Patients’ and nurses’ perceptions and experiences of a digitally enabled cardiac telerehabilitation program - a qualitative study

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Secondary prevention cardiac rehabilitation programs are paramount to prevent cardiovascular disease morbidity and mortality. However, they remain underutilized. Digital health programs provide an opportunity for healthcare delivery by breaking down access barriers. However, evidence for their implementation is lacking. Further evidence to ascertain the drivers for uptake and acceptance of digitally enabled cardiac telerehabilitation programs is required. Aims. To explore the perceptions and experiences of patients and their nurses enrolled in a digitally enabled cardiac telerehabilitation program, aiming to ascertain the drivers for program acceptance. Methods. A qualitative study utilizing semi-structured telephone interviews was conducted. Researchers independently analyzed data deductively to categorise participant perceptions about the program into positive, neutral or negative. The transcripts were then reviewed inductively to code for program benefits, challenges, and recommendations for improvement. Results. 12 out of 52 participants and 2 cardiac nurses, from across Australia, who had completed the intervention, participated in the semi-structured telephone interviews. Key benefits were the personalised nurse telehealth consultations (12/12), education aimed at maintaining learned healthy behaviours (10/12) and remote patient monitoring (5/12). However, digital connectivity was a challenge for patients. Nurses found that trust building was a challenge given there was no face-to-face care. Conclusion. Digitally enabled cardiac telerehabilitation is well accepted by patients and their nurses. Remote monitoring in combination with personalised telehealth nurse consultations enhance patient-clinician communication and were key success factors in this model of care. Challenges with digital connectivity should be considered and addressed in future interventions. Further quantitative research is necessary to validate these findings. Digital health telerehabilitation cardiac rehabilitation coronary artery disease health technology Figures Figure 1 Background Cardiac rehabilitation (CR) is a multidisciplinary, coordinated healthcare program, supporting patients to manage the risk factors for cardiovascular disease (CVD) ( 1 ). It includes clinician consultations, medication management, health education, psychological support, exercise classes, goal setting and self-management strategies to maintain a healthy lifestyle. These programs have shown effectiveness by enhancing quality of life, reducing rehospitalization occurrences and mitigating mortality ( 2 – 5 ). Thus, after experiencing a cardiac event, guidelines strongly advocate for patients to attend a secondary prevention cardiac rehabilitation program ( 6 ). However, attendance to traditional centre-based cardiac rehabilitation programs is low, with nearly nine out of ten Australians and three in four Americans who suffer a cardiac event not attending a cardiac rehabilitation program ( 7 , 8 ). Traditional face-to-face (F2F) cardiac rehabilitation programs, that have been in existence for over fifty years ( 9 ), encounter barriers that impede accessibility, including system level barriers (resource constraints and scarcity of available programs) and patient factors (time constraints, geographical location, transportation and parking) ( 10 ). Consequently, traditional programs remain largely inaccessible resulting in adverse health outcomes ( 11 ). Health services facilitated by technology present a novel prospect in healthcare delivery, dismantling access barriers and enabling clinicians to remotely monitor, track and communicate with their patients in real-time or asynchronously from a distance ( 1 , 12 ). The core components of a traditional centre-based cardiac rehabilitation program can be delivered via a digitally delivered model, using technologies such as telehealth, remote monitoring and mobile apps ( 13 ). These digitally delivered models are also proving to be effective, showing reductions in readmissions and emergency department visits( 14 ). However, participation rates remain stubbornly low (41%) ( 15 ), despite the fact that remotely delivered programs aim to increase access and uptake to secondary prevention care ( 15 , 16 ). Therefore, greater understanding about patients’ experiences and perceptions (and their treating providers) of participating in a digitally enabled cardiac telerehabilitation program is required to ascertain the drivers for program acceptance. Aims This study aimed to explore the perceptions and experiences of patients, and their cardiac nurses, enrolled in a nationally delivered, digitally enabled cardiac telerehabilitation program (called Heart Health at Home ). The objectives were to examine the positive and negative perspectives of the program, explore views about the benefits and challenges and to identify improvements and service enhancements. Methods Design This was a qualitative sub-study of a larger observational real-world propensity matched clinical trial, called Heart Health at Home (Clinical trial number: not applicable ). The results of this study also informed the design and implementation of the Risk-Guided CAD randomized controlled trial (RCT), currently in progress (ClinicalTrials.gov: NCT04966117). The study was approved by the Alfred Hospital Ethics Committee (Project Number: 321/21). Intervention The Heart Health at Home intervention was delivered over eight weeks and included six weekly one-on-one telehealth consultations with a cardiac nurse (Fig. 1 ). Nurses delivered the core components of phase two cardiac rehabilitation ( 17 ). This included nutritional counselling, behaviour change for a healthier lifestyle, psychosocial management and physical activity counselling, delivered via the following modalities: Telehealth – cardiac nurse telephone coaching to provide patient education and risk factor management, including patient assessments and personalised care plan development. Mobile application and nurse web portal – supported by the SmartCR mobile application and accompanying clinician web portal (Cardihab®, Queensland, Aus). The SmartCR app provided health metrics tracking (such as blood pressure), exercise monitoring, medication management and delivered motivational and educational materials to patients via prompted tasks and links to audio, written articles and video files. Each participant received an Omron HEM-7121 (Omron Healthcare Co. Lts, Kyoto, Japan) blood pressure device at the commencement of the program, enabling daily blood pressure monitoring and recording within the mobile app. Recruitment Patients were recruited nationally into the study within 30-days of a cardiac admission. Patients were identified via hospital pre-admission data as well as cardiac hospital claims data and were contacted via phone to ascertain their interest to enrol. Patients could also self-nominate to participate, or their treating health professional could refer them into the program. A representative sample of participants from across Australia, who had completed the intervention, were invited to participate. Two cardiac nurses, who delivered the intervention, were also recruited and interviewed. These nurses were experienced cardiac nurses with over a decade of experience working in cardiac rehabilitation. This was their first experience in delivering an entirely telehealth model of care with no face-to-face involvement. Data collection A semi-structured interview guide was developed (Supplementary Material 1). Semi-structured telephone interviews (range of interview durations 12–60min) were conducted by an experienced qualitative researcher (TT or DA). All participants provided consent to participate. Face to face interviews were not considered feasible for this study, given the geographical spread of our study participants and the remote mode of delivery of the program. Data analysis We transcribed the interview data verbatim (for both participants and nurses) and uploaded it into Microsoft Excel. Content analysis was conducted to deductively categorise participant perceptions about the program into positive, neutral or negative. The transcripts were then reviewed inductively to code for program benefits, challenges and recommendations. Any discrepancies were resolved by discussion and consultation between the investigators as required. Results Of 52​ participants who had completed the intervention (n = 40 males and n = 12 females), we were able to reach and contact 12 participants, who subsequently consented to participate in the semi-structured telephone interviews. The majority were male (n = 9 males and n = 3 females). Participants were represented from across Australia reflecting the demographic distribution of the entire cohort and resided in Victoria (n = 4), Western Australia (n = 1), Queensland (n = 4), ACT (n = 1), Tasmania (n = 1) and New South Wales (n = 1). Knowledge of cardiac rehabilitation and referral This cohort was not aware of cardiac rehabilitation and its benefits prior to the commencement of the digitally enabled cardiac telerehabilitation program. Half of all participants (n = 6) said that they were not referred to a cardiac rehabilitation program by their cardiologist or hospital and half (n = 6) mentioned that they did not know about cardiac rehabilitation prior to surgery. When asked if they felt that they needed to do a cardiac rehabilitation program after surgery, one in three (n = 4) said they did not feel the need for cardiac rehabilitation. The most common reason was due to feeling “ already healthy”, “surgery fixed things” and their “cardiologist did not recommend it”. However, half of the participants (n = 6) said that they needed to do cardiac rehabilitation to regain strength and get extra help. User experiences and perceptions Key themes and words used to describe the program positively, neutrally and negatively are highlighted in Table 1 . Table 1 Results from patient interviews: Perceptions, Themes, and Descriptive words Perceptions Themes Descriptive words Positive • The program was helpful, keeping patients focussed​ on achieving their health goals. ​ • The nurses were friendly, helpful, supportive and encouraging​. • Patients reiterated that they learned from the program, it improved their health literacy. • Program was good for recording and monitoring health habits. Good idea Learned a lot​ Achieved goals Coaching ​ Supportive Helpful ​ Positive Reassuring​ Practical Enjoyable​ Beneficial Encouraging​ Friendly Good​ Compassionate Happy​ Neutral • Patients who felt well post discharge saw the program as less relevant for them. • Patients described the program as a way to monitor health and regain abilities. Direct​ Monitoring ​ Laymen’s terms​ No problems ​ Non-judgemental Negative • Internet connection issues​ made some patients frustrated. • Some patients expressed that app had a few bugs that needed to be fixed. • The app was complex for some, with suggestions that it needs to be simplified.​ • The app reminders were annoying​ for some patients. • Patients wanted to use the app for longer following program completion. • The scope of the program was too limited for some, and a wider range of exercises was suggested to be added. ​ Annoyed​ Frustrated​ Benefits Almost all participants (11/12) mentioned that they benefited from the program, pointing out that they can “ now exercise more ” and are “ motivated to get out and walk ”. They expressed that they needed this program to “ regain strength and get back to pre-cardiac event abilities ”. Overall, participants rated the program an 8 out of 10. The benefits of the program were expressed as supportive, educational and motivational. The most supportive elements were the one-on-one personalised nurse telehealth consultations. All participants (12/12) mentioned that they benefited from talking to the nurses. “I liked the support and counselling from the nurses. I could talk things over with the nurse instead of going in to see doctors all the time...The nurses advised me how to do things – I wasn’t their very best patient, but I tried. It kept me focussed.” F, Qld Participants valued the care provided by the nurses, mentioning that it was nice to know that someone cares about them. “When you’ve had trouble with your ticker and you get to my age, it’s nice that people are interested and you’re not just a number. It was nice to be worried about.” M, Vic Similarly, the nurses mentioned that the telehealth counselling and coaching was the most important component of the program. The nurses revealed that despite the fact the entire model of care was delivered remotely, the personalised consultations were a value add that enabled greater patient centred care compared to face to face cardiac rehabilitation, which is typically delivered in a group setting. “Members are getting a half hour of direct information that I’d never be able to deliver in the hospital system. They’re getting much more direct one-on-one time even though its over the phone.” F, Nurse The clinician web portal provided the nurses with additional medical knowledge about each patient and empowered them to deliver patient centred and data driven consultations that were tailored to the specific needs of each patient. The nurses reiterated that the individualised, tailored care plan was another value add, over and above group-based face to face cardiac rehabilitation. “The program is tailored to the person and what works for them, and this depends on their age, whether they are working or retired, their background.” F, Nurse “Lots of different people have done the program and success depends on what works for the individual person, what their priorities are.” F, Nurse Similarly, the monitoring capabilities were also a core benefit of the program. Nearly half (5/12) of all participants liked that they could monitor their health metrics and valued that the nurses had access to their health information via the remote monitoring functionality of the program. This aspect kept participants motivated and held them accountable to their health goals. The monitoring also empowered participants during their primary care visits with their physicians, as it allowed them to show their progress over time. “I benefitted from being held accountable to take meds on time, monitor blood pressure, walk, etc, and from the encouragement, particularly around walking more. It was helpful/valuable being held accountable.” M, Qld “I learned a lot about healthy eating, walking and other things. It was a very good learning experience. I’m definitely an advocate for the program. Setting small goals and achieving them. I need less doctor visits now.” M, Vic Education and health literacy were another benefit and were highly valued as core components of the program. This model of care supported cardiac education, which was tailored to the risk factors of each patient. The nurses highlighted that the program assisted participants to return to pre-cardiac function and supported them to manage and view cardiovascular disease as a long-term chronic condition, thus allowing them to learn to live with their illness​ and manage their illness in a sustainable way. Moreover, the telehealth delivery increased convenience and flexibility for both participants and the nurses, improving patient and provider experience. “Members benefit from increased knowledge about cardiac issues and learn to live with their illness. They gain increased knowledge about risk factors, how to eat properly/nutrition, exercise, medication, mental health, wound care, managing infection, and staying safe. They are getting direct and holistic information that would never be delivered in a group hospital rehab setting. Use of phone increases flexibility.” F, Nurse The educational benefits were echoed by the participants, most (10/12) expressed that the program encouraged them to learn about their health, maintain their learned healthy behaviours, and held them accountable and on track​ to achieve their health goals. “A good supportive program with accountability, practical instruction, and good educational input that really helps set the stage for recovery after heart surgery.” M, Qld “I benefited a great deal. I’m still doing the healthy activities I started on the program. A worthwhile program to do, rehab gets you ready to get back to normal life.” M, Qld “I enjoyed it. Very good. Encouraged me to exercise more even though I was doing a lot of exercise. I learned a lot about exercises, particularly upper body exercises. The app was a big problem, pretty poor with internet connection, so I didn’t really use it. A lot of men don’t worry about their health, and this helps men be more health conscious.” M, Vic Overall, the one-on-one personalised consultations, which were delivered via telehealth, and complemented by a mobile app and web-portal, supported the nurses to provide better patient centre care remotely. These core benefits were expressed by both the participants and their nurses. In general, there was a positive sentiment towards the program, which was well accepted by patients and their nurses. “An excellent program, gave me great ideas, lots of encouragement. I’m sorry that it ended.” M, WA “Anyone who undergoes any heart operation would benefit from it.” M, Qld Challenges The challenges centred around the digital components of the program. One patient was not happy with the program, they found the program too limited and gave it a 4 out of 10 rating. Some participants expressed difficulties with the mobile app’s connection, such as internet difficulties. ​Additionally, participants felt that the exercise component within the app was limited and could be expanded to a broader range of exercise recommendations. Two (2/12) participants did not like the app and provided negative feedback. A further two (2/12) participants felt that the app could be improved but they were not negative towards the app. However, others mentioned that they wanted to use the app for longer following program completion and found the app useful. The lack of face-to-face care was highlighted as a challenge for the nurses and made trust building challenging. “The main challenge is that it’s on the phone, you can’t see them face to face so you miss a lot of information. You can’t see how overweight they are, or smell whether they smoke. You can’t pick up nuances over the phone. And getting their trust is a challenge. Also making sure they are safe based only on their descriptions.” F, Nurse Administratively navigating the healthcare system was another challenge for the nurses. They found it difficult to source medical records and patient histories from health professionals, particularly general practitioners. “We often struggle to get medical information, health summary’s, pathology results in a timely manner or at all in some cases. Sometimes despite multiple requests the information is never received, thus making it hard to have a personalised and tailored conversation about their health. For example, when we discuss cholesterol, it is good to discuss actual readings pertaining to the member, not just have a general discussion and asking them to raise with their GP for further information.” F, Nurse Discussion This was one of the first national and entirely remotely delivered cardiac rehabilitation programs in Australia. Thus, early insights regarding patient and nurse experiences were necessary to understand the drivers for program acceptance and to identify new opportunities for service enhancements. The intervention in our study included nurse consultations that were complemented by a mobile app and nurse web-portal. These technologies enabled patient remote monitoring and self-management of CVD risk factors. We explored the perceptions and experiences of patients (and their treating nurses) and identified key benefits and challenges to a digitally enabled cardiac telerehabilitation program. Remote monitoring complemented with one-on-one telehealth delivered nurse consultations were key positive components of this model of care. Challenges centred around the digital aspects, particularly connectivity with the mobile application and internet connection. The COVID-19 pandemic placed considerable challenges to traditional, in-person, models of secondary prevention programs and resulted in the expansion of telehealth delivered cardiac rehabilitation ( 18 , 19 ). Technological advancement, coupled with extensive adoption by patients and providers in response to the COVID-19 pandemic ( 18 , 20 , 21 ), has created a strategic opportunity to enhance healthcare delivery. The results of this qualitative evaluation build upon the evidence base supporting consumer engagement and patient comfort with telehealth delivered models of care. However, our findings suggest that although digital delivery increases access to care, digital components should be balanced with clinician involvement. Patient and clinician preferences in our study suggests that clinician consultations should be integrated within a digitally enabled model of care, not replaced by digital modalities. It was clear that nurse consultations were the most important component of the model of care, despite there being no face-to-face element. This was expressed by both participants and clinicians and aligns with existing evidence demonstrating the effectiveness of human communication via telehealth models of care ( 22 ). Digital health technologies that support participants to communicate with their clinicians have a high probability of success ( 12 , 22 , 23 ). Personalised human health coaching with individualised feedback, promotes high rates of acceptance ( 24 ) and has driven successful outcomes in other digital health cardiac rehabilitation interventions ( 12 , 14 , 23 , 25 ). A common thread amongst previous successful telehealth studies is that they incorporated a certain degree of clinician involvement which fostered personalised connections to routine care ( 23 , 26 ). Likewise, a common theme throughout the interviews of this qualitative study was not only that there was nurse coaching, but the delivery of the consultations was personalised and one-on-one. This is unlike face to face delivered cardiac rehabilitation, which is typically delivered in a group setting. Remote monitoring capabilities were also a major benefit of the program. Participants liked that they could monitor their health metrics and valued that the nurses had access to their health information via the remote monitoring platform. Remote patient monitoring was also valued by the nurses, empowering them to tailor the coaching consultations based on the data driven needs of each patient. These perspectives have been echoed among clinicians in other areas of cardiology ( 27 ). Remote monitoring appears to keep patients motivated and accountable to their goals. These results align with recent systematic review evidence suggesting that effective programs need to include goal directed and personalised interventions that are delivered via remote clinician consultations, including telemonitoring ( 24 , 28 , 29 ). These factors may increase patient health literacy, accountability, and self-efficacy to better self-manage symptoms and lifestyle post discharge. Other digital health delivered cardiac rehabilitation programs, that incorporated remote monitoring, have shown high rates of participant acceptance and adherence ( 30 ). The results of our qualitative evaluation align with the quantitative evidence which suggests that cardiac rehabilitation programs with digital enablement enhance healthcare accessibility ( 18 , 30 , 31 ), demonstrate feasibility and garner favourable acceptance from patients ( 30 , 32 , 33 ). Further, the efficacy of these emerging models of care remain independent of the environment within which they are delivered (home-based, centre-based or phone delivered) ( 22 , 34 , 35 ). Thus, offering patients choice of the cardiac rehabilitation setting is beneficial. Digitally enabled cardiac telerehabilitation programs have high acceptance among patients, but they also come with challenges. Participants expressed difficulties with the mobile app’s connection, such as internet difficulties and nurses found that administratively navigating the healthcare system was a challenge. This echoes recent evidence where cardiac rehabilitation staff require more administration support ( 19 ). Technical challenges such as reliable broadband internet connectivity can impact acceptability and act as a barrier to digitally enabled telerehabilitation programs ( 18 , 24 ). As technology evolves and internet coverage expands, this challenge is likely to naturally dissipate. However, it is a current concern particularly for vulnerable and disadvantaged populations and care must be taken to avoid worsening health disparities ( 36 – 38 ). Models of care that leverage new digital technologies must consider the social determinants of health and potential inequities of access to digital health programs in certain populations. It is important to provide access for groups with low digital literacy and digital access ( 37 ). Referral to cardiac rehabilitation programs lacks equity, characterized by diminished referral rates among woman, minority cohorts, individuals of lower socioeconomic status, and those residing in remote and regional areas ( 39 – 41 ). This is concerning because some of these populations experience elevated rates of CVD and are further challenged by limited access to care ( 42 ). For example, patients from low socioeconomic backgrounds lack access to the infrastructure and technology required to access remotely delivered cardiac rehabilitation, including reliable broadband internet service and electronic devices ( 38 ). Barriers for older patients include age-related sensory changes (fine motor skill deficiencies, vision loss, hearing, arthritis) that impair their ability to interact with the software ( 43 ). They also lack confidence in their tech capability ( 43 ). Further, a higher proportion of older adults also live in remote and regional areas ( 44 ). These areas have worse technological infrastructure ( 45 ), compounding difficulties in accessing remotely delivered care for older populations. Therefore, further research is required to understand the drivers impacting access and uptake for vulnerable populations. Strengthening equitable access is important to ensure that new models of care cater to all. Recommendations for program enhancements This study highlighted practical opportunities to optimise the program. We recommended the following model of care enhancements; a) to include a 6-month follow-up appointment and b) to include hard copy resources for patients who find the mobile app challenging. Nurses recommended that “the 6–8 weeks is very intensive, and I wish members could stay on the program for 6–12 months for follow up. They would feel even more motivated knowing someone was following up on them.” This supports previous evidence, whereby patients found it challenging to maintain self-management strategies post program, suggesting a need to develop strategies that support cardiac patients over the longer-term ( 46 ). Further, our RCT which is currently in progress, Risk-Guided CAD, will continue into a phase 3 cardiac rehabilitation intervention up to 12-months post discharge. Furthermore, we recommended that the mobile application increase the breadth of exercise options. Digital health products require continual optimisation and innovation to meet the needs of patients and providers. The findings from our study were implemented by the program sponsor and digital provider, adding new translational insights that support the growing call for more real-world studies ( 13 , 23 ). Strengths and limitations This was a sub-study of a national observational research study of which the recommended enhancements to the program were translated into real-world practice. However, the study limitations should be noted. There is potential for recall bias when asking participants to recall events from their past. Additionally, all patients were privately insured, albeit with national representation. Conclusion This study identified the perceptions and experiences of patients, and their nurses enrolled in a digitally enabled cardiac telerehabilitation program. Our findings suggest that the intervention was well accepted by patients and their nurses. Remote monitoring in combination with personalised telehealth nurse consultations enhance patient-clinician communication and were key success factors in this model of care. Challenges with digital connectivity should be considered and addressed in future interventions. Further quantitative research is necessary to validate these findings. Abbreviations CR Cardiac rehabilitation CVD cardiovascular disease F2F face-to-face CAD coronary artery disease Declarations Ethics approval and consent to participate The study was approved by the Alfred Hospital Ethics Committee (Project Number: 321/21) and all participants provided consent to participate. Consent for publication Not applicable Competing Interests J.B. and C.K. are employed by the health insurer, Medibank. Funding Medibank provided funding to Monash University (T.T. and D.A.) to conduct the evaluation. J.B. receives a postgraduate research scholarship from The University of Melbourne and Baker Institute. M.J.C. receives an endowed fellowship in the Cardiology Centre of Excellence from Filippo and Maria Casella. Author Contribution J.B. and C.K. contributed to the conception of the project and study design. J.B. was the study project manager and led the study implementation. J.B. was responsible for study recruitment. Researchers T.T. and D.A. performed the interviews and analysis. J.B. contributed to the drafting of the manuscript. M.J.C., C.K., T.T., and D.A. revised the manuscript critically. All the authors gave approval and agree to be accountable for all aspects of the work. Acknowledgement The authors would like to thank the study nurses who were instrumental in the program. 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Digital Health Interventions for Cardiac Rehabilitation: Systematic Literature Review. JMIR. 2021;23(2):e18773. Huang K, Liu W, He D, Huang B, Xiao D, Peng Y, et al. Telehealth interventions versus center-based cardiac rehabilitation of coronary artery disease: A systematic review and meta-analysis. EJPC. 2015;22(8):959–71. Ramachandran HJ, Jiang Y, Tam WWS, Yeo TJ, Wang W. Effectiveness of home-based cardiac telerehabilitation as an alternative to Phase 2 cardiac rehabilitation of coronary heart disease: a systematic review and meta-analysis. EJPC. 2021;29(7):1017–43. Rathore S, Kumar B, Tehrani S, Khanra D, Duggal B, Chandra Pant D. Cardiac rehabilitation: Appraisal of current evidence and utility of technology aided home-based cardiac rehabilitation. IHJ. 2020;72(6):491–9. Arcaya MC, Figueroa JF. Emerging Trends Could Exacerbate Health Inequities In The United States. Health Aff (Millwood). 2017;36(6):992–8. Hernandez MF, Rodriguez F. Health Techequity: Opportunities for Digital Health Innovations to Improve Equity and Diversity in Cardiovascular Care. Curr Cardiovasc Risk Rep. 2023;17(1):1–20. Li S, Fonarow GC, Mukamal K, Xu H, Matsouaka RA, Devore AD, et al. Sex and Racial Disparities in Cardiac Rehabilitation Referral at Hospital Discharge and Gaps in Long-Term Mortality. JAHA. 2018;7(8):e008088. Kotseva K, Wood D, De Bacquer D, investigators oboE. Determinants of participation and risk factor control according to attendance in cardiac rehabilitation programmes in coronary patients in Europe: EUROASPIRE IV survey. EJPC. 2020;25(12):1242–51. Chindhy S, Taub PR, Lavie CJ, Shen J. Current challenges in cardiac rehabilitation: strategies to overcome social factors and attendance barriers. Expert Rev. Cardiovasc. Ther. 2020;18(11):777–89. Australian Institute of Health and Welfare. Australia's health 2018. Canberra: AIHW; 2018. doi: 10.25816/5ec1e56f25480 . Bostrom J, Sweeney, G., Whiteson, J., Dodson, J.A. Mobile health and cardiac rehabilitation in older adults. Clin. Cardiol. 2020;43:118–26. Australian Institute of Health and Welfare. Older Australians [Internet]. Canberra: Australian Institute of Health and Welfare, 2024 [cited 2024 Oct. 3]. Available from: https://www.aihw.gov.au/reports/older-people/older-australians Authority ACaM. Communications and media in Australia Series: How we use the internet ACMA; 2022. Available from: https://www.acma.gov.au/publications/2023-12/report/communications-and-media-australia-how-we-use-internet Fletcher SM, Burley MB, Thomas KE, Mitchell EKL. Feeling Supported and Abandoned: mixed messages from attendance at a rural community cardiac rehabilitation program in australia. JCRP. 2014;34(1). Additional Declarations Competing interest reported. J.B. and C.K. are employed by the health insurer, Medibank. Supplementary Files SupplementarymaterialBMCDigitalHealth.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 22 Oct, 2024 Reviews received at journal 20 Oct, 2024 Reviews received at journal 18 Oct, 2024 Reviewers agreed at journal 10 Oct, 2024 Reviewers agreed at journal 10 Oct, 2024 Reviewers invited by journal 10 Oct, 2024 Editor invited by journal 07 Oct, 2024 Editor assigned by journal 04 Oct, 2024 Submission checks completed at journal 04 Oct, 2024 First submitted to journal 02 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5194531","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":371670308,"identity":"297f6504-b574-4079-aa3d-b0e6ab7fbde1","order_by":0,"name":"Justin Braver","email":"data:image/png;base64,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","orcid":"","institution":"The University of Melbourne","correspondingAuthor":true,"prefix":"","firstName":"Justin","middleName":"","lastName":"Braver","suffix":""},{"id":371670309,"identity":"f3dded71-d159-400c-882c-0c6904035e5a","order_by":1,"name":"Tess Tsindos","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Tess","middleName":"","lastName":"Tsindos","suffix":""},{"id":371670310,"identity":"83e3d7dd-ecc4-42f9-ae23-bcde94cb81af","order_by":2,"name":"Melinda J Carrington","email":"","orcid":"","institution":"Baker Heart and Diabetes Institute","correspondingAuthor":false,"prefix":"","firstName":"Melinda","middleName":"J","lastName":"Carrington","suffix":""},{"id":371670311,"identity":"cee5d58e-332d-4764-b224-6bacbaf5f72a","order_by":3,"name":"Catherine Keating","email":"","orcid":"","institution":"Medibank","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"","lastName":"Keating","suffix":""},{"id":371670312,"identity":"2d2ba3fd-5652-44bf-af1f-ce8b17fa5aca","order_by":4,"name":"Darshini Ayton","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Darshini","middleName":"","lastName":"Ayton","suffix":""}],"badges":[],"createdAt":"2024-10-02 18:38:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5194531/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5194531/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":68725951,"identity":"5608c9e5-0f9f-486e-b145-0f200b23a32c","added_by":"auto","created_at":"2024-11-11 11:34:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":54985,"visible":true,"origin":"","legend":"\u003cp\u003eModel of care\u003c/p\u003e","description":"","filename":"Figure1modelofcareBMCDigitalHealth.png","url":"https://assets-eu.researchsquare.com/files/rs-5194531/v1/354b3d216d862a6b86079256.png"},{"id":68727159,"identity":"2f55d14e-b261-45ce-8875-94455edb940d","added_by":"auto","created_at":"2024-11-11 11:42:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":531168,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5194531/v1/6fd903ca-95a0-4e2e-953e-1046a17c01fe.pdf"},{"id":68725953,"identity":"d3bc532c-6fdc-4748-aff3-0abca847a2ba","added_by":"auto","created_at":"2024-11-11 11:34:07","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":25538,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementarymaterialBMCDigitalHealth.docx","url":"https://assets-eu.researchsquare.com/files/rs-5194531/v1/e1facd3cb47e3b37b8e7b994.docx"}],"financialInterests":"Competing interest reported. J.B. and C.K. are employed by the health insurer, Medibank.","formattedTitle":"Patients’ and nurses’ perceptions and experiences of a digitally enabled cardiac telerehabilitation program - a qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eCardiac rehabilitation (CR) is a multidisciplinary, coordinated healthcare program, supporting patients to manage the risk factors for cardiovascular disease (CVD) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It includes clinician consultations, medication management, health education, psychological support, exercise classes, goal setting and self-management strategies to maintain a healthy lifestyle. These programs have shown effectiveness by enhancing quality of life, reducing rehospitalization occurrences and mitigating mortality (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Thus, after experiencing a cardiac event, guidelines strongly advocate for patients to attend a secondary prevention cardiac rehabilitation program (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, attendance to traditional centre-based cardiac rehabilitation programs is low, with nearly nine out of ten Australians and three in four Americans who suffer a cardiac event not attending a cardiac rehabilitation program (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Traditional face-to-face (F2F) cardiac rehabilitation programs, that have been in existence for over fifty years (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), encounter barriers that impede accessibility, including system level barriers (resource constraints and scarcity of available programs) and patient factors (time constraints, geographical location, transportation and parking) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Consequently, traditional programs remain largely inaccessible resulting in adverse health outcomes (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealth services facilitated by technology present a novel prospect in healthcare delivery, dismantling access barriers and enabling clinicians to remotely monitor, track and communicate with their patients in real-time or asynchronously from a distance (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The core components of a traditional centre-based cardiac rehabilitation program can be delivered via a digitally delivered model, using technologies such as telehealth, remote monitoring and mobile apps (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). These digitally delivered models are also proving to be effective, showing reductions in readmissions and emergency department visits(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, participation rates remain stubbornly low (41%) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), despite the fact that remotely delivered programs aim to increase access and uptake to secondary prevention care (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Therefore, greater understanding about patients\u0026rsquo; experiences and perceptions (and their treating providers) of participating in a digitally enabled cardiac telerehabilitation program is required to ascertain the drivers for program acceptance.\u003c/p\u003e\n\u003ch3\u003eAims\u003c/h3\u003e\n\u003cp\u003eThis study aimed to explore the perceptions and experiences of patients, and their cardiac nurses, enrolled in a nationally delivered, digitally enabled cardiac telerehabilitation program (called \u003cem\u003eHeart Health at Home\u003c/em\u003e). The objectives were to examine the positive and negative perspectives of the program, explore views about the benefits and challenges and to identify improvements and service enhancements.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003ch2\u003eDesign\u003c/h2\u003e\u003cp\u003eThis was a qualitative sub-study of a larger observational real-world propensity matched clinical trial, called \u003cem\u003eHeart Health at Home\u003c/em\u003e (Clinical trial number: \u003cem\u003enot applicable\u003c/em\u003e). The results of this study also informed the design and implementation of the Risk-Guided CAD randomized controlled trial (RCT), currently in progress (ClinicalTrials.gov: NCT04966117). The study was approved by the Alfred Hospital Ethics Committee (Project Number: 321/21).\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThe Heart Health at Home intervention was delivered over eight weeks and included six weekly one-on-one telehealth consultations with a cardiac nurse (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Nurses delivered the core components of phase two cardiac rehabilitation (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This included nutritional counselling, behaviour change for a healthier lifestyle, psychosocial management and physical activity counselling, delivered via the following modalities:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTelehealth \u0026ndash; cardiac nurse telephone coaching to provide patient education and risk factor management, including patient assessments and personalised care plan development.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMobile application and nurse web portal \u0026ndash; supported by the SmartCR mobile application and accompanying clinician web portal (Cardihab\u0026reg;, Queensland, Aus). The SmartCR app provided health metrics tracking (such as blood pressure), exercise monitoring, medication management and delivered motivational and educational materials to patients via prompted tasks and links to audio, written articles and video files.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eEach participant received an Omron HEM-7121 (Omron Healthcare Co. Lts, Kyoto, Japan) blood pressure device at the commencement of the program, enabling daily blood pressure monitoring and recording within the mobile app.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eRecruitment\u003c/h3\u003e\n\u003cp\u003ePatients were recruited nationally into the study within 30-days of a cardiac admission. Patients were identified via hospital pre-admission data as well as cardiac hospital claims data and were contacted via phone to ascertain their interest to enrol. Patients could also self-nominate to participate, or their treating health professional could refer them into the program. A representative sample of participants from across Australia, who had completed the intervention, were invited to participate. Two cardiac nurses, who delivered the intervention, were also recruited and interviewed. These nurses were experienced cardiac nurses with over a decade of experience working in cardiac rehabilitation. This was their first experience in delivering an entirely telehealth model of care with no face-to-face involvement.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eA semi-structured interview guide was developed (Supplementary Material 1). Semi-structured telephone interviews (range of interview durations 12\u0026ndash;60min) were conducted by an experienced qualitative researcher (TT or DA). All participants provided consent to participate. Face to face interviews were not considered feasible for this study, given the geographical spread of our study participants and the remote mode of delivery of the program.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eWe transcribed the interview data verbatim (for both participants and nurses) and uploaded it into Microsoft Excel. Content analysis was conducted to deductively categorise participant perceptions about the program into positive, neutral or negative. The transcripts were then reviewed inductively to code for program benefits, challenges and recommendations. Any discrepancies were resolved by discussion and consultation between the investigators as required.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e Of 52​ participants who had completed the intervention (n\u0026thinsp;=\u0026thinsp;40 males and n\u0026thinsp;=\u0026thinsp;12 females), we were able to reach and contact 12 participants, who subsequently consented to participate in the semi-structured telephone interviews. The majority were male (n\u0026thinsp;=\u0026thinsp;9 males and n\u0026thinsp;=\u0026thinsp;3 females). Participants were represented from across Australia reflecting the demographic distribution of the entire cohort and resided in Victoria (n\u0026thinsp;=\u0026thinsp;4), Western Australia (n\u0026thinsp;=\u0026thinsp;1), Queensland (n\u0026thinsp;=\u0026thinsp;4), ACT (n\u0026thinsp;=\u0026thinsp;1), Tasmania (n\u0026thinsp;=\u0026thinsp;1) and New South Wales (n\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e\n\u003ch3\u003eKnowledge of cardiac rehabilitation and referral\u003c/h3\u003e\n\u003cp\u003eThis cohort was not aware of cardiac rehabilitation and its benefits prior to the commencement of the digitally enabled cardiac telerehabilitation program. Half of all participants (n\u0026thinsp;=\u0026thinsp;6) said that they were not referred to a cardiac rehabilitation program by their cardiologist or hospital and half (n\u0026thinsp;=\u0026thinsp;6) mentioned that they did not know about cardiac rehabilitation prior to surgery. When asked if they felt that they needed to do a cardiac rehabilitation program after surgery, one in three (n\u0026thinsp;=\u0026thinsp;4) said they did not feel the need for cardiac rehabilitation. The most common reason was due to feeling \u0026ldquo;\u003cem\u003ealready healthy\u0026rdquo;, \u0026ldquo;surgery fixed things\u0026rdquo; and their \u0026ldquo;cardiologist did not recommend it\u0026rdquo;.\u003c/em\u003e However, half of the participants (n\u0026thinsp;=\u0026thinsp;6) said that they needed to do cardiac rehabilitation to regain strength and get extra help.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eUser experiences and perceptions\u003c/h2\u003e \u003cp\u003eKey themes and words used to describe the program positively, neutrally and negatively are highlighted in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults from patient interviews: Perceptions, Themes, and Descriptive words\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e Perceptions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDescriptive words\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; The program was helpful, keeping patients focussed​ on achieving their health goals.\u003c/p\u003e \u003cp\u003e​\u003c/p\u003e \u003cp\u003e\u0026bull; The nurses were friendly, helpful, supportive and encouraging​.\u003c/p\u003e \u003cp\u003e\u0026bull; Patients reiterated that they learned from the program, it improved their health literacy.\u003c/p\u003e \u003cp\u003e\u0026bull; Program was good for recording and monitoring health habits.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood idea\u003c/p\u003e \u003cp\u003eLearned a lot​\u003c/p\u003e \u003cp\u003eAchieved goals\u003c/p\u003e \u003cp\u003eCoaching ​\u003c/p\u003e \u003cp\u003eSupportive\u003c/p\u003e \u003cp\u003eHelpful ​\u003c/p\u003e \u003cp\u003ePositive\u003c/p\u003e \u003cp\u003eReassuring​\u003c/p\u003e \u003cp\u003ePractical\u003c/p\u003e \u003cp\u003eEnjoyable​\u003c/p\u003e \u003cp\u003eBeneficial\u003c/p\u003e \u003cp\u003eEncouraging​\u003c/p\u003e \u003cp\u003eFriendly\u003c/p\u003e \u003cp\u003eGood​\u003c/p\u003e \u003cp\u003eCompassionate\u003c/p\u003e \u003cp\u003eHappy​\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Patients who felt well post discharge saw the program as less relevant for them.\u003c/p\u003e \u003cp\u003e\u0026bull; Patients described the program as a way to monitor health and regain abilities.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDirect​\u003c/p\u003e \u003cp\u003eMonitoring ​\u003c/p\u003e \u003cp\u003eLaymen\u0026rsquo;s terms​\u003c/p\u003e \u003cp\u003eNo problems ​\u003c/p\u003e \u003cp\u003eNon-judgemental\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Internet connection issues​ made some patients frustrated.\u003c/p\u003e \u003cp\u003e\u0026bull; Some patients expressed that app had a few bugs that needed to be fixed.\u003c/p\u003e \u003cp\u003e\u0026bull; The app was complex for some, with suggestions that it needs to be simplified.​\u003c/p\u003e \u003cp\u003e\u0026bull; The app reminders were annoying​ for some patients.\u003c/p\u003e \u003cp\u003e\u0026bull; Patients wanted to use the app for longer following program completion.\u003c/p\u003e \u003cp\u003e\u0026bull; The scope of the program was too limited for some, and a wider range of exercises was suggested to be added. ​\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnnoyed​\u003c/p\u003e \u003cp\u003eFrustrated​\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eBenefits\u003c/h2\u003e \u003cp\u003eAlmost all participants (11/12) mentioned that they benefited from the program, pointing out that they can \u0026ldquo;\u003cem\u003enow exercise more\u003c/em\u003e\u0026rdquo; and are \u0026ldquo;\u003cem\u003emotivated to get out and walk\u003c/em\u003e\u0026rdquo;. They expressed that they needed this program to \u0026ldquo;\u003cem\u003eregain strength and get back to pre-cardiac event abilities\u003c/em\u003e\u0026rdquo;. Overall, participants rated the program an 8 out of 10.\u003c/p\u003e \u003cp\u003eThe benefits of the program were expressed as supportive, educational and motivational. The most supportive elements were the one-on-one personalised nurse telehealth consultations. All participants (12/12) mentioned that they benefited from talking to the nurses.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I liked the support and counselling from the nurses. I could talk things over with the nurse instead of going in to see doctors all the time...The nurses advised me how to do things \u0026ndash; I wasn\u0026rsquo;t their very best patient, but I tried. It kept me focussed.\u0026rdquo; F, Qld\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants valued the care provided by the nurses, mentioning that it was nice to know that someone cares about them.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When you\u0026rsquo;ve had trouble with your ticker and you get to my age, it\u0026rsquo;s nice that people are interested and you\u0026rsquo;re not just a number. It was nice to be worried about.\u0026rdquo; M, Vic\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilarly, the nurses mentioned that the telehealth counselling and coaching was the most important component of the program. The nurses revealed that despite the fact the entire model of care was delivered remotely, the personalised consultations were a value add that enabled greater patient centred care compared to face to face cardiac rehabilitation, which is typically delivered in a group setting.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Members are getting a half hour of direct information that I\u0026rsquo;d never be able to deliver in the hospital system. They\u0026rsquo;re getting much more direct one-on-one time even though its over the phone.\u0026rdquo; F, Nurse\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe clinician web portal provided the nurses with additional medical knowledge about each patient and empowered them to deliver patient centred and data driven consultations that were tailored to the specific needs of each patient. The nurses reiterated that the individualised, tailored care plan was another value add, over and above group-based face to face cardiac rehabilitation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The program is tailored to the person and what works for them, and this depends on their age, whether they are working or retired, their background.\u0026rdquo; F, Nurse\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Lots of different people have done the program and success depends on what works for the individual person, what their priorities are.\u0026rdquo; F, Nurse\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilarly, the monitoring capabilities were also a core benefit of the program. Nearly half (5/12) of all participants liked that they could monitor their health metrics and valued that the nurses had access to their health information via the remote monitoring functionality of the program. This aspect kept participants motivated and held them accountable to their health goals. The monitoring also empowered participants during their primary care visits with their physicians, as it allowed them to show their progress over time.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I benefitted from being held accountable to take meds on time, monitor blood pressure, walk, etc, and from the encouragement, particularly around walking more. It was helpful/valuable being held accountable.\u0026rdquo; M, Qld\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I learned a lot about healthy eating, walking and other things. It was a very good learning experience. I\u0026rsquo;m definitely an advocate for the program. Setting small goals and achieving them. I need less doctor visits now.\u0026rdquo; M, Vic\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEducation and health literacy were another benefit and were highly valued as core components of the program. This model of care supported cardiac education, which was tailored to the risk factors of each patient. The nurses highlighted that the program assisted participants to return to pre-cardiac function and supported them to manage and view cardiovascular disease as a long-term chronic condition, thus allowing them to learn to live with their illness​ and manage their illness in a sustainable way. Moreover, the telehealth delivery increased convenience and flexibility for both participants and the nurses, improving patient and provider experience.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Members benefit from increased knowledge about cardiac issues and learn to live with their illness. They gain increased knowledge about risk factors, how to eat properly/nutrition, exercise, medication, mental health, wound care, managing infection, and staying safe. They are getting direct and holistic information that would never be delivered in a group hospital rehab setting. Use of phone increases flexibility.\u0026rdquo; F, Nurse\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe educational benefits were echoed by the participants, most (10/12) expressed that the program encouraged them to learn about their health, maintain their learned healthy behaviours, and held them accountable and on track​ to achieve their health goals.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;A good supportive program with accountability, practical instruction, and good educational input that really helps set the stage for recovery after heart surgery.\u0026rdquo; M, Qld\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I benefited a great deal. I\u0026rsquo;m still doing the healthy activities I started on the program. A worthwhile program to do, rehab gets you ready to get back to normal life.\u0026rdquo; M, Qld\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I enjoyed it. Very good. Encouraged me to exercise more even though I was doing a lot of exercise. I learned a lot about exercises, particularly upper body exercises. The app was a big problem, pretty poor with internet connection, so I didn\u0026rsquo;t really use it. A lot of men don\u0026rsquo;t worry about their health, and this helps men be more health conscious.\u0026rdquo; M, Vic\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOverall, the one-on-one personalised consultations, which were delivered via telehealth, and complemented by a mobile app and web-portal, supported the nurses to provide better patient centre care remotely. These core benefits were expressed by both the participants and their nurses. In general, there was a positive sentiment towards the program, which was well accepted by patients and their nurses.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;An excellent program, gave me great ideas, lots of encouragement. I\u0026rsquo;m sorry that it ended.\u0026rdquo; M, WA\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Anyone who undergoes any heart operation would benefit from it.\u0026rdquo; M, Qld\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eChallenges\u003c/h2\u003e \u003cp\u003eThe challenges centred around the digital components of the program. One patient was not happy with the program, they found the program too limited and gave it a 4 out of 10 rating. Some participants expressed difficulties with the mobile app\u0026rsquo;s connection, such as internet difficulties. ​Additionally, participants felt that the exercise component within the app was limited and could be expanded to a broader range of exercise recommendations. Two (2/12) participants did not like the app and provided negative feedback. A further two (2/12) participants felt that the app could be improved but they were not negative towards the app. However, others mentioned that they wanted to use the app for longer following program completion and found the app useful.\u003c/p\u003e \u003cp\u003eThe lack of face-to-face care was highlighted as a challenge for the nurses and made trust building challenging.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The main challenge is that it\u0026rsquo;s on the phone, you can\u0026rsquo;t see them face to face so you miss a lot of information. You can\u0026rsquo;t see how overweight they are, or smell whether they smoke. You can\u0026rsquo;t pick up nuances over the phone. And getting their trust is a challenge. Also making sure they are safe based only on their descriptions.\u0026rdquo; F, Nurse\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdministratively navigating the healthcare system was another challenge for the nurses. They found it difficult to source medical records and patient histories from health professionals, particularly general practitioners.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We often struggle to get medical information, health summary\u0026rsquo;s, pathology results in a timely manner or at all in some cases. Sometimes despite multiple requests the information is never received, thus making it hard to have a personalised and tailored conversation about their health. For example, when we discuss cholesterol, it is good to discuss actual readings pertaining to the member, not just have a general discussion and asking them to raise with their GP for further information.\u0026rdquo; F, Nurse\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis was one of the first national and entirely remotely delivered cardiac rehabilitation programs in Australia. Thus, early insights regarding patient and nurse experiences were necessary to understand the drivers for program acceptance and to identify new opportunities for service enhancements. The intervention in our study included nurse consultations that were complemented by a mobile app and nurse web-portal. These technologies enabled patient remote monitoring and self-management of CVD risk factors. We explored the perceptions and experiences of patients (and their treating nurses) and identified key benefits and challenges to a digitally enabled cardiac telerehabilitation program. Remote monitoring complemented with one-on-one telehealth delivered nurse consultations were key positive components of this model of care. Challenges centred around the digital aspects, particularly connectivity with the mobile application and internet connection.\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic placed considerable challenges to traditional, in-person, models of secondary prevention programs and resulted in the expansion of telehealth delivered cardiac rehabilitation (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Technological advancement, coupled with extensive adoption by patients and providers in response to the COVID-19 pandemic (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), has created a strategic opportunity to enhance healthcare delivery. The results of this qualitative evaluation build upon the evidence base supporting consumer engagement and patient comfort with telehealth delivered models of care. However, our findings suggest that although digital delivery increases access to care, digital components should be balanced with clinician involvement. Patient and clinician preferences in our study suggests that clinician consultations should be integrated within a digitally enabled model of care, not replaced by digital modalities.\u003c/p\u003e \u003cp\u003eIt was clear that nurse consultations were the most important component of the model of care, despite there being no face-to-face element. This was expressed by both participants and clinicians and aligns with existing evidence demonstrating the effectiveness of human communication via telehealth models of care (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Digital health technologies that support participants to communicate with their clinicians have a high probability of success (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Personalised human health coaching with individualised feedback, promotes high rates of acceptance (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) and has driven successful outcomes in other digital health cardiac rehabilitation interventions (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). A common thread amongst previous successful telehealth studies is that they incorporated a certain degree of clinician involvement which fostered personalised connections to routine care (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Likewise, a common theme throughout the interviews of this qualitative study was not only that there was nurse coaching, but the delivery of the consultations was personalised and one-on-one. This is unlike face to face delivered cardiac rehabilitation, which is typically delivered in a group setting.\u003c/p\u003e \u003cp\u003eRemote monitoring capabilities were also a major benefit of the program. Participants liked that they could monitor their health metrics and valued that the nurses had access to their health information via the remote monitoring platform. Remote patient monitoring was also valued by the nurses, empowering them to tailor the coaching consultations based on the data driven needs of each patient. These perspectives have been echoed among clinicians in other areas of cardiology (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Remote monitoring appears to keep patients motivated and accountable to their goals. These results align with recent systematic review evidence suggesting that effective programs need to include goal directed and personalised interventions that are delivered via remote clinician consultations, including telemonitoring (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). These factors may increase patient health literacy, accountability, and self-efficacy to better self-manage symptoms and lifestyle post discharge. Other digital health delivered cardiac rehabilitation programs, that incorporated remote monitoring, have shown high rates of participant acceptance and adherence (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe results of our qualitative evaluation align with the quantitative evidence which suggests that cardiac rehabilitation programs with digital enablement enhance healthcare accessibility (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), demonstrate feasibility and garner favourable acceptance from patients (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Further, the efficacy of these emerging models of care remain independent of the environment within which they are delivered (home-based, centre-based or phone delivered) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Thus, offering patients choice of the cardiac rehabilitation setting is beneficial.\u003c/p\u003e \u003cp\u003eDigitally enabled cardiac telerehabilitation programs have high acceptance among patients, but they also come with challenges. Participants expressed difficulties with the mobile app\u0026rsquo;s connection, such as internet difficulties and nurses found that administratively navigating the healthcare system was a challenge. This echoes recent evidence where cardiac rehabilitation staff require more administration support (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Technical challenges such as reliable broadband internet connectivity can impact acceptability and act as a barrier to digitally enabled telerehabilitation programs (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). As technology evolves and internet coverage expands, this challenge is likely to naturally dissipate. However, it is a current concern particularly for vulnerable and disadvantaged populations and care must be taken to avoid worsening health disparities (\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eModels of care that leverage new digital technologies must consider the social determinants of health and potential inequities of access to digital health programs in certain populations. It is important to provide access for groups with low digital literacy and digital access (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Referral to cardiac rehabilitation programs lacks equity, characterized by diminished referral rates among woman, minority cohorts, individuals of lower socioeconomic status, and those residing in remote and regional areas (\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). This is concerning because some of these populations experience elevated rates of CVD and are further challenged by limited access to care (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). For example, patients from low socioeconomic backgrounds lack access to the infrastructure and technology required to access remotely delivered cardiac rehabilitation, including reliable broadband internet service and electronic devices (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Barriers for older patients include age-related sensory changes (fine motor skill deficiencies, vision loss, hearing, arthritis) that impair their ability to interact with the software (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). They also lack confidence in their tech capability (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Further, a higher proportion of older adults also live in remote and regional areas (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). These areas have worse technological infrastructure (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), compounding difficulties in accessing remotely delivered care for older populations. Therefore, further research is required to understand the drivers impacting access and uptake for vulnerable populations. Strengthening equitable access is important to ensure that new models of care cater to all.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for program enhancements\u003c/h2\u003e \u003cp\u003eThis study highlighted practical opportunities to optimise the program. We recommended the following model of care enhancements; a) to include a 6-month follow-up appointment and b) to include hard copy resources for patients who find the mobile app challenging. Nurses recommended that \u003cem\u003e\u0026ldquo;the 6\u0026ndash;8 weeks is very intensive, and I wish members could stay on the program for 6\u0026ndash;12 months for follow up. They would feel even more motivated knowing someone was following up on them.\u0026rdquo;\u003c/em\u003e This supports previous evidence, whereby patients found it challenging to maintain self-management strategies post program, suggesting a need to develop strategies that support cardiac patients over the longer-term (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Further, our RCT which is currently in progress, Risk-Guided CAD, will continue into a phase 3 cardiac rehabilitation intervention up to 12-months post discharge. Furthermore, we recommended that the mobile application increase the breadth of exercise options. Digital health products require continual optimisation and innovation to meet the needs of patients and providers. The findings from our study were implemented by the program sponsor and digital provider, adding new translational insights that support the growing call for more real-world studies (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis was a sub-study of a national observational research study of which the recommended enhancements to the program were translated into real-world practice. However, the study limitations should be noted. There is potential for recall bias when asking participants to recall events from their past. Additionally, all patients were privately insured, albeit with national representation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study identified the perceptions and experiences of patients, and their nurses enrolled in a digitally enabled cardiac telerehabilitation program. Our findings suggest that the intervention was well accepted by patients and their nurses. Remote monitoring in combination with personalised telehealth nurse consultations enhance patient-clinician communication and were key success factors in this model of care. Challenges with digital connectivity should be considered and addressed in future interventions. Further quantitative research is necessary to validate these findings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCardiac rehabilitation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecardiovascular disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eF2F\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eface-to-face\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecoronary artery disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e The study was approved by the Alfred Hospital Ethics Committee (Project Number: 321/21) and all participants provided consent to participate.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eJ.B. and C.K. are employed by the health insurer, Medibank.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eMedibank provided funding to Monash University (T.T. and D.A.) to conduct the evaluation. J.B. receives a postgraduate research scholarship from The University of Melbourne and Baker Institute. M.J.C. receives an endowed fellowship in the Cardiology Centre of Excellence from Filippo and Maria Casella.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJ.B. and C.K. contributed to the conception of the project and study design. J.B. was the study project manager and led the study implementation. J.B. was responsible for study recruitment. Researchers T.T. and D.A. performed the interviews and analysis. J.B. contributed to the drafting of the manuscript. M.J.C., C.K., T.T., and D.A. revised the manuscript critically. All the authors gave approval and agree to be accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank the study nurses who were instrumental in the program. The authors would also like to thank Professor Thomas Marwick for his support with the manuscript\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe analysed transcripts are stored but not publicly accessible to safeguard confidentiality. Upon reasonable request, de-identified data may be available from the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBeatty AL, Beckie TM, Dodson J, Goldstein CM, Hughes JW, Kraus WE, et al. A New Era in Cardiac Rehabilitation Delivery: Research Gaps, Questions, Strategies, and Priorities. Circ. 2023;147(3):254\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Vries H, Kemps HM, van Engen-Verheul MM, Kraaijenhagen RA, Peek N. Cardiac rehabilitation and survival in a large representative community cohort of Dutch patients. 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EHJDH. 2023;5(1):21\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCartledge S, Thomas EE, Murphy B, Abell B, Verdicchio C, Zecchin R, et al. Impact of Early COVID-19 Waves on Cardiac Rehabilitation Delivery in Australia: A National Survey. Heart, Lung and Circ. 2023;32(3):353\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssociation AAM. AMA Digital Health Research: Physicians\u0026rsquo; Motivations and Key Requirements for Adopting Digital Health: Adoption and attitudinal shifts from 2016 to 2022. Chicago (IL): American Medical Association; 2022 Sep.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAustralia\u0026rsquo;s health reimagined: The journey to a connected and confident consumer [Internet]. Sydney (AU): Deloitte; 2022 [cited 2024 Oct 2]. 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EHJDH. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSubedi N, Rawstorn JC, Gao L, Koorts H, Maddison R. Implementation of Telerehabilitation Interventions for the Self-Management of Cardiovascular Disease: Systematic Review. JMIR Mhealth Uhealth. 2020;8(11):e17957.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKenny E, Coyne R, McEvoy JW, McSharry J, Taylor RS, Byrne M. Behaviour change techniques and intervention characteristics in digital cardiac rehabilitation: a systematic review and meta-analysis of randomised controlled trials. Health Psych Rev. 2024;18(1):189\u0026ndash;228.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang WE, Shah LM, Spaulding EM, Wang J, Xun H, Weng D, et al. The role of a clinician amid the rise of mobile health technology. JAMIA. 2019;26(11):1385\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTreskes RW, Wildbergh TX, Schalij MJ, Scherptong RWC. 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BMC Cardiovasc Disord. 2018;18(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSubedi N, Rawstorn JC, Gao L, Koorts H, Maddison R. Implementation of Telerehabilitation Interventions for the Self-Management of Cardiovascular Disease: Systematic Review. JMIR mHealth and uHealth. 2020;8(11):e17957.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkinosun AS, Polson R, Diaz - Skeete Y, De Kock JH, Carragher L, Leslie S, et al. Digital Technology Interventions for Risk Factor Modification in Patients With Cardiovascular Disease: Systematic Review and Meta-analysis. JMIR mHealth and uHealth. 2021;9(3):e21061.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWongvibulsin S, Habeos EE, Huynh PP, Xun H, Shan R, Porosnicu Rodriguez KA, et al. Digital Health Interventions for Cardiac Rehabilitation: Systematic Literature Review. JMIR. 2021;23(2):e18773.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang K, Liu W, He D, Huang B, Xiao D, Peng Y, et al. Telehealth interventions versus center-based cardiac rehabilitation of coronary artery disease: A systematic review and meta-analysis. EJPC. 2015;22(8):959\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamachandran HJ, Jiang Y, Tam WWS, Yeo TJ, Wang W. Effectiveness of home-based cardiac telerehabilitation as an alternative to Phase 2 cardiac rehabilitation of coronary heart disease: a systematic review and meta-analysis. EJPC. 2021;29(7):1017\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRathore S, Kumar B, Tehrani S, Khanra D, Duggal B, Chandra Pant D. Cardiac rehabilitation: Appraisal of current evidence and utility of technology aided home-based cardiac rehabilitation. IHJ. 2020;72(6):491\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArcaya MC, Figueroa JF. Emerging Trends Could Exacerbate Health Inequities In The United States. Health Aff (Millwood). 2017;36(6):992\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHernandez MF, Rodriguez F. Health Techequity: Opportunities for Digital Health Innovations to Improve Equity and Diversity in Cardiovascular Care. Curr Cardiovasc Risk Rep. 2023;17(1):1\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi S, Fonarow GC, Mukamal K, Xu H, Matsouaka RA, Devore AD, et al. Sex and Racial Disparities in Cardiac Rehabilitation Referral at Hospital Discharge and Gaps in Long-Term Mortality. JAHA. 2018;7(8):e008088.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKotseva K, Wood D, De Bacquer D, investigators oboE. Determinants of participation and risk factor control according to attendance in cardiac rehabilitation programmes in coronary patients in Europe: EUROASPIRE IV survey. EJPC. 2020;25(12):1242\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChindhy S, Taub PR, Lavie CJ, Shen J. Current challenges in cardiac rehabilitation: strategies to overcome social factors and attendance barriers. Expert Rev. Cardiovasc. Ther. 2020;18(11):777\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAustralian Institute of Health and Welfare. Australia's health 2018. Canberra: AIHW; 2018. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.25816/5ec1e56f25480\u003c/span\u003e\u003cspan address=\"10.25816/5ec1e56f25480\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBostrom J, Sweeney, G., Whiteson, J., Dodson, J.A. Mobile health and cardiac rehabilitation in older adults. Clin. Cardiol. 2020;43:118\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAustralian Institute of Health and Welfare. Older Australians [Internet]. Canberra: Australian Institute of Health and Welfare, 2024 [cited 2024 Oct. 3]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.aihw.gov.au/reports/older-people/older-australians\u003c/span\u003e\u003cspan address=\"https://www.aihw.gov.au/reports/older-people/older-australians\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAuthority ACaM. Communications and media in Australia Series: How we use the internet ACMA; 2022. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.acma.gov.au/publications/2023-12/report/communications-and-media-australia-how-we-use-internet\u003c/span\u003e\u003cspan address=\"https://www.acma.gov.au/publications/2023-12/report/communications-and-media-australia-how-we-use-internet\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFletcher SM, Burley MB, Thomas KE, Mitchell EKL. Feeling Supported and Abandoned: mixed messages from attendance at a rural community cardiac rehabilitation program in australia. JCRP. 2014;34(1).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-digital-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Digital Health](https://bmcdigitalhealth.biomedcentral.com/)","snPcode":"44247","submissionUrl":"https://submission.nature.com/new-submission/44247/3","title":"BMC Digital Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Digital health, telerehabilitation, cardiac rehabilitation, coronary artery disease, health technology","lastPublishedDoi":"10.21203/rs.3.rs-5194531/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5194531/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground. \u003c/strong\u003eSecondary prevention cardiac rehabilitation programs are paramount to prevent cardiovascular disease morbidity and mortality. However, they remain underutilized. Digital health programs provide an opportunity for healthcare delivery by breaking down access barriers. However, evidence for their implementation is lacking. Further evidence to ascertain the drivers for uptake and acceptance of digitally enabled cardiac telerehabilitation programs is required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims. \u003c/strong\u003eTo explore the perceptions and experiences of patients and their nurses enrolled in a digitally enabled cardiac telerehabilitation program, aiming to ascertain the drivers for program acceptance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods. \u003c/strong\u003eA qualitative study utilizing semi-structured telephone interviews was conducted. Researchers independently analyzed data deductively to categorise participant perceptions about the program into positive, neutral or negative. The transcripts were then reviewed inductively to code for program benefits, challenges, and recommendations for improvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults. \u003c/strong\u003e12 out of 52 participants and 2 cardiac nurses, from across Australia, who had completed the intervention, participated in the semi-structured telephone interviews.\u003cstrong\u003e \u003c/strong\u003eKey benefits were the personalised nurse telehealth consultations (12/12), education aimed at maintaining learned healthy behaviours (10/12) and remote patient monitoring (5/12). However, digital connectivity was a challenge for patients. Nurses found that trust building was a challenge given there was no face-to-face care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion. \u003c/strong\u003eDigitally enabled cardiac telerehabilitation is well accepted by patients and their nurses. Remote monitoring in combination with personalised telehealth nurse consultations enhance patient-clinician communication and were key success factors in this model of care. Challenges with digital connectivity should be considered and addressed in future interventions. Further quantitative research is necessary to validate these findings.\u003c/p\u003e","manuscriptTitle":"Patients’ and nurses’ perceptions and experiences of a digitally enabled cardiac telerehabilitation program - a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-11 11:34:02","doi":"10.21203/rs.3.rs-5194531/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-22T08:56:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-20T20:28:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-18T11:25:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186220406833547877991345340726544960821","date":"2024-10-10T14:15:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304856606222620881200563845258935110152","date":"2024-10-10T10:24:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-10T10:18:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-10-07T11:53:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-04T13:17:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-04T13:16:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Digital Health","date":"2024-10-02T18:22:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-digital-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Digital Health](https://bmcdigitalhealth.biomedcentral.com/)","snPcode":"44247","submissionUrl":"https://submission.nature.com/new-submission/44247/3","title":"BMC Digital Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5da4ce3b-7048-4394-aa83-178c0d218e19","owner":[],"postedDate":"November 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-03-21T16:38:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-11 11:34:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5194531","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5194531","identity":"rs-5194531","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}