Effect of virtual cardiac rehabilitation during the COVID-19 pandemic on health-related quality of life of older adults with cardiac problems

Abstract

BACKGROUND:

In March 2020, on the recommendation of the Chief Medical Officer, routine elective hospital medical activity was suspended and a national ‘stay at home order’ was implemented for a period of 16 weeks in response to the global COVID-19 pandemic. Most hospitals suspended their Cardiac Rehabilitation services. Many older adults did not receive the medical help they needed. This will have an impact on their health-related quality of life (HRQoL) now and thereafter.

OBJECTIVE:

Explore the effect of Virtual Cardiac Rehabilitation VCR delivered during Covid-19 Pandemics on the overall health-related quality of life (HRQoL) of older adults with cardiac problems.

METHODS:

A retrospective study design was used. Rand-36 scores in a population of older adults aged 60+ who participated in VCR between March 2020 and September 2021 were compared pre- and post-program. Convenience sampling method was used and only those who gave informed written consent for data use were included. SPSS version 27 was used to analyze data using descriptive statistics.

RESULTS:

Significant increases in median post-VCR scores, compared to pre-VCR scores (p < 0.001) were shown in the Physical domain from (95% CI 307.5–342.5). Mental health domain from (95% CI 301.5–340.5). There was statistically highly significant difference in scores in Chester Step Test METs pre- post VCR 16% (p < 0.001). There were no significant differences found in patients’ perception of Physical Function, Role Limit (Emotional) and Energy/Fatigue (p > 0.05).

CONCLUSIONS:

VCR delivered during Covid-19 Pandemic, had positive effect on the overall HRQoL of older adults with cardiac problems. VCR offered as an option in CR may potentially improve completion rate and facilitate behavioral modifications.

Keywords

Virtual cardiac rehabilitation COVID-19 pandemic health-related quality of life older adults cardiac problems

1 Introduction

According to the Irish Citizens Information website, the measures to prevent the spread of Covid-19 were put in place in Ireland on 12 March 2020. Most of the amenities were closed. Hospital visits were restricted. These measures were extended to 24 March 2020. Many hospitals and GP practices were cancelling or postponing elective and preventive visits including Cardiac Rehabilitation (CR) services to reduce the risk of spreading Covid-19. Older people had to manage their activities of daily life, medicines and medical care follow-ups in the way they have never done it before.

HRQoL is recognized as multidimensional, and it encompasses domains that are associated with physical, mental/emotional, social, and functional status which is subjectively perceived [1]. Researchers agree that apart from the health status, the social and physical environment are the main factors that could impact HRQoL [2].

The researchers in their qualitative study examined the challenges experienced by elderly during the first two weeks of social distancing and self-isolation in the UK and the Republic of Ireland. The majority of responders in this study felt that their quality of life was more important for them than longevity [3]. Social distancing increases a person’s risk of death, and it may compete the risks of smoking, obesity, high blood pressure and lack of physical activity [4]. Studies show potential correlation of loneliness and its contribution to migraines, diabetes, and cardiovascular disease, in the elderlypopulation [5].

The need for a response of healthcare professionals to the negative experience of self-isolation in older adults was brought to attention in literature [6]. NICE defined CR as “a coordinated and structured programme of care designed to influence favourably the underlying causes of cardiovascular disease, as well as to provide the best possible physical, mental, and social conditions, so that people may, by their own efforts, preserve or resume optimal functioning in their community and through improved health behaviour, slow or reverse progression of the disease” [7].

In Ireland, CR is conducted in outpatient clinics and various community settings The patients are supervised, and they enroll in their CR rehab program approximately 2 weeks after percutaneous coronary intervention. Myocardial infarction and cardiac surgery patients usually begin rehabilitation 4–6 weeks post intervention (Irish Association of Cardiac Rehabilitation, 2013). CR program is usually conducted by CR physiotherapist and CR nurse. However, a multidisciplinary team is usually led by a consultant.

There are four phases of CR. The word “phase” refers to the standardized description of a sufficient milestone achieved by the patient after a cardiac intervention [8].

Main barriers observed in cardiac rehabilitation enrolment were poor understanding of the aim of the programs, extended waiting times, and interference with routine evening engagements [9, 10]. The secondary prevention and rehabilitation section of the European Association of Preventive Cardiology expressed their concern regarding restriction in accessing CR services during Covid-19 pandemics by patients in European CR centers. They called for papers that could promote continuous reflection and support the establishment of an outpatient CR alternatives during an unusual social restriction time [11]. According to the Irish Heart Attack Audit National Report 2017–2020 developed and published by National Office of Clinical Audit (NOCA) in 2022 71% of patients with ST elevation myocardial infarction (STEMI) were referred to CR but it was not recorded whether it was delivered or not [12]. In additional report published in May by NOCA (2021) on cardiac arrest hospital care in Ireland during Covid-19 Pandemics a decline in admission to hospital especially among older adults was reported. The authors recommended that CR should be continued in a virtual for whenever possible [13].

2 Methods

2.1 The VCR pilot program

In March 2020, ‘stay at home order’ was implemented for a period of 16 weeks in response to the global COVID-19 pandemic. These measures were extended, and many hospitals cancelled or suspended their Cardiac Rehabilitation services to reduce the risk of spreading Covid-19.

A group of 8 patients had 4 weeks of CR out of 6 weeks completed. An over the phone discussion with the patients was conducted individually. They all expressed an interest in participation in a virtual form of cardiac rehabilitation and were enthusiastic to continue their program in any available way. The lead CR Physiotherapist designed and discussed the VCR Pilot Program implementation idea with CR Nurse targeting a group of patients who would have been assessed initially before the ‘lockdown’ and they all were suitable to continue safely from their homes. The participation and completion of the pilot was 100%. The feedback was all positive. Some of the patients were happy to move to phase IV in a virtual form whenever it’s available. The CR Team then officially decided to keep the service going and to move phase 3 cardiac rehabilitation to virtual delivery model temporarily. Despite several studies have highlighted an improvement in HRQoL scores post regular CR interventions [14 –16], there is insufficient research on both quality as well as quantity of the effect of VCR on HRQoL during Covid-19 pandemics.

Therefore, this gap in literature justified the need for this study to be conducted. The aim of this study was to explore how did VCR delivered during Covid-19 Pandemics affected the HRQoL of older adults with cardiac problems.

2.2 Study design

A retrospective study design was used to compare pre- and post-programme Rand-36 scores in a population of older adults who participated in VCR between March 2020 and September 2021. A retrospective design was used so that data collected during the COVID-19 pandemic could be evaluated. Data collected at the time is valuable, as the influences on HRQoL were unique during the pandemic period and could not be replicated at any other timepoint. A qualitative study design was considered e.g., interview with participants, however it was deemed that there may be an element of recall bias [17]. This could happen when the outcome status influences the study participant adequately recall the prior exposure time. In this case asking the patients to cast their minds back and describe how VCR influenced their HRQoL at the time of the lockdown may not be accurate now. Therefore, it was decided that analyzing HRQoL information collected at the time would give a more accurate reflection.

2.3 Intervention. The VCR program

2.3.1 Initial VRC program development and resources

At the time of development of VCR, the vaccine has been developed but not distributed yet. Pandemic, crisis, and emergency situations place many healthcare workers in a position of making challenging decisions. It was an emerging opportunity to readjust current CR service and investigate further its impact on the HRQoL of our patients.

Phase 3 CR usually involves patients attending the hospital twice a week for a 6–8-week program of supervised exercise and education. A 6-week CR program has been redesigned by a senior CR Physiotherapist and adapted to eventual patient’s home environment. Voluntary participation, precautions and safety were discussed with patients in details during an initial assessment individually, including education on using the virtual form of the service, informed consent was obtained, and GP of each patient was informed about participation.

Eventual barriers in accessing the program were identified and addressed in the best possible way, including involving the patient’s relatives where appropriate. Recent evidence highlights the importance of a regular assessment of patient risk of isolation and preventing negative effects [18]. Therefore, VCR phase 3 involved an individual physical one to one initial and final assessment, health risk factor assessment, structured exercise training and education. Patient education sessions were conducted via Skype platform and included Physiotherapist, Nurse, Pharmacist and Cardiologist’s educational talks. Dietary and psychotherapeutic counseling was also provided.

2.3.2 The outcome measures

The VCR participants were asked to complete The RAND 36-item Short Form Health Survey (SF-36) pre and post completion of the program. The outcome measures that have been routinely used in an outpatient CR, were also used during the VCR physical initial and final one to one assessment. It consisted of Chester Step Test, Timed Up and Go Test (TUG), 30 Second Sit to Stand Test, Grip Strength Test, Double Heel Rise Test and Single Leg Stand test (SLS). The patients who were at higher risk of falling (according to clinical assessment), were cognitively impaired or had any other underlying condition were excluded and one to one option of CR was provided for them.

2.3.3 The structure of the program

The patients were moving through 8 exercise stations. They were encouraged to do so with no rest or minimal rest in between stations even while having water to keep their heart rates at required levels, and writing their heart rates down, (marched as required and as taught, guided by their perceived exertion rates and HR). Each station had 1 - 2 different exercises. Large and small muscle groups or different components were targeted throughout the session. The mode, frequency and duration of each session was increased each week.

The warmup consisted of increasing heart rate exercises, neural drive, muscle recruitment, improving mobility and improving techniqueexercises.

The cool down consisted of pulse lowering exercises, balance exercises, stretching and breathing exercises techniques, including breathing control, thoracic expansion, and diaphragm mobility exercises. Clinical Yoga and Pilates based exercises were also included [19]. (See Appendix 1. VCR exercise class structure sample available on request).

2.3.4 Monitoring

The eligible patients were monitored during their initial and final assessment using a telemetry central monitor Nihon Kohden WEP-5208. According to the outcomes of the assessments the participants were given their target heart rates and were taught how to pace themselves during their virtual sessions using the BORG rating of perceived exertion scale. They were also taught starting positions for some of the exercises and explained the importance of the starting position and quality of exercise overall. Each station was also video recorded, and participants were encouraged to watch it prior enrollment to familiarize themselves with each exercise again at home. All participants were advised to have a blood pressure monitor or/and pulse oximeter or watch, and they were taught on how to use it if required. They were taught and advised to check their blood pressure or/and heart rates pre session and post each session. After each class the CR nurse did the phone follow up and recorded all available parameters as per patient’s report. The register was checked before each session as well as the participants had 10–15 minutes allocated for chatting and interacting as a group before and after class with their microphones and cameras turned on. The patients were advised to mute their microphones and to turn off their cameras for the class time to minimize disruptions and assure privacy. An advisory health and safety consent form was discussed and signed by participants prior to enrollment. We believed that the social interaction between our social-distancing patients was an important part of the program. The participation reached 100% at that time.

2.4 Study population and sample selection

The targeted population in my proposed study were 60+ year old female and male self-isolating ‘high risk’ patients with cardiac problems who have been referred to CR by their cardiologist, cardio-respiratory physiotherapist, or/and cardiac-rehab nurse with consultation with their cardiologist. All participants who completed cardiac rehab while it was being delivered in the virtual format between March 2020 and September 2021 were eligible for inclusion. Participants were contacted for permission to have their previously collected data included in the study. Only those who gave informed written consent for data use were included. 27 patients gave written consent and were included in this study (n = 27).

Convenience sampling method was used. This type of sampling involves individuals of the population that are available for the researcher, and some studies suggest it may be cheaper than any alternative methods of sampling [20].

2.5 Data collection

Routinely collected data at that time that was analyzed in this study included age, gender, pre- and post-programme SF-36 scores, and cardiovascular risk factors. A survey RAND SF-36 method was used in this research. The SF-36 is an outcome measure that is routinely used for cardiac rehabilitation to measure changes in health-related quality of life before and after the intervention. The lower the score the more disability. The higher the score the less disability. No written permission is needed for use of this Health Survey. SF-36 has been validated and tested in multiple projects over the past couple of years [21 –23]. In this study using interviews/focus groups to gather data related HRQoL, was initially considered. However, given the fact that perception of the participants can be affected with the passing of time I realized that data collected at the time using the RAND-36 questionnaire routinely, was valuable and it would likely give the most accurate reflection of HRQoL rather than interviews/focus groups.

2.6 Data analysis

Data Extraction: The first step involved extracting anonymized data from an existing database. The variables extracted for analysis included demographic information (age, sex), cardiac risk factors (hypertension, waist circumference, diabetes, family history, smoking status, cholesterol), and patients’ RAND-36 scores before and after the programme.

Data Cleaning and Analysis: The data was cleaned and analyzed using Microsoft Excel and SPSS (Statistical Package for the Social Sciences Inc., Chicago, IL, USA, Version 27). This process ensures that the data is accurate and ready for analysis.

Descriptive Statistics: Descriptive statistics were used to characterize the data. This includes frequency (valid percentages) and distribution indicators (mean, standard deviation, median, interquartile range, etc.).

RAND-36 Scores Analysis: The RAND-36 scores, both before and after the VCR intervention, were analyzed for each of the 8 individual subscales: physical functioning, physical role limitations, emotional wellbeing, emotional role limitations, social functioning, fatigue, pain, and general health.

Composite Scores: The 8 subscales were also transformed into 2 composite subtotal scores: mental and physical. The scores for both composites, before and after the VCR intervention, were compared.

Non-parametric Tests: Given the small sample size and the repeated-measures study design, non-parametric tests were employed for this analysis. These tests are useful when the data does not follow a normal distribution.

Group Differences: Group differences on the RAND-36 items and subscales were explored using the Related Samples Wilcoxon signed rank test. This test is used to compare two related samples, matched samples, or repeated measurements on a single sample to assess whether their population mean ranks differ.

Statistical Significance: A p-value of less than 0.05 was set to determine statistical significance. This means that if the p-value is less than 0.05, the difference in the groups is considered statistically significant.

3 Results

3.1 Sample characteristics

Table 1 represents the sample characteristics. The study involved 27 volunteers (20 males, 7 females) with an average age of 66.52 years. Post-VCR, the mean BMI decreased by 30.4% and waist circumference by 2.15%. The most common cardiovascular risk factors were high cholesterol (92.5%, n = 25) and family history of heart disease (85.1%, n = 23).

Table 1
Sample characteristics

N Range Minimum Maximum Mean Std. deviation

AGE 27 44 35 79 66.52 8.225

BMI (pre) 26 17.2 22.5 39.7 28.258 3.7997

BMI (post) 26 16.4 22.5 38.9 27.954 3.6160

Waist circumference pre (cm) 27 41 77 118 93.72 10.005

Waist circumference post (cm) 27 43 73 116 91.70 9.068

Valid N (listwise) 26

	N	Range	Minimum	Maximum	Mean	Std. deviation
AGE	27	44	35	79	66.52	8.225
BMI (pre)	26	17.2	22.5	39.7	28.258	3.7997
BMI (post)	26	16.4	22.5	38.9	27.954	3.6160
Waist circumference pre (cm)	27	41	77	118	93.72	10.005
Waist circumference post (cm)	27	43	73	116	91.70	9.068
Valid N (listwise)	26

The BMI (Pre) data was missing for one participant therefore the mean was calculated for 26 (n = 26) participants.

Other risk factors included hypertension (74.1%, n = 19), stress (44.4%, n = 12), and diabetes (14.8%, n = 4). Among the participants, 63% were non-smokers, 33.3% were ex-smokers, and 3.7% were current smokers. Alcohol consumption was reported by 77.8% of patients. The BMI pre-VCR was calculated for 26 participants due to missing data for one participant.

3.2 The differences in pre - and post-VCR overall RAND-36 scores

According to Table 2 comparing pre and post VCR overall RAND-36 scores, there was an overall mean increase across all measurements post-VCR with respect to the pre-VCR RAND-36 scores.

Table 2
Descriptive statistics for the pre vs post -VCR measures

N Range Minimum Maximum Mean Std. deviation

Chester METs pre 27 4.2 3.0 7.2 5.867 1.1163

Chester METs post 27 2.8 5.0 7.8 6.826 0.8689

Physical function rand pre 27 75 25 100 74.44 19.530

Physical function rand post 27 75 25 100 79.63 20.612

Role limit physical pre 27 100 0 100 64.63 37.569

Role limit physical post 27 100 0 100 80.93 31.195

Role limit emotional pre 27 100.00 .00 100.00 79.8141 32.45479

Role limit emotional post 27 100.00 .00 100.00 83.3944 29.80572

Fatigue pre 27 75 25 100 69.07 21.485

Fatigue post 27 65 35 100 73.89 19.530

Emotional wellbeing pre 27 50 50 100 78.33 12.767

Emotional wellbeing post 27 45 55 100 83.89 11.735

Social function pre 27 62.5 37.5 100.0 74.815 22.7330

Social function post 27 62.5 37.5 100.0 80.648 21.7790

Pain pre 27 77.5 22.5 100.0 72.593 20.2684

Pain post 27 77.5 22.5 100.0 81.574 19.8328

General health pre 27 80.0 20.0 100.0 64.352 19.6556

General health post 27 75 25 100 70.56 15.338

Valid N (listwise) 27

	N	Range	Minimum	Maximum	Mean	Std. deviation
Chester METs pre	27	4.2	3.0	7.2	5.867	1.1163
Chester METs post	27	2.8	5.0	7.8	6.826	0.8689
Physical function rand pre	27	75	25	100	74.44	19.530
Physical function rand post	27	75	25	100	79.63	20.612
Role limit physical pre	27	100	0	100	64.63	37.569
Role limit physical post	27	100	0	100	80.93	31.195
Role limit emotional pre	27	100.00	.00	100.00	79.8141	32.45479
Role limit emotional post	27	100.00	.00	100.00	83.3944	29.80572
Fatigue pre	27	75	25	100	69.07	21.485
Fatigue post	27	65	35	100	73.89	19.530
Emotional wellbeing pre	27	50	50	100	78.33	12.767
Emotional wellbeing post	27	45	55	100	83.89	11.735
Social function pre	27	62.5	37.5	100.0	74.815	22.7330
Social function post	27	62.5	37.5	100.0	80.648	21.7790
Pain pre	27	77.5	22.5	100.0	72.593	20.2684
Pain post	27	77.5	22.5	100.0	81.574	19.8328
General health pre	27	80.0	20.0	100.0	64.352	19.6556
General health post	27	75	25	100	70.56	15.338
Valid N (listwise)	27

The concluding calculations in Table 2 showed a 16.3% mean increase in MET for the Chester Step test, a 6.97% increase in physical function, and decreases in fatigue and pain levels by 6.97% and 12.37% respectively. Improvements were also seen in emotional wellbeing (7.09%) and social functioning (7.79%).

Table 3 presents the bivariate relationships and significant differences in pre-VCR and post-VCR scores. Significant increases in post-VCR scores were observed for: Change from Previous Year (50%, p = 0.046), General Health (25%, p = 0.015), Pain (33.3%, p = 0.012), Social Functioning (16.6%, p = 0.016), Emotional Wellbeing (5%, p = 0.10), and Role Limit Physical (33.3%, p = 0.005). A significant difference of 16.34% (p < 0.001) was found in pre and post VCR Chester Step Test METs scores. No significant difference was found in Physical Function, Role Limit (Emotional), and Energy/Fatigue (p > 0.05)

Table 3

Pre and post VCR differences (nonparametric)^*

Subscales of HRQoL survey RAND-36	Median pre	Median post	Interquartile range pre	Interquartile range post	Sig. a,b P value
Physical function	80	85	20	25	0.065
Role limit emotional	100	100	33.3	25	0.233
Fatigue	65	80	35	30	0.061
Role limit (physical)	75	100	50	25	0.005
Emotional wellbeing	80	84	12	16	0.010
Social function	75	87.5	45	37.5	0.016
Pain	67.5	90	32.5	12.5	0.012
General health	60	75	30	20	0.015
Change from previous year	50	75	25	50	0.046
Chester step test MET’s	6	7	2	1.8	<0.001

The significance level is 0.050. Asymptotic significance (Sig.) (2-sided test) is displayed. According to Related-Samples Wilcoxon Signed Rank Test. P > 0.05 are considered the null hypothesis.

3.3 The differences in the physical and mental health domains of the RAND-36 pre- and post- VCR

The analyses looking at differences in the physical and mental health domains pre- and post- VCR showed statistically highly significant increases in median post-VCR scores, compared to pre-VCR scores in both domains Physical 11.4% (p < 0.001) and Mental 12.9% (p < 0.001).

The differences in the physical and mental health domains of the RAND-36 pre- and post- VCR are presented in Table 4.

Table 4
Pre- post differences in the physical and mental health domains of the RAND-36 (nonparametric)^*

Domains of HRQoL survey RAND-36 Median pre Median post Interquartile range pre Interquartile range post Sig. a,b P value

Mental health domain 301.5 340.5 90 73.5 <0.001

Physical health domain 307.5 342.5 105 57.5 <0.001

Domains of HRQoL survey RAND-36	Median pre	Median post	Interquartile range pre	Interquartile range post	Sig. a,b P value
Mental health domain	301.5	340.5	90	73.5	<0.001
Physical health domain	307.5	342.5	105	57.5	<0.001

The significance level is 0.050. Asymptotic significance (Sig.) (2-sided test) is displayed. According to Related-Samples Wilcoxon Signed Rank Test. P > 0.05 are considered the null hypothesis.

4 Discussion

This study demonstrates the positive impact of VCR on the health-related quality of life (HRQoL) for older adults with cardiac issues during the Covid-19 pandemic. It highlights the effectiveness and potential of VCR services for the 60+ population, particularly during periods of social restrictions. Significant improvements were observed in pain management, physical health limitations, overall health perception compared to the previous year, social functioning, and wellbeing. Although no significant changes were noted in Physical Function, Role Limit (Emotional), and Energy/Fatigue scores, the overall results underline the value of VCR in enhancing HRQoL among older adults with cardiac problems. The multicomponent programme containing exercise and psychological support was recommended for older adult population during Covid-19 pandemics [24]. This study provides compelling evidence that a multicomponent programme, encompassing exercise, dietician, and psychological support, is not just beneficial but essential for the older adult population, especially during challenging times like the Covid-19 pandemic.

One of the most striking findings of this study is the statistically significant and clinically meaningful improvement in the Chester Step Test METs. This underscores the positive impact of structured, graded VCR on the aerobic fitness of participants during the pandemic. A positive effect of physical activity and aerobic fitness on HRQoL was found in randomized controlled trials and cross-sectional studies included in systematic literature review in 2007 [25]. Good cardiovascular health (CVH) is associated with better HRQoL [26]. Alcohol intake, lack of education, smoking and high BMI are related to impaired HRQoL [27]. In this study, alcohol intake and high BMI were prevalent risk factors among the participants. However, the silver lining is the decrease in the mean BMI post-VCR, which may potentially improve the participants’ cardiovascular disease risk factors.

The main limitation of this study was that the sample was reduced. The aim of the study was narrowed and specific which could be deemed as a limitation itself. It was a necessity as data was collected during a particular time at which Covid-19 pandemics happened. Despite the limitations of a reduced sample size and a specific focus, this study has achieved its aim and fills a crucial gap in the literature. It provides valuable insights that will guide future research into the impact of virtual cardiac services on participants.

The development of the VCR service for self-isolating patients during Covid-19 was indeed challenging, but the rewards are evident in the improved HRQoL of older adults with cardiac issues. The resources and data available at the time were effectively utilized to achieve theseresults.

5 Conclusion

In summary, this work is the first step to promote a structured VCR services among older adults especially during unusual circumstance or for those who are unable to travel for variety of reasons. VCR should be tailored to the patient’s needs. Establishing a structured VCR services nationally and internationally and offering it as an option may improve completion rate, help to modify changeable cardiovascular risk factors, therefore it would positively affect patient’s HRQoL. This may enhance cost reduction strategies in healthcare. Cardiovascular risk factors affect HRQoL before the cardiac issue is diagnosed. Participation in VCR without pre-assessment and follow ups should be discouraged. The policymakers should encourage stakeholders to support Cardiac Rehabilitation services in hospitals and community as well as preventative purpose of VCR and CR should be facilitated among patient who had no CVD diagnosed but have more than 5 cardiovascular risk factors present. Further research is necessitated on structure and distribution of VCR.

Ethical approval

Ethical approval was obtained from the Clinical Research Ethics Committee of the Cork Teaching Hospitals. Date of approval: 23rd December 2021. CREC Review Reference Number: ECM 4 (d) 07/12/2021 & ECM 3 (ttt) 11/01/2022.

The participants were informed they have free will whether to take part in the intervention as well as in this study. Informed written consent was obtained from the participants. Cardiac Rehabilitation services In the Mater Private are paperless. There are no chart reviews involved.

Conflict of interest

None to report.

Funding

Funding was not provided for this study.

Appendix 1 VCR exercise class structure sample can be provided on request.

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