Design and Procedure

This research was cross-sectional in design. This work was undertaken by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR; globalcardiacrehab.com); York University’s Office of Research Ethics (Toronto, Canada) approved secondary use of the data for publication purposes. Participation in the survey constituted voluntary consent to participate. Responses were confidential.

The 40 ICCPR member associations and 10 ‘friend’ members (i.e., individual members from countries where there is no known cardiac association) at the time of the study were contacted and requested to circulate the survey to their members and any other programs of which they were aware in their regions (there are now more; see https://globalcardiacrehab.com/Members). Contacts of the investigators were also approached to circulate and complete the survey. Potential respondents were also recruited from the attendance list of the ICCPR webinar on COVID-19 and CR [26], which was attended by more than 300 participants. The survey was sent out on two occasions.

Data collection occurred from March to June 2020 via online survey administered through REDCap (English). The original survey was not available within China. Therefore, the survey was translated (Simplified Chinese) by co-author XL, a bilingual nurse with CR expertise. It was disseminated through Sojump, a professional online survey platform.

Sample

The sample comprised CR programs around the world, with programs defined as those that offer (1) initial assessment, (2) structured exercise, and (3) at least one other strategy to control risk factors. We asked the CR program manager to complete the survey where possible.

Countries were categorized by WHO region [27]. To ultimately understand representativeness of the sample, the availability of CR by country and programs per country was ascertained from ICCPR’s first global audit of CR (2016/2017) [28]. Through that process, it was estimated that there were 5,813 programs in 111 countries with CR internationally (note in the global audit only a random subsample of programs was recruited in the United States, but all programs were emailed for this study) [28]. Information from key informants and respondents were used to update these numbers where available.

Measures

A 33-item questionnaire was developed by the investigators to examine the objectives of this study (Online Appendix 1). Non-COVID-related questionnaire items were based on ICCPR’s previous CR program survey [18]. The questionnaire was divided into three sections: (1) CR program characteristics and impacts of COVID-19, (2) barriers and facilitators to delivering CR programs virtually, and (3) COVID-related impacts on staff and patients. The items had forced-choice (some were select all that apply) and open-ended response options, and skip-logic was used to get more detail where applicable. Input from CR providers was solicited and the survey piloted with a few centers from different WHO regions; minor changes were then made to questions and wording prior to launch of the survey.

Respondents were asked to report their country and the date. To contextualize responses, information on COVID-19 cases at the time of survey completion in each country was extracted from the website ‘Our World in Data’ [29] and confirmed with data available on each country’s government website. The Government Response Stringency Index – information on nine common policy responses that governments have taken to respond to the pandemic such as workplace closures and stay-at-home requirements (rescaled to a value from 0 to 100, with 100 = strictest responses) – was also extracted from this website for each country, with information corresponding to the mean date of survey completion by respondents in each country.

Data Analysis

Data were exported from REDCap and Sojump to SPSS version 26, where all the analysis was performed. All initiated surveys that had at least one response were included. The number of responses for each question varied due to missing data (e.g., respondent did not answer a question due to inapplicability, skip logic, or decided to not answer for other reasons); for descriptive analyses, percentages were computed using the number of valid responses for the specific item as the denominator.

Descriptive statistics (e.g., frequency with percentage) were applied for all closed-ended items in the survey. All open-ended responses were coded.

Respondents

Overall, 1062 responses were received, of which 1044 (98.3%) identified their country. As shown in Table 1, responses were received from 70 (34.5%) of the approximately 203 countries in the world (covering all six WHO regions; response rate by region ranged from 14.1–100.0%; median number of responding programs per country = 98.0; Q25–75 = 36.0–108.0), or 63.1% of the 111 countries identified to have any CR programs in ICCPR’s global audit [28]. Given the estimated number of programs globally [28] and updates gleaned through this process (no additional countries were determined to have CR, but 13 countries had increases in the number of programs since ICCPR’s 2016/17 audit, with a total of 60 additional programs globally; Table 1), responses were received from 18.3% of the estimated 5,813 programs worldwide.

In regard to location, 392 (37.4%) CR programs were located in a community hospital, 364 (34.7%) in a referral center, quaternary or tertiary facility, and/or academic center, 46 (4.4%) in a rehabilitation hospital or residential facility, and 70 (6.7%) in other locations, including private clinics, universities, and fitness centers. With regards to reimbursement, 690 (66.4%) programs have their services covered by the government, 557 (52.8%) programs’ services were paid directly by patients, and 484 (47.5%) were paid by health insurance (many programs had multiple sources).

Table 1 presents number of cases and stringency index by country. The COVID-19 restrictions that had taken place in their area at any time before respondents completed the survey were as follows: 961 (80.2%) reported that gatherings over a certain number of people were prohibited, 947 (79.4%) reported that anyone potentially exposed to COVID-19 was under quarantine or self-isolation, 891 (75.3%) reported schools were closed, 859 (72.1%) reported hospitals were not allowing visitors, 848 (71.7%) reported hospitals were not doing elective surgeries, 840 (71.2%) reported all but essential services/businesses were closed, 797 (67.0%) reported that people had to wear masks when physical distancing was not possible, 649 (54.4%) reported travel within their region was restricted, and 633 (54.4%) reported the enforcement of physical distancing with fines and other means.

Impact of COVID-19 on CR Program Delivery

Overall, 106 (14.4%) programs reported suspected or positive COVID-19 patients (see Table 1 for COVID-19 cases by region). At the time of survey completion, 367 (49.1%) programs reported they had completely stopped CR delivery for the COVID-19 pandemic, and 203 (27.1%) stopped for a period but had already resumed services (mean 8.3 ± 2.8 [standard deviation] weeks); 178 (23.8%) programs did not stop (see Table 1 for this information by country). As shown, Nigeria has the poorest CR density, and all programs closed. Of those that stopped for any amount of time, 363 (30.0%) made no other arrangements to provide patient care, and the 202 (16.7%) that did described the following: home-based CR/telehealth; online consultations; phone or email consultations; and education offered more often via phone, online, or via postal mail to patients. During COVID-19, 202 (42.3%) programs were only treating existing patients, while all others were still accepting new patients; programs reported having the capacity to serve a median of 20.0 (Q25–27 = 10.0–40.0) patients/month pre-COVID, and 3.0 (Q25–75 = 0.0–15.0) during. The most common program adaptations were: reducing the number of program elements offered (n = 228, 19.5%), deferring graduation until post-program assessments could be completed (n = 120; 10.3%), shortening the program duration (n = 95, 8.2%), and graduating patients more quickly (n = 85, 7.3%). On the other hand, 177 (15.1%) respondents reported adapting all program elements to retain service levels (see Table 2 for adaptations by WHO region).

Table 3 displays the components that are delivered by CR programs and continue to be provided during the COVID-19 pandemic. As shown, most impacted was supervised exercise training, resistance training, inclusion of family/informal caregivers, end of program re-assessment, and functional capacity testing. Indeed, of the programs providing services or without COVID-19 restrictions, 119 (14.5%) had changed the type of functional capacity test they use. Of these, 30 (26.3%) were performing functional capacity testing remotely, most commonly: a walk test (n = 19; 1.6%), step test (n = 6; 0.5%); 15 (1.3%) cited other tests, such as the Duke Activity Status Index (self-report survey) and timed sit-to-stand.

Of those that continued providing services, the COVID-19 pandemic had impacted the way exercise is prescribed for 306 (37.5%) programs (e.g., virtual consultations with no structured supervised exercise program), and monitored for 226 (27.8%; e.g., focus on rating of perceived exertion rather than target heart rate, all done virtually). Where patients were encouraged to exercise at home or in their community, the following changes were made to manage patient symptoms, reporting, or concerns: education about symptoms enhanced, regular virtual (phone and online) consultations with CR staff were added, and patients were encouraged to directly contact their physician if symptoms were experienced.

Furthermore, of programs continuing to provide services, in 111 (13.6%) programs, the type of provider delivering CR had changed, and in 122 (15.0%) patients have had to interact with a different provider (e.g., mainly one professional interacting with patients – mostly nurses, as access to allied health care providers ceased due to COVID-19).

Online Appendix 2 provides details of patient education delivery modes and providers, in light of the COVID-19 pandemic. As shown, there was a drastic reduction in exposure to all disciplines. Modes of delivery were chiefly phone, email, online resources, and mail; live video was only exploited in approximately 20% of programs. For those that offered it, education session frequency before COVID-19 was 8.7 ± 8.4/month/patient (mean of 50.1 ± 47.5 minutes/session), dropping to 4.1 ± 7.5 (mean of 20.2 ± 26.0 minutes/session) during the pandemic.

Alternative/Remote Delivery of CR due to COVID-19

Reimbursement and delivery of alternative models (e.g., home-based) is shown in Table 4, including the proportion of patients served (shown before COVID by country elsewhere) [30]. Of those delivering alternative models, 226 (31.7%) programs offered low-tech home-based (e.g., landlines, mail only), 175 (24.5%) offered high-tech home-based, 83 (11.7%) some hybrid format with supervised and unsupervised sessions, 74 (10.4%) offered community-based, and 6 (0.9%) offered ‘other’ models (e.g., livestream).

Forms of communication used in remote models are also shown in Table 4. Overall, 182 (62.8%) programs reported barriers to using these communication tools, most commonly: lack of patient access (i.e., patients not having computer with email; n = 146, 12.5%), difficulties for the patients (e.g., lack of technical knowledge; n = 111, 9.6%), logistical problems such as connectivity issues (n = 107, 9.2%), and difficulties for the clinical staff (e.g., being too busy, lack of staff; n = 53, 4.6%).

Barriers to delivering CR remotely were: patients did not have the technology to connect with program staff remotely (n = 195, 16.8%), lack of equipment/program resources for secure and private remote delivery (n = 148, 12.7%), insufficient funding (n = 123, 10.5%), insufficient staff (n = 118, 10.1%), patients’ risk is too high for unsupervised exercise/safety concerns (n = 111, 9.5%), too inefficient (i.e., cannot see as many patients because they do not offer remote program elements in a group, but only individually; n = 90, 7.7%), staff need training (n = 90, 7.7%), and no policy (n = 69, 5.9%); other barriers (n = 24, 2.1%) included language proficiency, remote delivery not reimbursed, not enough referrals, and hours.

Finally, to increase their capacity to deliver home-based/remote CR services to patients (open-ended item), respondents perceived they would need: time to research and develop the model (including appropriate services for illiterate patients); secure/private means for staff to communicate with patients electronically; equipment to communicate remotely with patients (e.g., multiple laptops with built-in cameras and microphones, headsets); facilities/space (e.g., videoconferencing in private room); home equipment to loan patients including tablets, wearables/activity trackers for exercise monitoring and assessment of all risk factors (e.g., sphygmomanometers/cuffs); cheap and reliable wireless technology to monitor for adverse events remotely (e.g., heart rate and rhythm); reliable and low-cost high-speed internet access for staff and patients (including those living in rural and remote areas); a dedicated multidisciplinary team (including more nurses and exercise physiologists); staff training (by those with experience in remote models), physician champions; administrative staff to facilitate scheduling of virtual sessions; a structured, evidence-based home-based CR program software platform or smartphone app (including that it has capacity to reach groups of patients, that family/informal caregivers can also access it, that it is comprehensive [e.g., includes structured exercise livestreaming, education], and includes tracking diaries with two-way communication; or funding for technology upgrades), with associated assessment tools (including functional capacity) and policies to implement; technology support staff (with time) to train patients (potentially in-person when they are in acute care) and staff to use the remote technology (e.g., zoom) and equipment, and also for database management support; ability to have at least one safe in-person session with each patient to ensure safety and education; financial resources as well as reimbursement of remote model; and patient as well as provider awareness of availability of the remote model (including referrals).

Impact on CR staff

CR team communication was also impacted. Overall, 295 (25.0%) reported having only ad-hoc meetings as needed, 274 (23.0%) reported they were having routine staff meetings via remote means (e.g., videoconferencing), 137 (11.8%) reported not being able to communicate as much as needed (e.g., staff re-deployed, staff lack home technology), and 88 (7.6%) reported they could not really communicate except via email.

Occupational impacts on staff are displayed by WHO region in Table 5. Moreover, 114 (15.3%) staff reported feeling stigmatized outside of work for being a healthcare worker (i.e., greater risk of COVID-19 exposure), 275 (36.9%) felt valued for providing care, and 325 (43.6%) felt no stigma (others responded ‘not applicable’). Negative psychosocial impacts that do or could impact their work are shown in Figure 1 (respondents were directed to check all that apply; n = 98, 8.4% responded ‘not applicable’ as they have experienced no COVID-19 impacts; n = 267, 22.8% of respondents reported no personal suffering due to COVID-19; and n = 233, 20.0% have been using the opportunity to catch up on things and learn).

When asked whether they had the equipment (e.g., video camera, remote access to hospital servers) and space/privacy to work from home efficiently during business hours, 198 (26.6%) responded affirmatively, 141 (19.0%) responded only for work that does not involve patient care, and 272 (36.6%) reported no (for reasons provided including: no access to work materials and hospital server remotely).

Table 5 also displays whether programs have treated suspected or COVID-19 positive patients by WHO region, and associated concerns. Figure 2 displays perceived risk in contacting COVID-19 through their CR work by country (global mean = 30.0% ± 27.4). Generalized linear mixed models, accounting for country as a higher-order variable, revealed degree of perceived risk was associated with country stringency index (p = 0.01), but not number of cases (p = 0.80).

Impact on Patients

CR staff reported patients contacting them and expressing the following reservations and concerns regarding COVID-19: whether they need to change their exercise prescriptions (n = 337, 28.7%), adherence to a heart-healthy diet while concerned about going to grocery stores (n = 333, 28.4%), about their mental well-being (n = 331; 28.2%), using technology to interact with the program (n = 329, 27.9%), questions about medications (n = 318, 26.9%), stopping exercise due to a lack of space to exercise in their homes or inability to exercise outside without potential COVID-19 exposure (n = 303, 25.7%), questions about how to safely receive CR care without COVID-19 exposure (n = 255, 21.4%), their risk of death from COVID-19 due to pre-existing CVD (n = 249, 21.2%), and many patients contacted programs about reservations regarding receiving CR care and staff had to let them know they closed down the program temporarily (n = 230, 19.6%). On the other hand, 142 (12.2%) reported patients had not really been contacting the program more often due to COVID-19, and 62 (5.3%) reported patients seemed to be avoiding contacting their programs at all, under the assumption that services were suspended.

Resumption of CR services

Overall, 273 (36.8%) reported that their institution had a policy regarding the circumstances under which regular services could resume (for n = 167, 22.5% this was not applicable). Figure 3 illustrates the factors that respondents perceive should form the basis for resumption of face-to-face CR services given COVID-19. Other responses included: number of deaths reduced for two consecutive weeks, as well as when government allows gyms to open for business and instructs hospitals to open outpatient services.