Evaluating the impact of the COVID-19 pandemic on the delivery and efficiency of cardiac rehabilitation

The SARS-CoV-2 (COVID-19) pandemic brought disruption to cardiac rehabilitation (CR) services in the UK, requiring innovation and use of remote interventions. This retrospective longitudinal study compares single-centre CR service data across three time periods: ‘pre’ (June 2019 to December 2019), ‘during’ (January 2020 to May 2020) and ‘post’ (June 2020 to December 2020), evaluating adaptations in programme delivery and subsequent effect on efficiency.

There were 614 patients (72.7% male) identified between June 2019 and December 2020. Eligible CR referrals reduced 30.3% and encountered >50% decrease in engagement ‘during’ the pandemic, compared with ‘pre’ pandemic. The ‘post’ pandemic hybrid redesign led to a significant reduction in hospital discharge to CR contact (mean 5.39 days, p=0.001), and time spent in CR (41.33 days, p=0.001) when compared with ‘pre’ and ‘during’ figures. CR engagement significantly increased ‘post’ pandemic for ST-elevation myocardial infarction (STEMI)/non-STEMI (NSTEMI)/acute coronary syndrome (ACS) (56%, p=0.02) and ‘post’ cardiac surgery (76%, p=0.015). Referrals to cardiac psychology increased >50% ‘post’ pandemic (7.8%, p=0.038).

A ‘post’ pandemic hybrid CR programme is effective at reducing wait times, increasing engagement and reducing time to completion of CR, compared with ‘pre’ and ‘during’ pandemic figures. A significant increase in cardiac psychology referrals ‘post’ pandemic highlights the importance of psychology support within CR.

Introduction

Cardiac rehabilitation (CR) is a multi-factorial intervention incorporating education, physical activity and psychosocial support to address the risk factors for cardiovascular disease (CVD) and improve health behaviour.^1,2 A recent Cochrane review evaluating 85 randomised-controlled trials concluded that the benefits of exercise-based CR include reduced mortality, lowering hospital admissions, and may improve health-related quality of life.³

Research by Hinde et al. suggests the achievement of 85% engagement in CR could see a reduction of 49,000 hospital admissions and 19,500 fewer deaths over 10 years, saving millions in costs to the National Health Service (NHS).⁴ The NHS Long Term Plan (2019) has utilised these figures to set a target of 85% uptake in CR by 2028.⁵ However, data from the National Audit of Cardiac Rehabilitation (NACR) 2018 report found only 50% of those eligible for CR participated.⁶

Further research demonstrates that, offering timely CR leads to a 15.3% increased likelihood of engagement and associated improvement in long-term health.⁷ This emphasises the importance of the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) standards, which recommend three working days for CR recruitment and further completion of an initial assessment within 10 days.¹

In order to encourage uptake, patient preference is key. Therefore, the delivery of a rehab programme may take the form of group, home or web-based sessions over a recommended minimum intervention period of eight weeks.¹

Over the last 10 years, CR has typically been group-based, with the NACR 2018 report finding 75.4% of UK participants completed group-based classes.⁸  However, the SARS-CoV-2 (COVID-19) pandemic has seen a significant shift in the delivery of CR, with a 60% increase in home-based CR.⁹

Across the UK, many services were suspended or reduced in capacity during the height of the pandemic, with staff redeployed to inpatient roles in order to assist with the COVID-19 crisis. An international cross-sectional survey of healthcare professionals reported that 49.3% of CR services (from 333 responses) were suspended because of COVID-19 (89.7% responses from the UK).¹⁰ All elective cardiac surgery was cancelled in the UK following government enforcement for a three-month period from 15 April 2020, with data suggesting a 50–75% reduction in surgeries across 60 cardiac centres worldwide.^11-13

Noticeably, the number of patients attending hospital with emergency cardiac presentations also declined during the pandemic. A 40% reduction in hospital admissions across England was reported for those with acute coronary syndrome (ACS), comparing data from the same period in 2019.¹³ The British Heart Foundation (BHF) reported nearly 6,000 more deaths due to coronary conditions in 2020, with disruption to cardiac services a likely contributing factor.¹⁴

The emergence of cardiac COVID-19 phenotypes, those developing or worsening a pre-existing cardiac condition post-infection, will also create new challenges for cardiac services.¹⁵

Disruption to CR saw a 33% drop in the number of eligible patients participating in UK CR programmes, comparing data from August 2019 to January 2020 and February to July 2020.⁸ Prior to the pandemic, increasing access to CR and engagement in specific populations was already a priority, with overall targets set to increase uptake by 2028. For services re-starting post-pandemic, innovation and adaptability have been required to increase engagement in a changing healthcare system. With the benefits of CR for those with CVD well researched, it is vital that services continue to deliver CR and address the impact of the pandemic on those with CVD. The European Association of Preventative Cardiology (EAPC) Delphi Consensus has recommended a shift to digital-based support is required to enable continued provision.¹⁶

With changes to CR delivery and increasing engagement a national priority, the aim of this study was to utilise data collected over three COVID-19 time periods (‘pre’, ‘during’ and ‘post’) to evaluate the impact of COVID-19 on CR service delivery and engagement. In turn, this may lead to further insight into possible solutions for improving access to CR in a post-COVID-19 pandemic healthcare setting.

Method

We conducted a retrospective longitudinal study of data collected for patients referred to the King’s College Hospital NHS Trust CR programme between June 2019 and December 2020. Patients considered as eligible referrals (as per BACPR and trust guidelines) were those aged 18 years or above with an admission due to either:¹

1. ST-elevated myocardial infarction (STEMI), non-ST-elevated myocardial infarction (NSTEMI), acute coronary syndrome (ACS).
2. Elective percutaneous coronary intervention (PCI).
3. Elective or emergency cardiac surgery (coronary artery bypass grafting [CABG] or heart valve surgery [HVS]).

Data were collected for 614 eligible patients who were referred either internally following acute admission or from external referral. Patients registered with a general practitioner in the London boroughs of either Southwark or Lambeth were eligible for inclusion within the study.

Data were collected via the trust electronic patient record (EPR) system and divided into three time-periods: ‘pre’ (June 2019 to December 2019), ‘during’ (January 2020 to May 2020) and ‘post’ (June 2020 to December 2020) COVID-19 pandemic. Each of the time periods depicted stages of the COVID-19 pandemic and were chosen to enable comparison in the delivery and efficiency of the CR service during this unprecedented time. All information was stored anonymously and securely, as per trust guidelines.

Pre-pandemic, the CR programme consisted of ≥12 weeks of exercise and education with patients attending face-to-face sessions once a week. The exercise programme, centred on a core principle of cardiovascular and resistance exercises, was tailored to the individual patient based on their physical needs and limitations. The education component consisted of 10 separate 30-minute group sessions delivering information specific to cardiovascular risk factor management and behaviour change. Patients attended a face-to-face clinic appointment for initial assessment to establish their rehabilitation goals and record clinical outcomes. On completion of the programme, patients underwent reassessment and were provided with onward community referral, as appropriate, in order to maintain long-term benefits. All assessments were carried out by either a CR specialist nurse or physiotherapist.

During the pandemic, the CR programme was forced to reduce its capacity in seeing patients face-to-face, to decrease the risk of COVID-19 transmission and protect against severe illness. Within this stage of the pandemic, the essential redeployment of CR staff to assist with inpatient services led to a change in the method of CR service. Patients were offered a ≥8-week programme of telephone/video-based education and home-activity guidance. With assistance from the rehab team, each patient would choose the rehabilitation subject areas or components applicable to them and receive the relevant guidance and education through ≥30 minute appointments one to two times per week.

Post-pandemic, the CR service was able to restart more fully, although reduced staffing and ongoing restrictions for outpatient services meant a radical re-think to the CR delivery approach. The remote CR service continued to offer patients a ≥8-week programme of telephone/video-based education, advice and guidance. However, the ‘post’ pandemic programme quickly evolved to allow face-to-face initial assessments and group exercise as restrictions eased. Bringing these programmes together established a hybrid approach, offering patients a menu-based approach towards CR, and the ability to ‘mix and match’ remote and face-to-face rehabilitation components. Patients would be able to choose their method of assessment (video/telephone/in-person), the specific subject areas of education they wish to receive and mode of delivery (video/telephone/in-person) and their preferred mode of activity/exercise component delivery (home-based or face-to-face).

Demographic data were collected across all three time periods, including: number of eligible patients, age, sex, ethnicity and admission type. Further data were amassed for outcomes including: discharge to CR contact, length of time in CR and referral to psychology.

Data analyses were conducted using SPSS version 26 software. Demographic and outcome data for each of the three time periods were compared using ANOVA analysis, with further subanalysis investigating the influence of each admission type (medical, PCI, surgery) on CR service outcomes across the ‘pre’, ‘during’ and ‘post’ time periods.

Results

In the time period between June 2019 and December 2020, 614 patients (mean age, 61.97 years) were identified as eligible for CR and included within the study. Demographic data (table 1) demonstrate a majority of male patients (72.7%) and a higher proportion from a White British/Irish/European ethnic background (47.65%). Patient demographics (age, gender, and ethnicity) remained relatively consistent across the ‘pre’/’during’/’post’ periods (table 2).

The overall number of patients identified as eligible for CR reduced by 30.3% in the ‘during’ COVID-19 period (n=101), when compared with the ‘pre’ COVID-19 period (n=333). Engagement in CR was at its lowest ‘during’ the pandemic (22.7%) but increased to the highest level ‘post’ pandemic (53.9%). For those engaging in CR, the mean patient journey both ‘pre’ and ‘during’ was 92 days and 90 days, respectively. ‘Post’ COVID-19, and with the new hybrid approach to CR, this reduced significantly to 41 days (p=0.001).

Subanalysis of patient demographics and outcomes based on admission type (table 3), demonstrates a significant improvement in CR engagement for medical (STEMI/NSTEMI/ACS) and surgical admissions (56.1%, p=0.0001 and 76.4%, p=0.015, respectively), in the ‘post’ pandemic period when compared with ‘pre’ and ‘during’ periods. Patients undergoing elective PCI engaged less with CR ‘during’ and ‘post’ COVID-19 (12% and 30%, respectively) when compared with the ‘pre’ COVID-19 period (37%).

‘Post’ pandemic data demonstrates initial patient contact by CR to be significantly quicker following discharge (mean 5.39 days, p=0.001) when compared with ‘pre’ and ‘during’. Data also demonstrated 7.8% of patients required referral to cardiac psychology ‘post’ COVID-19, a significant increase of >50% (p=0.038) from the ‘pre’ and ‘during’ COVID-19 periods.

Discussion

The COVID-19 pandemic caused severe disruption to cardiac services, including a reduction in those with emergency cardiac conditions presenting to hospital for treatment.^13,14 Our findings are in agreement with national reports, demonstrating a 30.3% decrease in eligible CR referrals in the months during the COVID-19 pandemic. While the temporary postponement of elective cardiac surgery and angioplasty would reduce the number of eligible referrals, only 49 medical patients (STEMI/NSTEMI/ACS) were identified and eligible in the ‘during’ COVID-19 period, which is <50% of eligible referrals seen both ‘pre’ and ‘post’ COVID-19. The decrease in these acute medical referrals (STEMI/NSTEMI/ACS) may be explained by a fear of attending hospital due to risk of contracting the virus.¹⁴ A real reduction in acute events may have also contributed, with lockdown significantly changing daily routines, providing the time for people to engage in positive health changes, such as improved dietary habits and reduced alcohol consumption.¹⁷ However, Mafham et al. (2020) note that a reduction in admissions preceded full lockdown measures, suggesting that a real decrease is unlikely to be a significant contributor to the reduction in cardiac presentations to hospital.¹³  Ultimately, the long-term impact of the pandemic on future demand for cardiac services is yet to be realised. It is important for CR services to prepare and monitor for a possible increase in referrals post-pandemic and develop efficient models of delivery to ensure demand can be met.

The COVID-19 pandemic lockdown increased social restrictions, job uncertainty and financial strain. A survey completed by Mind (2020) found that as many as 60% of adults reported a deterioration in mental health during lockdown.¹⁸ This decline in mental health may, in turn, have led to negative coping strategies, reductions in healthy lifestyle choices and subsequent increases in risk factors for CVD.¹⁹

Our study demonstrated a statistically significant increase in referrals to cardiac psychology post-COVID-19, supporting research that demonstrates the negative impact of the COVID-19 pandemic on mental health.²⁰ Our findings highlight the importance for CR services having integrated psychological support within their programmes, or the ability for timely signposting on to appropriate mental health services.

Our hybrid model of service delivery ‘post’ pandemic has been shown to be effective at significantly reducing discharge to CR contact times, across all three admission categories. Whilst ‘post’ pandemic average wait times (5.39 days) remained marginally higher than the standard of three working days, a significant improvement was seen when compared with ‘pre’ and ‘during’ pandemic time periods.¹ Unsurprisingly, discharge to rehab contact times lengthened during the pandemic, and was at its highest with an average of 11.69 days ‘during’ COVID-19, reflecting the impact of staff redeployment. This may have contributed towards the >50% reduction in engagement in CR during the pandemic. Research by Hinde et al. (2020) has suggested that shorter wait times lead to a greater likelihood of engagement and, thus, improved long-term health-cost benefits.⁷ Reducing wait times for CR has been highlighted as a key standard by numerous national organisations, including the National Institute for Health and Care Excellence (NICE).²¹ Our findings further support the research by Hinde et al. demonstrating a statistically significant improvement in engagement ‘post’ COVID-19 (53.9%), when shorter wait times were achieved.⁷

The hybrid model of CR we introduced ‘post’ pandemic may itself have led to the reduction in CR discharge to contact times and improved engagement. Offering remote telephone/video clinics allows flexibility with appointments and the opportunity to fit in with patients’ daily schedules, particularly with many people increasingly now working from home as a result of the pandemic. Lack of time and travel have been shown to be significant barriers to CR engagement.²² Providing patients with a choice in mode of CR delivery improves involvement within their care, and provides a solution to previous barriers. This may have been a significant contributory factor for the increased engagement with CR seen within our study. Further research on patient satisfaction would be beneficial for gaining further understanding of patient views towards the hybrid model, ensuring optimisation of service delivery and continued increase in CR engagement.

While engagement was shown to have improved ‘post’ pandemic, further progress is required to reach the NHS 85% CR engagement target by 2028. Interestingly, our study shows that those following STEMI/NSTEMI/ACS and surgical procedures had significant increases in engagement ‘post’ COVID-19 (56%/76.4%). As mentioned, this may be due to the incorporation of remote interventions within service delivery, alongside changes to lifestyle habits. However, patients referred following elective PCI demonstrated a reduced engagement ‘post’ pandemic compared with ‘pre’ pandemic figures. It may be that patients undergoing less invasive cardiac interventions/events have a lower mortality risk and, thus, reduced motivation to participate in CR, with delays and cancellations to elective angioplasty procedures due to the pandemic further diminishing perceived risk.²³ This could lead to increased difficulty engaging this cohort post-pandemic. Our findings have shown that engagement in CR varies between cardiac admission types, and as such, it may be that different approaches, or more specific engagement targets, are required rather than a blanket target for all.

Referrals to CR ‘pre’, ‘during’ and ’post’ COVID-19 remained representative of the local demographic, with those of a White British, Irish or European ethnicity accounting for the highest proportion (47.65%). Those of a Black/African/Caribbean/Black British background also remained consistent and representative of the demographics within the local boroughs, where approximately 20–24% of the local populations are of a Black/African/Caribbean/Black British ethnicity.^24,25 With London having the highest aggregation of ethnic groups compared with the rest of the UK, it would be beneficial to complete further analysis into the ‘pre’ and ‘post’ periods to compare engagement figures for those of different ethnicities.²⁶ This is particularly important as figures from the NACR (2020) highlight that inequalities between different ethnicities remains a key issue for CR engagement, with an 11% relative decrease in ethnic minority participation in 2020 compared with 2019.⁸

A statistically significant reduction in time from CR contact to discharge was evident ‘post’ COVID-19 (41.33 days). The BACPR (2017) guidelines have previously recommended an eight-week minimum intervention for CR.¹ However, CR has changed dramatically due to the pandemic, with a 60% increase in those completing home-based programmes.⁹ It may be that hybrid CR models do not require the same length of intervention, with a more streamlined delivery including quicker contact times from hospital discharge. Shorter patient journey time in CR may enable faster turnover and greater rates of completion, thus, enabling larger numbers of patients to be supported within their recovery. This is of particular importance when acknowledging earlier discussions around the emergence of new cardiac COVID-19 phenotypes and future service demands. It will be important for further research to analyse the outcomes of patients post-pandemic, as well as patient satisfaction towards hybrid models of delivery, to ensure shorter time spent in CR does not negatively affect patient outcomes.

This study does have limitations, particularly as it includes patients from a single urban centre CR programme and has an under-representation of female participants. The dates used within this study reflected the time-periods of COVID-19 as it emerged within the UK (first wave) and the direct impact on the local London area specifically.

Conclusion

During the COVID-19 pandemic, our CR programme experienced a significant decrease in both identified eligible referrals and those engaging with the programme. This service disruption significantly increased wait times for CR, and subsequently prolonged the length of time spent in rehabilitation. The requirement for cardiac psychology increased and was at its highest post-pandemic, highlighting the importance of integrating psychology support within current CR programmes. Post-pandemic service redesign, including greater patient choice in mode of delivery, reduced the waiting times for CR post-discharge and length of time required in CR. Our findings demonstrate that a redesigned hybrid model of care in CR has the potential to increase efficiency and improve patient engagement. Further research evaluating outcome measures ‘post’ pandemic will elucidate the impact of the redesigned hybrid CR model on patient outcomes.

Key messages

• Post-pandemic service redesign, including the choice of telephone/video clinics, is effective at reducing waiting times and increasing engagement in cardiac rehabilitation
• Engagement in cardiac rehabilitation varies between clinical diagnoses and admission types, meaning that different rehab approaches and engagement targets may be required, rather than a blanket target for all cardiac diagnoses and treatment

Conflicts of interest

None declared.

Funding

None.

Ethical Approval

This study was considered an evaluation of clinical service and Health Research Authority (HRA) ethics committee approval was not required (confirmed by the HRA “Is my study research?” algorithm outcome). This was assessed and approved through the King’s College Research & Innovation team.

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