Telehealth is here to stay but not without challenges: a consultation of cardiac rehabilitation clinicians during COVID-19 in Victoria, Australia

Status and analysis of Free Hospital-Based Internet + Nursing Health Consultation Services: a retrospective study

BACKGROUND

With the increasing demand for healthcare services, Free Hospital-Based Internet + Nursing Health Consultation Services have emerged as an innovative model to provide patients with timely and convenient nursing guidance.

OBJECTIVE

To comprehensively evaluate the implementation and effectiveness of Free Hospital-Based Internet + Nursing Health Consultation Services, identify existing challenges, and propose evidence-based optimization strategies to enhance the precision and efficiency of future services.

METHODS

A retrospective analysis was conducted based on the hospital information system, retrieving orders for Free Hospital-Based Internet + Nursing Health Consultation Services from Mianyang Central Hospital between 2021 and 2023. This analysis included the staffing structure on the nurse's side and details of patient orders. Statistical analyses were performed using SPSS 25.0 software.

RESULTS

Our hospital's talent pool for Free Hospital-Based Internet + Nursing Health Consultation Services comprises 128 nurses, with dynamic adjustments to the nurses and departments based on health consultation orders. From 2021 to 2023, the total number of consultations was 2,328, with a consultation time of 3,001,409 min. Among them, 2,203 consultations were accepted, 25 were declined, and 100 exceeded the time limit. The top three departments in terms of consultation volume were Obstetrics and Gynecology (25.78%), Pediatrics (23.92%), and Dermatology (20.96%). With the annual growth in the service, the total number of consultations, accepted consultations, declined consultations, and overdue orders increased each year, although the differences were not statistically significant (P > 0.05). The consultation waiting time showed a decreasing trend, recorded at 665, 356, and 404 min, respectively. The average consultation time remained stable at 1,414, 1,373, and 1,346 min.

CONCLUSION

Nurse-led Free Hospital-Based Internet + Nursing Health Consultation Services provide patients with convenient and efficient health consultation channels, helping to meet the growing health demands of patients. As the service has expanded over the years, the overall consultation volume has shown an upward trend while maintaining stable service quality and gradually reducing waiting times, offering more timely nursing health consultation services. Future recommendations include multicenter studies to explore the effectiveness and safety of Free Hospital-Based Internet + Nursing Health Consultation Services.

Technology-enabled hybrid cardiac rehabilitation: Qualitative study of healthcare professional and patient perspectives at three cardiac rehabilitation centres in England

Coronary heart disease (CHD) is a leading cause of death in the UK. Clinical guidelines recommend cardiac rehabilitation (CR), including health education, cardiovascular risk reduction advice, physical activity and stress management components. However, uptake of standard in-person, group-based CR is only around 50%. Hybrid cardiac rehabilitation (CR), combining in-person and remote service delivery, may improve CR uptake and reduce inequalities in service access. This study used focus groups and semi-structured interviews to explore staff and patient experiences of using the Active+me REMOTE hybrid CR app, a cloud-based platform providing access to education modules, behaviour change support, live exercise classes, physical activity and health monitoring across three sites in the East of England. Twelve staff and six patients participated. Topic guides explored participants' experiences of delivering or receiving hybrid CR, barriers and facilitators associated with the hybrid CR pathway, and implications for future implementation of Active+me REMOTE. Qualitative data were collected remotely, audio-recorded and independently transcribed. Staff data were analysed deductively, using the Consolidated Framework for Implementation Research (CFIR). Patient data were analysed inductively using thematic analysis. Despite some technical issues and governance delays, Active+me REMOTE was perceived as acceptable, convenient and allowed tailoring of support to meet patients' needs and circumstances. Data upload from wearable devices (blood pressure monitors) allowed staff to monitor patients' progress and empowered patients to direct their recovery. Staff initially felt they should screen patients to ensure that hybrid CR was offered to digitally literate, physically active individuals, although screening became less common as staff familiarity with the app increased. Findings suggest that effective implementation of hybrid CR requires system-level resource to facilitate governance approvals and embed hybrid CR delivery as standard care. Sufficient time must be allowed for staff training and to support patient enrolment to hybrid services. The study was registered on 3/7/2023 (ISRCTN320764).

The NASSS (Non-Adoption, Abandonment, Scale-Up, Spread and Sustainability) framework use over time: A scoping review

The Non-adoption, Abandonment, Scale-up, Spread, Sustainability (NASSS) framework (2017) was established as an evidence-based, theory-informed tool to predict and evaluate the success of implementing health and care technologies. While the NASSS is gaining popularity, its use has not been systematically described. Literature reviews on the applications of popular implementation frameworks, such as the RE-AIM and the CFIR, have enabled their advancement in implementation science. Similarly, we sought to advance the science of implementation and application of theories, models, and frameworks (TMFs) in research by exploring the application of the NASSS in the five years since its inception. We aim to understand the characteristics of studies that used the NASSS, how it was used, and the lessons learned from its application. We conducted a scoping review following the JBI methodology. On December 20, 2022, we searched the following databases: Ovid MEDLINE, EMBASE, PsychINFO, CINAHL, Scopus, Web of Science, and LISTA. We used typologies and frameworks to characterize evidence to address our aim. This review included 57 studies that were qualitative (n=28), mixed/multi-methods (n=13), case studies (n=6), observational (n=3), experimental (n=3), and other designs (e.g., quality improvement) (n=4). The four most common types of digital applications being implemented were telemedicine/virtual care (n=24), personal health devices (n=10), digital interventions such as internet Cognitive Behavioural Therapies (n=10), and knowledge generation applications (n=9). Studies used the NASSS to inform study design (n=9), data collection (n=35), analysis (n=41), data presentation (n=33), and interpretation (n=39). Most studies applied the NASSS retrospectively to implementation (n=33). The remainder applied the NASSS prospectively (n=15) or concurrently (n=8) with implementation. We also collated reported barriers and enablers to implementation. We found the most reported barriers fell within the Organization and Adopter System domains, and the most frequently reported enablers fell within the Value Proposition domain. Eighteen studies highlighted the NASSS as a valuable and practical resource, particularly for unravelling complexities, comprehending implementation context, understanding contextual relevance in implementing health technology, and recognizing its adaptable nature to cater to researchers' requirements. Most studies used the NASSS retrospectively, which may be attributed to the framework's novelty. However, this finding highlights the need for prospective and concurrent application of the NASSS within the implementation process. In addition, almost all included studies reported multiple domains as barriers and enablers to implementation, indicating that implementation is a highly complex process that requires careful preparation to ensure implementation success. Finally, we identified a need for better reporting when using the NASSS in implementation research to contribute to the collective knowledge in the field.

Stakeholder perceptions of factors contributing to effective implementation of exercise cardiac telerehabilitation in clinical practice

AIMS

Cardiac exercise telerehabilitation is effective and can be cost-effective for managing ischaemic heart disease, but implementation of evidence-based interventions in clinical practice remains a challenge. We aimed to identify factors that cardiac rehabilitation stakeholders perceived could influence the effectiveness of implementing an evidence-based, real-time remotely monitored cardiac exercise telerehabilitation intervention (REMOTE-CR).

METHODS AND RESULTS

Online interviews and focus groups were conducted with cardiac rehabilitation consumers (n = 16, 5 female, 61.1 ± 10.0 years), practitioners (n = 20, 14 female; 36.6 ± 11.8 years), and health service managers (n = 11, 7 female; 46.2 ± 9.2 years) recruited from one metropolitan and three inner-regional healthcare services in Western Victoria, Australia. Discussions were guided by two theoretical frameworks (Non-adoption, Abandonment, Scale-up, Spread, and Sustainability; Consolidated Framework for Implementation Research), and analysed thematically. Factors perceived to influence effective implementation of REMOTE-CR spanned all domains of the theoretical frameworks, related to six major themes (resources, change management, stakeholder targeting, knowledge, intervention design, security) and were largely consistent across study sites; however, the relative importance of each factor may vary between sites.

CONCLUSION

Effective implementation of exercise telerehabilitation interventions like REMOTE-CR will require a coordinated context-specific approach that considers factors across all levels of the healthcare system and implementation science frameworks. Key requirements include prioritizing resources, managing change, selecting target stakeholders, developing digital health capabilities, and selecting fit-for-purpose technologies that enable programme delivery objectives.

Psychological Factors That Contribute to the Use of Video Consultations in Health Care: Systematic Review

BACKGROUND

There are numerous benefits to delivering care via video consultations (VCs). Yet, the willingness of health care professionals (HCPs) to use video as a modality of care is one of the greatest barriers to its adoption. Decisions regarding whether to use video may be based on assumptions and concerns that are not necessarily borne of evidence. To effectively address psychological barriers to VC, it is essential to gain a better understanding of specific factors (eg, attitudes, beliefs, and emotions) that influence HCPs' VC use.

OBJECTIVE

This study's aim was to conduct a systematic literature review of psychological factors in HCPs that impair or promote VC use.

METHODS

Databases were searched in February 2023 for peer-reviewed primary research papers on VCs that discussed psychological factors of health professionals affecting the use of video to deliver health services. A psychological factor was defined as an intraindividual influence related to, or in reaction to, VC use-in this case, the individual being an HCP. Search terms included variations on "telehealth," "clinician," and psychological factors (eg, attitude and beliefs) in combination. Peer-reviewed papers of all methodological approaches were included if they were in an Australian setting and the full text was available in English. Studies where the main intervention was another digital health modality (eg, remote monitoring and telephone) were excluded. Studies were also excluded if they only reported on extrinsic factors (eg, environmental or economic). Information extracted included author, year, medical specialty, psychological component mentioned, explanation as to why the psychological factor was related to VC use, and exemplar quotes from the paper that correspond to a psychological component. Each extracted psychological factor was classified as a positive, negative, ambivalent, or neutral perspective on VC, and a thematic analysis then generated the factors and themes. Theories of behavior were considered and discussed to help frame the interaction between themes.

RESULTS

From 4592 studies, data were extracted from 90 peer-reviewed papers. Cognitive and emotional motivators and inhibitors, such as emotional responses, self-efficacy, attitudes, and perceived impact on the clinician as a professional, all interact to influence HCP engagement in VCs. These factors were complex and impacted upon one another. A cyclical relationship between these factors and intention to engage in VCs and actual use of VCs was found. These findings were used to form the psychological attributes of VC engagement (PAVE) model. Evidence suggests that HCPs fall within 4 key user categories based on the amount of cognitive and practical effort needed to deliver VCs.

CONCLUSIONS

Although further research is needed to validate the current findings, this study provides opportunity for more targeted interventions that address psychological factors impeding effective use of VCs.

From theoretical models to practical deployment: A perspective and case study of opportunities and challenges in AI-driven cardiac auscultation research for low-income settings

This article includes a literature review and a case study of artificial intelligence (AI) heart murmur detection models to analyse the opportunities and challenges in deploying AI in cardiovascular healthcare in low- or medium-income countries (LMICs). This study has two parallel components: (1) The literature review assesses the capacity of AI to aid in addressing the observed disparity in healthcare between high- and low-income countries. Reasons for the limited deployment of machine learning models are discussed, as well as model generalisation. Moreover, the literature review discusses how emerging human-centred deployment research is a promising avenue for overcoming deployment barriers. (2) A predictive AI screening model is developed and tested in a case study on heart murmur detection in rural Brazil. Our binary Bayesian ResNet model leverages overlapping log mel spectrograms of patient heart sound recordings and integrates demographic data and signal features via XGBoost to optimise performance. This is followed by a discussion of the model's limitations, its robustness, and the obstacles preventing its practical application. The difficulty with which this model, and other state-of-the-art models, generalise to out-of-distribution data is also discussed. By integrating the results of the case study with those of the literature review, the NASSS framework was applied to evaluate the key challenges in deploying AI-supported heart murmur detection in low-income settings. The research accentuates the transformative potential of AI-enabled healthcare, particularly for affordable point-of-care screening systems in low-income settings. It also emphasises the necessity of effective implementation and integration strategies to guarantee the successful deployment of these technologies.

The Unintended Consequences of Telehealth in Australia: Critical Interpretive Synthesis

BACKGROUND

Despite more than 2 decades of telehealth use in Australia and the rapid uptake during the COVID-19 pandemic, little is known about its unintended consequences beyond its planned and intended outcomes.

OBJECTIVE

The aim of this review was to synthesize evidence on the unintended consequences of telehealth use in Australia to clarify its impact beyond its planned and intended outcomes.

METHODS

We conducted a search of 4 electronic databases: Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, and Scopus. A critical interpretive synthesis approach was adopted for its flexibility and interpretive nature. We extracted data about study characteristics and the types and models of telehealth services. The extracted unintended consequences were coded and mapped into the domains and dimensions of the Australian Health Performance Framework.

RESULTS

Of the 4241 records identified by the search, 94 (2.22%) studies were eligible for data extraction and analysis. Of these 94 studies, 23 (24%) reported largely positive unintended consequences of telehealth associated with health status, while 6 (6%) noted a potential negative impact of telehealth on socioeconomic status. The findings of 4 (4%) of the 94 studies highlighted societal and financial consequences of telehealth beyond the health system. Almost all studies (93/94, 99%) reported unintended consequences under the 5 dimensions of the Australian Health Performance Framework.

CONCLUSIONS

Our synthesis offers a framework for understanding the unintended consequences of the use of telehealth as an alternative to in-person care in Australia. While we have documented many unintended benefits of telehealth use, our findings also shed light on many challenges of delivering care via telehealth across different domains and dimensions. These findings hold significant practice and policy-making implications for ensuring safe and high-quality care delivery via telehealth.

Co-designing a cardiac rehabilitation program with knowledge users for patients with cardiovascular disease from a remote area

BACKGROUND

Cardiovascular disease is the leading cause of death worldwide. Cardiac rehabilitation (CR) programs are recognized as effective in reducing the burden of cardiovascular disease. However, CR programs are offered inequitably across regions and are available in less than 15% of remote areas worldwide. The main goal of this study was to design a CR program adapted to the contexts of remote areas to improve the service offered to patients.

METHODS

We used an iterative user-centered design approach to understand the user context and services offered in cardiac rehabilitation in remote areas. We conducted two co-design processes with knowledge users in two remote regions. Two advisory committees were created in each of these regions, comprising managers (n = 6), healthcare professionals (n = 12) and patients (n = 2). We utilized the BACPR guidelines and the Hautes Autorités de santé operational model to support data collection in coding sessions to develop the CR program. We conducted four cycles of co-design with each of the committees to develop the cardiac rehabilitation program. Qualitative data were analyzed iteratively after each cycle.

RESULTS

The co-design process resulted in developing a prototype cardiac rehabilitation program similar in both regions. It is based on a contextualized six-phase pathway of care designed for remote regions. For each phase 0 to 6 of the care pathway, knowledge users were asked to describe how to offer these phases in remote areas. Participants made structural changes to phases 0, 2, 3 and 4 in order to overcome staffing shortages in remote areas. These changes make it possible to decentralize cardiac rehabilitation expertise away from specialized centers, to ensure equity of service across the territory. Therapeutic patient education was integrated into phase 4 to meet patients' needs. Participants suggested that three follow-up offerings could come from nursing services to increase access to the cardiac rehabilitation program (primary care, home care, special chronic disease programs) in patients' home communities.

CONCLUSION

The co-design process enables us to meet the needs of remote regions in program development. This final program can be the subject of future implementation research.

Uptake and implementation of cardiac telerehabilitation: A systematic review of provider and system barriers and enablers

BACKGROUND

Cardiac telerehabilitation has demonstrated effectiveness for patient health outcomes, but uptake and implementation into practice have been limited and variable. While patient-level influences on uptake have been identified, little is known about provider- and system-level factors.

AIMS

To identify provider and system barriers and enablers to uptake and implementation of cardiac telerehabilitation.

METHODS

A systematic review was conducted, including a search of six databases (MEDLINE, Embase, CINAHL, Scopus, Web of Science, and PsycINFO) from 2000 to March 2023. Two reviewers independently screened eligible articles. Study quality was evaluated according to study design by the Critical Appraisal Skills Programme (CASP) checklist for qualitative data, the Appraisal Tool for Cross-sectional Studies (AXIS), and the Mixed Methods Appraisal Tool (MMAT) for mixed methods. Data were analysed using narrative synthesis.

RESULTS

Twenty eligible studies (total 1674 participants) were included. Perceived provider-level barriers included that cardiac telerehabilitation is resource intensive, inferior to centre-based delivery, and lack of staff preparation. Whereas provider-level enablers were having access to resources, adequate staff preparation, positive staff beliefs regarding cardiac telerehabilitation and positive team dynamics. System-level barriers related to unaligned policy, healthcare system and insurance structures, technology issues, lack of plans for implementation, and inadequate resources. System-level enablers included cost-effectiveness, technology availability, reliability, and adaptability, and adequate program development, implementation planning and leadership support.

CONCLUSIONS

Barriers and enablers at both provider and system levels must be recognised and addressed at the local context to ensure better uptake of cardiac telerehabilitation programs.

Patients' experiences and perspectives regarding the use of digital technology to support exercise-based cardiac rehabilitation: a qualitative interview study

Introduction

Despite the well-known benefits of exercise-based cardiac rehabilitation for the secondary prevention of cardiovascular disease, participation in cardiac rehabilitation programmes and adherence to secondary prevention recommendations remain limited. Digital technologies have the potential to address low participation and adherence but attempts at implementing digital health interventions in real-life clinical practice frequently encounter various barriers. Studies about patients' experiences and perspectives regarding the use of digital technology can assist developers, researchers and clinicians in addressing or pre-empting patient-related barriers. This study was therefore conducted to investigate the experiences and perspectives of cardiac rehabilitation patients in Austria with regard to using digital technology for physical activity and exercise.

Methods

Twenty-five current and former cardiac rehabilitation patients (18 men and 7 women, age range 39 to 83) with various cardiac conditions were recruited from a clinical site in Salzburg, Austria. Semi-structured qualitative interviews were audio-recorded and transcribed verbatim. The analysis followed a descriptive phenomenological approach, applying the framework analysis method.

Results

The sample was diverse, including interviewees who readily used digital devices to support their physical activity, exercise and health monitoring, and interviewees who did not. Simplicity, convenience and accessibility were highlighted as important facilitators for the use of digital technology, while annoyance with digital devices, concerns about becoming dependent on them, or simply a preference to not use digital technology were commonly stated reasons for non-use. Interviewees' views on data protection, data sharing and artificial intelligence revealed wide variations in individuals' prior knowledge and experience about these topics, and a need for greater accessibility and transparency of data protection regulation and data sharing arrangements.

Discussion

These findings support the importance that is attributed to user-centred design methodologies in the conceptualisation and design of digital health interventions, and the imperative to develop solutions that are simple, accessible and that can be personalised according to the preferences and capabilities of the individual patient. Regarding data protection, data sharing and artificial intelligence, the findings indicate opportunity for information and education, as well as the need to offer patients transparency and accountability in order to build trust in digital technology and digital health interventions.

Expanding access to telehealth in Australian cardiac rehabilitation services: a national survey of barriers, enablers, and uptake

Aims

Cardiac rehabilitation (CR) is traditionally delivered in-person; however, the COVID-19 pandemic provided impetus for alternative offerings such as telehealth. We investigated uptake, barriers, and enablers in a national survey during the pandemic in Australia.

Methods and results

We surveyed CR programmes between April and June 2021 using professional association networks. The anonymous online questionnaire addressed programme characteristics, COVID-19 impacts, and barriers to and enablers of telehealth use. Open-text responses were coded and presented as themes. In total, there were responses from 105 programmes (33% response rate). All states and geographical areas were represented. The use of every modality of telehealth care (telephone, video conferencing, text messaging, and web-based) increased significantly during and after COVID with a strong preference for telephone (85% of services). Respondents perceived video (53%) and telephone (47%) formats as safe and effective for delivering CR. The most common barriers to telehealth were difficulties conducting assessments and reduced engagement with patients. Prominent enablers were increased reach and reduced patient barriers to CR access.

Conclusion

Telehealth use by CR programmes increased during the peak pandemic period. However, additional support is required to ensure that telehealth services can be maintained. There is considerable potential to increase the reach of CR by embedding telehealth into existing models of care.

Screening for - and prevalence of - anxiety and depression in cardiac rehabilitation in the post-COVID era. An observational study

BACKGROUND

Approximately 20-30% of patients with a cardiac disease suffer from anxiety and/or depression, leading to poor health outcomes. To identify this subgroup, clinical guidelines recommend screening for anxiety and depression in cardiac rehabilitation (CR). It is unknown how screening practice is delivered post-COVID.

METHODS

This observational study used data from the National Audit of Cardiac Rehabilitation from April 2018-March 2022. Descriptive statistics were used to assess screening rates and prevalence, while a multivariate logistic regression model was performed to analyse determinants for screening for anxiety and depression among patients participating in cardiac rehabilitation.

RESULTS

The population consisted of 245,705 patients, where 128,643 (52.4%) were screened and 117,062 (47.6%) were not. Patients attending CR during first year of COVID-19 were less likely to be screened. Patients with female gender, living alone, non-white ethnicity, living in the most deprived areas, current smoking, and physical inactivity were less likely to be screened, while patients who were revascularized, having an objective physical fitness test, and attending a certified CR center were more likely to be screened. For patients attending CR during COVID-19, the prevalence of anxiety and depression decreased significantly. For anxiety the prevalence dropped from 34.4% to 15.8%, for depression the prevalence dropped from 33.5% to 16.5%.

CONCLUSION

CR service provision was negatively impacted during COVID-19, leading to much lower screening for anxiety and depression in the CR setting. Prevalence of anxiety and depression decreased during COVID-19 for this population, possibly because psychologically affected patients refrained from attending CR.

Changes in disease-related knowledge and educational needs of patients with coronary heart disease over a six-month period between hospital discharge and follow-up

OBJECTIVE

To describe changes in the disease-related knowledge and educational needs of individuals with coronary heart disease (CHD).

METHODS

Patients hospitalized for CHD answered questionnaires about disease-related knowledge (Coronary Artery Disease Education Questionnaire-short version (CADE-Q-SV), score 0-20), educational needs (investigator-designed questions), health literacy (Short version of the European Health Literacy Survey Questionnaire (HLS-EU-Q16)), self-care (Self-Care of Coronary Heart Disease Inventory version (SC-CHDI)), and physical activity (Leisure-time Physical Activity Questionnaire) at discharge (T1) and six months later (T2).

RESULTS

Participants' (N = 308; mean [M] age=65.5 years [SD=8.7]; 81.5% male) knowledge scores increased from M= 13.8 (SD=3.2) to M= 14.8 (SD=2.8) (p < 0.001). At T1, educational level, age, health literacy, smoking, and self-care maintenance explained 14.5% of knowledge variability. At T2, these variables plus lack of awareness of CHD diagnosis explained 20.3% of the variability. Substantial educational needs were reported at both time points, although 89% received predischarge education.

CONCLUSION

The patients' educational needs were unfulfilled despite an increase in disease-related knowledge over time. Improved evidence-based patient education and follow-ups that address diagnosis, treatment, and self-care are needed.

PRACTICE IMPLICATIONS

Healthcare professionals can improve care of patients with CHD by providing focused patient education, prioritizing "need-to-know" topics and considering patients' health literacy.

Moving Forward With Telehealth in Cancer Rehabilitation: Patient Perspectives From a Mixed Methods Study

BACKGROUND

The COVID-19 pandemic accelerated the use of telehealth in cancer care and highlighted the potential of telehealth as a means of delivering the much-needed rehabilitation services for patients living with the side effects of cancer and its treatments.

OBJECTIVE

This mixed methods study aims to explore patients' experiences of telehealth and their preferences regarding the use of telehealth for cancer rehabilitation to inform service development.

METHODS

The study was completed in 2 phases from October 2020 to November 2021. In phase 1, an anonymous survey (web- and paper-based) exploring the need, benefits, barriers, facilitators, and preferences for telehealth cancer rehabilitation was distributed to survivors of cancer in Ireland. In phase 2, survivors of cancer were invited to participate in semistructured interviews exploring their experiences of telehealth and its role in cancer rehabilitation. Interviews were conducted via telephone or video call following an interview guide informed by the results of the survey and transcribed verbatim, and reflexive thematic analysis was performed using a qualitative descriptive approach.

RESULTS

A total of 48 valid responses were received. The respondents were at a median of 26 (range 3-256) months after diagnosis, and 23 (48%) of the 48 participants had completed treatment. Of the 48 respondents, 31 (65%) reported using telehealth since the start of the pandemic, 15 (31%) reported having experience with web-based cancer rehabilitation, and 43 (90%) reported a willingness for web-based cancer rehabilitation. A total of 26 (54%) of the 48 respondents reported that their views on telehealth had changed positively since the start of the pandemic. Semistructured interviews were held with 18 survivors of cancer. The mean age of the participants was 58.9 (SD 8.24) years, 56% (10/18) of the participants were female, and 44% (8/18) of the participants were male. Reflexive thematic analysis identified 5 key themes: telehealth improves accessibility to cancer rehabilitation for some but is a barrier for others, lived experiences of the benefits of telehealth in survivorship, the value of in-person health care, telehealth in cancer care and COVID-19 (from novelty to normality), and the future of telehealth in cancer rehabilitation.

CONCLUSIONS

Telehealth is broadly welcomed as a mode of cancer rehabilitation for patients living with and beyond cancer in Ireland. However, issues regarding accessibility and the importance of in-person care must be acknowledged. Factors of convenience, time savings, and cost savings indicate that telehealth interventions are a desirable patient-centered method of delivering care when performed in suitable clinical contexts and with appropriate populations.

No transport? No worries! Cardiac telerehabilitation is a feasible and effective alternative to centre-based programs

Given the under-utilisation of cardiac rehabilitation despite its benefits, there has been a shift towards alternative delivery models. The recent coronavirus disease 2019 (COVID-19) pandemic has accelerated this shift, leading to a growing interest in home-based cardiac rehabilitation including telerehabilitation. There is increasing evidence to support cardiac telerehabilitation, with studies generally demonstrating comparable outcomes and potential cost-benefits. This review aims to provide a synopsis of the current evidence on home-based cardiac rehabilitation with a focus on telerehabilitation and practical considerations.

Health Care Professionals' Experiences and Views of eHealth in Pediatric Care: Qualitative Interview Study Applying a Theoretical Framework for Implementation

BACKGROUND

The development and evaluation of eHealth interventions in clinical care should be accompanied by a thorough assessment of their implementation. The NASSS (Non-adoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies) framework was designed to facilitate the implementation and scale-up of health technology programs, providing an option for analyzing the progression of these initiatives as they are implemented in real-time. Considering health care provider perspectives within the framework for implementation offers valuable insights into the early identification of barriers and facilitators in the implementation of potentially effective eHealth innovations. Nevertheless, there is a dearth of studies on eHealth interventions that encompass longer time frames and delve into the complexities of scaling up and sustaining such interventions within real-world health care environments.

OBJECTIVE

This study aims to investigate the perspectives and insights of health care professionals (HCPs) regarding the implementation of an eHealth intervention in pediatric health care while applying the NASSS framework to theorize and evaluate the conditions influencing the implementation of eHealth solutions.

METHODS

Semistructured interviews were performed with health care providers, including both staff and management personnel, within a university pediatric hospital (N=10). The data collection process occurred concurrently with a clinical trial focused on developing and assessing an eHealth app for self-management in pediatric care following hospital discharge. Using an abductive approach, the interviews were initially analyzed qualitatively and subsequently mapped onto the 7 domains of the NASSS framework to identify factors influencing implementation, encompassing facilitators, barriers, and varying levels of complexity.

RESULTS

In the realm of pediatric care, the family was identified as the primary unit of care, and patient heterogeneity was a prominent feature. The implementation of eHealth tools, while deemed usable and flexible, was also seen as a delicate balance between safety and adaptability, highlighting challenges related to health care integration. Child participation and secrecy, especially for adolescents, contributed to the complexity of using eHealth. HCPs had high eHealth literacy, and thus challenges concerning adoption were related to work adaptations and the risk of "app overload." The readiness for implementation was experienced as induced through the research study and the pandemic situation. However, to move from research to implementation in clinical practice, organizational challenges identified a need to update the concept of care and ensure activity measurements. In a wider context, HCPs raised concerns related to regulatory requirements for documentation, public procurement, and data safety. Implementation became more complex due to a lack of overview in a large organization.

CONCLUSIONS

Important perspectives for implementation were considerations of regulatory requirements, as well as the need for a shared vision of eHealth and the establishment of eHealth-related work as part of regular health care. Key contextual factors that support reach and impact are communication channels between different levels at the hospital and a need for paths and procedures compatible with legal, technological, and security concerns. Further research should focus on how eHealth interventions are perceived by children, adolescents, their parents, and other stakeholders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04150120; https://clinicaltrials.gov/ct2/show/NCT04150120.

Autopsy of a failed trial part 1: A qualitative investigation of clinician's views on and experiences of the implementation of the DAISIES trial in UK-based intensive eating disorder services

OBJECTIVE

The DAISIES trial, comparing inpatient and stepped-care day patient treatment for adults with severe anorexia nervosa was prematurely terminated in March 2022 due to poor recruitment. This qualitative study seeks to understand the difficulties faced during the trial by investigating stakeholders' views on and experiences of its implementation.

METHOD

Semi-structured interview and focus group transcripts, and trial management and oversight group meeting minutes from May 2020-June 2022 were analysed using thematic analysis. Participants were 47 clinicians and co-investigators involved with the DAISIES trial. The Non-Adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework was applied to the interpretive themes to classify barriers and facilitators to implementation.

RESULTS

Five themes were identified: incompatible participation interests; changing standard practice; concerns around clinical management; systemic capacity and capability issues; and Covid-19 disrupting implementation. Applying the NASSS framework indicated the greatest implementation challenges to arise with the adopters (e.g. patients, clinicians), the organisational systems (e.g. service capacity), and the wider socio-political context (e.g. Covid-19 closing services).

CONCLUSIONS

Our findings emphasise the top-down impact of systemic-level research implementation challenges. The impact of the Covid-19 pandemic accentuated pre-existing organisational barriers to trial implementation within intensive eating disorder services, further limiting the capacity for research.

Hybrid cardiac telerehabilitation for coronary artery disease in Australia: a cost-effectiveness analysis

BACKGROUND

Traditional cardiac rehabilitation programs are centre-based and clinically supervised, with their safety and effectiveness well established. Notwithstanding the established benefits, cardiac rehabilitation remains underutilised. A possible alternative would be a hybrid approach where both centre-based and tele-based methods are combined to deliver cardiac rehabilitation to eligible patients. The objective of this study was to determine the long-term cost-effectiveness of a hybrid cardiac telerehabilitation and if it should be recommended to be implemented in the Australian context.

METHODS

Following a comprehensive literature search, we chose the Telerehab III trial intervention that investigated the effectiveness of a long-term hybrid cardiac telerehabilitation program. We developed a decision analytic model to estimate the cost-effectiveness of the Telerehab III trial using a Markov process. The model included stable cardiac disease and hospitalisation health states and simulations were run using one-month cycles over a five-year time horizon. The threshold for cost-effectiveness was set at $AU 28,000 per quality-adjusted life-year (QALY). For the base analysis, we assumed that 80% completed the programme. We tested the robustness of the results using probabilistic sensitivity and scenario analyses.

RESULTS

Telerehab III intervention was more effective but more costly and was not cost-effective, at a threshold of $28,000 per QALY. For every 1,000 patients who undergo cardiac rehabilitation, employing the telerehabilitation intervention would cost $650,000 more, and 5.7 QALYs would be gained, over five years, compared to current practice. Under probabilistic sensitivity analysis, the intervention was cost-effective in only 18% of simulations. Similarly, if the intervention compliance was increased to 90%, it was still unlikely to be cost-effective.

CONCLUSION

Hybrid cardiac telerehabilitation is highly unlikely to be cost-effective compared to the current practice in Australia. Exploration of alternative models of delivering cardiac telerehabilitation is still required. The results presented in this study are useful for policymakers wanting to make informed decisions about investment in hybrid cardiac telerehabilitation programs.

Impact of Early COVID-19 Waves on Cardiac Rehabilitation Delivery in Australia: A National Survey

BACKGROUND

The novel coronavirus disease of 2019 (COVID-19) pandemic significantly disrupted health care, especially outpatient services such as cardiac rehabilitation (CR). We investigated the impact of early COVID-19 waves on the delivery of Australian CR programs, comparing this time period with usual practice prior to the pandemic (2019) and current practice (2021) once the early waves had subsided. Specifically, we aimed to understand how the delivery of programs during COVID-19 compared to usual practice.

METHODS

An anonymous online cross-sectional survey of Australian CR program staff was conducted, comprising three sections: program and respondent characteristics, COVID-19 impact on program delivery, and barriers to, and enablers of, program delivery. Respondents were asked to consider three key timepoints: 1) Pre-COVID-19 (i.e. usual practice in 2019), 2) Early COVID-19 waves (March-December 2020), and 3) Currently, at time of survey completion post early COVID-19 waves (May-July 2021).

RESULTS

Of the 314 Australian CR programs, 115 responses were received, of which 105 had complete data, representing a 33% response rate. All states and territories were represented. During early COVID-19 waves programs had periods of closure (40%) or reduced delivery (70%). The majority of programs reported decreased CR referrals (51.5%) and decreased participation (77.5%). The two core components of CR-exercise and education-were significantly impacted during early COVID-19 waves, affecting both the number and duration of sessions provided. Exercise session duration did not return to pre-pandemic levels (53.5 min compared to 57.7 min, p=0.02). The majority of respondents (77%) reported their CR program was inferior in quality to pre-pandemic and more organisational support was required across information technology, staffing, administration and staff emotional and social support.

CONCLUSION

Australian CR programs underwent significant change during the early COVID-19 waves, consistent with international CR reports. Fewer patients were referred and attended CR and those who did attend received a lower dose of exercise and education. It will be important to continue to monitor the long-term impacts of the COVID-19 pandemic to ensure CR programs return to pre-pandemic functioning and continue to deliver services in line with best practice and evidence-based recommendations.

Developing a group-based virtual education curriculum for cardiac rehabilitation and the associated toolkit to support implementation in Canada and across the globe

BACKGROUND

To overcome the many barriers faced by the long-lasting pandemic, the development of new ways to deliver cardiac rehabilitation (CR)'s components was needed.

OBJECTIVE

This mixed-methods study describes the process to create a virtual education curriculum and assess the level of user engagement and acceptability in CR participants.

METHODS

A 4-phase approach was used to develop the new virtual education curriculum for CR and collect feedback regarding patients' engagement with and acceptability of the curriculum in a convenience sample of 80 CR participants. Data were analyzed using a reflexive thematic analysis approach and mapped to the evidence-based implementation strategies, followed by stakeholder engagement. Considering all information gathered and applying best practices in patient education and curriculum development, a 16-week virtual education curriculum was established.

RESULTS

Five themes were identified on how the current education could be improved: focus on self-management, emphasize emotional wellbeing, improve facilitation, incorporate existing resources, and improve content flow. The recommendations associated with each theme informed the new curriculum and a tailored implementation plan to support the use of virtual education as part of routine care within the program. A toolkit that included a screening tool for comfort with/access to technology, patient-centered manuals with weekly learning plans, and a facilitator's manual was created. Overall, all recommended weekly education was completed by more than 70% of the participants, with greater acceptability.

CONCLUSIONS

The present study offers an example of a collaborative approach to tailoring strategies for the development of a new group-based virtual education model of CR.

Evaluating the effectiveness of a comprehensive patient education intervention in a hybrid model of cardiac rehabilitation: A pilot study

Objective

To evaluate the effectiveness of a comprehensive educational intervention in a hybrid model of cardiac rehabilitation in Spain during the COVID-19 pandemic.

Methods

In a prospective pretest-posttest pilot study a pooled sample of patients attending hybrid cardiac rehabilitation in Spain received a culturally-adapted education intervention for 6 weeks. Participants completed surveys at pre- and post-rehabilitation assessing disease-related knowledge, health literacy, adherence to the Mediterranean Diet and self-efficacy. Physical activity was measured by number of steps per day using wearable activity tracking devices. Satisfaction with the educational materials was also evaluated by a survey with a 10 point Likert-type scale and yes/no and open-ended questions.

Results

Eighty-one(99%) participants completed both assessments. There was significant improvement in disease-related knowledge(p < 0.001), physical activity(p < 0.001), and adherence to the diet(p = 0.005) post-rehabilitation. The number of participants that were classified as having “high health literacy skills” increased by 17%. Post-rehabilitation knowledge was associated with education level (ß = 0.430; p = 0.001),pre-rehabilitation knowledge (ß = 0.510; p = 0.002), and high health literacy skills (ß = 0.489; p = 0.01). Educational materials were highly satisfactory to participants.

Conclusion

Significant increases in disease-related knowledge and health behaviors in patients attending hybrid models of cardiac rehabilitation are encouraging results that support the value of implementing comprehensive educational initiatives to programs in Spain.

Innovation

This work presents preliminary evidence of the effectiveness of the first comprehensive education intervention that is open access and culturally adapted to people living with cardiovascular disease in Spain.

The Impact of the SARS-CoV-2 Virus (COVID-19) Pandemic and the Rapid Adoption of Telehealth for Cardiac Rehabilitation and Secondary Prevention Programs in Rural and Remote Australia: A Multi-Method Study

INTRODUCTION

Centre-based cardiac rehabilitation (CR) programs were disrupted and urged to adopt telehealth modes of delivery during the COVID-19 public health emergency. Previously established telehealth services may have faced increased demand. This study aimed to investigate a) the impact of the COVID-19 pandemic on CR attendance/completion, b) clinical outcomes of patients with cardiovascular (CV) diseases referred to CR and, c) how regional and rural centre-based services converted to a telehealth delivery during this time.

METHODS

A cohort of patients living in regional and rural Australia, referred to an established telehealth-based or centre-based CR services during COVID-19 first wave, were prospectively followed-up, for ≥90 days (February to June 2020). Cardiac rehabilitation attendance/completion and a composite of CV re-admissions and deaths were compared to a historical control group referred in the same period in 2019. The impact of mode of delivery (established telehealth service versus centre-based CR) was analysed through a competitive risk model. The adaption of centre-based CR services to telehealth was assessed via a cross-sectional survey.

RESULTS

1,954 patients (1,032 referred during COVID-19 and 922 pre-COVID-19) were followed-up for 161 (interquartile range 123-202) days. Mean age was 68 (standard deviation 13) years and 68% were male. Referrals to the established telehealth program did not differ during (24%) and pre-COVID-19 (23%). Although all 10 centre-based services surveyed adopted telehealth, attendance (46.6% vs 59.9%; p<0.001) and completion (42.4% vs 75.4%; p<0.001) was significantly lower during COVID-19. Referral during vs pre-COVID-19 (sub hazard ratio [SHR] 0.77; 95% CI 0.68-0.87), and to a centre-based program compared to the established telehealth service (SHR 0.66; 95% CI 0.58-0.76) decreased the likelihood of CR uptake.

DISCUSSION

An established telehealth service and rapid adoption of telehealth by centre-based programs enabled access to CR in regional and rural Australia during COVID-19. However, further development of the newly implemented telehealth models is needed to promote CR attendance and completion.