Information and communication technology-based cardiac rehabilitation homecare programs

Figures & data

Figure 1 The three phases in the traditional secondary prevention of cardiovascular disease in the Australian cardiac rehabilitation service delivery model.

Figure 2 Flow diagram of the literature search and the selection of studies.

Table 1 Summary of the studies included in this review

Study		Type of trial, N, cardiac event/s		Intervention	Improved primary and/or secondary outcomes through ICT intervention
Multifactorial Telehealth delivery of home-based CR, with the majority of patient-provider contact delivered by telephone
DeBusk^Citation36 (MULTIFIT)	RCT, 585, post-MI		Nurse-initiated phone contacts Computer-generated progress reports mailed to patients		At the end of I2 months, the intervention group showed significantly greater: smoking cessation rates; total cholesterol and LDL cholesterol reductions; functional capacity.
Kodis et al^Citation37	Retrospective review, 1,042 post-CABG		Prescription and detailed guidelines for home-based exercise Telephone calls to home-based groups two to three times over 6 months		Substantial improvements at 6 months in: VO2; peak workload and metabolic equivalents; HDL cholesterol.
vale et al^Citation38 (COACH)	RCT, 792, CABG, PCI, AMI, UA		Patient contacted by telephone within 2 weeks after randomization Three telephone coaching sessions at 6-week intervals for 6 months Patients invited to contact coach if required Progress reports mailed to participants		Intervention group showed: significant improvement in total cholesterol; substantial improvements in coronary risk factors and in patient HRQoL.
Arthur et al^Citation39	RCT, 242 post-CABG		A total of 6 months of monitored, home-based exercise training Telephoned every 2 weeks Exercise logs monitored monthly		Significant improvement in peak oxygen in both groups at 6 weeks. Home group greater total social support at 3 months and 6 months, and greater improvement in HRQoL (physical) at 6 months.
Dalal et al^Citation34 (CHARMS)	RCT and preference arms, 230, MI		Nurse support typically provided by four calls over 6 weeks Self-help package (the “Heart” manual)		At 9 months, similar results to hospital-based CR in: depression and anxiety score; HRQoL and; total cholesterol levels.
Hawkes et al^Citation40 O’Neil et al^Citation45	RCT, 430, MI		A total of 10×30-minute scripted telephone health coaching sessions over 6 months		Significant improvement in health status in both groups, difference between groups not significant.
(ProActive Heart)			Handbook for patients and educational resource to use during health sessions		Intervention showed a significant reduction in anxiety.
Telehealth delivery of home-based CR, with the patient-provider contact delivered by telephone augmented by ECG monitoring
Ades et al^Citation42	Controlled study, 133, CABG, MI, PCI		For 3 months, participants exercised three times per week with a stationary cycle ergometer with direct communication to the nurse Simultaneous conference calls with other CR patients		The home-based group increased peak aerobic capacity to a similar degree to that of on-site CR patients. Similar HRQoL outcomes.
Kortke et al^Citation43	Open clinical study, 170, CABG, PCI		A 3-month ambulant CR Cardiovascular function recorded by a mobile telemedicine unit (ECG and heart rate monitor) and transmitted telephonically		The intervention showed significant improvement in maximal physical performance, physical and psychological HRQoL, lower cost.
Delivery of home-based CR with the majority of patient-provider contact for risk factor modification via the Internet
Lear et al^Citation47 (vCRP)	RCT, 78, ACS or PCI		A 4-month Internet-based program to mimic a standard hospital-based CR (vCRP) Recordable heart rate monitor Data capture for test results, education sessions, progress notes, monthly ask-an-expert group chat sessions, and private online chat sessions		The vCRP group showed significantly higher exercise capacity and dietary quality, with reductions in cholesterol levels. No differences in lipids, blood pressure, and physical activity were noted between the two study groups.
Clark et al^Citation48 (eOCR)	Pilot study, 16 health professionals and 24 patients, post-MI or angioplasty		Internet-based self-management Website system Cardiac case manager delivers education, tracks patient progress, and contacts patients and/or their caregivers via Web-based email and discussion boards or by telephone		The Website increased the reach of CR program within regions. Profiled the potential users of this type of health care (ie, active Internet users). Online discussion rooms and workbooks were not used.
Interventions using Smartphones as tools to deliver CR remotely through SMS messaging and/or journaling applications, connected measurement devices, and remote coaching
Lounsbury et al^Citation49	Retrospective analysis, 237, patients enrolled in CR		Five to seven SMS messages/week consisting of heart-healthy tips, requests for weight, minutes of exercise, blood pressure, and medication adherence		Intervention participants attended significantly more CR sessions and were significantly more likely to complete CR than patients not participating in texting.
Dale et al^Citation50 (Text4Heart)	RCT protocol, 120 (estimate), Mi, angina, or PCI		mHealth intervention group receive the core components of CR delivered via text messages (SMS) from a library of 503 messages and a supporting website over the course of 24 weeks (5-7 messages per week)		Adherence to healthy behaviors at 6 months, overall CVD risk, body composition, illness perceptions, self-efficacy, anxiety/depression, and medication adherence.
Varnfield et al^Citation51 (CAP)	RCT, 120, Mi		Smartphone application with accelerometer and health diary, visual feedback, text message reminders, educational videos, and Web portal; goal setting and education provided through weekly telephonic mentoring sessions		Significant higher uptake, adherence, and completion rates. Significant improvements on the 6-Minute Walk Test for both groups from baseline to 6 weeks. Slight weight reduction and significant improvements in emotional state and HRQoL.

Abbreviations: CR, cardiac rehabilitation; N, number; ICT, information and communication technology; RCT, randomized controlled trial; MI, myocardial infarction; LDL, low-density lipoprotein; CABG, coronary artery bypass surgery; VO₂, peak oxygen uptake; HDL, high-density lipoprotein; HRQoL, health-related quality of life; COACH, Coaching patients On Achieving Cardiovascular Health; PCI, percutaneous coronary intervention; AMI, acute myocardial infarction; UA, unstable angina; CHARMS, Cornwall Heart Attack Rehabilitation Management Study; ECG, electrocardiogram; vCRP, virtual cardiac rehabilitation program; vCRP, virtual cardiac rehabilitation program; ACS, acute coronary syndrome; eOCR, electronic outpatient cardiac rehabilitation; SMS, short message system; mHealth, mobile health; CVD, cardiovascular disease; CAP, Care Assessment Platform; CAP-CR, Care Assessment Platform cardiac rehabilitation.

Figure 3 Examples of user interfaces for delivering cardiac rehabilitation through the Internet (A) and a journaling application on a mobile phone combined with portal (B). Figure 3A courtesy of Professors Kerry Mummery and Robyn Clark.

Abbreviation: eOCR, electronic outpatient cardiac rehabilitation.

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