The Evolution of Cardiac Rehabilitation Since COVID-19

During the COVID-19 pandemic, cardiac rehabilitation programs (CRPs) rapidly transitioned to virtual, mostly one-to-one, care. Four years later, the lasting effects on contemporary program delivery are unknown. Therefore, this study aimed to examine the evolution of CRPs pre-COVID-19 to present (February-August 2024) in Canada.

A questionnaire was disseminated to Canadian CRP managers.

Of 260 CRPs, 108 representatives of 150 CRPs (57.7%) responded. Since pre-COVID-19, there has been a reduction in proportion of CRPs offering a traditional in-person program model from 92.8% to 67.6% (p<0.001), an increase offering hybrid models (i.e., in-person with virtual components) from 12.0% to 43.7% (p<0.001), and an increase in virtual models from 24.6% to 50% (p<0.001). Pre-COVID-19, 71.5% of programs relied on one delivery model, declining to 51.1% post-COVID-19. CRPs offering 2-3 models rose from 28.5% to 48.9% (p<0.04). These models will continue in >89% of CRPs for ≥1 to 2 years. Program model allocation was based mainly on patient preference (41%) or patient/clinician collaborative discussions (35%), with 73.9% of these programs recommending in-person programming to higher-risk patients. There was an increase in CRPs that were under capacity pre-COVID-19 to present (6.3%-40.5%; p<0.001), yet the mean number of patients enrolled/month increased (+5.8%; 77±91 to 81.5±98; p<0.001). Exercise delivery is mostly group-based (>61%). Of all CRPs, >84% perceived that patients were at least somewhat satisfied with all model components, except fully virtual telephone (57.8%), unless the telephone was within hybrid models (72.2%). Resource and education barrier scores were lower for virtual and hybrid than for in-person programming (p<0.001). Patients with language/communication barriers presented the greatest challenge to exercise program delivery, with <54% of programs offering spoken language translation services for the in-person component.

The pandemic accelerated a shift towards diversified program models. Virtual, hybrid, and group-based models may be driving increased accessibility and reduced resource barriers, ultimately expanding patient reach. Further resource allocation is needed for language translation services to better serve diverse populations and accommodate in-person programming for people at higher medical risk and those with mobility deficits. A more widespread triaging process for tailored model allocation should be implemented by all CRPs. Leveraging technology to provide confidence that virtual-based programs are suitable for higher-risk and vulnerable populations, improving connectedness/peer support, and removing barriers for using technology for those who lack experience and/or have cognitive impairment are important initiatives.