery. Those that remain open are implementing new technologies to ensure their patients receive CR safely, despite the challenges.

Highlights

- COVID-19 has impacted cardiac rehabilitation (CR) delivery around the globe.- In this cross-sectional study, a survey was completed by 1062 (18.3%) CR programs from 70 (63.1%) countries.- The pandemic has resulted in at least temporary cessation of ~75% of CR programs, with others ceasing initiation of new patients, reducing components delivered, and/or changing of mode delivery with little opportunity for planning and training.- There is also significant psychosocial and economic impact on CR providers.- Alternative CR model (e.g., home-based, virtual) reimbursement advocacy is needed, to ensure safe, accessible secondary prevention delivery.

Orthopaedic provider perceptions of virtual care : which providers prefer virtual care?

AIMS

The purpose of our study was to determine which groups of orthopaedic providers favour virtual care, and analyze overall orthopaedic provider perceptions of virtual care. We hypothesize that providers with less clinical experience will favour virtual care, and that orthopaedic providers overall will show increased preference for virtual care during the COVID-19 pandemic and decreased preference during non-pandemic circumstances.

METHODS

An orthopaedic research consortium at an academic medical system developed a survey examining provider perspectives regarding orthopaedic virtual care. Survey items were scored on a 1 to 5 Likert scale (1 = "strongly disagree", 5 = "strongly agree") and compared using nonparametric Mann-Whitney U test.

RESULTS

Providers with less experience were more likely to recommend virtual care for follow-up visits (3.61 on the Likert scale (SD 0.95) vs 2.90 (SD 1.23); p = 0.006) and feel that virtual care was essential to patient wellbeing (3.98 (SD 0.95) vs 3.00 (SD 1.16); p < 0.001) during the pandemic. Less experienced providers also viewed virtual visits as providing a similar level of care as in-person visits (2.41 (SD 1.02) vs 1.76 (SD 0.87); p = 0.006) and more time-efficient than in-person visits (3.07 (SD 1.19) vs 2.34 (SD 1.14); p = 0.012) in non-pandemic circumstances. During the pandemic, most providers viewed virtual care as effective in providing essential care (83.6%, n = 51) and wanted to schedule patients for virtual care follow-up (82.2%, n = 50); only 10.9% (n = 8) of providers preferred virtual visits in non-pandemic circumstances.

CONCLUSION

Orthopaedic providers with less clinical experience seem to favourably view virtual care both during the pandemic and under non-pandemic circumstances. Providers in general appear to view virtual care positively during the pandemic but are less accommodating towards it in non-pandemic circumstances. Cite this article: Bone Jt Open 2021;2(6):405-410.

Lifestyle, psychological, socioeconomic and environmental factors and their impact on hypertension during the coronavirus disease 2019 pandemic

SUMMARY

The coronavirus disease 2019 (COVID-19) pandemic considerably affects health, wellbeing, social, economic and other aspects of daily life. The impact of COVID-19 on blood pressure (BP) control and hypertension remains insufficiently explored. We therefore provide a comprehensive review of the potential changes in lifestyle factors and behaviours as well as environmental changes likely to influence BP control and cardiovascular risk during the pandemic. This includes the impact on physical activity, dietary patterns, alcohol consumption and the resulting consequences, for example increases in body weight. Other risk factors for increases in BP and cardiovascular risk such as smoking, emotional/psychologic stress, changes in sleep patterns and diurnal rhythms may also exhibit significant changes in addition to novel factors such as air pollution and environmental noise. We also highlight potential preventive measures to improve BP control because hypertension is the leading preventable risk factor for worldwide health during and beyond the COVID-19 pandemic.

Rapid reviews: the pros and cons of an accelerated review process

Although systematic reviews are the method of choice to synthesize scientific evidence, they can take years to complete and publish. Clinicians, managers, and policy-makers often need input from scientific evidence in a more timely and resource-efficient manner. For this purpose, rapid reviews are conducted. Rapid reviews are performed using an accelerated process. However, they should not be less systematic than standard systematic reviews, and the introduction of bias must be avoided. In this article, we describe what rapid reviews are, present their characteristics, give some examples, highlight potential pitfalls, and draw attention to the importance of evidence summaries in order to facilitate adoption in clinical decision-making.

Telemedicine in Peru as a Result of the COVID-19 Pandemic: Perspective from a Country with Limited Internet Access

The COVID-19 pandemic contributed to the worldwide implementation of telemedicine because of the need for medical care for patients, especially those with chronic diseases. This perspective paper presents the current situation of telemedicine in Peru, showing advances in regulation, cases of successful implementation, and the current challenges. Access to health should be available to all, and more efforts need to be implemented to offer access to the internet to achieve high-quality telemedicine to all the vulnerable groups in Peru.

The Impact of Signals Transmission on Patients' Choice through E-Consultation Websites: An Econometric Analysis of Secondary Datasets

(1) Background: The COVID-19 pandemic has dramatically and rapidly changed the overall picture of healthcare in the way how doctors care for their patients. Due to the significant strain on hospitals and medical facilities, the popularity of web-based medical consultation has drawn the focus of researchers during the deadly coronavirus disease (COVID-19) in the United States. Healthcare organizations are now reacting to COVID-19 by rapidly adopting new tools and innovations such as e-consultation platforms, which refer to the delivery of healthcare services digitally or remotely using digital technology to treat patients. However, patients' utilization of different signal transmission mechanisms to seek medical advice through e-consultation websites has not been discussed during the pandemic. This paper examines the impact of different online signals (online reputation and online effort), offline signals (offline reputation) and disease risk on patients' physician selection choice for e-consultation during the COVID-19 crisis. (2) Methods: Drawing on signaling theory, a theoretical model was developed to explore the antecedents of patients' e-consultation choice toward a specific physician. The model was tested using 3-times panel data sets, covering 4231 physicians on Healthgrades and Vitals websites during the pandemic months of January, March and May 2020. (3) Results: The findings suggested that online reputation, online effort and disease risk were positively related to patients' online physician selection. The disease risk has also affected patients' e-consultation choice. A high-risk disease positively moderates the relationship between online reputation and patients' e-consultation choice, which means market signals (online reputation) are more influential than seller signals (offline reputation and online effort). Hence, market signals strengthened the effect in the case of high-risk disease. (4) Conclusions: The findings of this study provide practical suggestions for physicians, platform developers and policymakers in online environments to improve their service quality during the crisis. This article offers a practical guide on using emerging technology to provide virtual care during the pandemic. This study also provides implications for government officials and doctors on the potentials of consolidating virtual care solutions in the near future in order to contribute to the integration of emerging technology into healthcare.

Internet-based treatment of anxiety and depression in patients with ischaemic heart disease attending cardiac rehabilitation: a feasibility study (eMindYourHeart)

Aims

Anxiety and depression are prevalent in 20% of patients with ischaemic heart disease (IHD); however, treatment of psychological conditions is not commonly integrated in cardiac rehabilitation (CR). Internet-based psychological treatment holds the potential to bridge this gap. To examine the feasibility of an eHealth intervention targeting anxiety and depression in patients with IHD attending CR.

Methods and results

We used a mixed-methods design, including quantitative methods to examine drop-out and change in anxiety and depression scores, and qualitative methods (thematic analysis) to evaluate patients' and nurses' experiences with the intervention. The therapist-guided intervention consisted of 12 modules provided via a web-based platform. The primary outcome was drop-out, with a drop-out rate <25% considered acceptable. Patients were considered as non-drop-out if they completed ≥5 modules. Out of 60 patients screened positive for anxiety and/or depression, 29 patients were included. The drop-out rate was 24% (7/29). Patients had a mean improvement in anxiety and depression scores of 5.5 and 4.6, respectively. On average, patients had 8.0 phone calls with their therapist and 19.7 written messages. The qualitative analysis of patients' experiences identified four themes: treatment platform, intervention, communication with therapist, and personal experience. Patients were positive towards the intervention, although some found the assignments burdensome. From the nurses, we identified three themes: intervention, inclusion procedure, and collaboration with study team. The nurses were positive, however, due to limited time some struggled with the inclusion procedure.

Conclusion

Integrating an eHealth intervention in CR is feasible and the drop-out rate acceptable.

Hypertension, a Moving Target in COVID-19: Current Views and Perspectives

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) associates with a considerable high rate of mortality and represents currently the most important concern in global health. The risk of more severe clinical manifestation of COVID-19 is higher in males and steeply raised with age but also increased by the presence of chronic comorbidities. Among the latter, early reports suggested that arterial hypertension associates with higher susceptibility to SARS-CoV-2 infection, more severe course and increased COVID-19-related deaths. Furthermore, experimental studies suggested that key pathophysiological hypertension mechanisms, such as activation of the renin-angiotensin system (RAS), may play a role in COVID-19. In fact, ACE2 (angiotensin-converting-enzyme 2) is the pivotal receptor for SARS-CoV-2 to enter host cells and provides thus a link between COVID-19 and RAS. It was thus anticipated that drugs modulating the RAS including an upregulation of ACE2 may increase the risk for infection with SARS-CoV-2 and poorer outcomes in COVID-19. Since the use of RAS-blockers, ACE inhibitors or angiotensin receptor blockers, represents the backbone of recommended antihypertensive therapy and intense debate about their use in the COVID-19 pandemic has developed. Currently, a direct role of hypertension, independent of age and other comorbidities, as a risk factor for the SARS-COV-2 infection and COVID-19 outcome, particularly death, has not been established. Similarly, both current experimental and clinical studies do not support an unfavorable effect of RAS-blockers or other classes of first line blood pressure lowering drugs in COVID-19. Here, we review available data on the role of hypertension and its management on COVID-19. Conversely, some aspects as to how the COVID-19 affects hypertension management and impacts on future developments are also briefly discussed. COVID-19 has and continues to proof the critical importance of hypertension research to address questions that are important for global health.

Health Apps for Combating COVID-19: Descriptive Review and Taxonomy

BACKGROUND

Mobile phone apps have been leveraged to combat the spread of COVID-19. However, little is known about these technologies' characteristics, technical features, and various applications in health care when responding to this public health crisis. The lack of understanding has led developers and governments to make poor choices about apps' designs, which resulted in creating less useful apps that are overall less appealing to consumers due to their technical flaws.

OBJECTIVE

This review aims to identify, analyze, and categorize health apps related to COVID-19 that are currently available for consumers in app stores; in particular, it focuses on exploring their key technical features and classifying the purposes that these apps were designed to serve.

METHODS

A review of health apps was conducted using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. The Apple Store and Google Play were searched between April 20 and September 11, 2020. An app was included if it was dedicated for this disease and was listed under the health and medical categories in these app stores. The descriptions of these apps were extracted from the apps' web pages and thematically analyzed via open coding to identify both their key technical features and overall purpose. The characteristics of the included apps were summarized and presented with descriptive statistics.

RESULTS

Of the 298 health apps that were initially retrieved, 115 met the inclusion criteria. A total of 29 technical features were found in our sample of apps, which were then categorized into five key purposes of apps related to COVID-19. A total of 77 (67%) apps were developed by governments or national authorities and for the purpose of promoting users to track their personal health (9/29, 31%). Other purposes included raising awareness on how to combat COVID-19 (8/29, 27%), managing exposure to COVID-19 (6/29, 20%), monitoring health by health care professionals (5/29, 17%), and conducting research studies (1/29, 3.5%).

CONCLUSIONS

This study provides an overview and taxonomy of the health apps currently available in the market to combat COVID-19 based on their differences in basic technical features and purpose. As most of the apps were provided by governments or national authorities, it indicates the essential role these apps have as tools in public health crisis management. By involving most of the population in self-tracking their personal health and providing them with the technology to self-assess, the role of these apps is deemed to be a key driver for a participatory approach to curtail the spread of COVID-19. Further effort is required from researchers to evaluate these apps' effectiveness and from governmental organizations to increase public awareness of these digital solutions.

The Future of Telemedicine in the Management of Heart Failure Patients

Telemedicine (TM) is potentially a way of escalating heart failure (HF) multidisciplinary integrated care. Despite the initial efforts to implement TM in HF management, we are still at an early stage of its implementation. The coronavirus disease 2019 pandemic led to an increased utilisation of TM. This tendency will probably remain after the resolution of this threat. Face-to-face medical interventions are gradually transitioning to the virtual setting by using TM. TM can improve healthcare accessibility and overcome geographic inequalities. It promotes healthcare system efficiency gains, and improves patient self-management and empowerment. In cooperation with human intervention, artificial intelligence can enhance TM by helping to deal with the complexities of multicomorbidity management in HF, and will play a relevant role towards a personalised HF patient approach. Artificial intelligence-powered/telemedical/heart team/multidisciplinary integrated care may be the next step of HF management. In this review, the authors analyse TM trends in the management of HF patients and foresee its future challenges within the scope of HF multidisciplinary integrated care.

Use of ureteric stent related mobile phone application (UROSTENTZ App) in COVID-19 for improving patient communication and safety: a prospective pilot study from a university hospital

INTRODUCTION

During the COVID-19 led lockdown, a reliable system to monitor ureteral stent insertion and timely removal became an important facet of their use. This study looks at the use of 'Urostentz' smartphone application (app) for stent procedures and whether it improved patient communication and safety during the lockdown.

MATERIAL AND METHODS

The 'Urostentz' app was used for patients who underwent ureteric stent after ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL) procedure. It is a smartphone app developed to improve patient safety, facilitate data collection, and provide an efficient interface to simplify ureteral stent tracking and patient communication. It also helps clinicians track stent-related symptoms (SRS) and provide digital remote assistance.

RESULTS

A total of 33 patients registered with a mean age of 47.8 years (range:18-80) and a male: female ratio of 4.5:1. Of these, 29 (87.9%) used the Urostentz app, and 55.2% had SRS. The number of effective communication episodes ranged from 1-7/patient. Based on the symptoms and communication, stent was removed during lockdown (n = 2), within 1 week of lockdown lifted (n = 24) and within 2 weeks of lockdown lifted (n = 5). None of the patients suffered any stent-related complications and there were no cases of forgotten stents or readmissions despite the lockdown and lack of communication using standard practices.

CONCLUSIONS

The Urostentz app proved to an effective medium of communication to provide guidance and personalized digital remote healthcare. It also allowed prompt removal of stents avoiding prolonged stent symptoms or forgotten stents. Such apps can have a much wider application in the post-COVID-19-era to reduce unnecessary post-procedural visits and reduce health care costs.

Exploring the effectiveness of telehealth interventions for diagnosis, contact tracing and care of Corona Virus Disease of 2019 (COVID19) patients in sub Saharan Africa: a rapid review

The efficacy of leveraging telehealth services on clinical outcomes remains scarcely documented. We conducted a rapid review to explore the effectiveness of telehealth interventions for the diagnosis, contact tracing and care of the corona virus disease of 2019 in sub Saharan Africa. Using MEDLINE, Science Direct and Cochrane Library databases, a review was conducted during the month of July 2020 of peer reviewed articles reporting on the use of telehealth interventions in sub-Saharan Africa. All the studies were assessed against the inclusion criteria by two independent reviewers. The 7 studies included in the synthesis were conducted in 2 countries [Nigeria (× 1), Zimbabwe (× 1)], and commentaries covering the entire sub Saharan Africa in general (× 4) and to Uganda (× 1). All the included articles and commentaries were published in 2020. We established that mobile applications are effective in providing information for referrals of potential patients infected by COVID 19 and provides convenient access to routine care without the risk of exposure through close contact. In countries such as Nigeria, mobile positioning data significantly improved decision making, capacity and scope of contact tracing and surveillance of known contacts of confirmed cases. We noted that collaborations between the government, mobile network operators and technology companies were utilised for successful mobile positioning data tracing interventions for COVID patients. Mobile applications such as the Vula platform in South Africa were also noted as effective in providing psychological support to health care workers attending to patients.

Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework

BACKGROUND

COVID-19 has thrust video consulting into the limelight, as health care practitioners worldwide shift to delivering care remotely. Evidence suggests that video consulting is acceptable, safe, and effective in selected conditions and settings. However, research to date has mostly focused on initial adoption, with limited consideration of how video consulting can be mainstreamed and sustained.

OBJECTIVE

This study sought to do the following: (1) review and synthesize reported opportunities, challenges, and lessons learned in the scale-up, spread, and sustainability of video consultations, and (2) identify transferable insights that can inform policy and practice.

METHODS

We identified papers through systematic searches in PubMed, CINAHL, and Web of Science. Included articles reported on synchronous, video-based consultations that had spread to more than one setting beyond an initial pilot or feasibility stage, and were published since 2010. We used the Nonadoption, Abandonment, and challenges to the Scale-up, Spread, and Sustainability (NASSS) framework to synthesize findings relating to 7 domains: an understanding of the health condition(s) for which video consultations were being used, the material properties of the technological platform and relevant peripherals, the value proposition for patients and developers, the role of the adopter system, organizational factors, wider macro-level considerations, and emergence over time.

RESULTS

We identified 13 papers describing 10 different video consultation services in 6 regions, covering the following: (1) video-to-home services, connecting providers directly to the patient; (2) hub-and-spoke models, connecting a provider at a central hub to a patient at a rural center; and (3) large-scale top-down evaluations scaled up or spread across a national health administration. Services covered rehabilitation, geriatrics, cancer surgery, diabetes, and mental health, as well as general specialist care and primary care. Potential enablers of spread and scale-up included embedded leadership and the presence of a telehealth champion, appropriate reimbursement mechanisms, user-friendly technology, pre-existing staff relationships, and adaptation (of technology and services) over time. Challenges tended to be related to service development, such as the absence of a long-term strategic plan, resistance to change, cost and reimbursement issues, and the technical experience of staff. There was limited articulation of the challenges to scale-up and spread of video consultations. This was combined with a lack of theorization, with papers tending to view spread and scale-up as the sum of multiple technical implementations, rather than theorizing the distinct processes required to achieve widespread adoption.

CONCLUSIONS

There remains a significant lack of evidence that can support the spread and scale-up of video consulting. Given the recent pace of change due to COVID-19, a more definitive evidence base is urgently needed to support global efforts and match enthusiasm for extending use.

Scalable Telehealth Services to Combat Novel Coronavirus (COVID-19) Pandemic

An ongoing pandemic, the novel coronavirus disease 2019 (COVID-19) is threatening the nations of the world regardless of health infrastructure conditions. In the age of digital electronic information and telecommunication technology, scalable telehealth services are gaining immense importance by helping to maintain social distances while providing necessary healthcare services. This paper aims to review the various types of scalable telehealth services used to support patients infected by COVID-19 and other diseases during this pandemic. Recently published research papers collected from various sources such as Google Scholar, ResearchGate, PubMed, Scopus, and IEEE Xplore databases using the terms "Telehealth", "Coronavirus", "Scalable" and "COVID-19" are reviewed. The input data and relevant reports for the analysis and assessment of the various aspects of telehealth technology in the COVID-19 pandemic are taken from official websites. We described the available telehealth systems based on their communication media such as mobile networks, social media, and software based models throughout the review. A comparative analysis among the reviewed systems along with necessary challenges and possible future directions are also drawn for the proper selection of affordable technologies. The usage of scalable telehealth systems improves the quality of the healthcare system and also reduces the infection rate while keeping both patients and doctors safe during the pandemic.

The role of eHealth, telehealth, and telemedicine for chronic disease patients during COVID-19 pandemic: A rapid systematic review

OBJECTIVE

To summarize the current status of, and the current expert opinions, recommendation and evidence associated with the use and implementation of electronic health (eHealth), telemedicine, and/or telehealth to provide healthcare services for chronic disease patients during the COVID-19 pandemic.

MATERIALS AND METHODS

We searched four electronic databases (PubMed, Google Scholar, Science Direct, and Web of Science Core Collection) to identify relevant articles published between 2019 and 2020. Searches were restricted to English language articles only. Two independent reviewers screened the titles, abstracts, and keywords for relevance. The potential eligible articles, papers with no abstract, and those that fall into the uncertain category were read in full text independently. The reviewers met and discussed which articles to include in the final review and reached a consensus.

RESULTS

We identified 51 articles of which 25 articles met the inclusion criteria. All included articles indicated the promising potential of eHealth, telehealth, and/or telemedicine solutions in delivering healthcare services to patients living with chronic diseases/conditions during the COVID-19 pandemic. We synthesized the main findings into ten usages and eight recommendations concerning the different activities for delivering healthcare services remotely for those living with chronic diseases/conditions in the era of COVID-19.

DISCUSSION AND CONCLUSIONS

There is limited evidence available about the effectiveness of such solutions. Further research is required during this pandemic to improve the credibility of evidence on telemedicine, telehealth, and/or eHealth-related outcomes for those living with chronic diseases.

Family physician's perception towards virtual care during COVID-19 pandemic: A cross-sectional study

Background:

Design and Setting:

Results:

Conclusion:

Promoting adherence to physical activity among individuals with cardiovascular disease using behavioral counseling: A theory and research-based primer for health care professionals

Physical activity (PA) promotion remains a cornerstone of primary and secondary prevention efforts to reduce morbidity and mortality from cardiovascular disease (CVD). While frontline health care providers (HCPs; e.g., family physicians, cardiologists, registered nurses, nurse practitioners, etc.) are in an optimal position to administer PA-promoting interventions to their patients, many HCPs may feel ill-equipped to address common obstacles to implementing and maintaining complex health behavior change. Behavioral counseling refers to a collection of theory- and empirically-supported strategies and approaches to health behavior promotion that can be learned and applied by HCPs for CVD prevention and treatment. In this selective review, we discuss prominent theories of health behavior change and the empirical intervention literature regarding PA promotion in community and CVD-samples and provide practical recommendations for integrating effective behavioral counseling strategies to clinical practice for frontline HCPs. We argue that behavioral counseling interventions for PA can be effectively executed within the contextual constraints of health settings through subtle shifts in communication strategies and brief counseling approaches. The administration of behavioral counseling for PA by HCPs has enormous potential to reduce CVD incidence and progression at a population level.

The corona-virus disease 2019 pandemic compromised routine care for hypertension: a survey conducted among excellence centers of the European Society of Hypertension

BACKGROUND

The Covid-19 pandemic caused a shutdown of healthcare systems in many countries. We explored the impact on hypertension care in the Excellence Center (EC) network of the European Society of Hypertension.

METHODS

We conducted a 17-question electronic survey among ECs.

RESULTS

Overall, 52 ECs from 20 European and three non-European countries participated, providing hypertension service for a median of 1500 hypertensive patients per center per year. Eighty-five percent of the ECs reported a shutdown lasting for 9 weeks (range 0-16). The number of patients treated per week decreased by 90%: from a median of 50 (range 10-400) before the pandemic to a median of 5.0 (range 0-150) during the pandemic (P < 0.0001). 60% of patients (range 0-100%) declared limited access to medical consultations. The majority of ECs (57%) could not provide 24-h ambulatory BP monitoring, whereas a median of 63% (range 0-100%) of the patients were regularly performing home BP monitoring. In the majority (75%) of the ECs, hypertension service returned to normal after the first wave of the pandemic. In 66% of the ECs, the physicians received many questions regarding the use of renin-angiotensin system (RAS) blockers. Stopping RAS-blocker therapy (in a few patients) either by patients or physicians was reported in 27 and 36.5% of the ECs.

CONCLUSION

Patient care in hypertension ECs was compromised during the Covid-19-related shutdown. These data highlight the necessity to develop new strategies for hypertension care including virtual clinics to maintain services during challenging times.

Tools to Support Self-Care Monitoring at Home: Perspectives of Patients with Heart Failure

Self-care monitoring at home can be a challenge for patients with heart failure (HF). Tools that leverage information and communication technology (ICT), comprise medical devices, or have written material may support their efforts at home. The aim of this study was to describe HF patients’ experiences and their prioritization of tools that support, or could support, self-care monitoring at home. A descriptive qualitative design employing semi-structured interviews was used with HF patients living at home and attending an HF outpatient clinic in Norway. We used a deductive analysis approach, using the concept of self-care monitoring with ICT tools, paper-based tools, medical devices, and tools to consult with healthcare professionals (HCPs) as the categorization matrix. Nineteen HF patients with a mean age of 64 years participated. ICT tools are used by individual participants to identify changes in their HF symptoms, but are not available by healthcare services. Paper-based tools, medical devices, and face-to-face consultation with healthcare professionals are traditional tools that are available and used by individual participants. HF patients use traditional and ICT tools to support recognizing, identifying, and responding to HF symptoms at home, suggesting that they could be used if they are available and supplemented by in-person consultation with HCPs.

The Structure and the Outcome of Telephone-Based Cardiac Consultations During Lockdown: A Lesson From COVID-19

Background In response to COVID-19, Saudi Arabia as many countries, implemented "lockdown" to contain the epidemic. This resulted in suspension of all outpatient services. The reliability of the alternative telecommunication cardiac services during that time is not well studied. Accordingly, the objective of this study is to describe the structure of the telephone-based cardiac consultation (TBCC) and to explore its outcome. Methods This is a cross-sectional study that has a prospective follow up on patients who underwent medical intervention. During the period of lockdown, Alre'aiah health care society in Almadinah Almunawwarah, Saudi Arabia, provided a community health service. This was achieved by announcing telephone numbers for consultations in most specialties. This study includes all TBCC of a single cardiologist. Detailed demographic data, medical, social and drug histories of the patients were collected in charts. Individuals were requested to measure blood pressure (BP) and heart rate (HR) at the time of TBCC. Accordingly, cardiovascular assessment and appropriate intervention were executed. Patients who needed medical intervention were followed up in one week. The data were analyzed using appropriate statistical methods. Results From 01 April till 15 June 2020, a total of 168 individuals sought TBCC. Their median age was 51.5 ± 12.7 years, and (57.1%) were females. Healthy individuals constituted (33.9%), and (59.9%) were non-smokers. The most common reported medical illnesses were hypertension (27.3%), diabetes (23.8%), heart failure (16.1%), and coronary artery disease (14.9%). Palpitations were encountered by 58 patients. None of them had high-risk features or cardiac disease. Stress, excessive smoking, and caffeine intake were thought to be responsible for palpitations in 52 individuals who were reassured and educated, and newly diagnosed hypertension was established prospectively in eight patients and they were started on medications. Chest pain was reported by 51 individuals. The diagnosis of typical angina was made in nine patients and they were instructed to seek emergency care. Atypical angina pain was established in 10 cases who were advised to seek formal consultation once lockdown ends. Reassurance was achieved in 32 individuals who had features of non-angina pain. Uncontrolled hypertension was reported by 32 patients. Blood pressure control was achieved prospectively in 70% of these patients who followed up by adjusting their antihypertensive drugs. Twenty-seven patients with heart failure complained of worsening shortness of breath. New York Heart Association (NYHA) class 1-2 was reported by 21 patients, and they were managed by doubling diuretic dose, 19 of them followed back and reported significant improvement. NYHA class 3-4 was established in 6 patients and they were instructed to seek emergency care. Conclusions When standard face-to-face cardiac consultations are compromised, a structured TBCC is considered feasible, seems effective, and promising alternative method of delivering the utmost cardiac care to the community. When conducted properly, it is useful to triage patients.

Cardiac Rehabilitation in Canada During COVID-19

Background

Cardiac rehabilitation programs (CRPs) had to change quickly in response to a shift in clinical priorities related to to the coronavirus disease 2019 (COVID-19). Yet, no study has examined the effect of COVID-19 on CRPs and if there has been an adequate transition to alternative programming.

Methods

To examine the status of CRPs during the COVID-19 pandemic, a web-based questionnaire was completed by CRP managers from April 23rd to May 14th, 2020.

Results

Overall, 114 representatives of 144 CRPs (79.1% of Canadian programs) responded. Of respondents, 41.2% (n = 47) reported CRP closure; primary reasons were staff redeployment and facility closure (41% of 51 responses, for both). Redeployment occurred in open CRPs and closed CRPs (30% ± 34% and 47% ± 38% of employees, respectively; P = 0.05) and reduced hours in 17.8% ± 31% and 22.5% ± 33% for remaining employees; P = 0.56. Of open CRPs, 84.8% accepted referrals for medically high-risk patients pre-COVID-19; this level fell to only 43.5% during the COVID-19 pandemic, P < 0.001. There was a significant reduction in patients with cognitive/communication/mobility deficits who were eligible to participate during the COVID-19 pandemic. Of respondents, 57%-82.6% reported safety concerns related to prescribing exercise to medically high-risk and vulnerable populations. CRPs transitioned from group-based to one-to-one delivery models->80% by phone and/or e-mail. Any tele-rehabilitation (one-to-one/group) was also used by 32.7% and 43.5% of CRPs to deliver exercise and education, respectively (mostly one-to-one). Resource barriers cited by open and closed CRPs were related to technology-no tele-rehabilitation, lack of equipment and patient access (35% of all barriers)-and 25.3% of barriers were owing to greater demands on staff time.

Conclusions

Within 2-months of COVID-19 being declared a pandemic, 41.2% of CRPs were closed and almost half of employees redeployed. Less time-efficient one-to-one models of remote care, mostly by phone/e-mail, were adopted. Vulnerable populations were disproportionately affected, becoming ineligible owing to safety concerns. Strategies to open closed CRPs, admission of high-risk/vulnerable populations, and offering of group-based tele-rehabilitation should be a national priority.

A Clinical Pathway for Hospitalized Pediatric Patients With Initial SARS-CoV-2 Infection

The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread quickly across the globe, creating unique and pressing challenges for today's physicians. Although this virus disproportionately affects adults, initial SARS-CoV-2 infection can present a significant disease burden for the pediatric population. A review of the literature yields descriptive studies in pediatric patients; however, no evidence-based or evidence-informed guidelines for the diagnosis and treatment of the hospitalized pediatric patient have been published in peer-reviewed journals. The authors, working at a quaternary care children's hospital in the national epicenter of the SARS-CoV-2 pandemic, found an urgent need to create a unified, multidisciplinary, evidence-informed set of guidelines for the diagnosis and management of coronavirus disease 2019 in children. In this article, the authors describe our institutional practices for the hospitalized pediatric patient with confirmed or suspected initial SARS-CoV-2 infection. The authors anticipate that developing evidence-informed and institution-specific guidelines will lead to improvements in care quality, efficiency, and consistency; minimization of staff risk of exposure to SARS-CoV-2; and increased provider comfort in caring for pediatric patients with SARS-CoV-2 infection.

Recommendations for Cardiovascular Prevention During the Sars-Cov-2 Pandemic: An Executive Document by the Board of the Italian Society of Cardiovascular Prevention

In 2020, the Sars-Cov-2 pandemic is causing a huge and dramatic impact on healthcare systems worldwide. During this emergency, fragile patients suffering from other comorbidities, especially patients susceptible to or affected by cardiovascular disease, are the ones most exposed to the poorer outcomes. Therefore, it is still mandatory to continue to strictly adhere to the rules of cardiovascular prevention. This document aims to provide all doctors with simple and clear recommendations in order to spread useful messages to the widest number of subjects in order to continue the battle against cardiovascular diseases even in times of pandemic.

Use of Telemedicine and Virtual Care for Remote Treatment in Response to COVID-19 Pandemic

The current coronavirus disease 2019 (COVID-19) pandemic has caused significant strain on medical centers resources. Thus, concerns about the reducing and management of COVID-19 are on the rise, as there is need to provide diagnosis, treatment, monitoring, and follow-ups during the pandemic. Therefore, the COVID-19 pandemic has radically and quickly altered how medical practitioners provide care to patients. Medical centers are now responding to COVID-19 through rapid adoption of digital tools and technologies such as telemedicine and virtual care which refer to the delivery of healthcare services digital or at a distance using Information and Communications Technology (ICT) for treatment of patients. Telemedicine is expected to deliver timely care while minimizing exposure to protect medical practitioners and patients. Accordingly, a rapid literature review was conducted, and 35 research studies published from 2019 to May 2020 were employed to provide theoretical and practical evidence on the significance of using telemedicine and virtual care for remote treatment of patients during the COVID-19 pandemic. This article provides practical guide based on how to use telemedicine and virtual care during the COVID-19 pandemic. This study provides implication on the potentials of consolidating virtual care solutions in the near future towards contributing to integrate digital technologies into healthcare.