Advances in technological interventions to remotely monitor patients after cardiac surgery are increasingly being explored to improve outcomes [22]. As such we designed a pilot study to test the feasibility of using a novel telehealth intervention to particularly target vulnerable or frail patients undergoing heart surgery. We believed that our study would address the important knowledge gap by assessing if technological interventions could help patients transition home after discharge. Our study demonstrated that a large proportion of patients undergoing cardiac surgery were vulnerable and eligible to participate (34%) highlighting the need for our work. We were also able to enroll a large proportion of patients (74%) but did encounter some challenges as only 1/3 of enrolled patients completed the study as designed.
Our results demonstrated that although it was possible to enroll and remotely monitor patients following cardiac surgery, frail/ vulnerable patients pose unique challenges for this type of intervention. Specifically, more than half of our consented patients had to be excluded from our study because they could not be discharged home within 10 days of surgery or required transfer to another hospital for recovery before they could be discharged home. Most of these excluded patients had a much higher frailty score (as defined by EFS, CFS) than the ones who were included in the study. While not surprising, these observations highlight how progressively frail patients have an increased burden of comorbidities and suffer a greater number of adverse postoperative outcomes and slower overall recovery [23, 24]. Our findings are supported by previous reports observed in frail patients undergoing cardiac surgery in other Canadian populations [25–27]. We acknowledge that we chose to exclude patients that needed prolonged hospitalization given that the goal of the telehealth intervention was to facilitate early transition home after discharge. It also does not mean that the patients that were excluded due to prolonged hospitalization might not have benefited from the technology.
It is also important to note that the actual tablet platform did have some issues that are worth reporting. One-third of the participants sent home with the tablet device withdrew from our study, predominantly due to difficulties in using the technology. Technology, especially for older adults is a complex relationship encompassing psychological and contextual factors [28] with perceived barriers not limited to lack of prior knowledge, fear of consequences, and lack of readiness in using a technological intervention [29]. Many of the patients who withdrew had the above perceptional barriers and could not avail assistance from family or friends to help them with using the tablet and the blood pressure device. Additionally, our observations suggest that self-monitoring every day at a fixed time for 30 consecutive days may also be a reason for stress/ monotony/ fatigue and the consequent withdrawals. Despite these barriers, among patients who completed the study, there was a high degree of satisfaction and willingness to again use technology-assisted programs to monitor their health.
We chose hospital readmission as the primary clinical outcome of interest for THE-FACS intervention. This was based on the available literature, and unpublished data from the NBHC, showing that frail patients have a higher risk of hospital readmission within 30 days of cardiac surgery [26, 30]. It is generally reported that rates of readmission after cardiac surgery can range between 10–15% and are influenced largely by patient characteristics (PMID: 34112216). In the present pilot study, none of the patients who received THE-FACS intervention required readmission to the hospital. This finding was in contrast with our historical controls which had a rate of readmission of 14.3%. However, one should note that despite this apparent difference between THE-FACS intervention and historical controls, the results failed to reach statistical significance. This is not surprising given the small size of our pilot study which was not powered to detect a difference between groups. Our observations are interesting and suggest that a telehealth intervention could have a significant impact on facilitating discharge home but will need to be validated in a larger cohort. It remains to be proven as to the utility of technology-based home monitoring programs to reduce the rates of hospital readmissions in vulnerable/ frail patients within 30 days of cardiac surgery.
Most patients who completed the study were highly satisfied with THE-FACS intervention and most would like to use the technology again for home monitoring of their health. However, the satisfaction survey was not conducted on patients who withdrew consent and did not complete the study and is as such a limitation of our data. As the maximum number of participants in the latter group faced technological difficulties when using the intervention, we acknowledge that our satisfaction survey would have been biased and reflected on only those participants who are technologically proficient to complete the study.
We, therefore, conclude that THE-FACS is a telehealth intervention that holds promise in our quest to identify solutions for increasing vulnerable or frail patients undergoing surgery who need help with their transition to home life. Our findings suggest that perhaps this type of intervention could help reduce hospital readmission within 30 days of surgery but would require a much larger study to answer that question. However, we also identified significant challenges in applying this approach to the most vulnerable or frail patients suggesting that unique solutions would need to be developed to limit withdrawal or dismissal of the technology. One needs to keep in mind that the most vulnerable patients were the most likely to require prolonged hospitalization and as such were excluded from the present pilot.
Although we observed how novel, self-monitoring technological interventions can prove to be challenging for the most frail/ vulnerable, elderly patients who had undergone cardiac surgery, we could see its tremendous potential if adapted to individual needs. As a continuation of the potential benefits of home-monitoring previously mentioned [4], it would be important to explore the applicability of digital therapeutics in a larger cohort of patients undergoing cardiac surgery in New Brunswick. A risk/ benefit analysis considering multiple aspects not limited to outcomes, costs, time, resources, etc. for both the patients and their caregivers/ family, and the healthcare system would provide a comprehensive knowledge regarding the large-scale utility and long-term sustainability of technology-based home monitoring platforms in cardiac surgery patients.