Impact of Tele-Coaching During the COVID-19 Pandemic on Risk-Reduction Behavior of Patients with Heart Failure
Introduction
Corona virus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2),1 reached Europe in early 2020 with Italy, Spain, and the United Kingdom being worst affected.2–4 While most patients (81%) developed only mild symptoms typical of upper respiratory tract infections, 14% suffered from severe disease and 5–6% from critical illness, for example, respiratory failure, sepsis, or multiorgan failure.5 The case-fatality rate increased with age (8% among people aged 70–79 and 14.8% among those >80 years of age) and was highest among those with pre-existing conditions, including hypertension, chronic respiratory disease, cancer, and chronic heart failure (CHF).5
Many countries restricted routine hospital visits and nonurgent surgery to allow for increased volumes of COVID-19 patients.6 Patients with chronic diseases such as CHF are likely to suffer significantly from reduced capacities of the health care system during a pandemic.7 Telemedicine systems provide several advantages for managing patients during this time.8 These services can prevent overcrowding in emergency departments and primary care clinics by offering a first contact point for low-acuity patients, but also by providing continuity of care of patients with chronic illness. By reducing in-person clinic visits, telemedicine ensures that medical facilities are reserved for critically ill patients, and reduces exposures among health care workers and patients to SARS-CoV-2 and other infectious diseases.9 For high-risk patients with pre-existing chronic diseases who are afraid of accessing health care facilities, telemedicine offers the possibility to consult health care providers in a contactless manner.9
In this study, we investigated whether a specific tele-coaching module on COVID-19 impacts the rate of COVID-19 cases in CHF patients at high risk of hospitalization. Secondarily, we analyzed the effect of the module on (1) the knowledge of COVID-19 symptoms, preventive measures to avoid infection, and when and how to seek medical attention; (2) behavioral changes in regard to preventive measures; and (3) in-person physician–patient contacts, as well as hospitalizations.
Methods
The Telehealth System
Mecor® is a tele-monitoring and tele-coaching service for patients with CHF in Germany and Switzerland run by Health Care Systems GmbH (HCSG). It comprises daily monitoring of CHF symptoms (e.g., dyspnea) and signs (e.g., weight, edema) by the patients, as well as regular tele-coaching sessions about disease-related topics (adherence to medication, nutrition, physical activity) conducted by specially trained tele-nurses. In case of a deteriorating health condition, as evident by monitoring trends in the patient documentation, a tele-nurse contacts the patient and evaluates the situation, suggesting either a behavior change or an unplanned, in some cases even urgent, physician consultation.
This telehealth system is offered to patients of partner insurance companies who were previously hospitalized with heart failure. To be eligible for a voluntary participation in Mecor, patients have to be diagnosed with heart failure (ICD codes I50*, I11.0*, I13.0*, I42.0) and to be hospitalised in the 18 months prior. Patients suffering from severely impaired hearing or sight, dementia, schizophrenia, dependency syndromes, severe chronic kidney disease (Stages 4 and 5) or with very high levels of nursing care requirement are excluded from the program.
Ethics
The study was approved by the local ethics committee of the Technical University Munich. Our research conformed to the ethical standards of the Declaration of Helsinki. All subjects gave written informed consent to participate in the telehealth program, including data collection and presentation for research purposes. Personal data were processed in accordance with Directive 95/46/EC (GDPR; Supplementary Appendix A).
Study Design and Study Population
To compare the efficacy of tele-coaching to transmit specific knowledge and to endorse favorable behavioral change, we conducted a prospective cohort study (Fig. 1). The study population consisted of CHF patients already registered as participants in the telehealth program with a prescheduled routine tele-coaching call between April 3 and 9, 2020 (intervention group) or April 20 and 30, 2020 (control group). All participants attended regular tele-coaching sessions about CHF-related topics at regular intervals (6–12 weeks) for the whole duration of this study.
Based on the date of their prescheduled tele-coaching call, patients were allocated to a “tele-coaching + written information” (intervention) group (n = 419; dates of coaching calls prescheduled between April 3 and 9, 2020) and a “written information only” (control) group (n = 1,748; dates of coaching calls prescheduled between April 20 and 30, 2020). The intervention group received COVID-19–specific tele-coaching (Supplementary Appendix B) instead of the routine coaching between April 3 and 9, 2020, followed by written information (Supplementary Appendix C). The control group only received written information about COVID-19 (Supplementary Appendix C) between April 3 and 15.
Between April 20 and 30, 2020, both the intervention and control group patients’ knowledge and risk perception about COVD-19 were assessed using a structured questionnaire (Supplementary Appendix D). Due to capacity constraints of the tele-coaching center for tightly synchronized initial and follow-up interviews, there were fewer patients in the intervention group than in the control group. Of the 419 patients who had received both tele-coaching and written information, 378 were reached for follow-up (follow-up rate 90.2%). The standardized interview assessed knowledge about preventive and risk-reduction measures by open, unprompted questions. If the patient was not able to name a risk-reduction measure spontaneously, it was considered as not known and no answer was prompted. Behavior change, current health status, and medical attendance were evaluated with prompted questions offering a battery of choices for each item. All items were self-reported. Omitting any information specific to COVID-19 to patients of the control group was judged to be unethical, and this group received the tele-coaching after the questionnaire.
Endpoints
The prespecified primary endpoint was the number of COVID-19 infections. Secondary endpoints for comparison between the intervention and control group were as follows: (1) knowledge on COVID-19–related risk-reduction measures, symptoms, reasons for seeking medical attention, and contact methods for medical attention; (2) change in self-reported behavior; (3) self-reported interactions with medical professionals; and (4) psychological impact of COVID-19.
Statistical Analysis
Individual patient data were extracted from electronic health records in the data controller’s data center and analyzed using Prims Graphpad v9 according to the study design. Investigators who were not part of the data controller’s organization were provided with anonymized data.
All patients who completed the structured questionnaire were included in the analysis (intention-to-treat), and individual data points were excluded if no answer was recorded. For continuous variables, an unpaired two-sided t test was used, Mann–Whitney test was used for nonparametric numerical answers, while Fisher’s exact test was applied for categorical data. A p-value of <0.05 was considered statistically significant in all comparisons. The Benjamini-Hochberg procedure with a false discovery rate of 0.1 was applied to all statistical tests to account for multiple comparisons, and p-values above the critical p-value are marked as nonsignificant.
Results
Baseline Characteristics
Baseline clinical characteristics were similar between the two groups (Table 1). In addition, there was no significant difference at baseline of the 41 patients lost to follow-up in the tele-coaching group.
TELE-COACHING AND WRITTEN INFORMATION, N = 378 | ONLY WRITTEN INFORMATION, N = 1,748 | P | |
---|---|---|---|
Age | |||
Mean ± SD | 76 ± 9.1 | 76 ± 9.3 | 0.27a |
Median (range) | 78 (41–98) | 78 (27–99) | |
Gender, n (%) | |||
M | 245 (65) | 1,101 (63) | 0.64b |
F | 133 (35) | 647 (37) | |
Current dyspnea (NYHA class), n (%) | |||
I | 10 (3) | 43 (3) | 0.27c |
II | 153 (41) | 789 (46) | |
III | 208 (55) | 895 (51) | |
IV | 7 (2) | 18 (1) | |
Health perception (EQ-5D-5L), mean ± SD | 66 ± 1.1 | 64 ± 0.5 | 0.35a |
Respiratory disease,dn (%) | 169 (45) | 802 (46) | 0.93b |
Diabetes,en (%) | 166 (44) | 717 (41) | 0.23b |
Hyperlipidemia, n (%) | 223 (59) | 1,013 (58) | 0.73b |
Cardiac arrhythmia, n (%) | 237 (63) | 1,091 (62) | >0.99b |
Hypertension, n (%) | 323 (85) | 1,488 (85) | >0.99b |
Coronary artery disease, n (%) | 225 (60) | 1,010 (58) | 0.69b |
Chronic kidney disease, n (%) | 122 (32) | 566 (32) | 0.95b |
Number of comorbidities,fn (%) | |||
0 | 6 (2) | 6 (0.3) | 0.25c |
1 | 4 (1) | 46 (3) | |
2 | 45 (12) | 207 (12) | |
3 | 79 (21) | 420 (24) | |
4 | 116 (31) | 475 (27) | |
5 | 76 (20) | 375 (21) | |
6 | 41 (11) | 172 (10) | |
7 | 11 (3) | 47 (3) |
Numbers of COVID-19 Infections
Overall, the number of COVID-19 cases was low during the short follow-up period. Only 4% of patients had a SARS-CoV-2 test (13 in the tele-coaching group and 69 in the written information only group) with a total 5 patients (0.2%) testing positive; all of these were in the written information only group.
Pre-Existing COVID-19 Knowledge
Knowledge about typical symptoms of COVID-19 was assessed by an open question. There was no significant difference in the recall of fever and cough as symptoms (Fig. 2A). Significantly more patients in the tele-coaching group knew about shortness of breath as a characteristic symptom of COVID-19 (30% vs. 24%, p = 0.017). However, symptom recall for shortness of breath was lower than that for fever and cough (Fig. 2A).
Looking at risk-reduction measures, there was no significant difference in the knowledge about the use of face masks, hand hygiene, and reduction of social contacts (household visitors) between the two groups (Fig. 2B). This knowledge was widespread in both groups with 55–68% of patients recalling these measures on open questioning. Patients from the control group recalled the importance of avoiding public transport and reducing medical interaction more often than patients from the tele-coaching group (39% vs. 29%, p = 0.0003 for use of public transport and 28% vs. 22%, p = 0.023 for medical interactions, Fig. 2B).
Behavioral Changes
In the tele-coaching group, patients reported a significantly higher rate of behavioral changes (Fig. 3) with respect to following risk reducing measures: increased surface cleaning (80% vs. 70%, p = 0.0006), increased room ventilation (88% vs. 78%, p < 0.0001), reduced use of public transport (78% vs. 68%, p = 0.0003), and increased utilization of face masks (60% vs. 51%, p = 0.013). There was no statistically significant difference in the reported reduction of private contacts, grocery shopping, or increase in hand washing (Fig. 3).
There was a higher number of patients vaccinated against pneumococcus in the tele-coaching group (60% vs. 52%, p = 0.014) and no significant difference in vaccination rates for influenza between the two groups (69% vs. 71%). Overall, six patients, three from each group, got vaccinated against pneumococcus after the tele-coaching or the written information, respectively.
Medical Interaction
When patients were asked about situations when they may seek medical attention, cardiac decompensation was mentioned by 32% in the COVID-19–specific tele-coaching group and 24% in the written information only group (p = 0.0049, Fig. 4A), whereas no difference was seen for COVID-19 infection as reason for consultation (tele-coaching group 65%, written information only 61%).
A high proportion of patients was aware of how to contact their primary care physician or community doctor (82% after tele-coaching and 77% after written information, not significant, Fig. 4B), but only a small percentage spontaneously recalled how to reach medical attention out-of-hours or in an emergency. However, for both scenarios, patients after tele-coaching were better informed (37% vs. 25%, p < 0.0001 for out-of-hours doctor and 46% vs. 36%, p = 0.0006 for emergency services).
There was a statistically significant difference in the number of overall medical appointments, both at the hospital and at community doctors, with lower numbers for patients who received COVID-19–specific tele-coaching (50 vs. 87 visits per 1,000 participants, p = 0.033 for hospital visits, Figure 4D, and 341 vs. 413 per 1,000 participants, p = 0.0002 for community doctors, Fig. 4C). No significant difference was detected in the type of visit to community doctor (home visit, clinic visit, phone call) and in the numbers of hospital admissions. The number of out-of-hours visits was too small to discern any statistical differences.
Impact on Mental Health
Finally, we assessed worries associated with the COVID-19 pandemic and with perceived impairment resulting from physical distancing (Fig. 5). After tele-coaching or written information patients expressed no or only little worries due to COVID-19 and only moderate or minimal impairment by social isolation due to COVID-19. There were no statistically significant differences between both groups.
Discussion
Our study compares the impact of the addition of a COVID-19–specific tele-coaching module to written information alone on numbers of COVID-19 infections as well as the knowledge about the disease, change of preventive behavior, and utilization of medical services in a high-risk population of patients with CHF. It was integrated into a well-established tele-coaching and tele-monitoring program, and thus allowed communication of new information through familiar channels. The advice on preventive precautions was based on the official recommendations at the time, given by the Robert-Koch-Institute and the German Ministry of Health.10
Due to the low numbers of confirmed SARS-CoV-2 infections in our study population, our study was unable to demonstrate an effect of a COVID-19–specific tele-coaching module on COVID-19-infections. During our study, only five positive polymerase chain reaction (PCR) results for SARS-CoV-2 were reported. All positive PCRs were from the written information only group, likely due to its bigger size. These low numbers are consistent with the low incidence of COVID-19 in Germany in March and April 2020.2
There was no difference between the tele-coaching or written information only groups with respect to general knowledge about preventive measures and basic hygiene precautions, such as the use of face masks, regular hand washing, and reduction of social contacts. This might reflect the efficacy of the public health campaign propagated in the media in Germany at the time of the study, which focused on these measures.10 Given the already widely prevalent knowledge about these measures, there was no additional benefit from a COVID-19–specific tele-coaching in our high-risk study population.
However, before the availability of widely available vaccines, a reduction in SARS-CoV-2 transmission can only be achieved through behavioral changes. Interestingly, more patients in the tele-coaching group reported increased use of face masks and avoidance of public transport as compared with patients who received written information only. They also reported a significantly higher rate of behavioral change with regard to cleaning surfaces and ventilating rooms. Thus, it appears that written communication and tele-coaching are equally efficient in conveying information; however, tele-coaching has a more profound impact on modifying behavior. This finding is consistent with previous studies, which have shown that regular follow-ups within tele-coaching and tele-monitoring programs lead to more sustained behavior changes.11–13
A main finding of our study was that during this short-term follow-up, patients after COVID-19–specific tele-coaching reported significantly lower numbers of medical contacts, both at community doctors and in hospitals. Besides being an effect of tele-coaching, the reduction in medical attendance seen in our study could be driven by fear and insecurities. During the COVID-19 pandemic, a decrease in emergency department admissions up to 30–40% has been reported, even for severe diseases such as acute coronary syndromes, stroke, and acute heart failure.14–17 This significant short-term drop has been attributed to pandemic-related factors more so than to a decline in incidence of the very conditions.16 Patients seemed to delay or avoid seeking medical help during the early pandemic period due to fear of infection.16 Importantly, our data elicit no significant difference between the tele-coaching and the written information only group regarding reported worries about COVID-19 or impairment due to social distancing. This is of particular importance, as previous studies have shown that tele-monitoring and tele-coaching can provide benefit by reassuring patients, but might also be perceived as a burden worrying about health.18 Whether this short-term effect during the surge of the infection process in Germany is sustainable is uncertain and needs to be evaluated in longer term follow-ups.
As patients were instructed to avoid in-person medical contacts, one would expect to observe an increase in phone calls in this time period. Interestingly, this was not the case, suggesting an overall reduction in seeking medical help, instead of a shift toward contactless options. As fear about COVID-19 appeared to be similar in both groups and limitations in access to health care affected them to the same extent, one can speculate that the relative reduction in medical contacts and especially hospitalizations is at least partially an effect of targeted tele-coaching. Possibly, COVID-19–specific tele-coaching raised the patients’ awareness of avoiding unnecessary medical contacts, or it led to an actual reduction in acute decompensation of CHF due to better patient’s self-management. The latter has already been shown in previous studies that reported a benefit of tele-coaching in heart failure patients.13,19–24
Although the majority of patients in both groups knew how to contact their primary care physicians, only about half of the patients knew how to seek help out-of-hours or in case of an emergency. These numbers seem particularly low, and might be partially explained by the study design with open questions. Nevertheless, tele-coaching significantly increased knowledge about how to seek medical help.
Interestingly, given our cohort of CHF patients at high risk of hospitalization, only a small proportion of patients mentioned decompensation of heart failure as possible reason for seeking medical attention. Considering the context of the COVID-19 pandemic, chronically ill patients might repress thoughts about their own chronic conditions and avoid medical contact at any cost. Moreover, patients with CHF are known to often have poor understanding of their disease and to have problems in interpreting their symptoms correctly.25 While the classical symptoms of fever and cough were well known, only 24% of patients mentioned shortness of breath as a possible manifestation of COVID-19. In our cohort of patients with CHF worsening dyspnea is an early symptom not only for decompensation but also for COVID-19 or other respiratory tract infections.5 Tele-coaching increased this knowledge significantly, and may lead to timely medical presentation and help detecting early manifestations of COVID-19. Beyond the impact in care for the individual patient, earlier diagnosis helps containing propagation of COVID-19 through quarantine measurements.10
Our research has certain limitations mostly due to its design. All CHF patients were subscribers to a nurse-led, tele-coaching program, and were thus acquainted with contacts in writing or in person. Our study focused on CHF such that we have no data on how tele-medical advice may be perceived by patients primarily affected by other chronic medical conditions. The main limitation of our study is its relatively short follow-up period of 3–4 weeks and its relatively small size, which limits its power to detect relevant changes in COVID-19 infection rates and/or mortality.
Conclusion
A COVID-19–specific tele-coaching session integrated in an already well-established tele-coaching and tele-monitoring program increased the knowledge about some but not all COVID-19–specific topics more effectively than written information only. Furthermore, it resulted in higher rates of behavioral changes, especially COVID-19–specific hygiene measures. During short-term follow-up, patients from the tele-coaching group reported fewer rates of medical contacts, both at the community doctors and at the hospital. Overall specific tele-coaching can be regarded an effective method to support behavioral change and reduce in-person medical contact.
Acknowledgment
We thank Frank Stadler for his support with data extraction from the Mecor® system.
Ethics Approval
This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the Technical University Munich (April 2020, No. 204/20S).
Disclosure Statement
Dr. C. Kloss is managing partner of HCSG; Dr. P. Bregenhorn and F. Stadler are employees of HCSG. Dr. S. Leiter reports support from the FPS Foundation, which owns shares in HCSG, outside the submitted work. Dr. K. Knoll has received a grant from the German Heart Foundation/German Foundation of Heart Research. Dr. S. Rosner, Dr. T. Trenkwalder, Dr. A. Erben, Prof. H. Schunkert, and Prof. W. Reinhard declare that they have no conflict of interest in regard to this work.
Funding Information
Dr. Katharina Knoll received a research grant from the German Heart Foundation/German Foundation of Heart Research (Grant No. F/26/20).
Supplementary Material
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