Since the COVID-19 pandemic started in 2020, the delivery of cardiac rehabilitation (CR) has been impacted,1,2 with programs closing or switching to fully virtual or hybrid delivery.3 Barriers and facilitators to attending different CR models have been described in the literature4-6; however, little is known about patient preferences for onsite visits since the start of the pandemic. Patient preferences influence their decisions to initiate and continue their care. This study investigated patient satisfaction and preferences for onsite CR visits.
METHODS
This research was cross-sectional in design. Participation in the survey constituted voluntary consent and responses were confidential. Those who attended a 16-wk CR program (University Health Network, Canada) between January 2020 and June 2022 and indicated they were interested in research were invited to complete the online survey administered through REDCap (English). Data collection occurred from June to September 2022. The study was approved as a quality improvement project by local Research Ethics (21-0329).
A 10-item questionnaire was developed by the investigators to examine the objectives of this study (see Supplemental Digital Content 1, available at: http://links.lww.com/JCRP/A448). The items had Likert-type scales, forced-choice, and open-ended response options; skip-logic was used to get more detail.
Only completed surveys that indicated the CR model were included. Descriptive statistics were applied for all closed-ended items in the survey. All open-ended responses were coded. Data were analyzed using SPSS version 29 (IBM).
RESULTS
Overall, 2369 patients were invited to complete the survey and 603 responses were received. Of these, 417 (69%) indicated they attended the hybrid program (HP) and 186 (31%) the fully virtual program (FVP). The majority of patients attending each CR model indicated they were male > 65 yr (HP: 67% [57% >= 65 yr]; FVP: 75% [63% >= 65 yr]). Thirteen respondents reported they were completing the survey on behalf of family members or spouses.
The Table presents results regarding patient satisfaction with CR models and preferences for onsite visits. Overall, 290 (70%) patients who attended the HP indicated they were satisfied with this CR model. The main reason was the possibility to meet onsite during the first classes and connect with their instructor and peers, as well as learning skills and receiving training before going to virtual sessions. Patients who attended the FVP were also satisfied with their CR model (n = 133, 72%) because of feeling safe; having a practical, flexible, and convenient program; and not having to travel or commit to attend classes onsite.
From the HP, 53% of respondents indicated they definitely would have a better experience with exercise if they could come onsite more often versus 25% from the FVP. Participants from both CR models reported they are comfortable with online learning as long as they receive training and clear instructions to access the classes, there are no technical issues, and materials are good and easily accessible. Participants from both models indicated they would learn better if the healthy eating, risk factors, and emotional well-being education was delivered in person.
The majority of respondents from the FVP (52%) reported that they would not receive better support from other patients if they were able to see them in person. Responses showed that they do not seek support from other patients, as they have this from family and friends, or they believe the support during online sessions was enough as they felt comfortable and safe in their own environment. For the HP participants, ~70% responded they definitely or probably would receive better support from peers if they were able to see them in person more often. They reported the importance for face-to-face contact and how being around others that have been through similar situations can help their mental health.
Overall, 48% of respondents from the FVP reported they would not choose the HP in the future if more than four onsite classes were offered. From the HP, 35% respondents answered that all 16 sessions should be onsite. When asked about when the onsite classes should be offered, most respondents from both models indicated that these sessions should be spread throughout the program.
In regard to satisfaction and preferences by age, those < 65 yr and attending the FVP were more satisfied than older participants. The younger group also indicated they probably would not have a better experience with exercise and education if they would be able to come onsite at all. In regard to sex, women attending the HP were more satisfied when compared with those attending the FVP. Women attending both CR models indicated they would have a better experience with exercise if they were able to come onsite more often/come onsite at all. They also believed they would have better support from other patients if they were able to come onsite.
DISCUSSION
In this cross-sectional study, we identified satisfaction and preferences for onsite CR visits from patients attending HP and FVP. Some of the results have been previously reported such as the importance of connecting with other patients and CR staff (identified by hybrid model participants) and the need for training and organizational adjustments to adopt virtual CR (identified by FVP model participants).5,6 However, we have also identified other novel results, which include preferences for exercise classes onsite with education being delivered online (different from studies conducted prior to the pandemic)7,8; onsite sessions spread throughout the program; and education about healthy eating, risk factors, and emotional well-being being delivered in person. Participants from the FVP indicated that attending onsite sessions would not be practical or needed; in contrast, nearly one-third of respondents from the HP reported their preference for all sessions to be held onsite. Results also differ by age and sex and support previous studies.9,10 These findings suggest the importance of offering different CR models and guide patients to choose one based on their preferences and needs.
This study was limited by a convenience sample (potentially resulting in selection bias), results from one site only (affecting generalizability of results), and the reliability and validity of the survey, which is unknown. The survey was completed online, so preferences of those who do not have internet access or technology literacy is unknown.
In conclusion, although all participants were satisfied with their CR model, there are specific preferences that should be taken into consideration. Future research should investigate differences in certain preferences related to specific groups (eg, diagnosis and socioeconomic status) and assess the use of personalized support tools to help identify these preferences and guide patients to the best CR model based on these responses.
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