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(CPR)
[1–2] [PREPRINTER stage]
EURO PEAN SO CIETY O F CARDIOLOGY ®
Commentary
Telehealth-based cardiac rehabilitation: A solution to the problem of access? Lis Neubeck
The benefits of cardiac rehabilitation (CR) following a cardiac event are well established.1 Participation in a CR programme reduces cardiovascular risk factors, improves quality of life, increases adherence to cardioprotective medications and decreases morbidity and mortality.1 Importantly, these benefits have been demonstrated to be the same regardless of programme duration,2 whether they are delivered by a generalist or specialist,2 and whether they are delivered in a hospital or at home.3 Much of CR is delivered in a face-to-face, group-based setting, in a model that has not changed over the past two decades.4 Despite the clear benefits of these programmes, substantial challenges remain. Globally, uptake of CR following a cardiac event is between 15–30%,5 with a recent paper indicating that only 25% of people have even a minimum level of secondary prevention after a cardiac event, including appropriate medications, lifestyle advice and referral to CR.6 Access to these programmes is limited by many factors, including distance to the providing centre, feelings of embarrassment that participants have about taking part in group exercise sessions and language barriers.5 It has been suggested that programmes that are delivered remotely, such as telehealth-based programmes might overcome these barriers.7 Systematic reviews have shown the benefits of telehealth programmes when compared to usual care.7,8 However, what has been unknown is whether telehealth programmes are as effective at reducing cardiovascular risk factors and improving quality of life as the traditional, face-to-face model of CR. In their paper in this issue of the European Journal of Preventive Cardiology, Huang and colleagues undertook a systematic review of 15 papers, reporting nine randomised controlled trials (RCTs).9 These RCTs compared a telehealth intervention to face-to-face CR. In this nicely conducted review, the results indicate that there was no difference between the telehealth interventions and face-to-face CR in terms of exercise capacity, weight, blood pressure, lipid profiles, smoking, quality of life and psychosocial state. These encouraging findings suggest that there are alternatives that are non-inferior to the face-to-face model of care. This is of great relevance because Internet access is
European Journal of Preventive Cardiology 0(00) 1–2 ! The European Society of Cardiology 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2047487315574282 ejpc.sagepub.com
increasing exponentially, such that almost half of the world’s population now has Internet access10 and 72% of people in a recent survey stated that they had sought health information on the Internet in the preceding year.11 Indeed, up to a third of US adults have gone online to find a diagnosis before consulting a health care professional.11 The changing face of technology brings hope that new models of care might effectively enable people who do not currently access CR to participate. This might equally apply in low and middle income countries, which have had very low access to face-to-face services. The term ‘leapfrogging’ has been used to describe how technology is helping to bypass traditional barriers of access that these countries face.12 Technology may be utilised to overcome barriers of distance and time and could help to provide information translated into other languages. It could also potentially overcome personal embarrassment that people may feel about participating in a face-to-face programme.5 However, together with opportunities that technologies bring there are challenges. All health-related websites are not created equal and there is an overwhelming amount of poor, inaccurate or even dangerous information available on the Internet.13 Disparity still occurs between those of higher socio-economic status and those of lower socio-economic status.11 Since cardiovascular disease often affects older people, it is worth noting that specific challenges exist for older people in gaining access to the Internet. This may be in relation to cost of devices, cost of downloading digital data, visual acuity and fear of making mistakes, which might ‘break’ the computer.14 Newer models of care, such as mobile app-based interventions, show considerable promise in increasing
Sydney Nursing School, University of Sydney, Australia The George Institute for Global Health, Australia Corresponding author: Lis Neubeck, Sydney Nursing School, Charles Perkins Centre, Building D17, University of Sydney, Camperdown, NSW 2006, Australia. Email: [email protected]
Downloaded from cpr.sagepub.com at WESTERN OREGON UNIVERSITY on May 28, 2015
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(CPR)
[1–2] [PREPRINTER stage]
2
European Journal of Preventive Cardiology 0(00)
options to improve access. A recent RCT that compared mobile app-based CR to face-to-face CR demonstrated significant gains in risk factor reduction in both arms of the study.15 Moreover, there was significantly greater adherence and completion in the mobile app group,15 which is of great interest when we consider the low uptake and adherence to a face-to-face model of care. Mobile apps have enormous potential to improve health. There are over 43,000 health-related apps listed in the iTunes store.16 Although the quality of these apps is generally low, there is potential to use existing apps to facilitate risk factor reduction. A chief barrier to use of existing apps is the difficulty in identifying which ones are appropriate, due to cataloguing limitations on the app distribution platforms. There are some sites that strive to list recommended and tested health-related apps, for example, the NHS Health Apps Library.17 While at present there are only a few apps listed that are suitable for risk factor reduction in cardiovascular disease, this is an area that will undoubtedly improve as demand to access suitable apps grows. Another area that deserves exploration is the use of social media to deliver CR. A vast number of social media sites exist, for example, Twitter and Facebook. Access to social media accounts for 25% of time spent online.10 One third of older adults using the Internet will use it to access Facebook or Linkedin.11 Social media have not yet been robustly tested, although show promise in areas such as smoking cessation18 and social media-based models of care could provide a low cost adjunct to other services to increase consumer engagement. The solution to ensuring equitable access to CR is likely to be multi-faceted and the findings that telehealth is non-inferior to face-to-face CR9 gives us confidence that telehealth-based options are an important part of the overall package of CR strategies. Funding LN is funded by an NHMRC early career fellowship (APP1036763).
Conflict of interest None declared.
References 1. Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011; CD001800. 2. Clark AM, Hartling L, Vandermeer B, et al. Secondary prevention programmes for coronary heart disease: a meta-regression showing the merits of shorter, generalist, primary care-based interventions. Eur J Cardiovasc Prev Rehabil 2007; 14: 538–546.
3. Dalal HM, Zawada A, Jolly K, et al. Home based versus centre based cardiac rehabilitation: Cochrane systematic review and meta-analysis. Brit Med J. 2010; 340: b5631. 4. Briffa T, Kinsman L, Maiorana A, et al. An integrated and coordinated approach to preventing recurrent coronary heart disease events in Australia. Policy statement from the Australian Cardiovascular Health and Rehabilitation Association. Med J Aust. 2009; 190: 683–686. 5. Neubeck L, Freedman S, Clark A, et al. Participating in cardiac rehabilitation: A systematic review and metasynthesis of qualitative data. Eur J Cardiovasc Prev Rehabil. 2011; 19: 194–503. 6. Redfern J, Hyun K, Chew DP, et al. Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand. Heart 2014; 16: 1281–1288. 7. Neubeck L, Redfern J, Fernandez R, et al. Telehealth interventions for the secondary prevention of coronary heart disease: a systematic review. Eur J Cardiovasc Prev Rehabil 2009; 16: 281–289. 8. Clark RA, Conway A, Poulsen V, et al. Alternative models of cardiac rehabilitation: a systematic review. Eur J Prev Cardiol 2013; 22: 35–74. 9. Huang K, Liua W, Heb D, et al. Telehealth interventions versus centre-based cardiac rehabilitation of coronary artery disease: a systematic review and meta-analysis. Eur J Prev Cardiol 2014. 10. Internet World Stats. The Internet Big Picture. http:// wwwinternetworldstatscom/statshtm. (2013; accessed 25 March 2013). 11. Fox S and Duggan M. Mobile health 2012. Pew Research Center’s Internet American Life Project. http://www. pewinternet.org/2012/11/08/mobile-health-2012/(2012, accessed 30 November 2014). 12. Bastawrous A and Armstrong MJ. Mobile health use in low-and high-income countries: an overview of the peer-reviewed literature. J Royal Soc Med 2013; 106: 130–142. 13. Kitchens B, Harle CA and Li S. Quality of health-related online search results. Decis Support Syst 2014; 57: 454–462. 14. Macias W and McMillan S. The return of the house call: The role of Internet-based interactivity in bringing health information home to older adults. J Health Commun 2008; 23: 34–44. 15. Varnfield M, Karunanithi M, Lee C-K, et al. Smartphonebased home care model improved use of cardiac rehabilitation in postmyocardial infarction patients: results from a randomised controlled trial. Heart 2014; 100: 1770–1779. 16. IMS Institute for Health Informatics. Patient apps for improved healthcare: from novelty to mainstream.http://www.imshealth.com/deployedfiles/ imshealth/Global/Content/Corporate/IMS%20Health% 20Institute/Reports/Patient_Apps/IIHI_Patient_Apps_ Report.pdf (2013, accessed 22 September 2014). 17. NHS England. NHS choices health apps library. http:// apps.nhs.uk/ (2014, accessed 16 October 2014). 18. Struik LL and Baskerville NB. The role of Facebook in crush the crave, a mobile-and social media-based smoking cessation intervention: Qualitative framework analysis of posts. J Med Int Res 2014; 16: e170.
Downloaded from cpr.sagepub.com at WESTERN OREGON UNIVERSITY on May 28, 2015
(CPR)
[1–2] [PREPRINTER stage]
EURO PEAN SO CIETY O F CARDIOLOGY ®
Commentary
Telehealth-based cardiac rehabilitation: A solution to the problem of access? Lis Neubeck
The benefits of cardiac rehabilitation (CR) following a cardiac event are well established.1 Participation in a CR programme reduces cardiovascular risk factors, improves quality of life, increases adherence to cardioprotective medications and decreases morbidity and mortality.1 Importantly, these benefits have been demonstrated to be the same regardless of programme duration,2 whether they are delivered by a generalist or specialist,2 and whether they are delivered in a hospital or at home.3 Much of CR is delivered in a face-to-face, group-based setting, in a model that has not changed over the past two decades.4 Despite the clear benefits of these programmes, substantial challenges remain. Globally, uptake of CR following a cardiac event is between 15–30%,5 with a recent paper indicating that only 25% of people have even a minimum level of secondary prevention after a cardiac event, including appropriate medications, lifestyle advice and referral to CR.6 Access to these programmes is limited by many factors, including distance to the providing centre, feelings of embarrassment that participants have about taking part in group exercise sessions and language barriers.5 It has been suggested that programmes that are delivered remotely, such as telehealth-based programmes might overcome these barriers.7 Systematic reviews have shown the benefits of telehealth programmes when compared to usual care.7,8 However, what has been unknown is whether telehealth programmes are as effective at reducing cardiovascular risk factors and improving quality of life as the traditional, face-to-face model of CR. In their paper in this issue of the European Journal of Preventive Cardiology, Huang and colleagues undertook a systematic review of 15 papers, reporting nine randomised controlled trials (RCTs).9 These RCTs compared a telehealth intervention to face-to-face CR. In this nicely conducted review, the results indicate that there was no difference between the telehealth interventions and face-to-face CR in terms of exercise capacity, weight, blood pressure, lipid profiles, smoking, quality of life and psychosocial state. These encouraging findings suggest that there are alternatives that are non-inferior to the face-to-face model of care. This is of great relevance because Internet access is
European Journal of Preventive Cardiology 0(00) 1–2 ! The European Society of Cardiology 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2047487315574282 ejpc.sagepub.com
increasing exponentially, such that almost half of the world’s population now has Internet access10 and 72% of people in a recent survey stated that they had sought health information on the Internet in the preceding year.11 Indeed, up to a third of US adults have gone online to find a diagnosis before consulting a health care professional.11 The changing face of technology brings hope that new models of care might effectively enable people who do not currently access CR to participate. This might equally apply in low and middle income countries, which have had very low access to face-to-face services. The term ‘leapfrogging’ has been used to describe how technology is helping to bypass traditional barriers of access that these countries face.12 Technology may be utilised to overcome barriers of distance and time and could help to provide information translated into other languages. It could also potentially overcome personal embarrassment that people may feel about participating in a face-to-face programme.5 However, together with opportunities that technologies bring there are challenges. All health-related websites are not created equal and there is an overwhelming amount of poor, inaccurate or even dangerous information available on the Internet.13 Disparity still occurs between those of higher socio-economic status and those of lower socio-economic status.11 Since cardiovascular disease often affects older people, it is worth noting that specific challenges exist for older people in gaining access to the Internet. This may be in relation to cost of devices, cost of downloading digital data, visual acuity and fear of making mistakes, which might ‘break’ the computer.14 Newer models of care, such as mobile app-based interventions, show considerable promise in increasing
Sydney Nursing School, University of Sydney, Australia The George Institute for Global Health, Australia Corresponding author: Lis Neubeck, Sydney Nursing School, Charles Perkins Centre, Building D17, University of Sydney, Camperdown, NSW 2006, Australia. Email: [email protected]
Downloaded from cpr.sagepub.com at WESTERN OREGON UNIVERSITY on May 28, 2015
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(CPR)
[1–2] [PREPRINTER stage]
2
European Journal of Preventive Cardiology 0(00)
options to improve access. A recent RCT that compared mobile app-based CR to face-to-face CR demonstrated significant gains in risk factor reduction in both arms of the study.15 Moreover, there was significantly greater adherence and completion in the mobile app group,15 which is of great interest when we consider the low uptake and adherence to a face-to-face model of care. Mobile apps have enormous potential to improve health. There are over 43,000 health-related apps listed in the iTunes store.16 Although the quality of these apps is generally low, there is potential to use existing apps to facilitate risk factor reduction. A chief barrier to use of existing apps is the difficulty in identifying which ones are appropriate, due to cataloguing limitations on the app distribution platforms. There are some sites that strive to list recommended and tested health-related apps, for example, the NHS Health Apps Library.17 While at present there are only a few apps listed that are suitable for risk factor reduction in cardiovascular disease, this is an area that will undoubtedly improve as demand to access suitable apps grows. Another area that deserves exploration is the use of social media to deliver CR. A vast number of social media sites exist, for example, Twitter and Facebook. Access to social media accounts for 25% of time spent online.10 One third of older adults using the Internet will use it to access Facebook or Linkedin.11 Social media have not yet been robustly tested, although show promise in areas such as smoking cessation18 and social media-based models of care could provide a low cost adjunct to other services to increase consumer engagement. The solution to ensuring equitable access to CR is likely to be multi-faceted and the findings that telehealth is non-inferior to face-to-face CR9 gives us confidence that telehealth-based options are an important part of the overall package of CR strategies. Funding LN is funded by an NHMRC early career fellowship (APP1036763).
Conflict of interest None declared.
References 1. Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011; CD001800. 2. Clark AM, Hartling L, Vandermeer B, et al. Secondary prevention programmes for coronary heart disease: a meta-regression showing the merits of shorter, generalist, primary care-based interventions. Eur J Cardiovasc Prev Rehabil 2007; 14: 538–546.
3. Dalal HM, Zawada A, Jolly K, et al. Home based versus centre based cardiac rehabilitation: Cochrane systematic review and meta-analysis. Brit Med J. 2010; 340: b5631. 4. Briffa T, Kinsman L, Maiorana A, et al. An integrated and coordinated approach to preventing recurrent coronary heart disease events in Australia. Policy statement from the Australian Cardiovascular Health and Rehabilitation Association. Med J Aust. 2009; 190: 683–686. 5. Neubeck L, Freedman S, Clark A, et al. Participating in cardiac rehabilitation: A systematic review and metasynthesis of qualitative data. Eur J Cardiovasc Prev Rehabil. 2011; 19: 194–503. 6. Redfern J, Hyun K, Chew DP, et al. Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand. Heart 2014; 16: 1281–1288. 7. Neubeck L, Redfern J, Fernandez R, et al. Telehealth interventions for the secondary prevention of coronary heart disease: a systematic review. Eur J Cardiovasc Prev Rehabil 2009; 16: 281–289. 8. Clark RA, Conway A, Poulsen V, et al. Alternative models of cardiac rehabilitation: a systematic review. Eur J Prev Cardiol 2013; 22: 35–74. 9. Huang K, Liua W, Heb D, et al. Telehealth interventions versus centre-based cardiac rehabilitation of coronary artery disease: a systematic review and meta-analysis. Eur J Prev Cardiol 2014. 10. Internet World Stats. The Internet Big Picture. http:// wwwinternetworldstatscom/statshtm. (2013; accessed 25 March 2013). 11. Fox S and Duggan M. Mobile health 2012. Pew Research Center’s Internet American Life Project. http://www. pewinternet.org/2012/11/08/mobile-health-2012/(2012, accessed 30 November 2014). 12. Bastawrous A and Armstrong MJ. Mobile health use in low-and high-income countries: an overview of the peer-reviewed literature. J Royal Soc Med 2013; 106: 130–142. 13. Kitchens B, Harle CA and Li S. Quality of health-related online search results. Decis Support Syst 2014; 57: 454–462. 14. Macias W and McMillan S. The return of the house call: The role of Internet-based interactivity in bringing health information home to older adults. J Health Commun 2008; 23: 34–44. 15. Varnfield M, Karunanithi M, Lee C-K, et al. Smartphonebased home care model improved use of cardiac rehabilitation in postmyocardial infarction patients: results from a randomised controlled trial. Heart 2014; 100: 1770–1779. 16. IMS Institute for Health Informatics. Patient apps for improved healthcare: from novelty to mainstream.http://www.imshealth.com/deployedfiles/ imshealth/Global/Content/Corporate/IMS%20Health% 20Institute/Reports/Patient_Apps/IIHI_Patient_Apps_ Report.pdf (2013, accessed 22 September 2014). 17. NHS England. NHS choices health apps library. http:// apps.nhs.uk/ (2014, accessed 16 October 2014). 18. Struik LL and Baskerville NB. The role of Facebook in crush the crave, a mobile-and social media-based smoking cessation intervention: Qualitative framework analysis of posts. J Med Int Res 2014; 16: e170.
Downloaded from cpr.sagepub.com at WESTERN OREGON UNIVERSITY on May 28, 2015
