How ICT has helped home-based cardiac rehab

Australian researchers have traced the growth in the use of ICT-based programs to improve adherence to cardiac rehabilitation programs, finding that a range of choices should be made available that individuals can tailor to their own needs.

In a literature review conducted by Marlien Varnfield and Mohan Karunanithi of the Australian eHealth Research Centre and published in Smart Homecare Technology and TeleHealth, the growth of home-based cardiac rehab (CR) is traced over the last 20-odd years, moving from telephone coaching to text messaging to remote monitoring using the sensors that now come as standard in smartphones.

Evidence is growing that these sorts of interventions help by improving physiological and psychological outcomes but also in overcoming the barriers of hospital outpatient centre-based CR programs.

Cardiac rehab is a proven approach to secondary prevention for patients recovering after a cardiac event. In Australia and New Zealand, it usually takes the form of a structured six to eight-week course after discharge of supervised ambulatory programs, followed by an ongoing maintenance phase to reduce risk factors through self-management.

However, as the authors point out, adherence to these programs is very low, for a range of reasons. In Australia, several studies have shown that shown that as few as 20 per cent of patients complete a CR program with remote indigenous patients are even less likely to participate. The authors say the low CR participation rate here is reflective of other developed countries.

Some of the reasons behind this include limited referrals to CR programs due to scepticism by doctors and patients, logistical reasons such as site locations, limited transport and lack of availability, as well as personal factors such as a dislike of group-based classes, the need to return to work and family commitments.

As the authors write, to overcome some of the barriers to the traditional delivery of CR, different delivery platforms and approaches have been developed in recent years. These include patient-provider contact delivered by telephone systems; the use of the internet, with the majority of patient-provider contact for risk factor management taking place online; and interventions using smartphones as tools to deliver CR through SMS, journaling applications, connected measurement devices, and remote coaching.

Home-based CR using these technologies began to be introduced in the late 1990s, but the authors say researchers have been preoccupied with improving CR program delivery into patients’ homes through remote monitoring since the 1960s. These, however, have been limited to the exercise component of CR rather than a comprehensive approach.

Some of the first projects looked at delivering home-based programs using visits by nurses backed up by coaching over the phone and computer-generated mailings. For example, Robert DeBusk of Stanford University in the US pioneered home-based CR using telephone calls and computer-generated progress reports through the MULTIFIT program back in 1996.

Closer to home, Margarite Vale and Michael Jelinek have worked for over two decades on the Coaching patients On Achieving Cardiovascular Health (COACH) system, a home-based model that involves medications management as well as coaching sessions delivered by phone and mail-outs. COACH has since been extended to other chronic diseases such as diabetes and is widely supported in Australia.

In the UK, the Cornwall Heart Attack Rehabilitation Management Study (CHARMS) added a self-help manual to a six-week exercise, stress management, and education with telephone-supported home-based CR, the authors write.

They also point to a 2000 US study that pioneered remote physiological monitoring following the introduction of technology to send ECG recordings over the phone to care centres for support. This study showed that home-based CR had similar improvements in exercise capacity as home-based CR.

The internet, of course, has been hailed as a breakthrough for a number of health interventions, including cardiac rehab. The authors point to a 2013 UK literature review of nine patient-focused, internet-based approaches to CR, which found that uptake rates with internet interventions were high but adherence was low.

Two other papers of note were recent studies from Canada and South Australia. The first was a virtual CR program (vCRP), delivered through the internet, that mimicked standard hospital-based CR delivery.

“It included a recordable heart rate monitor that connected with the vCRP website; data capture for exercise stress test and blood test results; education sessions; progress notes; monthly ask-an-expert group chat sessions; and private online chat sessions with clinicians,” the authors write. “The vCRP group showed significantly higher exercise capacity and dietary quality.”

The SA study is part of several led by Philip Tideman and colleagues from South Australia's Integrated Cardiovascular Clinical Network (iCCNet). One of their pilot studies involves an internet-based self-management website system called electronic outpatient cardiac rehabilitation (eOCR) for rural patients, through which case managers could provide education, track patient progress and have contact with the patient.

“The eOCR system was able to increase the reach of a CR and secondary prevention program within regions where previously limited services had been available,” the authors write.

Following website-based interventions comes mobile interventions, with smartphones now containing the capability to do much more. Smartphones are being used for SMS-based programs, journaling applications, connected devices and remote coaching.

The point to a US study into the effect of a text messaging program on the number of sessions completed in outpatient CR, together with other outcomes, which showed that patients who participated in the text-messaging program attended significantly more sessions and were more likely to complete outpatient CR than patients who did not.

In New Zealand, the University of Auckland has also been heavily involved in developing mHealth applications to deliver CR. Researchers led by Robyn Whittaker have developed the Text4Heart system, which is currently undergoing a large trial.

“Participants receive a tailored program of SMS text messages via their mobile phone with evidence-based information on actions that will reduce the risk of subsequent events,” the authors write. “The results from these research studies could aid in understanding the effectiveness of mobile phone applications, combined with health coaching, used in long-term interventions requiring a degree of self-management.”

In Queensland, researchers have developed the Care Assessment Platform (CAP), which the authors say was the first to employ new-generation smartphones with built-in sensors, mobile health diary applications and a corresponding internet portal to deliver components of a comprehensive CR program at home.

This program uses physical activity measurements from a built-in accelerometer as well as from the WellnessDiary journaling application. It also employed telephone-based coaching as well as allowing participants to view their own data displayed as text or graphs.

According to the authors – both of whom have been involved in developing CAP-CR – the results of a recent trial validating the program were published recently and were “remarkable”.

They showed improved uptake and an adherence of 94 per cent among participants, which resulted in completion rates of 30 per cent when compared to those attending centre-based CR programs.

“Moreover, CAP-CR participants demonstrated similar improvements in physical activity, nutrition, and the lowering of depression as those of the centre-based CR group,” they write. “CAP-CR was also effective in significantly reducing anxiety and increasing [health-related quality of life].”

Not surprisingly, the authors see smartphones as the future, as they offer the flexibility that some internet-based interventions do not. They also now include capabilities that can be harnessed for health purposes, including in-built sensors that enable geolocation, activity measurement (accelerometers), storage and connectivity to the internet via the mobile network.

Many now also have wireless connectivity features that can connect to health devices such as blood pressure and glucose level monitors, thereby enabling the automated and accurate capture of measurements as they are performed.

One size does not fit all, however, and the authors conclude that while ICT has the potential to revolutionise the way in which CR programs are delivered, all options should be explored.

“Instead of providing one uniform intervention for all, irrespective of the patient’s condition, it is appropriate to provide a set of choices of interventions or components thereof from which individuals can then self-tailor an intervention that best suits their personal needs and circumstances,” they write.

Information and communication technology-based cardiac rehabilitation homecare programs by Marlien Varnfield and Mohan Karunanithi is published in Smart Homecare Technology and TeleHealth.

Posted in Australian eHealth

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