Sociodemographic Characteristics Predicting Digital Health Intervention Use After Acute Myocardial Infarction

Advancing telemedicine in cardiology: A comprehensive review of evolving practices and outcomes in a postpandemic context

Telemedicine, telehealth, e-Health, and other related terms refer to the exchange of medical information or medical care from one site to another through electronic communication between a patient and a health care provider. As telemedicine infrastructure has changed since the coronavirus disease 2019 (COVID-19) pandemic, this review provides an overview of telemedicine use and effectiveness in cardiology, with emphasis on coronary artery disease in the postpandemic context. Prepandemic studies tend to report statistically insignificant or modest improvements in cardiovascular disease outcome from telemedicine use to usual care. In contrast, postpandemic studies tend to report positive outcomes or comparable acceptance of telemedicine use to usual care. Today, telemedicine can effectively replace in person follow-up visits to produce comparable (but not necessarily superior) outcomes in cardiovascular disease management. A benefit of telemedicine is the potential reduction in follow-up time or time to intervention, which may lead to earlier detection and prevention of adverse events. Nonetheless, barriers remain to effective telemedicine implementation in the postpandemic context. Ensuring accessible and user-friendly telemedicine devices, maintaining adherence to remote rehabilitation procedures, and normalizing use of telemedicine in routine follow-up visits are examples. Current knowledge gaps include the true economic cost of telemedicine infrastructure, feasibility of use in specific cardiology contexts, and sex/gender differences in telemedicine use. Future telemedicine developments will need to address these concerns before acceptance of telemedicine as the new standard of care.

Rationale and Design of the mTECH-Rehab Randomized Controlled Trial: Impact of a Mobile Technology Enabled Corrie Cardiac Rehabilitation Program on Functional Status and Cardiovascular Health

BACKGROUND

Cardiac rehabilitation (CR) is an evidence-based, guideline-recommended intervention for patients recovering from a cardiac event, surgery or procedure that improves morbidity, mortality, and functional status. CR is traditionally provided in-center, which limits access and engagement, most notably among underrepresented racial and ethnic groups due to barriers including cost, scheduling, and transportation access. This study is designed to evaluate the Corrie Hybrid CR, a technology-based, multicomponent health equity-focused intervention as an alternative to traditional in-center CR among patients recovering from a cardiac event, surgery, or procedure compared with usual care alone.

METHODS

The mTECH-Rehab (Impact of a Mobile Technology Enabled Corrie CR Program) trial will randomize 200 patients who either have diagnosis of myocardial infarction or who undergo coronary artery bypass grafting surgery, percutaneous coronary intervention, heart valve repair, or replacement presenting to 4 hospitals in a large academic health system in Maryland, United States, to the Corrie Hybrid CR program combined with usual care CR (intervention group) or usual care CR alone (control group) in a parallel arm, randomized controlled trial. The Corrie Hybrid CR program leverages 5 components: (1) a patient-facing mobile application that encourages behavior change, patient empowerment, and engagement with guideline-directed therapy; (2) Food and Drug Administration-approved smart devices that collect health metrics; (3) 2 upfront in-center CR sessions to facilitate personalization, self-efficacy, and evaluation for the safety of home exercise, followed by a combination of in-center and home-based sessions per participant preference; (4) a clinician dashboard to track health data; and (5) weekly virtual coaching sessions delivered over 12 weeks for education, encouragement, and risk factor modification. The primary outcome is the mean difference between the intervention versus control groups in distance walked on the 6-minute walk test (ie, functional capacity) at 12 weeks post randomization. Key secondary and exploratory outcomes include improvement in a composite cardiovascular health metric, CR engagement, quality of life, health factors (including low-density lipoprotein-cholesterol, hemoglobin A1c, weight, diet, smoking cessation, blood pressure), and psychosocial factors. Approval for the study was granted by the local institutional review board. Results of the trial will be published once data collection and analysis have been completed.

CONCLUSIONS

The Corrie Hybrid CR program has the potential to improve functional status, cardiovascular health, and CR engagement and advance equity in access to cardiac rehabilitation.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05238103.

Does clinical research account for diversity in deploying digital health technologies?

Digital health technologies (DHTs) should expand access to clinical research to represent the social determinants of health (SDoH) across the population. The frequency of reporting participant SDoH data in clinical publications is low and is not known for studies that utilize DHTs. We evaluated representation of 11 SDoH domains in 126 DHT-enabled clinical research publications and proposed a framework under which these domains could be captured and subsequently reported in future studies. Sex, Race, and Education were most frequently reported (in 94.4%, 27.8%, and 20.6% of publications, respectively). The remaining 8 domains were reported in fewer than 10% of publications. Medical codes were identified that map to each of the proposed SDoH domains and the resulting resource is suggested to highlight that existing infrastructure could be used to capture SDoH data. An opportunity exists to increase reporting on the representation of SDoH among participants to encourage equitable and inclusive research progress through DHT-enabled clinical studies.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Interventions for Caregivers of Heart Disease Patients in Rehabilitation: Scoping Review

Map the interventions/components directed to the caregivers of heart disease patients in cardiac rehabilitation programs that promote their role and health.

METHODS

The Joanna Briggs Institute method was used to guide this scoping review. Two independent reviewers assessed articles for relevance and extracted and synthesized data. Inclusion criteria comprised articles published in English, Spanish, and Portuguese since 1950. The following databases were searched: CINAHL Complete (Via EBSCO), Medline (via PubMed), Scopus, PEDro, and Repositórios Científicos de Acesso Aberto de Portugal (RCAAP).

RESULTS

From 351 articles retrieved, 10 were included in the review. The interventions identified directed to the caregiver were: educational interventions and lifestyle changes; physical exercise; psychological interventions/stress management; and a category "Other" with training interventions in basic life support, elaboration of guidelines/recommendations, and training for the role of caregiver.

CONCLUSIONS

It was found that most of the related cardiac rehabilitation interventions are aimed at the dyad heart failure patient and their caregivers/family. Including specific interventions targeting caregivers improves the caregiver's health and empowers them. Patient care planning should include interventions specifically aimed at them that result in health gains for caregivers and patients, striving to improve the quality of care. This study was not registered.

Comparison of 30-day planned and unplanned readmissions in a tertiary teaching hospital in China

PURPOSE

The purpose of this study was to analyze and compare the clinical characteristics of patients with 30-day planned and unplanned readmissions and to identify patients at high risk for unplanned readmissions. This will facilitate a better understanding of these readmissions and improve and optimize resource utilization for this patient population.

METHODS

A retrospective cohort descriptive study was conducted at the West China Hospital (WCH), Sichuan University from January 1, 2015, to December 31, 2020. Discharged patients (≥ 18 years old) were divided into unplanned readmission and planned readmission groups according to 30-day readmission status. Demographic and related information was collected for each patient. Logistic regression analysis was used to assess the association between unplanned patient characteristics and the risk of readmission.

RESULTS

We identified 1,118,437 patients from 1,242,496 discharged patients, including 74,494 (6.7%) 30-day planned readmissions and 9,895 (0.9%) unplanned readmissions. The most common diseases of planned readmissions were antineoplastic chemotherapy (62,756/177,749; 35.3%), radiotherapy sessions for malignancy (919/8,229; 11.2%), and systemic lupus erythematosus (607/4,620; 13.1%). The most common diseases of unplanned readmissions were antineoplastic chemotherapy (2038/177,747; 1.1%), age-related cataract (1061/21,255; 5.0%), and unspecified disorder of refraction (544/5,134; 10.6%). There were statistically significant differences between planned and unplanned readmissions in terms of patient sex, marital status, age, length of initial stay, the time between discharge, ICU stay, surgery, and health insurance.

CONCLUSION

Accurate information on 30-day planned and unplanned readmissions facilitates effective planning of healthcare resource allocation. Identifying risk factors for 30-day unplanned readmissions can help develop interventions to reduce readmission rates.

Patterns of Engagement With an Application-Based Dietary Self-Monitoring Tool Within a Randomized Controlled Feasibility Trial

Introduction

The Dietary Approaches to Stop Hypertension dietary pattern is a proven way to manage hypertension, but adherence remains low. Dietary tracking applications offer a highly disseminable way to self-monitor intake on the pathway to reaching dietary goals but require consistent engagement to support behavior change. Few studies use longitudinal dietary self-monitoring data to assess trajectories and predictors of engagement. We used dietary self-monitoring data from participants in Dietary Approaches to Stop Hypertension Cloud (N=59), a feasibility trial to improve diet quality among women with hypertension, to identify trajectories of engagement and explore associations between participant characteristics.

Methods

We used latent class growth modeling to identify trajectories of engagement with a publicly available diet tracking application and used bivariate and regression analyses to assess the associations of classifications of engagement with participant characteristics.

Results

We identified 2 latent classes of engagement: consistent engagers and disengagers. Consistent engagers were more likely to be older, more educated, and married or living with a partner. Although consistent engagers exhibited slightly greater changes in Dietary Approaches to Stop Hypertension score, the difference was not significant.

Conclusions

This study highlights an important yet underutilized methodologic approach for uncovering dietary self-monitoring engagement patterns. Understanding how certain individuals engage with digital technologies is an important step toward designing cost-effective behavior change interventions.

Trial registration

This study is registered at www.clinicaltrials.gov NCT03215472.

Behaviour change techniques in cardiovascular disease smartphone apps to improve physical activity and sedentary behaviour: Systematic review and meta-regression

Background

Smartphone apps are increasingly used to deliver physical activity and sedentary behaviour interventions for people with cardiovascular disease. However, the active components of these interventions which aim to change behaviours are unclear.

Aims

To identify behaviour change techniques used in smartphone app interventions for improving physical activity and sedentary behaviour in people with cardiovascular disease. Secondly, to investigate the association of the identified techniques on improving these behaviours.

Methods

Six databases (Medline, CINAHL Plus, Cochrane Library, SCOPUS, Sports Discus, EMBASE) were searched from 2007 to October 2020. Eligible studies used a smartphone app intervention for people with cardiovascular disease and reported a physical activity and/or sedentary behaviour outcome. The behaviour change techniques used within the apps for physical activity and/or sedentary behaviour were coded using the Behaviour Change Technique Taxonomy (v1). The association of behaviour change techniques on physical activity outcomes were explored through meta-regression.

Results

Forty behaviour change techniques were identified across the 19 included app-based interventions. Only two studies reported the behaviour change techniques used to target sedentary behaviour change. The most frequently used techniques for sedentary behaviour and physical activity were habit reversal and self-monitoring of behaviour respectively. In univariable analyses, action planning (β =0.42, 90%CrI 0.07–0.78) and graded tasks (β =0.33, 90%CrI -0.04-0.67) each had medium positive associations with increasing physical activity. Participants in interventions that used either self-monitoring outcome(s) of behaviour (i.e. outcomes other than physical activity) (β = − 0.47, 90%CrI -0.79--0.16), biofeedback (β = − 0.47, 90%CrI -0.81--0.15) and information about health consequences (β = − 0.42, 90%CrI -0.74--0.07) as behaviour change techniques, appeared to do less physical activity. In the multivariable model, these predictors were not clearly removed from zero.

Conclusion

The behaviour change techniques action planning and graded tasks are good candidates for causal testing in future experimental smartphone app designs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01319-8.

Cost-effectiveness of a Digital Health Intervention for Acute Myocardial Infarction Recovery

BACKGROUND

Acute myocardial infarction (AMI) is a common cause of hospital admissions, readmissions, and mortality worldwide. Digital health interventions (DHIs) that promote self-management, adherence to guideline-directed therapy, and cardiovascular risk reduction may improve health outcomes in this population. The "Corrie" DHI consists of a smartphone application, smartwatch, and wireless blood pressure monitor to support medication tracking, education, vital signs monitoring, and care coordination. We aimed to assess the cost-effectiveness of this DHI plus standard of care in reducing 30-day readmissions among AMI patients in comparison to standard of care alone.

METHODS

A Markov model was used to explore cost-effectiveness from the hospital perspective. The time horizon of the analysis was 1 year, with 30-day cycles, using inflation-adjusted cost data with no discount rate. Currencies were quantified in US dollars, and effectiveness was measured in quality-adjusted life-years (QALYs). The results were interpreted as an incremental cost-effectiveness ratio at a threshold of $100,000 per QALY. Univariate sensitivity and multivariate probabilistic sensitivity analyses tested model uncertainty.

RESULTS

The DHI reduced costs and increased QALYs on average, dominating standard of care in 99.7% of simulations in the probabilistic analysis. Based on the assumption that the DHI costs $2750 per patient, use of the DHI leads to a cost-savings of $7274 per patient compared with standard of care alone.

CONCLUSIONS

Our results demonstrate that this DHI is cost-saving through the reduction of risk for all-cause readmission following AMI. DHIs that promote improved adherence with guideline-based health care can reduce hospital readmissions and associated costs.