OUP accepted manuscript

Aims

Enforced suspension and reduction of in-person cardiac rehabilitation (CR) services during the coronavirus disease-19 (COVID-19) pandemic restrictions required rapid implementation of remote delivery methods, thus enabling a cohort comparison of in-person vs. remote-delivered CR participants. This study aimed to examine the health-related quality of life (HRQL) outcomes and patient experiences comparing these delivery modes.

Methods and results

Participants across four metropolitan CR sites receiving in-person (December 2019 to March 2020) or remote-delivered (April to October 2020) programmes were assessed for HRQL (Short Form-12) at CR entry and completion. A General Linear Model was used to adjust for baseline group differences and qualitative interviews to explore patient experiences. Participants (n = 194) had a mean age of 65.94 (SD 10.45) years, 80.9% males. Diagnoses included elective percutaneous coronary intervention (40.2%), myocardial infarction (33.5%), and coronary artery bypass grafting (26.3%). Remote-delivered CR wait times were shorter than in-person [median 14 (interquartile range, IQR 10–21) vs. 25 (IQR 16–38) days, P < 0.001], but participation by ethnic minorities was lower (13.6% vs. 35.2%, P < 0.001). Remote-delivered CR participants had equivalent benefits to in-person in all HRQL domains but more improvements than in-person in Mental Health, both domain [mean difference (MD) 3.56, 95% confidence interval (CI) 1.28, 5.82] and composite (MD 2.37, 95% CI 0.15, 4.58). From qualitative interviews (n = 16), patients valued in-person CR for direct exercise supervision and group interactions, and remote-delivered for convenience and flexibility (negotiable contact times).

Conclusion

Remote-delivered CR implemented during COVID-19 had equivalent, sometimes better, HRQL outcomes than in-person, and shorter wait times. Participation by minority groups in remote-delivered modes are lower. Further research is needed to evaluate other patient outcomes.

Remote delivery of cardiac rehabilitation can achieve equivalent health-related quality of life outcomes to in-person methods in patients with coronary heart disease: a multi-site study

Funding Acknowledgements

Type of funding sources: None.

Background In-person exercise-based cardiac rehabilitation (CR) has well-established benefits for health-related quality of life (HRQL) for patients with coronary heart disease (CHD). During COVID-19 pandemic restrictions, remote delivery replaced in-person CR, but the impact on HRQL is unclear. This study addresses this gap.

Methods Consecutive patients commencing CR at four sites in one Local Health District in Sydney were recruited (n = 194), recruited from December 2019 to October 2020. Remote delivery from March 2020 created a natural comparison group to in-person CR. HRQL was measured at CR entry and completion using the SF-12v2 and linear regression was used for analyses.

Results Participants were aged mean 65.94 (SD 10.45) years, were 80.9% male and diagnoses included elective PCI (37.9%), CABG (26.7%), and MI (34.9%) either with PCI (23.6%) or alone (11.3%). Participants received remote (n = 103, 53.1%) or in-person (n = 91, 46.9%; ≥ assessment + 2 sessions) CR, with more completions for in-person (75.8% vs 63.1%, p=.03). Remote participants were more likely to be white than ethnic minority (35.2% vs 13.6% p&lt;.001), however, there were no differences in baseline HRQL for delivery group after adjustment.

HRQL improved from CR entry to completion regardless of delivery mode (adjusted). Most improvements occurred in physical function (SMD 6.37, 95% CI 4.81,7.92), role physical (SMD 5.72, 95% CI 4.29. 7.16) and physical component (SMD 5.77 95% CI 4.43, 7.12) scores. Least improvement occurred in mental component scores (SMD 1.65, 95%CI .53, 2.78).

Conclusion Remotely delivered CR provides comparable HRQL outcomes to in-person delivery, thus providing a promising alternative. Data are needed on cost-effectiveness, as well as staff and patient preferences.

Target Audience and Preferences Related to an Australian Coronary Heart Disease Specific Mobile App: A Mixed Methods Study

BACKGROUND

Widespread availability of mobile technologies offers the opportunity to support secondary prevention of coronary heart disease (CHD) via mobile apps, however, the target audience and their app preferences are unknown. This study aims to identify the potential audience for an Australian CHD specific app and their recommendations and preferences.

METHODS

A two-phase mixed methods study: Phase 1: CHD patients (n=282) were surveyed on mobile app engagement. Phase 2: Four focus groups with regular app users (n=12) identified preferences and recommendations generated after using a CHD-specific publicly available app (MyHeartMyLife) for 2 weeks. Data were thematically analysed.

RESULTS

Survey participants were aged ≥56 years (238/282, 84.4%) and male (204/282, 72.3%). More than one third (108/282, 38.3%) were regular app users, of whom 83/108, (76.9%) used health apps. Regular app users were more likely to be <56 years (versus ≥70 years; OR 4.70, 95% CI 1.92, 11.51), employed (OR 3.07, 95% CI 1.63, 5.77) and had completed high school education (OR 2.37, 95% CI 1.30, 4.34). Focus group participants using the CHD-specific app were aged 41-79 years (mean 62.2 SD 5.3 years) and 10/12 were male. Coronary heart disease specific app preferences generated included: immediate access to relevant and practical health information and records; behaviour change motivation; more experienced app users located and used app features readily and provided support for less experienced users. In addition, ensuring ease of reading and interpreting data, adding physical activity tracking, the ability to integrate and synchronise with other apps and devices, and capacity to store additional personal medical records were also recommended.

CONCLUSIONS

The target audience for CHD-specific apps is aged <56 years, employed, has completed high school and is an experienced app user. User preferences and recommendations identified features present in publicly available apps, but many features need development.

Mobile Technology Use Across Age Groups in Patients Eligible for Cardiac Rehabilitation: Survey Study

Background

Emerging evidence indicates mobile technology–based strategies may improve access to secondary prevention and reduce risk factors in cardiac patients. However, little is known about cardiac patients’ use of mobile technology, particularly for health reasons and whether the usage varies across patient demographics.

Objective

This study aimed to describe cardiac patients’ use of mobile technology and to determine variations between age groups after adjusting for education, employment, and confidence with using mobile technology.

Methods

Cardiac patients eligible for attending cardiac rehabilitation were recruited from 9 hospital and community sites across metropolitan and rural settings in New South Wales, Australia. Participants completed a survey on the use of mobile technology devices, features used, confidence with using mobile technology, willingness and interest in learning, and health-related use.

Results

The sample (N=282) had a mean age of 66.5 (standard deviation [SD] 10.6) years, 71.9% (203/282) were male, and 79.0% (223/282) lived in a metropolitan area. The most common diagnoses were percutaneous coronary intervention (33.3%, 94/282) and myocardial infarction (22.7%, 64/282). The majority (91.1%, 257/282) used at least one type of technology device, 70.9% (200/282) used mobile technology (mobile phone/tablet), and 31.9% (90/282) used all types. Technology was used by 54.6% (154/282) for health purposes, most often to access information on health conditions (41.4%, 117/282) and medications (34.8%, 98/282). Age had an important independent association with the use of mobile technology after adjusting for education, employment, and confidence. The youngest group (<56 years) was over 4 times more likely to use any mobile technology than the oldest (>69 years) age group (odds ratio [OR] 4.45, 95% CI 1.46-13.55), 5 times more likely to use mobile apps (OR 5.00, 95% CI 2.01-12.44), and 3 times more likely to use technology for health-related reasons (OR 3.31, 95% CI 1.34-8.18). Compared with the older group, the middle age group (56-69 years) was more than twice as likely to use any mobile technology (OR 2.42, 95% CI 1.27-4.59) and mobile technology for health-related purposes (OR 1.92, 95% CI 1.04-3.53). Participants who had completed high school were twice as likely to use mobile technology (OR 2.62, 95% CI 1.45-4.70), mobile apps (OR 2.05, 95% CI 1.09-3.84), and mobile technology for health-related reasons (OR 5.09, 95% CI 2.89-8.95) than those who had not completed high school. Associations were also present between participants living in metropolitan areas and mobile technology use (OR 1.07, 95% CI 1.07-4.24) and employment and mobile app use (OR 2.72, 95% CI 1.44-5.140).

Conclusions

Mobile technology offers an important opportunity to improve access to secondary prevention for cardiac patients, particularly when modified to suit subgroups. High levels of mobile technology use and health motivation need to be harnessed for secondary prevention.

Cardiac Patients' Experiences and Perceptions of Social Media: Mixed-Methods Study

Background

Traditional in-person cardiac rehabilitation has substantial benefits for cardiac patients, which are offset by poor attendance. The rapid increase in social media use in older adults provides an opportunity to reach patients who are eligible for cardiac rehabilitation but unable to attend traditional face-to-face groups. However, there is a paucity of research on cardiac patients’ experiences and perspectives on using social media to support their health.

Objective

The aim of this study was to describe cardiac rehabilitation patients’ experiences in using social media in general and their perspective on using social media, particularly Facebook, to support their cardiac health and secondary prevention efforts.

Methods

A mixed-methods study was undertaken among cardiac rehabilitation patients in both urban and rural areas. First, this study included a survey (n=284) on social media use and capability. Second, six focus group interviews were conducted with current Facebook users (n=18) to elucidate Facebook experience and perspectives.

Results

Social media use was low (28.0%, 79/282) but more common in participants who were under 70 years of age, employed, and had completed high school. Social media users accessed Web-based information on general health issues (65%, 51/79), medications (56%, 44/79), and heart health (43%, 34/79). Participants were motivated to invest time in using Facebook for “keeping in touch” with family and friends and to be informed by expert cardiac health professionals and fellow cardiac participants if given the opportunity. It appeared that participants who had a higher level of Facebook capability (understanding of features and the consequences of their use and efficiency in use) spent more time on Facebook and reported higher levels of “liking,” commenting, or sharing posts. Furthermore, higher Facebook capability appeared to increase a participants’ willingness to participate in a cardiac Facebook support group. More capable users were more receptive to the use of Facebook for cardiac rehabilitation and more likely to express interest in providing peer support. Recommended features for a cardiac rehabilitation Facebook group included a closed group, expert cardiac professional involvement, provision of cardiac health information, and ensuring trustworthiness of the group.

Conclusions

Cardiac health professionals have an opportunity to capitalize on cardiac patients’ motivations and social media, mostly Facebook, as well as the capability for supporting cardiac rehabilitation and secondary prevention. Participants’ favored purposeful time spent on Facebook and their cardiac health provides such a purpose for a Facebook intervention. The study results will inform the development of a Facebook intervention for secondary prevention of cardiovascular disease.

Who gets stroke prevention? Stroke prevention in atrial fibrillation patients in the inpatient setting

BACKGROUND

Current guidelines strongly recommend antithrombotic therapy, particularly warfarin, for stroke prevention in atrial fibrillation (AF) patients at high risk of stroke. Despite this, use of these medications is far from optimal. The aim of this study was to describe the use of stroke prevention medication in inpatients and identify factors associated with prescription in one local health district in Sydney, Australia.

METHODS

A prospective audit of medical records for patients admitted with an AF diagnosis to five hospitals in the health district and excluding cardiac surgery patients was undertaken. Patients were classified as high or low for stroke risk as well as for risk of bleeding and predictors were identified by logistic regression.

RESULTS

A total of 204 patients were enrolled from July 2012 to April 2013, with a mean age of 75 years (SD 13) and half (50%) were male. Valve disease was present in 17% and 15% received a procedure for their AF (cardioversion/ablation/pulmonary vein isolation). Patients were least likely to be prescribed warfarin/novel oral anticoagulant (NOAC) if they were non-valvular and did not undergo cardioversion/ablation (p=.03), and least likely to be prescribed aspirin if they had no AF procedure (p=.01). In non-valvular patients who did not have cardioversion/ablation the odds of being prescribed warfarin/NOAC were increased by being classified at high risk of stroke (OR 3.1, 95% CI 1.0 -9.5) and decreased if there was a prescription for aspirin (OR .3. 95% CI .1 -.6).

CONCLUSIONS

Overall use of stroke prevention medication indicates that gaps remain in translation of evidence into clinical practice.

Profile of atrial fibrillation inpatients: Cardiovascular risk factors and cardiac rehabilitation programme delivery and referral patterns

Atrial fibrillation (AF) is increasingly common; however, the cardiovascular risk factor profile and the patterns of delivery and referral to cardiac rehabilitation (CR) in this population are poorly described. We conducted an audit of medical records (n = 145) of patients admitted with AF in one local health district in Sydney, Australia. Patients were aged a mean 72 years, and 51% were male. Lack of risk factor documentation was common. Despite this, 65% had two or more modifiable cardiovascular risk factors, including hypertension (63%) and hypercholesterolaemia (52%). Referral to Phase II CR occurred for 25% and was decreased with permanent AF diagnosis and increased with more risk factors. AF patients admitted to hospital have multiple cardiovascular risk factors but limited risk factor screening and/or referral to outpatient CR programmes.

Evaluation of a brief educational intervention to improve knowledge of sublingual nitroglycerin in cardiac rehabilitation patients

OBJECTIVE

This study aimed to evaluate the impact of a brief educational intervention delivered in cardiac rehabilitation (CR) on patients' knowledge of sublingual nitroglycerin (SLN).

METHODS

Patients (n=86) commencing CR were provided with a brief educational intervention tailored to deficits identified in an assessment of SLN knowledge using the Sublingual Nitroglycerin Questionnaire, with reassessment at the end of program completion (6-8 weeks).

RESULTS

The mean age of patients was 64.95 years (standard deviation (SD) 10.87); 74% were male, 78% were married and 60% had not completed high school. Most (70%) had no prior coronary heart disease (CHD) history and 80% had been referred to CR following percutaneous coronary intervention. SLN knowledge scores increased from baseline to outcome. Patients were significantly more likely to know: the name of their SLN medication (11% increase, p=0.001), the recommended timing between doses (29% increase, p=0.02), the maximum number of doses (27% increase, p=0.005), to have SLN on their person at the time of the interview (25% increase, p<0.001) and to know the interaction between SLN and sildenafil (36% increase, p=0.001). The independent predictors of SLN knowledge included having better knowledge at baseline (β=0.28) and having consulted a general practitioner post discharge and before commencing CR (β=1.48).

CONCLUSION

A brief standardised knowledge intervention, individually tailored to identified deficits in a knowledge screen and delivered during CR, shows promise for improving patient knowledge of SLNs. The role of general practitioners in delivering medication education needs further investigation.

A pre-test post-test study of a brief educational intervention demonstrates improved knowledge of potential acute myocardial infarction symptoms and appropriate responses in cardiac rehabilitation patients

BACKGROUND

Patient delay in recognizing and responding to potential acute myocardial infarction (AMI) symptoms is an international issue. Cardiac rehabilitation provides an ideal opportunity to deliver an intervention.

AIMS

This study examines an individual educational intervention on knowledge of heart attack warning signs and specific chest pain action plans for people with coronary heart disease.

METHODS

Cardiac rehabilitation participants at five hospitals were assessed at program entry and tailored education was provided using the Heart Foundation of Australia's Heart Attack Warning Signs campaign educational tool. Participants (n=137) were reassessed at program conclusion (six to eight weeks).

RESULTS

Study participants had a mean age of 64.48 years (SD 12.22), were predominantly male (78%) and most commonly presented with a current referral diagnosis of a percutaneous coronary intervention (PCI) (80%) and/or AMI (60%). There were statistically significant improvements in the reporting of 11 of the 14 warning signs of heart attack, with patients reporting 2.56 more warning signs on average at outcome (p<.0001). Patients reported more heart attack warning signs if they had completed high school education (β=1.14) or had better knowledge before the intervention (β=.57). There were statistically significant improvements in reporting of all appropriate actions in response to potential AMI symptoms, with patients reporting an average of 1.3 more actions at outcome (p<.001), with no change in the median time they would tolerate symptoms (p=.16).

CONCLUSIONS

A brief education session using a single standardised tool and adapted to a patient assessment is effective in improving knowledge of potential AMI symptoms and appropriate responses in cardiac rehabilitation up to two months following.