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R
ehabilitation after cardiac sur- or socially deprived people, ethnic provided by 62.4% of the centers,
gery often improves self- minorities, and those from rural whereas outpatient care is provided
assessment and clinical param- areas who encounter difficulties in on a day-hospital basis by 10.9%
eters,1 reduces risk factors, and can attending center-based facilities. of facilities, with 20% of the cen-
increase physical capacity. A 20% Home-based cardiac rehabilitation ters referring patients to ambulatory
reduction in all-cause mortality and a programs could yield clinical out- structures.11 Indeed, differences
27% reduction in cardiac mortality comes similar to those of rehabilita- from region to region are present. In
have been reported in systematic tion programs, with a possible posi- the Lombardy region, all patients
reviews.2,3 However, despite interna- tive impact on some areas of health who have undergone cardiac sur-
tional guidelines that recommend care utilization.9,10 gery are admitted for in-hospital
cardiac rehabilitation,1 the propor- rehabilitation. Moreover, patients
tion of patients admitted to a reha- In Italy, formal cardiac rehabilita- who have undergone cardiac surgery
bilitative program remains small.4 –7 tion is offered within a rehabilitative without complications are allowed
Mostly, patients are discharged to the hospital.11 However, the inclusion to participate in pilot programs at
home without any rehabilitation.8 of patients in rehabilitation pro- home using telemedicine as an alter-
grams following surgery differs native to an in-hospital rehabilitation
For this reason, home-based car- among Italian regions. The ISYDE program. In particular, all patients
diac rehabilitation (HBCR) programs study,11 designed to provide discharged 5 to 10 days after cardiac
have been introduced in the United a detailed snapshot of cardiac reha- surgery stayed at a rehabilitative cen-
States and some European coun- bilitation in Italy for patients after a ter for a mean period of 18 days.12
tries in attempts to increase patient surgical procedure, shows that in-
participation, in particular for older hospital rehabilitation service was Up to 2006, in the Lombardy region,
all patients after cardiac surgery
followed an in-hospital rehabilita-
tion program. From 2006 onward,
a regional project (CRITERIA) pro-
The Bottom Line posed, at an experimental level, an
HBCR program with telemedicine to
What do we already know about this topic? follow up patients at low to medium
risk for early mortality after cardiac
Rehabilitation after cardiac surgery often improves quality of life, reduces surgery at home.
cardiovascular disease risk factors, and can increase physical capacity. A
20% reduction in all-cause mortality and a 27% reduction in cardiac Telemedicine and application of
mortality following cardiac rehabilitation also have been reported in information and communication
technology in the health system have
systematic reviews.
been shown to support and manage
What new information does this study offer? home care programs quite effi-
ciently.13 However, few studies have
This study compared exercise capacity after a home-based cardiac reha- examined the application of HBCR
bilitation (HBCR) program or an in-hospital program in patients with a low with telemedicine in patients after
to medium risk for early mortality after cardiac surgery. The study found cardiac surgery, myocardial infarc-
that the HBCR program was feasible, safe, and comparable to the con- tion, and percutaneous transluminal
ventional in-hospital rehabilitation approach, indicating that rehabilitation coronary angioplasty14,15; to our
following cardiac surgery in patients at low risk for early mortality can be knowledge, we have performed the
implemented effectively at home when programmed with an integrated only investigation in Italy to test
the feasibility of this approach in
telemedicine service.
patients following cardiac surgery.16
If you’re a patient, what might these findings mean
for you? The current study was aimed at
reproducing at home the in-hospital
If you are at low risk for early mortality after cardiac surgery, you may cardiac rehabilitation protocol pro-
achieve a better quality of life with a complete, supervised rehabilitation cedures in patients at low to medium
program at home via telemedicine. risk after cardiac surgery. The pri-
mary objectives of the study were:
Table 1.
Rehabilitative Intervention in the 2 Different Settingsa
Home-Based In-Hospital
Rehabilitation Rehabilitation
Measure What When and How (nⴝ100) (nⴝ100)
Increase to 50 W for
35 min
(1) to evaluate the feasibility of Participants Inclusion criteria were: over 18 years
implementing an in-hospital rehabil- The study participants were divided of age, EuroSCORE between 0 and
itation protocol in a home setting into 2 groups: (1) an HBCR group 5 (European System for Cardiac
with an up-to-date telemedicine plat- and (2) an in-hospital group, which Operative Risk Evaluation: 0 –2⫽
form and (2) to compare key efficacy served as a comparison group. low-risk group, 3–5⫽medium-risk
indicators such as exercise capacity group, ⱖ6⫽high-risk group),17 no
(assessed using the Six-Minute Walk HBCR group. The HBCR group major complications after surgery,
Test [6MWT]). Length of the rehabil- (n⫽100) included all patients allo- and hemoglobin value ⬎8.5 g/dL. All
itative period, number of days from cated in our institute (Fondazione enrolled patients were required to
the surgical intervention to rehabili- Salvatore Maugeri) who underwent have the availability of a caregiver at
tation, and mean total duration of the cardiac surgery procedures between home and to live within 30 km from
rehabilitative sessions were second- January 2006 and June 2010 at a the hospital. The main exclusion cri-
ary outcome measures. single cardiac surgery center (Fon- teria were insulin-dependent diabe-
dazione Poliambulanza Istituto tes and overt chronic respiratory
Method Ospedaliero, Brescia, Italy). All par- insufficiency. Allocation to the HBCR
Design ticipants gave their written informed group was made based on the
The study was designed as quasi- consent. patients’ preference. Among 387
experimental. patients who were admitted to the
All drugs for routine therapy and Age (y), X (SD) 63 (11) 63 (12) ns
an emergency kit (antibiotics, anti- Male (n) 89 86 ns
inflammatory drugs, sedatives, CABG (n) 61 57 ns
diuretics, beta-blockers, and gen-
Valve (n) 26 36 ns
eral medicaments) were supplied
CABG⫹valve (n) 6 5 ns
to each participant. A DVD illustrat-
ing the correct way to perform cal- Plastic surgery on valve (n) 7 2 ns
listhenic exercises also was pro- EuroSCORE, X (SD) 3.78 (1.7) 3.95 (2.5) ns
vided. Furthermore, a 1-lead ECG COPD (n) 4 2 ns
recorder and a computer notebook Renal insufficiency (n) 2 2 ns
with mobile broadband capabilities
Diabetes (n) 10 16 ns
(which allowed point-multipoint
Body weight (kg), X (SD) 62 (5) 64 (8) ns
video and audio transmissions simul-
taneously) were provided to each LVEF (%), X (SD) 56.2 (7.3) 55.7 (7.7) ns
participant. An electronic health 6MWT score (m), X (SD) 354 (102) 334 (90) ns
record was prepared for each Hemoglobin (mg/dL), X (SD) 11 (1.7) 10.2 (1.3) .001
patient, and the patient’s general Cholesterol (mg/dL), X (SD) 145.9 (37) 155.7 (33) ns
practitioner was informed.
Triglycerides (mg/dL), X (SD) 123.3 (43.3) 116.6 (39) ns
a
Video conference rehabilitation ses- CABG⫽coronary artery bypass graft, COPD⫽chronic obstructive pulmonary disease, LVEF⫽left
ventricular ejection fraction, 6MWT⫽Six-Minute Walk Test, ns⫽not significant. EuroSCORE value
sions directed by a nurse or a thera- represents a score for the prediction of early mortality in patients after cardiac surgery in Europe on
pist were provided every morning the basis of 17 objective risk factors: 9 patient-related factors, 4 derived from the patient’s preoperative
cardiac status, and 4 dependent on the timing and nature of the operation performed. The system is
and afternoon (Fig. 1). We are cur- additive and identifies 3 different categories of patients: low risk⫽0 –2, medium risk⫽3–5, and high
rently using a multiple platform riskⱖ6. Baseline differences between the 2 groups were analyzed by chi-square test for discrete
variables, by the Student t test for normally distributed continuous variable, and by the Mann-Whitney
video conference that can follow test for non–normally distributed continuous variables.
multiple patients simultaneously,
mimicking the in-hospital program.
We can follow up to 8 patients week. The nurse tutor provided ser- telemonitoring through 1-lead ECG
at each rehabilitation session. The vices every 2 weeks at home. During recordings. Daily, the nurse tutor
operator of telemedicine rehabil- this visit, the nurse performed a contacted the participant by tele-
itation views on the monitor a 12-lead ECG recording. Rehabilita- phone for the collection of his clini-
mosaic composed of a video of each tion sessions (Monday–Friday) lasted cal data, confirmation or variation of
patient participating in the session, approximately 100 minutes at the the therapy, and resolution of possi-
but the interaction is one to one. morning session and 40 minutes ble needs (ie, to dress the surgical
Conversely, the patient views only at the afternoon session. Saturday wound and adaptation of the daily
the operator. It is possible to allow sessions consisted of the morning physical performance). In case of
direct communication with the indi- session only. The maximum period mild complications, the participant
vidual patient during the rehabilita- of the rehabilitation program was was supported by teleassistance or
tion session and shift from one to 24 working days (4 weeks). The unscheduled home visits performed
another. The platform allows the training included 60 minutes of arm by either a nurse or physical thera-
management of video signal in full and leg isotonic calisthenic exercises pist. In cases of severe complica-
screen mode (ie, turning off the as well as exercises for posture and tions, the participant had access to a
microphone and displaying a full respiration and techniques for mus- cardiologist or to the emergency
screen video). cle relaxation. These exercises had department.
to be performed once a day in the
All training exercise sessions (Tab. 1) morning with the help of the DVD. During the HBCR program, par-
were supervised at the participant’s The cycle ergometer exercise was ticipants visited the hospital to
home by the physical therapist the performed twice a day (40 minutes/ undergo routine blood tests and
day after discharge and once a session) with the help of cardiac clinical examinations (ie, cardiac
Table 4.
Clinical Outcomes and Process Measures Evaluated at the End of the Programa
In-Hospital Home-Based
Rehabilitation Rehabilitation
Measure (nⴝ100) (nⴝ100) P
Time from surgical intervention to rehabilitation (d), 9.8 (7.8–11.8) 7.9 (5.8–9.0) .01
X (95% CI)
12-lead ECG/patient (n), X (95% CI) 5.2 (4.7–5.7) 4.1 (3.8–4.5) .02
Chest radiographs/patient (n), X (95% CI) 1.3 (1.2–1.4) 1.2 (1.1–1.3) .05
Blood withdrawings/patient (n), X (95% CI) 7.1 (6.6–7.7) 5.6 (5.2–6.1) .001
a
CABG⫽coronary artery bypass graft, COPD⫽chronic obstructive pulmonary disease, LVEF⫽left ventricular ejection fraction, 6MWT⫽Six-Minute Walk Test,
95% CI⫽95% confidence interval, ECG⫽electrocardiogram, ns⫽not significant. Data are reported as mean (95% CI) or percentage.
subjected to statistical analysis. Table Both groups increased their 6MWT atrial fibrillation (n⫽1), and psychi-
3 shows the clinical and functional scores (F⫽159.34, P⬍.001, Tab. 4, atric cause (n⫽1). Four participants
participants’ characteristics at time Fig. 2). The HBCR group improved were sent to the emergency depart-
of enrollment in the 2 groups. No by ⫹109.3 m (95% CI⫽85.6 –133.0), ment. No deaths occurred. Only 1
significant baseline differences in the and the in-hospital group improved participant dropped out of the study
participants’ characteristics were by ⫹89.1 m (95% CI⫽69.1–109.1). for personal reasons. The global sat-
found except for hemoglobin level, These increases were statistically isfaction of the HBCR group was
which was higher in the in-hospital nonsignificant, and no within-group reported as “very much high” by
group (P⬍.001). differences were found (F⫽0.024, 80% of the participants, “high” by
P⫽nonsignificant). At the end of 12% of the participants, “medium”
During the program, a total of 3,042 the program, the graded symptom- by 4% of the participants, and “low”
calls were made. Ninety-nine per- limited exercise test accounting for by 4% of the participants.
cent of the calls were scheduled by maximal exercise capacity in the
the nurse tutor. Only 1% of calls HBCR group was similar to that of In the in-hospital group, clinical
were requested by the participant. the in-hospital group (107.4 [3.7] W events were reported in 18 par-
The mean (standard deviation) num- versus 100.8 [4] W, respectively). ticipants who required hospitaliza-
bers of home care visits made by tion due to atrial tachyarrhythmia
nurse, physical therapist, and cardi- The mean numbers of 12-lead ECGs (n⫽11), infection complications
ologists were 1.6⫾1.0, 2.5⫾1.0, and per participant, chest radiographs (n⫽3), pericardial effusion (n⫽2), or
0.2⫾0.4 visits/patient, respectively. per participant, and blood with- dehiscence of the wound (n⫽2).
drawings per participant were sig- Seven participants prematurely inter-
The outcomes and clinical measures nificantly fewer in the HBCR group rupted the program, and 3 partici-
of the 2 groups are described in (P⬍.02, P⬍.001, and P⬍.05, respec- pants dropped out for personal rea-
Table 4. Length of rehabilitative tively) than in the in-hospital group sons. No deaths occurred in this
period was similar in the 2 groups (Tab. 4). On the contrary, a higher group as well.
(Tab. 4). However, the number of mean number of echocardiographs
days from the surgical intervention per participant was performed in the Discussion
to rehabilitation were significantly HBCR group (P⬍.001). At the international level, guidelines
higher in the in-hospital rehabilita- state that all patients who undergo
tive setting (P⬍.01, Tab. 4). The percentage of participants cardiac surgery should participate in
with coronary artery disease under a cardiac rehabilitation program.
Comparing data at entry and dis- antiplatelet or anticoagulant therapy However, because of organization
charge from the program in the 2 at discharge was 100% in the HBCR and cost problems, in-hospital reha-
groups, we found that both groups group and 98% in the in-hospital bilitation is reserved for patients
increased LVEF without significant group (Tab. 3); participants using who are very ill. Although many
differences within groups (F⫽3.73, statins at discharge, an obligatory patients at low to medium risk could
P⫽nonsignificant). On the contrary, therapy for patients with coronary be rehabilitated at home, HBCR
a significant increase in hemoglobin artery disease, was 94% in the HBCR remains a very small service com-
concentration, which was more evi- group and 70% in the in-hospital pared with the number of patients
dent in the HBCR group, was found group (P⬍.01) (Tab. 4). who can take advantage of it. This
at the end of the program (F⫽59.36, study represents the first experience
P⬍.001). Participants in the HBCR Clinical Events of a home-based rehabilitation pro-
group performed the exercise pro- No statistically significant differ- gram monitored by telemedicine in a
grams for a mean (SD) total time of ences in clinical events, evaluated homogeneous group of patients at
983.9 (358.1) minutes compared by chi-square test for discrete vari- low to medium (noncomplicated)
with 891.0 (464.4) minutes for the ables, were observed between the 2 risk who underwent cardiac surgery
in-hospital group (P⫽nonsignificant) groups. During the HBCR period, and comparing exercise capacity
(Tab. 4). In particular, participants complications were documented in with a conventional in-hospital reha-
at home spent more time on a cyclo- 19 participants due to the following bilitation program. In our previous
ergometer (645.6 [278.1] minutes, issues: pericardial effusion (n⫽4); study,16 a feasibility study of 47
16.9 [6.9] sessions/participant) with atrial tachyarrhythmia (n⫽9), stroke patients, we gave a detailed descrip-
respect to rehabilitative sessions (n⫽1), thrombosis (n⫽1), wound tion of the service and of the first
(338.6 [137.6] minutes, 21.5 [9.3] infection (n⫽1), congestive heart release of the telemedicine platform
sessions/participant). failure decompensation (n⫽1), in these patients, and the results of
the program were not validated. between the 2 studies in that Ades ever, it also could reflect a different
The present study was a quasi- and colleagues used direct voice con- medical or functional recovery of
experimental study performed on tact but did not use a video the patients. The home-based pro-
100 patients at home with respect to conference. gram was effective and comparable
a comparative in-hospital group; a to the conventional inpatient rehabil-
different technology (video confer- Our study showed that HBCR is fea- itative approach, providing similar
ence during rehabilitation sessions) sible and yields similar outcomes for improvement in exercise capacity
was provided to help physical thera- the majority of patients. The applica- and quality of life as that found in the
pists to follow up on patients at tion of information and communi- study by Ades and colleagues.9
home in real time or later (store and cation technology facilitated imple-
forward system), and results on vali- mentation of the HBCR program, Supervision and education of HBCR
dation of the program are presented. and the use of telemedicine allowed by the physical therapist provided an
a safer approach to the program. important validation of the HBCR
In contrast to the present study, There was a selection bias because concept. Indeed, the physical thera-
Dalleck et al6 included in their reha- patients could decide whether to pist has unique skills compared with
bilitation program patients with dif- enter the study (ie, to undergo HBCR a nurse or exercise physiologist in
ferent types of cardiac conditions or usual in-hospital rehabilitation) this setting and, with the cardiolo-
(postcardiac surgery, acute myocar- and intervention could not be ran- gists’ supervision, is fundamental in
dial infarction, and percutaneous domized to individual patients. providing valuable guidance both in
transluminal coronary angioplasty) Although the percentage of patients the inpatient setting and in a home
and with a different incidence of who had chosen the home-based care setting (as shown by HBCR).
events in the first period after sur- model is relatively low, the data are The physical therapist can promote
gery. They compared changes in in agreement with the findings of a favorable patient outcomes after dis-
risk factors for cardiovascular dis- previous study.19 This low rate of charge by structured assessments
ease in a conventional rehabilitation enrollment was mainly related to and sharing of patient information
outpatient program toward rehabili- patients’ fear of clinical complica- during the in-hospital or home set-
tation performed in a telemedicine tions to be managed at home by ting. The physical therapist, embrac-
center, located 240 km far from relatives during convalescence. ing the role of advocate for the
the conventional cardiac rehabilita- This observation highlights the role cardiac rehabilitation, can educate
tion center. The 2 studies are similar that structured assessments and shar- patients on the value of participat-
in the technology used but com- ing of patient information in the ing in this important lifestyle inter-
pletely different regarding the in-hospital setting have in promoting vention and ensuring that the
modality used to deliver the service: favorable patient outcomes after patients’ adherence to recommen-
in the telemedicine rural center,6 discharge.20 dations may lower the risk of read-
there was a junior exercise physiol- mission. Moreover, supervision by
ogist, whereas in the current study, a Because the patients came only from health staff using telemedicine
physical therapist and a nurse were one cardiac surgery center, it is dif- allows the performance of HBCR
present in hospital as pivotal people ficult to transfer our results to the patients at low to medium risk with-
for telesupport and telemonitoring general population. The participa- out compromising the high medical
of the program and for assisting tion of a greater number of patients, safety that exists in the in-hospital
patients at their home. facilitated by telemedicine, obvi- environment. Similar results were
ously could lead to events reduction reported by other authors.21,22 In
In the study by Ades et al,9 patients (eg, secondary prevention). particular, the use of supervised
were recruited not only after coro- ECG and video conference capabili-
nary artery bypass graft but also We have found that the number ties allowed objective parameters to
after acute myocardial infarction and of days from the surgical interven- be monitored during the HBCR. This
percutaneous transluminal coronary tion to rehabilitation was signifi- approach also provided accurate
angioplasty. That study compared cantly higher in the in-hospital reha- data on exercise time and bypassed
home rehabilitation and outpatient bilitative setting. The most plausible reliance on self-reported exercise
service of cardiac rehabilitation, explanation for the different times time, which may lead to an over-
whereas our study compared home to rehabilitation between the 2 estimation or underestimation of
rehabilitation and in-hospital rehabil- groups could be that hospital admis- exercise.23
itation. An important difference in sion requires hospital patient turn-
technology support also was found over, such as bed availability. How-
A therapeutic approach was fol- HBCR that contributed to their out- The possibility to adopt the same
lowed in this study in agreement comes, but we believe that many program in different settings justi-
with the coronary prevention guide- patients, with those inclusion crite- fies future randomized controlled
lines.24 In particular, the use of anti- ria, could benefit from a HBCR pro- studies to explore the real effective-
platelet or anticoagulant therapy for gram, particularly if other possibili- ness of telemedicine-based cardiac
reducing cardiovascular events has ties for cardiac rehabilitation do not rehabilitation programs. Mixed mod-
been shown to be equally dispensed exist in their location. Further stud- els could take into consideration the
in both settings. ies should analyze whether it is pos- management of patients with post-
sible to reach similar outcomes. surgery complications, with half of
The number of clinical events was Because of its observational and the conventional period of rehabili-
not significantly different between retrospective nature, this quasi- tation (ie, first 10 days) in the hospi-
the 2 programs: acute intervention experimental study could not apply tal and continuing at home for a sim-
was necessary only in a few cases an intention-to-treat analysis. During ilar period of time.
at home, whereas events arising dur- the exercise sessions, a greater pro-
ing in-hospital rehabilitation were portion on the cycle performed by Dr Scalvini and Dr Giordano provided con-
directly managed in the hospital. the HBCR group could have influ- cept/idea/research design. Dr Scalvini and
The study was not designed for enced the results. The inpatient sat- Dr Comini provided writing. Dr Zanelli,
cost evaluation, but we can consider isfaction was not measured by the Dr Troise, and Dr Febo provided data collec-
that the HBCR program, with equiv- same questionnaire used for HBCR. tion. Dr Comini and Dr Dalla Tomba pro-
vided data analysis. Dr Scalvini provided
alent efficacy, might result in a cost-
project management and fund procure-
benefit to the health care system Conclusions ment. Dr Scalvini, Dr Zanelli, Dr Dalla
(Lombardy region) because the The HBCR program was feasible, Tomba, Dr Troise, Dr Febo, and Dr Giordano
mean (standard deviation) fee per safe, and comparable to the con- provided study participants. Dr Comini
patient in the program is €2,972⫾ ventional in-hospital rehabilitation provided institutional liaisons. Dr Scalvini,
Dr Zanelli, Dr Comini, Dr Dalla Tomba,
€1,000.8 (US $3,945⫾$1,328) in approach, indicating that rehabilita- Dr Troise, and Dr Giordano provided consul-
HBCR compared with €7,079.6⫾ tion following cardiac surgery can tation (including review of manuscript
€2,228.7 (US $9,396⫾$2,958) in be implemented effectively at home before submission). The authors thank
in-hospital rehabilitation. when programmed with an inte- Mrs Doriana Baratti and Mr Giuliano Assoni
grated telemedicine service. In the for their excellent professional assistance and
Dr Margherita Penna for providing phar-
A well-designed and surveyed pro- Lombardy region, a great number of macy assistance. The authors are indebted to
gram, both for medical treatment patients who have undergone car- Dr Alessandro Bettini, medical writer, for the
and exercise training, could become diac surgery without complications English revision of the manuscript.
an attractive method to restore func- could participate in HBCR programs The study was approved by deliberation VIII/
tional capacity in selected patients using telemedicine as an alternative 002471 (May 11, 2006) and by the Scientific
after cardiac surgery. The good to in-hospital rehabilitation. and Technical Committee (CTS June 15,
results of this study are corroborated 2006) of Fondazione Salvatore Maugeri and
by the good results of a satisfaction The choice of participating in HBCR followed the principles stated in the Decla-
ration of Helsinki.
questionnaire. is expected to provide more options
for patients at low to medium risk. The current program is the result of the
Limitations In an era of cost-containment in authors’ participation in the CRITERIA Proj-
ect, a joint project of 2 structures: Fondazi-
Although patients self-selected into health care, the challenge to car- one Salvatore Maugeri IRCCS and Centro
the groups are representative of a diac rehabilitation specialists will be Cardiologico della Fondazione Monzino
particular subgroup of patients who to encourage home cardiac rehabili- IRCCS. This project, under the scientific
underwent cardiac surgery (with tation using a new integrated care responsibility of Dr Maurizio Marzegalli
EuroSCORE less than 5, without any model with the help of information (Cardiological Department, San Carlo Hos-
pital, Milan, Italy), was financed by the Ital-
complication after surgery, and communication technologies, appro- ian Health Ministry (Programma Di Ricerca
meeting all of the inclusion criteria), priately identifying who could be ex art.12, lett.b, D.Lgs. #502/92) and by the
the results could be applied to a safely allocated. Indeed, although Lombardy Region Decree of the General
broader population with the same patients with severe conditions Director (Health General Directorate
inclusion criteria. This study did not require a more conventional #15882, September 29, 2003) and coordi-
nated by the Lombardy Region Health and
specifically take into consideration in-hospital cardiac rehabilitation set- Family General Directorates.
(eg, asking the patients via a ques- ting, patients at low to medium risk
tionnaire) whether there were intrin- appear to be more likely triaged to DOI: 10.2522/ptj.20120212
sic factors to the patients who chose supervised home programs.
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Appendix.
Questionnaire of Satisfaction for the Home-Based Cardiac Rehabilitation Program
Question 6: Are you satisfied with the support of the system in dealing with acute crises?
Completely Satisfied Quite Satisfied Neither Satisfied nor Unsatisfied Quite Unsatisfied Totally Unsatisfied
Question 7: Do you feel more secure since having access to the service?
Very Secure Much Secure Quite Secure Poorly Secure Not At All
Question 8: How frequently do you contact your family doctor since you have had access to the service?
Much More Frequently More Frequently As Before Less Frequently Much Less Frequently
Question 9: Do you believe the access to the system improved your life?
Very Much Much Fairly Poorly Not At All
Question 10: Did the access to the service help your family or the people you live with?
Very Much Much Fairly Poorly Not At All