Cardiac rehabilitation (CR) remains underutilized on a global scale despite ample evidence validating its benefits.1,2 Regrettably, CR participation has further worsened during the COVID-19 pandemic, as numerous center-based CR (CBCR) programs were forced to suspend their services in lieu of infection control guidelines.3 To ameliorate this situation, many institutions worldwide have recommended using telehealth and home-based CR (HBCR),4,5 given its potential benefits in increasing patient adherence, reducing costs, and improving care coordination.6 Telehealth-based delivery of HBCR (telerehabilitation)-the delivery of health care, health education, and information services via remote technologies-overcomes many barriers faced by traditional programs, especially during the ongoing pandemic.3 Consequently, it is crucial that both health care workers and patients are sufficiently equipped with the necessary technology and knowledge to ensure equitable care. Telerehabilitation is a viable option in Singapore, due to measures taken to ensure its citizens develop basic digital health literacy.7
Telerehabilitation and HBCR have been shown to be equivalent in clinical efficacy to CBCR. Both modes are able to reduce total mortality and morbidity, improve exercise capacity, and improve health-related quality of life.1,8 However, studies exploring the perspectives and preferences of patients receiving telerehabilitation are scarce, particularly in an Asian setting.1 Accordingly, with a focus on cardiovascular disease, we aimed to assess patient perspectives on telerehabilitation in Singapore.
METHODS
An asynchronous CR program utilizing telerehabilitation was launched in August 2020 within a national cardiology specialty center. The program comprised: (a) one CR orientation session via the Zoom video-conferencing platform where patients interact with CR nurses and physiotherapists, (b) two 6-min walk test assessments (at baseline and upon completion), (c) five in-person supervised exercise classes, and (d) two teleconsultation sessions (scheduled after exercise sessions 2 and 4) where CR physiotherapists review symptoms and discuss exercise prescriptions with patients over the phone. After completion of this CR program, which served as early outpatient CR, patients were referred to a community partner for long-term maintenance CR that continues indefinitely. Upon program completion, patients completed two anonymous online questionnaires to assess the video conferencing and teleconsultation components and the overall program. A CR physician reviewed patients for their suitability for participation in the asynchronous CR program 2 wk after hospital discharge for acute coronary syndrome or elective percutaneous coronary intervention. Patients accepted into the CR program had undergone complete coronary revascularization, had left ventricular ejection fraction >=50%, and were able to use a smartphone for videoconferencing.
RESULTS
Between August and December 2020, 18 patients completed the asynchronous CR program. Their demographics are summarized in the Table. The majority of these patients either agreed or strongly agreed that videoconferencing and teleconsultation were easy to use (90 and 83%, respectively), saved time (83% for both), saved money (78 and 67%, respectively), had lowered infection risk compared with in-person sessions (100% for both), were as valuable as in-person sessions (100 and 92%, respectively), more convenient than in-person sessions (72 and 83%, respectively), and were explained clearly to them (94 and 92%, respectively). All patients were either satisfied or very satisfied with both telerehabilitation modalities, would like at least some future appointments to use either modality, and would recommend the program to others. The overall ratings for videoconferencing, teleconsultation, and the overall program were 9, 8.6, and 9.3 (out of 10), respectively.
Notably, one patient each (dissimilar patients due to different age category entered) for both questionnaires strongly disagreed that the videoconferencing and teleconsultation methods were easy to use. However, all of their other replies were positive and both patients rated each modality 9 out of 10. This suggests that the "strongly disagree" response may be potentially erroneous. Nonetheless, these results were included in our overall results (Figure).
DISCUSSION
Our study suggests that telerehabilitation is well received, even in patients >65 yr, as well as in those who have limited experience in technology usage (ie, social media and messaging platforms). In many developed countries with an aging population like Singapore, trends in health care expenditure need to shift accordingly so that the already limited resources are utilized effectively. Services like telehealth for CR have been observed to incur a lower cost as compared with conventional ones.6 In the long run, this allows additional resources to be channeled appropriately to achieve optimal care. Although our study did not directly assess the cost-effectiveness of the implementation of telehealth for CR, the majority of participants acknowledged cost savings of the CR program.
Moreover, it is possible to envision a future where telehealth for CR is prevalent. With the Fourth Industrial Revolution upon us, the ability to harness technologies becomes easier than ever. This is also evident from our findings where, despite belonging to an older age group, most of the participants were familiar with mobile devices and applications. However, caution must be exercised when implementing programs such as the asynchronous CR program to avoid inequalities of care among vulnerable and marginalized populations.9 Nevertheless, an asynchronous CR program has been shown to be as effective as traditional CR regardless of patient demographics.10
The main limitation of our study is its small sample size. As such, it may not reflect the demographics of patients eligible for CR. The small sample size could be a result of the challenge we faced in garnering patient participation in the questionnaires. Questionnaires were neither mandatory nor incentivized. However, to facilitate and remind patients to complete the questionnaires, QR codes were placed prominently in the gym. Moreover, the CR staff also reminded patients to complete the questionnaires.
The progressive relaxation of lockdown measures in Singapore since completion of the study may have also led to a change in perception toward telerehabilitation and further evaluation is required to confirm our findings especially in older age groups. Responses by participants of a hybrid CR program utilizing telerehabilitation are highly encouraging. From a patient perspective, incorporation of telerehabilitation to enable remote CR is feasible, acceptable, and should be considered as an alternative CR delivery method.
Krishi Desai
Yishun Innova Junior College, Singapore
Denishkrshna Anbarasan, BSc
National University of Singapore, Singapore
Geetha Kayambu, PhD
Department of Rehabilitation, National University
Hospital, Singapore
Tee Joo Yeo
National University Heart Centre, Singapore
ACKNOWLEDGMENTS
We would like to thank the following personnel for their significant contributions toward this study: Serene Lim Peiying, Qamaruzaman Syed Gani, Shefali Poojari, Lee Si Hooi, Candice Wee Xin Yi, Lai Shuet Ming, Ng Hsuen Nin, Ong Mui Cheu, Ooi Lean See, Chong Wooi Fuon, and Karen Koh Wei Ling.
REFERENCES