Cost-effectiveness of telehealth-delivered diet and exercise interventions: A systematic review

OBJECTIVES

Telehealth is a promising tool for delivering lifestyle interventions for the management of health conditions. However, limited evidence exists regarding the cost-effectiveness of these interventions. This systematic review aimed to evaluate the current literature reporting on the cost-effectiveness of telehealth-delivered diet and/or exercise interventions.

METHODS

Four electronic databases (PubMed, CENTRAL, CINAHL and Embase) were searched for published literature from database inception to November 2020. This review adhered to the preferred reporting items for systematic reviews and meta-analyses guidelines and the ISPOR Criteria for Cost-Effectiveness Review Outcomes Checklist. The quality of reporting was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist. The extracted data were grouped into subcategories according to telehealth modality, organised into tables and reported narratively.

RESULTS

Twenty-four studies of controlled trials (11 combined diet and exercise, 9 exercise-only and 4 diet-only telehealth-delivered interventions) were included for data extraction and quality assessment. Interventions were reported as cost-effective in 12 studies (50%), five studies (21%) reported inconclusive results, and seven studies (29%) reported that the interventions were not cost-effective. Telephone interventions were applied in eight studies (33%), seven studies (29%) used internet interventions, six studies (25%) used a combination of internet and telephone interventions, and three studies (13%) evaluated mHealth interventions. Quality of study reporting varied with between 54% and 92% of Consolidated Health Economic Evaluation Reporting Standards items reported.

CONCLUSIONS

This review suggests that telehealth-delivered lifestyle interventions can be cost-effective compared to traditional care. There is a need for further investigations that employ rigorous methodology and economic reporting, including appropriate decision analytical models and longer timeframes.

A Systematic Review of Clinical Practice Guidelines and Consensus Statements for Cardiac Rehabilitation Delivery: Consensus, Divergence, and Important Knowledge Gaps

BACKGROUND

After 2020, clinical practice recommendations have been released to inform cardiac rehabilitation (CR) programs of best practices for post-COVID programming. The objective of this systematic review was to identify and summarize recommendations from clinical practice guidelines (CPGs) and consensus statements for CR delivery postpandemic.

METHODS

Five databases (March 2020 through April 2023), grey literature and Web sites of CR international associations were searched. Inclusion criteria were local, national, and international association-endorsed CPGs, and/or position, expert, and scientific statements related to CR delivery (program models, program elements, and core components). Two researchers independently screened the citations for inclusion. The Appraisal of Guidelines for Research and Evaluation (AGREE) II was used for quality assessment. Results were analyzed in accordance with the Synthesis Without Meta-analysis (SWiM) reporting guidelines.

RESULTS

Overall, 4890 records were identified; 4 CPGs, 9 position/scientific statements, and 6 expert/Delphi consensus papers were included. All guidelines/statements included information related to program delivery models, with 95% endorsing the use of virtual, hybrid, home-based, and telerehabilitation, especially during the pandemic. Outside of the context of COVID-19, program components including referral, CR indications, CR contraindications, timing, and structure were included in the 4 CPGs and 2 of 15 statements. Recommendations related to CR core components were primarily focused on exercise, with no changes since before the pandemic except for COVID-19 considerations for safety. One guideline was specific to women, and 1 scientific statement to heart failure with preserved ejection fraction.

CONCLUSIONS

Although 19 documents were identified, CR delivery in low resource settings and for culturally and linguistically diverse populations require attention. Additionally, few recommendations on nutrition, psychosocial counselling, and patient education were reported.

Safety and long-term outcomes of remote cardiac rehabilitation in coronary heart disease patients: A systematic review

Objective

To systematically review the safety and the long-term mortality and morbidity risk-rates of the remotely-delivered cardiac rehabilitation (RDCR) interventions in coronary heart disease (CHD) patients.

Methods

The protocol was registered in the International Prospective Register of Systematic Reviews (CRD42023455471). Five databases (Pubmed, Scopus, Cochrane Central Register of Controlled Trials in the Cochrane Library, Cinahl and Web of Science) were reviewed from January 2012 up to August 2023. Inclusion criteria were: (a) randomized controlled trials, (b) RDCR implementation of at least 12 weeks duration, (c) assessment of safety, rates of serious adverse events (SAEs) and re-hospitalization incidences at endpoints more than 6 months. Three reviewers independently performed data extraction and assessed the risk of bias using the Cochrane Risk of Bias tool.

Results

14 studies were identified involving 2012 participants and a range of RDCR duration between 3 months to 1 year. The incidence rate of exercise-related SAEs was estimated at 1 per 53,770 patient-hours of RDCR exercise. A non-statistically significant reduction in the re-hospitalization rates and the days lost due to hospitalization was noticed in the RDCR groups. There were no exercise-related deaths. The overall study quality was of low risk.

Conclusions

RDCR can act as a safe alternative delivery mode of cardiac rehabilitation (CR). The low long-term rates of reported SAEs and re-hospitalization incidences of the RDCR could enhance the uptake rates of CR interventions. However, further investigation is needed in larger populations and longer assessment points.

Cost-effectiveness of telehealth-delivered nutrition interventions: a systematic review of randomized controlled trials

CONTEXT

Telehealth-delivered nutrition interventions are effective in practice; however, limited evidence exists regarding their cost-effectiveness.

OBJECTIVE

To evaluate the cost-effectiveness of telehealth-delivered nutrition interventions for improving health outcomes in adults with chronic disease.

DATA SOURCES

PubMed, CENTRAL, CINAHL, and Embase databases were systematically searched from database inception to November 2021. Included studies were randomized controlled trials delivering a telehealth-delivered diet intervention conducted with adults with a chronic disease and that reported on cost-effectiveness or cost-utility analysis outcomes.

DATA EXTRACTION

All studies were independently screened and extracted, and quality was appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

DATA ANALYSIS

All extracted data were grouped into subcategories according to their telehealth modality and payer perspective, and were analyzed narratively.

RESULTS

Twelve randomized controlled trials comprising 5 phone-only interventions, 3 mobile health (mHealth), 2 online, and 1 each using a combination of phone-online or phone-mHealth interventions, were included in this review. mHealth interventions were the most cost-effective intervention in all studies. Across all telehealth interventions and cost analyses from health service perspectives, 60% of studies were cost-effective. From a societal perspective, however, 33% of studies reported that the interventions were cost-effective. Of the 10 studies using cost-utility analyses, 3 were cost saving and more effective, making the intervention dominant, 1 study reported no difference in costs or effectiveness, and the remaining 6 studies reported increased cost and effectiveness, meaning payers must decide whether this falls within an acceptable willingness-to-pay threshold for them. Quality of study reporting varied with between 63% to 92%, with an average of 77% of CHEERS items reported.

CONCLUSION

Telehealth-delivered nutrition interventions in chronic disease populations appear to be cost-effective from a health perspective, and particularly mHealth modalities. These findings support telehealth-delivered nutrition care as a clinically beneficial, cost-effective intervention delivery modality.

Remote Cardiac Rehabilitation With Wearable Devices

Although cardiac rehabilitation (CR) has been shown to improve exercise tolerance and prognosis in patients with cardiovascular diseases, there remains low participation in outpatient CR. This may be attributed to the patients' busy schedules and difficulty in visiting the hospital due to distance, cost, avoidance of exercise, and severity of coronary disease. To overcome these challenges, many countries are exploring the possibility of remote CR. Specifically, there is increasing attention on the development of remote CR devices, which allow transmission of vital information to the hospital via a remote CR application linked to a wearable device for telemonitoring by dedicated hospital staff. In addition, remote CR programs can support return to work after hospitalization. Previous studies have demonstrated the effects of remote CR on exercise tolerance. However, the preventive effects of remote CR on cardiac events and mortality remain controversial. Thus, safe and effective remote CR requires exercise risk stratification for each patient, telenursing by skilled staff, and multidisciplinary interventions. Therefore, quality assurance of telenursing and multi-disciplinary interventions will be essential for remote CR. Remote CR may become an important part of cardiac management in the future. However, issues such as cost-effectiveness and insurance coverage still persist.

Correlation between MOVA3D, a Monocular Movement Analysis System, and Qualisys Track Manager (QTM) during Lower Limb Movements in Healthy Adults: A Preliminary Study

New technologies based on virtual reality and augmented reality offer promising perspectives in an attempt to increase the assessment of human kinematics. The aim of this work was to develop a markerless 3D motion analysis capture system (MOVA3D) and to test it versus Qualisys Track Manager (QTM). A digital camera was used to capture the data, and proprietary software capable of automatically inferring the joint centers in 3D and performing the angular kinematic calculations of interest was developed for such analysis. In the experiment, 10 subjects (22 to 50 years old), 5 men and 5 women, with a body mass index between 18.5 and 29.9 kg/m2, performed squatting, hip flexion, and abduction movements, and both systems measured the hip abduction/adduction angle and hip flexion/extension, simultaneously. The mean value of the difference between the QTM system and the MOVA3D system for all frames for each joint angle was analyzed with Pearson's correlation coefficient (r). The MOVA3D system reached good (above 0.75) or excellent (above 0.90) correlations in 6 out of 8 variables. The average error remained below 12° in only 20 out of 24 variables analyzed. The MOVA3D system is therefore promising for use in telerehabilitation or other applications where this level of error is acceptable. Future studies should continue to validate the MOVA3D as updated versions of their software are developed.

Effectiveness of smartphone-assisted cardiac rehabilitation: a systematic review and meta-analysis

PURPOSE

To explore the effectiveness of smartphone-assisted home cardiac rehabilitation and whether it can be used as a remote detection method to promote home cardiac rehabilitation.

METHODS

Four databases were searched to collect randomized controlled trials (RCTs) about smartphone-assisted cardiac rehabilitation. The Cochrane risk-of-bias tool was used to assess the methodological quality of the included studies. Two independent investigators performed the literature screening, information extraction, and risk of bias assessment. Any disagreements were resolved by a third investigator. Meta-analysis and systematic review were performed. Sensitivity analysis and subgroup analysis were carried out to explore the sources of heterogeneity.

RESULTS

A total of 14 RCTs involving 1962 patients were included. Meta-analysis showed that compared with conventional cardiac rehabilitation/usual care, smartphone-assisted cardiac rehabilitation significantly improved VO2peak in patients with cardiovascular disease (WMD= 1.32, 95%CI:0.82 to 1.81, p > 0.05) and enhanced their treatment compliance (RR = 1.62, 95%CI:1.21 to 2.17, p > 0.05). There were no significant differences in six-minute walk distance (WMD = 12.88, 95%CI:-0.82 to 26.57, p > 0.05), body mass index (BMI) (WMD=-0.14, 95%CI:-0.34 to 0.06, p > 0.05), life quality, psychological status, and other cardiovascular risks.

CONCLUSION

Smartphone-assisted cardiac rehabilitation showed significant improvement in exercise capacity and treatment compliance in patients with cardiac rehabilitation but did not improve BMI, quality of life, psychological status, or reduce other cardiovascular risks. Smartphone-based cardiac rehabilitation is increasingly used as a remote detection method for cardiac rehabilitation in middle-income countries, which provides new insights into home cardiac rehabilitation.

Comparing the effect of the Model of Therapeutic Engagement in cardiac rehabilitation on the sense of coherence and adherence to treatment: a randomized clinical trial

PURPOSE

The study aimed to compare the effectiveness of a traditional cardiac rehabilitation (CR) program with an enhanced program incorporating the model of therapeutic engagement (MTE) and extended remote support for patients undergoing coronary artery bypass graft (CABG) patients.

MATERIALS AND METHODS

In a randomized controlled trial, 88 CABG patients were assigned to experimental and control groups. The experimental group received integrated MTE cardiac rehabilitation, and assessments were conducted at three time points: pre-CR, one month later, and three months post-CR. The study measured medication adherence (MARS-5) and sense of coherence (SoC-13) scales.

RESULTS

The study found no significant differences in demographic factors between the experimental and control groups. However, significant differences were observed in MARS and individuals' SoC scores over time in the experimental group, with notable improvements (p < 0.001). The control group showed significant changes only up to one month. Group effects were evident, with consistent increases in the experimental group's outcomes at each assessment point.

CONCLUSION

Integrating the MTE into CR programs offers benefits in terms of medication adherence and individuals' sense of coherence, which warrants further investigation and clinical implementation.

Design of Lung Transplant Go (LTGO): A randomized controlled trial evaluating the efficacy of a telerehabilitation behavioral exercise intervention to improve physical activity, physical function, and blood pressure control after lung transplantation

Background

Lung transplantation is an established treatment option for persons with advanced lung disease. After transplantation, lung function typically returns to near normal levels, however exercise capacity remains low due to chronic deconditioning, limited physical function, and inactive lifestyles which undermine the intended benefits of the highly selective, resource-intensive transplant procedure. Pulmonary rehabilitation is recommended to improve fitness and activity tolerance, however due to multiple barriers, lung transplant recipients either never participate, or fail to complete, pulmonary rehabilitation programs.

Purpose

To describe the design of Lung Transplant Go (LTGO), a trial modified for the remote environment based on recommendations to preserve trial integrity during COVID. The aims are to evaluate a behavioral exercise intervention to improve physical function, physical activity, and blood pressure control in lung transplant recipients conducted safely and effectively using a telerehabilitation (telerehab) platform, and to explore the role of potential mediators and moderators of the relationship between LTGO and outcomes.

Methods

Single-site, 2-group randomized controlled trial with lung transplant recipients randomized 1:1 to either the LTGO intervention (a 2-phased, supervised, telerehab behavioral exercise program), or to enhanced usual care (activity tracking and monthly newsletters). All study activities, including intervention delivery, recruitment, consenting, assessment, and data collection, will be performed remotely.

Conclusion

If efficacious, this fully scalable and replicable telerehab intervention could be efficiently translated to reach large numbers of lung recipients to improve and sustain self-management of exercise habits by overcoming barriers to participation in existing, in-person pulmonary rehabilitation programs.

Role of wearable devices in cardiac telerehabilitation: A scoping review

BACKGROUND

Cardiac rehabilitation (CR) is an evidence-based comprehensive program that includes exercise training, health education, physical activity promotion, and extensive counseling for the management of cardiovascular risk factors. Wearable devices monitor certain physiological functions, providing biometric data such as heart rate, movement, sleep, ECG analysis, blood pressure, energy expenditure, and numerous other parameters. Recent evidence supports wearable devices as a likely relevant component in cardiovascular risk assessment and disease prevention. The purpose of this scoping review is to better understand the role of wearable devices in home-based CR (HBCR) and to characterize the evidence regarding the incorporation of wearable devices in HBCR programs and cardiovascular outcomes.

METHODS & FINDINGS

We created a search strategy for multiple databases, including PubMed, Embase (Elsevier), CINAHL (Ebsco), Cochrane CENTRAL (Wiley), and Scopus (Elsevier). Studies were included if the patients were eligible for CR per Medicare guidelines and >18 years of age and if some type of wearable device was utilized during HBCR. Our search yielded 57 studies meeting all criteria. The studies were classified into 4 groups: patients with coronary heart disease (CHD) without heart failure (HF); patients with HF; patients with heart valve repair or replacement; and patients with exposure to center-based CR. In three groups, there was an upward trend toward improvement in quality of life (QOL) and peak VO2, less sedentary time, and an increase in daily step count in the intervention groups compared to control groups.

CONCLUSIONS

HBCR using wearable devices can be a comparable alternative or adjunct to center-based CR for patients with CHD and HF. More studies are needed to draw conclusions about the comparability of HBCR to center-based CR in patients with heart valve repair or replacement.

Cost-effectiveness of home-based cardiac rehabilitation: a systematic review

OBJECTIVE

Centre-based cardiac rehabilitation (CR) is recognised as cost-effective for individuals following a cardiac event. However, home-based alternatives are becoming increasingly popular, especially since COVID-19, which necessitated alternative modes of care delivery. This review aimed to assess whether home-based CR interventions are cost-effective (vs centre-based CR).

METHODS

Using the MEDLINE, Embase and PsycINFO databases, literature searches were conducted in October 2021 to identify full economic evaluations (synthesising costs and effects). Studies were included if they focused on home-based elements of a CR programme or full home-based programmes. Data extraction and critical appraisal were completed using the NHS EED handbook, Consolidated Health Economic Evaluation Reporting Standards and Drummond checklists and were summarised narratively. The protocol was registered on the PROSPERO database (CRD42021286252).

RESULTS

Nine studies were included in the review. Interventions were heterogeneous in terms of delivery, components of care and duration. Most studies were economic evaluations within clinical trials (8/9). All studies reported quality-adjusted life years, with the EQ-5D as the most common measure of health status (6/9 studies). Most studies (7/9 studies) concluded that home-based CR (added to or replacing centre-based CR) was cost-effective compared with centre-based options.

CONCLUSIONS

Evidence suggests that home-based CR options are cost-effective. The limited size of the evidence base and heterogeneity in methods limits external validity. There were further limitations to the evidence base (eg, limited sample sizes) that increase uncertainty. Future research is needed to cover a greater range of home-based designs, including home-based options for psychological care, with greater sample sizes and the potential to acknowledge patient heterogeneity.

Hybrid cardiac telerehabilitation for coronary artery disease in Australia: a cost-effectiveness analysis

BACKGROUND

Traditional cardiac rehabilitation programs are centre-based and clinically supervised, with their safety and effectiveness well established. Notwithstanding the established benefits, cardiac rehabilitation remains underutilised. A possible alternative would be a hybrid approach where both centre-based and tele-based methods are combined to deliver cardiac rehabilitation to eligible patients. The objective of this study was to determine the long-term cost-effectiveness of a hybrid cardiac telerehabilitation and if it should be recommended to be implemented in the Australian context.

METHODS

Following a comprehensive literature search, we chose the Telerehab III trial intervention that investigated the effectiveness of a long-term hybrid cardiac telerehabilitation program. We developed a decision analytic model to estimate the cost-effectiveness of the Telerehab III trial using a Markov process. The model included stable cardiac disease and hospitalisation health states and simulations were run using one-month cycles over a five-year time horizon. The threshold for cost-effectiveness was set at $AU 28,000 per quality-adjusted life-year (QALY). For the base analysis, we assumed that 80% completed the programme. We tested the robustness of the results using probabilistic sensitivity and scenario analyses.

RESULTS

Telerehab III intervention was more effective but more costly and was not cost-effective, at a threshold of $28,000 per QALY. For every 1,000 patients who undergo cardiac rehabilitation, employing the telerehabilitation intervention would cost $650,000 more, and 5.7 QALYs would be gained, over five years, compared to current practice. Under probabilistic sensitivity analysis, the intervention was cost-effective in only 18% of simulations. Similarly, if the intervention compliance was increased to 90%, it was still unlikely to be cost-effective.

CONCLUSION

Hybrid cardiac telerehabilitation is highly unlikely to be cost-effective compared to the current practice in Australia. Exploration of alternative models of delivering cardiac telerehabilitation is still required. The results presented in this study are useful for policymakers wanting to make informed decisions about investment in hybrid cardiac telerehabilitation programs.

The era of technology in healthcare: an evaluation of telerehabilitation on patient outcomes-a systematic review and meta-analysis protocol

BACKGROUND

The World Health Organization announced the outbreak of the Coronavirus disease as a global pandemic on March 11, 2020. Since then, rapid implementation of telehealth approaches into the healthcare system have been evident. The pandemic has drastically impacted the lives of many around the globe and has detrimentally affected our healthcare systems, specifically with the delivery of healthcare. This has had many implications on rehabilitation services such as, occupational therapy, physiotherapy, and speech therapy. The delivery of mental health services remotely may be referred to as teletherapy, telemental health, telepsychiatry, and telepsychology. Telerehabilitation has become a necessity over the course of the pandemic due to safety concerns with COVID-19 transmission. The primary aim of this systematic review protocol is to evaluate the literature on the effect of telerehabilitation on patient outcomes and propose directives for future research based on the evidence reviewed.

METHODS

A systematic review and meta-analysis will be conducted to examine the literature on the effect of telerehabilitation on patient outcomes following the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PRISMA, 2015). The systematic review will use the following databases to examine the literature on telerehabilitation and patient outcomes: APA PsychINFO, Embase (Ovid), MEDLINE (Ovid), CINAHL, and Scopus.

DISCUSSION

The utilization of telerehabilitation and similar telehealth treatments has increased throughout the COVID-19 pandemic. However, much is still unclear regarding the effectiveness of these methods in the delivery and service of healthcare, and their effect on health outcomes. This review will identify and address the knowledge gaps in the literature, which will provide further directions for future research.

TRIAL REGISTRATION

This systematic review has been registered with PROSPERO under registration number CRD42022297849.

The Italian Society of Cardiology and Working Group on Telecardiology and Informatics 2023 updated position paper on telemedicine and artificial intelligence in cardiovascular disease

In 2015, the Italian Society of Cardiology and its Working Group on Telemedicine and Informatics issued a position paper on Telecardiology, resuming the most eminent evidence supporting the use of information and communication technology in principal areas of cardiovascular care, ranked by level of evidence. More than 5 years later and after the global shock inflicted by the SARS-CoV-2 pandemic, an update on the topic is warranted. Recent evidence and studies on principal areas of cardiovascular disease will be therefore reported and discussed, with particular focus on telemedicine for cardiovascular care in the COVID-19 context. Novel perspectives and opportunities disclosed by artificial intelligence and its applications in cardiovascular disease will also be discussed. Finally, modalities by which machine learning have realized remote patient monitoring and long-term care in recent years, mainly filtering critical clinical data requiring selective hospital admission, will be provided.

The cost-effectiveness of exercise-based cardiac telerehabilitation intervention: a systematic review

INTRODUCTION

Alternatives such as remotely delivered therapy in the home environment or telehealth represent an opportunity to increase overall cardiac rehabilitation (CR) utilization. Implementing alternatives into regular practice is the next step in development; however, the cost aspect is essential for policymakers. Limited economic budgets lead to cost-effectiveness analyses before implementation. They are appropriate in cases where there is evidence that the compared intervention provides a similar health benefit to usual care. This systematic review aimed to compare the cost-effectiveness of exercise-based telehealth CR interventions compared to standard exercise-based CR.

EVIDENCE ACQUISITION

PubMed and Web of Science databases were systematically searched up to August 2022 to identify randomized controlled trials assessing patients undergoing telehealth CR. The intervention was compared to standard CR protocols. The primary intent was to identify the cost-effectiveness. Interventions that met the criteria were home-based telehealth CR interventions delivered by information and communications technology (telephone, computer, internet, or videoconferencing) and included the results of an economic evaluation, comparing interventions in terms of cost-effectiveness, utility, costs and benefits, or cost-minimization analysis. The systematic review protocol was registered in the PROSPERO Registry (CRD42022322531).

EVIDENCE SYNTHESIS

Out of 1525 identified studies, 67 articles were assessed for eligibility, and, at the end of the screening process, 12 studies were included in the present systematic review. Most studies (92%) included in this systematic review found strong evidence that exercise-based telehealth CR is cost-effective. Compared to CBCR, there were no major differences, except for three studies evaluating a significant difference in average cost per patient and intervention costs in favor of telehealth CR.

CONCLUSIONS

Telehealth CR based on exercise is as cost-effective as CBCR interventions. Funding telehealth CR by third-party payers may promote patient participation to increase overall CR utilization. High-quality research is needed to identify the most cost-effective design.

Is telerehabilitation an effective maintenance strategy for patients with chronic obstructive pulmonary diseases: a systematic review

BACKGROUND

Pulmonary rehabilitation (PR) has proven to improve the physical and psychosocial function in patients with chronic obstructive pulmonary disease (COPD). However, the gains achieved during pulmonary rehabilitation diminish over time without an effective maintenance strategy. With several factors affecting access to pulmonary rehabilitation, calls for innovative models were made, which saw the emergence of studies exploring telerehabilitation (TR) as an alternative to traditional pulmonary rehabilitation models. Although there are current reviews exploring the effectiveness of telerehabilitation as an alternative for conventional PR, no review has considered telerehabilitation effectiveness in the long term. Hence, this review aims at examining the effectiveness of telerehabilitation following to pulmonary rehabilitation in patients with chronic obstructive pulmonary disease.

MAIN BODY

A systematic review of the literature using CINAHL, MEDLINE, SCOPUS, Web of science PEDRO, AMED and EMBASE databases was conducted to assess the effectiveness of telerehabilitation following PR in patients with COPD. Health-related quality of life (HRQoL) and exercise capacity was maintained within 6-12 months of a TR maintenance programme. However, there was no significant increase in HRQoL and exercise capacity between the intervention and control groups in 6-12 months.

CONCLUSIONS

This review suggests that a TR maintenance strategy effectively maintains benefits gained and may improve HRQoL and exercise capacity within 6-12 months for patients with COPD. Nonetheless, it is impossible to extrapolate the findings to the general population due to the paucity of included studies. Further high quality randomised controlled trials examining TR in the long-term is required in the future.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s42269-023-00980-8.

Exercise Progression Protocol for Lung Transplant GO: A Multicomponent Telerehab Exercise Intervention for Patients After Lung Transplantation

Lung transplantation is one of the fastest growing solid organ transplant procedures in the United States. After transplantation, lung function typically returns to near normal levels; however, reduced physical function and an inactive lifestyle compromise this benefit. To promote rehabilitation goals, lung transplant recipients (LTRs) are advised to participate in pulmonary rehab, but participation is low due to barriers related to scheduling, travel requirements, lack of insurance coverage, and the concern about exposure to infection. Telerehabilitation offers a flexible alternative with the potential to promote self-management of exercise in LTRs. The purpose of this report was to describe the exercise progression protocol for the Lung Transplant GO multicomponent telerehab exercise intervention for patients after lung transplantation. The progression protocol is an evidence-informed exercise protocol designed to improve physical function and physical activity in LTRs safely and effectively in a remote environment. The protocol standardizes the prescription of exercise while permitting adaptation of the program to meet the needs of the individual. Using this model, the decisions about program progression are systematic, transparent, and replicable to other LTRs.

[Cardiac tele-rehabilitation in times of pandemic. Experience at the National Cardiovascular Institute INCOR in Lima-Peru]

Objective

Cardiac Rehabilitation (CR) programs based on telehealth are an alternative in the context of a pandemic and represent an opportunity to continue in the intervention of cardiovascular diseases (CVD). The present study aims to evaluate the effect of a Cardiac Tele-Rehabilitation (CTR) program on quality of life, anxiety/depression index, exercise safety and Level Of disease awareness in patients discharged from a national referral institute in times of pandemic.

Methods

A pre-experimental study in cardiac patients who entered the cardiac rehabilitation program at INCOR from August to December 2020. The study included low-risk patients who were administered a questionnaire (on cardiovascular disease, exercise safety, anxiety/depression, and quality of life) at the beginning and end of the program, which was applied through a virtual platform. Descriptive and comparative before-after analysis was used through hypothesis testing.

Results

Sixty-four patients were included (71.9% male). The mean age was 63.6 ±11.1 years. Regarding exercise safety, an increase in the mean score was found after the application of the program (3.06 ± 0.8 to 3.18 ± 0.7, p=0.324). Concerning anxiety, the mean score was reduced from 8.61 to 4.75, while for depression, the reduction was from 7.27 to 2.92. Regarding the quality-of-life score, the global component improved from 111.48 to 127.92.

Conclusions

The CTR program implemented through a virtual platform during the COVID-19 pandemic enhanced quality of life and decreased stress and depression in cardiac patients discharged from a national cardiovascular referral center.

[What imaging and what tools for modern cardiac rehabilitation ?]

Conventional Cardiovascular Rehabilitation (RCV) is a global approach; it integrates reconditioning with personalized effort, physical activity (PA), therapeutic education, dietary management, smoking cessation, medication compliance. It requires a multidisciplinary approach with interventions by cardiologists, paramedics, physiotherapists, teachers of adapted physical activity (APA), dieticians, addictologists, and a specialized technical platform for evaluation and reconditioning at the 'effort. The benefit of cardiovascular rehabilitation is supported by numerous studies, it is strongly recommended class IA [1], but the supply of care is insufficient. It is therefore necessary to develop a modality of care in RCV at home, subject to the same requirements as the programs in the center, thanks to the contributions of new technology and connected objects. Technological innovations have made it technically possible to treat and monitor patients remotely [14]. Telerehabilitation is an example of the application of technology-based care. It can be defined as the provision of Secondary Prevention at a distance. It consists of remote monitoring of patient physiological data, remote coaching, e-learning and social interaction [10]. From a theoretical point of view, cardiac telerehabilitation has the potential to go beyond traditional rehabilitation; it removes the barriers that prevent patients with ischemic heart disease from participating in rehabilitation programs in conventional centers. Several studies show that telerehabilitation represents an alternative, less expensive, effective, and profitable, it could, in addition to existing services, improve access to rehabilitation [15]. Increasing participation rates in cardiac rehabilitation can reduce disease burden. The study of the economic and social impact of increasing the use of cardiac rehabilitation and cardiac telerehabilitation shows that and the resulting benefits exceed its costs. Mots-clés: Réadaptation en centre; réadaptation à domicile; téléréadaptation.

Costs and effects of telerehabilitation in neurological and cardiological diseases: A systematic review

INTRODUCTION

Telerehabilitation in neurological and cardiological diseases is an alternative rehabilitation that improves the quality of life and health conditions of patients and enhances the accessibility to health care. However, despite the reported benefits of telerehabilitation, it is necessary to study its impact on the healthcare system.

METHODS

The systematic review aims to investigate the costs and results of telerehabilitation in neurological and cardiological diseases. MEDLINE and EMBASE databases were searched from 2005 to 2021, for studies that assess the costs and results of telerehabilitation compared to traditional rehabilitation (center-based programs) in neurological and cardiological diseases. A narrative synthesis of results was carried out.

RESULTS

A total of 8 studies (865 participants) of 430 records were included. Three studies were related to the costs and results of telerehabilitation in neurological diseases (specifically in stroke). In total, five studies assessed telerehabilitation in cardiological diseases (chronic heart failure, coronary heart disease, acute coronary syndrome, and cardiovascular diseases). The duration of the telerehabilitation ranged from 6 to 48 weeks. The studies included cost-analysis, cost-benefit, cost-effectiveness, or cost-utility. In total, four studies found significant cost/savings per person between $565.66 and $2,352.00 (p < 0.05). In contrast, most studies found differences in costs and clinical effects between the telerehabilitation performed and the rehabilitation performed at the clinic. Just one study found quality-adjusted life years (QALY) significant differences between groups [Incremental cost-effectiveness ratio (ICER) per QALY ($-21,666.41/QALY).

DISCUSSION

Telerehabilitation is an excellent alternative to traditional center rehabilitation, which increases the accessibility to rehabilitation to more people, either due to the geographical situation of the patients or the limitations of the health systems. Telerehabilitation seems to be as clinical and cost-effective as traditional rehabilitation, even if, generally, telerehabilitation is less costly. More research is needed to evaluate health-related quality of life and cost-effectiveness in other neurological diseases.

SYSTEMATIC REVIEW REGISTRATION

[https://figshare.com/articles/journal_ contribution/Review_Protocol_Costs_and_effects_of_Telerehabilitation_in_ Neurological_and_Cardiological_Diseases_A_Systematic_Review/19619838], identifier [19619838].

A scoping review of feasibility, cost, access to rehabilitation services and implementation of telerehabilitation: Implications for low- and middle-income countries

Objective

To scope all published information reporting on the feasibility, cost, access to rehabilitation services, implementation processes including barriers and facilitators of telerehabilitation (TR) in low- and middle-income countries (LMICs) and high-income countries (HICs).

Methods

A comprehensive electronic search of PubMed, Scopus, PEDro, Cochrane library, EBSCOhost (Academic search premier, Africa-wide information, CINAHL, Eric, MEDLINE, Health sources - Nursing/Academic edition), Africa online, as well as ProQuest databases were conducted. To maximise the coverage of the literature, the reference lists of included articles identified through the search were also screened. The analysis included both descriptive summary and inductive thematic analysis.

Results

Twenty-nine studies were included. TR was reported to be feasible, cost-saving and improved access to rehabilitation services in both HICs and LMICs settings. Asynchronous methods using different mobile apps (Skype, WhatsApp, Google meet, Facebook messenger, Viber, Face time and Emails) were the most common mode of TR delivery. Barriers to the implementation were identified and categorised in terms of human, organisational, technical and clinical practice related factors. Facilitators for health professionals and patients/caregivers’ dyads were also identified.

Conclusion

TR could be considered a feasible service delivery mode in both HICs and LMICs. However, the mitigation of barriers such as lack of knowledge and technical skills among TR providers and service users, lack of secure platform dedicated for TR, lack of resources and connectivity issues which are particularly prevalent in LMICs will be important to optimise the benefits of TR.

Effects of eHealth Interventions on Quality of Life and Psychological Outcomes in Cardiac Surgery Patients: Systematic Review and Meta-analysis

BACKGROUND

Patients undergoing heart surgery may experience a range of physiological changes, and the postoperative recovery time is long. Patients and their families often have concerns about quality of life (QoL) after discharge. eHealth interventions may improve patient participation, ensure positive and effective health management, improve the quality of at-home care and the patient's quality of life, and reduce rates of depression.

OBJECTIVE

The purpose of this study was to evaluate the effects of eHealth interventions on the physiology, psychology, and compliance of adult patients after cardiac surgery to provide a theoretical basis for clinical practice.

METHODS

We conducted systematic searches of the following 4 electronic databases: PubMed, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials. Mean (SD) values were used to calculate the pooled effect sizes for all consecutive data, including QoL, anxiety, and depression. Where the same results were obtained using different instruments, we chose the standardized mean difference with a 95% CI to represent the combined effect size; otherwise, the mean difference (MD) with a 95% CI was used. Odds ratios were used to calculate the combined effect size for all dichotomous data. The Cohen Q test for chi-square distribution and an inconsistency index (I²) were used to test for heterogeneity among the studies. We chose a fixed-effects model to estimate the effect size if there was no significant heterogeneity in the data (I²≤50%); otherwise, a random-effects model was used. The quality of the included studies was assessed using the Cochrane risk-of-bias tool for randomized trials (RoB 2).

RESULTS

The search identified 3632 papers, of which 19 met the inclusion criteria. In terms of physical outcomes, the score of the control group was lower than that of the intervention group (MD 0.15, 95% CI 0.03-0.27, I²=0%, P=.02). There was no significant difference in the mental outcomes between the intervention and control groups (MD 0.10, 95% CI -0.03 to 0.24, I²=46.4%, P=.14). The control group's score was lower than that of the intervention group for the depression outcomes (MD -0.53, 95% CI -0.89 to -0.17, I²=57.1%, P=.004). Compliance outcomes improved in most intervention groups. The results of the sensitivity analysis were robust. Nearly half of the included studies (9/19, 47%) had a moderate to high risk of bias. The quality of the evidence was medium to low.

CONCLUSIONS

eHealth improved the physical component of quality of life and depression after cardiac surgery; however, there was no statistical difference in the mental component of quality of life. The effectiveness of eHealth on patient compliance has been debated. Further high-quality studies on digital health are required.

TRIAL REGISTRATION

PROSPERO CRD42022327305; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=327305.

Cardiac telerehabilitation in a middle-income country: analysis of adherence, effectiveness and cost through a randomized clinical trial

BACKGROUND

The benefits of cardiac rehabilitation (CR) are already well established; however, such intervention has been underused, mainly in low- and middle-income countries.

AIM

To compare adherence, effectiveness, and cost of a home CR with the traditional CR (TCR) in a middle-income country (MIC).

DESIGN

Single-blind randomized control trial.

SETTING

A university hospital.

POPULATION

Individuals with coronary disease that were eligible were invited to participate. A randomized sample of 51 individuals was selected, where two participants were not included by not meeting inclusion criteria.

METHODS

The home-CR group participated in health education activities, carried out two supervised exercise sessions, and was instructed to carry out 58 sessions at home. Weekly telephone calls were made. The TCR group held 24 supervised exercise sessions and were instructed to carry out 36 sessions at home.

RESULTS

49 individuals (42 male, 56.37±10.35years) participated in the study, 23 in the home-CR group and 26 in the TCR group. After the intervention, adherence in the home-CR and TCR groups was 94.18% and 79.08%, respectively, with no significant difference (P=0.191). Both protocols were effective for the other variables, with no differences. The cost per patient for the service was lower in the home-CR (US$ 59.31) than in the TCR group (US$ 135.05).

CONCLUSIONS

CR performed at home in an MIC demonstrated similar adherence and effectiveness compared to the TCR program, but with a lower cost for the service. The results corroborate the possibility of using home CR programs, even in MICs, after exercise risk stratification and under remote supervision.

CLINICAL REHABILITATION IMPACT

Home-CR can contribute to overcome participants' barriers with compatible cost. Home-CR is effective in improving functional capacity and risk factors control. Perform risk stratification and remote supervision are essential to offer Home-CR.

The Box—eHealth in the Outpatient Clinic Follow-up of Patients With Acute Myocardial Infarction: Cost-Utility Analysis

Background

Smartphone compatible wearables have been released on the consumers market, enabling remote monitoring. Remote monitoring is often named as a tool to reduce the cost of care.

Objective

The primary purpose of this paper is to describe a cost-utility analysis of an eHealth intervention compared to regular follow-up in patients with acute myocardial infarction (AMI).

Methods

In this trial, of which clinical results have been published previously, patients with an AMI were randomized in a 1:1 fashion between an eHealth intervention and regular follow-up. The remote monitoring intervention consisted of a blood pressure monitor, weight scale, electrocardiogram device, and step counter. Furthermore, two in-office outpatient clinic visits were replaced by e-visits. The control group received regular care. The differences in mean costs and quality of life per patient between both groups during one-year follow-up were calculated.

Results

Mean costs per patient were €2417±2043 (US $2657±2246) for the intervention and €2888±2961 (US $3175±3255) for the control group. This yielded a cost reduction of €471 (US $518) per patient. This difference was not statistically significant (95% CI –€275 to €1217; P=.22, US $–302 to $1338). The average quality-adjusted life years in the first year of follow-up was 0.74 for the intervention group and 0.69 for the control (difference –0.05, 95% CI –0.09 to –0.01; P=.01).

Conclusions

eHealth in the outpatient clinic setting for patients who suffered from AMI is likely to be cost-effective compared to regular follow-up. Further research should be done to corroborate these findings in other patient populations and different care settings.

Trial Registration

ClinicalTrials.gov NCT02976376; https://clinicaltrials.gov/ct2/show/NCT02976376

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.8038

Heart Failure Patients’ Adherence to Hybrid Comprehensive Telerehabilitation and Its Impact on Prognosis Based on Data from TELEREH-HF Randomized Clinical Trial

(1) Background Adherence to treatment guidelines in heart failure (HF) patients is of major prognostic importance, but thorough implementation of guidelines in routine care remains insufficient. Introducing hybrid comprehensive telerehabilitation (HCTR) consisting of telecare, telerehabilitation, and remote monitoring of implantable devices might be an option to improve adherence to recommendation and can affect the prognosis. The purpose is to investigate the association of adherence to HCTR with mortality and hospitalization. (2) Methods This analysis formed part of TELEREH-HF multi-center, randomized trial that enrolled 850HF patients (NYHA I-III;LVEF ≤ 40%). Patients were randomized 1:1 to 9-week HCTR (1 week in hospital and 8 weeks at home) plus usual care or usual care only and followed-up for 14 to 26 months. This analysis focuses on the HCTR group. Adherent patients were those who adhered both to the number of training sessions prescribed and to the duration of the prescribed cycle by at least 80%; non-adherent patients were those who adhered<20% to the prescribed number of training sessions and their duration. The remaining patients were classified as partially adherent. (3) Results There were 350 (88.4%) adherent patients, 39 (9.8%) partially adherent patients, and 7 (1.8%) non-adherent patients. There were 46 deaths during follow-up. Non-adherence or partial adherence was associated with higher risk of cardiovascular (CV) mortality (hazard ratio (HR) = 2.62, p = 0.021); all-cause mortality or HF hospitalization (HR = 1.71, p = 0.038); CV mortality or HF hospitalization (HR = 1.89, p = 0.014). (4) Conclusions The adherence to HCTR was high. Adherence to HCTR was associated with improved prognosis for CV mortality and the reduction in the combined outcome of CV mortality or HF hospitalization.

A scoping review of feasibility, cost-effectiveness, access to quality rehabilitation services and impact of telerehabilitation: A review protocol

Background

Telerehabilitation is an emerging segment of telehealth and telemedicine that has a potential to deliver quality, accessible, cost-effective and efficient rehabilitation services where geographical distance is a critical factor. The objectives of this review are: to describe the feasibility and cost-effectiveness of telerehabilitation, to scope to what extent telerehabilitation has the potential impact on access to quality of rehabilitation services with specific references to low to middle income countries, and to understand key process factors including barriers and facilitators relevant to the implementation of telerehabilitation.

Methods

A scoping review of the literature will be conducted. An electronic search literature will be conducted in PubMed, Scopus, Cochrane library, Africa-wide information, CINAHL, MEDLINE, ProQuest, Web of science and reference lists. The review team will develop a data charting form and pilot it on four randomly-selected studies. The form will be refined based on the results of the piloted articles. Studies identified will be screened at the title and abstract levels by the first reviewer, followed by an independent verification for the accuracy and eligibility by two more reviewers prior to obtaining the full texts. Studies to be included must report on feasibility, cost-effectiveness, access to rehabilitation services, implementation process factors including barriers and facilitators of telerehabilitation. The analysis will include both descriptive summary and inductive thematic analysis.

Conclusion

Telerehabilitation has ability to change the current standard of care and allow for improved access and health outcomes in cost-effective ways, while addressing the scarce and unequal distribution of limited number of healthcare providers especially in low to middle income country settings. Thus, the research findings could be used by different stakeholders including: researchers, clinicians, policy makers, and implementation teams as they determine the appropriate setup for new telerehabilitation programs.

[New treatments and technologies in cardiac rehabilitation programs]

The article presents a review of literature data reflecting the relevance and modern views on the effectiveness and expediency of using various options for rehabilitation programs for cardiovascular diseases. The issues of the history of the development of cardiac rehabilitation both abroad and in Russia are consecrated. The article also presents alternative models for conducting cardiac rehabilitation, in particular, using remote and telemedicine technologies. The widespread use of smartphones and high-speed Internet access contributed to the further introduction and use of telemedicine technologies in cardiac rehabilitation. The article discusses the possibilities of telerehabilitation of cardiological patients and shows its comparable effectiveness with traditional cardiac rehabilitation.

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.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 2

Background: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients’ groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. Methods: Generation of evidence and search of literature have been described in part 1. Results: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for “distress management” and “lifestyle changes”. PE is able to increase patients’ knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients’ groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. Conclusions: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

Traditional versus extended hybrid cardiac rehabilitation based on the continuous care model for coronary artery bypass surgery patients in a middle-income country: A Randomized Clinical Trial

OBJECTIVE

To compare traditional (1-month supervised) versus hybrid cardiac rehabilitation (CR; usual care) with an additional 3 months offered remotely based on the continuous care model (CCM; intervention), in coronary artery bypass graft (CABG) patients.

DESIGN

randomized controlled trial, with blinded outcome assessment.

SETTING

A major heart center in a middle-income country.

PARTICIPANTS

Of 107 eligible patients that were referred to CR during the period of study, 88 (82.2%) were enrolled (target sample size). Participants were randomly assigned 1:1 (concealed; 44 per parallel arm). There was 92.0% retention.

INTERVENTION

After CR, participants were given an app and communicated biweekly with the nurse from months 1-4 to control risk factors.

MAIN OUTCOME MEASURES

Quality of life (QoL; SF-36; primary outcome), functional capacity (treadmill test), depression, anxiety and stress (DASS-21) were evaluated pre-CR, after one month, and three months after CR (end of intervention), as well as re-hospitalization.

RESULTS

The analysis of variance interaction effects for the physical and mental component summary scores of QoL were <.001, favoring intervention (per protocol); there were also significant increases from pre-CR to 1 month, and from 1 month to the final assessment in the intervention arm (p-values<.001), with change in the control arm only to 1 month. The effect sizes were 0.115 and 0.248, respectively. Similarly, the interaction effect for functional capacity was significant (p<.001), with a clinically-significant 1.5 MET increase in the intervention arm. There were trends for group effects for the psychosocial indicators, with paired t-tests revealing significant increases in each at both assessment points in the intervention arm. At 4 months, there were 4 (10.3%) re-hospitalizations in the control arm, and none in intervention (p=.049). Intended theoretical mechanisms were also impacted by the intervention.

CONCLUSION

Extending CR in this accessible manner, rendering it more comprehensive, was effective in improving outcomes.

Offering, participation and adherence to cardiac rehabilitation programmes in the elderly: a European comparison based on the EU-CaRE multicentre observational study

AIMS 

Cardiac rehabilitation (CR) is strongly recommended but participation of elderly patients has not been well characterized. This study aims to analyse current rates and determinants of CR referral, participation, adherence, and compliance in a contemporary European cohort of elderly patients.

METHODS AND RESULTS 

The EU-CaRE observational study included data from consecutive patients aged ≥ 65 with acute coronary syndrome, revascularization, stable coronary artery disease, or heart valve replacement, recruited in eight European centres. Rates and factors determining offering, participation, and adherence to CR programmes and compliance with training sessions were studied across centres, under consideration of extensive-outpatient vs. intensive-inpatient programmes. Three thousand, four hundred, and seventy-one patients were included in the offering and participation analysis. Cardiac rehabilitation was offered to 80.8% of eligible patients, formal contraindications being the main reason for not offering CR. Mean participation was 68.0%, with perceived lack of usefulness and transport issues being principal barriers. Mean adherence to CR programmes of participants in the EU-CaRE study (n = 1663) was 90.3%, with hospitalization/physical impairment as principal causes of dropout. Mean compliance with training sessions was 86.1%. Older age was related to lower offering and participation, and comorbidity was associated with lower offering, participation, adherence, and compliance. Intensive-inpatient programmes displayed higher adherence (97.1% vs. 85.9%, P < 0.001) and compliance (full compliance: 66.0% vs. 38.8%, P < 0.001) than extensive-outpatient programmes.

CONCLUSION 

In this European cohort of elderly patients, older age and comorbidity tackled patients' referral and uptake of CR programmes. Intensive-inpatient CR programmes showed higher completion than extensive-outpatient CR programmes, suggesting this formula could suit some elderly patients.

Digital Health Interventions for Cardiac Rehabilitation: Systematic Literature Review

Background

Cardiovascular disease (CVD) is the leading cause of death worldwide. Despite strong evidence supporting the benefits of cardiac rehabilitation (CR), over 80% of eligible patients do not participate in CR. Digital health technologies (ie, the delivery of care using the internet, wearable devices, and mobile apps) have the potential to address the challenges associated with traditional facility-based CR programs, but little is known about the comprehensiveness of these interventions to serve as digital approaches to CR. Overall, there is a lack of a systematic evaluation of the current literature on digital interventions for CR.

Objective

The objective of this systematic literature review is to provide an in-depth analysis of the potential of digital health technologies to address the challenges associated with traditional CR. Through this review, we aim to summarize the current literature on digital interventions for CR, identify the key components of CR that have been successfully addressed through digital interventions, and describe the gaps in research that need to be addressed for sustainable and scalable digital CR interventions.

Methods

Our strategy for identifying the primary literature pertaining to CR with digital solutions (defined as technology employed to deliver remote care beyond the use of the telephone) included a consultation with an expert in the field of digital CR and searches of the PubMed (MEDLINE), Embase, CINAHL, and Cochrane databases for original studies published from January 1990 to October 2018.

Results

Our search returned 31 eligible studies, of which 22 were randomized controlled trials. The reviewed CR interventions primarily targeted physical activity counseling (31/31, 100%), baseline assessment (30/31, 97%), and exercise training (27/31, 87%). The most commonly used modalities were smartphones or mobile devices (20/31, 65%), web-based portals (18/31, 58%), and email-SMS (11/31, 35%). Approximately one-third of the studies addressed the CR core components of nutrition counseling, psychological management, and weight management. In contrast, less than a third of the studies addressed other CR core components, including the management of lipids, diabetes, smoking cessation, and blood pressure.

Conclusions

Digital technologies have the potential to increase access and participation in CR by mitigating the challenges associated with traditional, facility-based CR. However, previously evaluated interventions primarily focused on physical activity counseling and exercise training. Thus, further research is required with more comprehensive CR interventions and long-term follow-up to understand the clinical impact of digital interventions.

Cardiopulmonary Telerehabilitation

Cardiopulmonary telerehabilitation is a safe and effective alternative to traditional center-based rehabilitation. It offers a sustainable solution to more conveniently meet the needs of patients with acute or chronic, preexisting or newly acquired, cardiopulmonary diseases. To maximize success, programs should prioritize basic, safe, and timely care options over comprehensive or complex approaches. The future should incorporate new strategies learned during a global pandemic and harness the power of information and communication technology to provide evidence-based patient-centered care. This review highlights clinical considerations, current evidence, recommendations, and future directions of cardiopulmonary telerehabilitation.

Physical activity and sedentary behaviour in secondary prevention of coronary artery disease: A review

Comprehensive management of coronary artery disease (CAD) includes physical exercise as a part of daily lifestyle therapy. Still CAD patients generally have low physical activity (PA) and high sedentary behaviour (SB). This review summarizes the effect of exercise training and habitual PA and SB on physical fitness and quality of life (QoL) as well as on rehospitalizations and mortality in patients with stable CAD, recent acute coronary syndrome (ACS) or recent revascularization. A literature review of the influence of exercise, and PA and SB profiles in secondary prevention of CAD was performed using PubMed. All articles published between January 2001 and April 2019, meeting the inclusion criteria were considered. A total of 25 cross-sectional or prospective studies or randomized controlled trials (RCT) were included to this review. Exercise training was found to improve maximal oxygen consumption, QoL, and to reduce rehospitalizations and mortality among patients with established CAD. Remote PA interventions have not been as effective as the supervised exercise sessions in reducing the clinical endpoints. High SB, especially when combined to low PA, is associated with poor cardiorespiratory fitness and worse long-term prognosis among patients with ACS. In conclusion, exercise training and high PA are beneficial for patients with stable CAD, recent ACS or recent revascularization. High SB is associated with poor cardiopulmonary fitness and increased mortality in ACS patients. Novel tools using online applications and smart devices are promising means to offer remote guidance for PA among patients unable to participate in regular exercise sessions.

Cost-effectiveness of cardiac telerehabilitation in coronary artery disease and heart failure patients: systematic review of randomized controlled trials

This systematic review aims to assess the cost-effectiveness of cardiac telerehabilitation in comparison with centre-based cardiac rehabilitation (CR). Evidence of cost-effectiveness is an important step towards implementation and reimbursement of telerehabilitation services. Electronic databases were searched for economic evaluations of telerehabilitation programmes. Only randomized controlled trials (RCTs) published in English were eligible for inclusion. Study quality and risk of bias were assessed using the Consensus Health Economic Criteria (CHEC) list. A total of eight economic evaluations met the review inclusion criteria. The total sample size consisted of 751 patients ranging from a minimum of 46 patients to a maximum of 162 patients per study. Maximal follow-up was 5 years. A total of seven of the eight included studies demonstrated that telerehabilitation could lead to similar or lower long-term costs and are thus as cost-effective as traditional centre-based CR. There is significant heterogeneity between all included telerehabilitation interventions in duration, used technology, cost included and follow-up. Based on these small short duration trials, telerehabilitation may be as cost-effective as traditional centre-based approaches. However, more assessments of the value for money of telerehabilitation in larger and longer RCTs are needed both in high- as low-income countries.

Determining if Telehealth Can Reduce Health System Costs: Scoping Review

Background

Telehealth represents an opportunity for Australia to harness the power of technology to redesign the way health care is delivered. The potential benefits of telehealth include increased accessibility to care, productivity gains for health providers and patients through reduced travel, potential for cost savings, and an opportunity to develop culturally appropriate services that are more sensitive to the needs of special populations. The uptake of telehealth has been hindered at times by clinician reluctance and policies that preclude metropolitan populations from accessing telehealth services.

Objective

This study aims to investigate if telehealth reduces health system costs compared with traditional service models and to identify the scenarios in which cost savings can be realized.

Methods

A scoping review was undertaken to meet the study aims. Initially, literature searches were conducted using broad terms for telehealth and economics to identify economic evaluation literature in telehealth. The investigators then conducted an expert focus group to identify domains where telehealth could reduce health system costs, followed by targeted literature searches for corresponding evidence.

Results

The cost analyses reviewed provided evidence that telehealth reduced costs when health system–funded travel was prevented and when telehealth mitigated the need for expensive procedural or specialist follow-up by providing competent care in a more efficient way. The expert focus group identified 4 areas of potential savings from telehealth: productivity gains, reductions in secondary care, alternate funding models, and telementoring. Telehealth demonstrated great potential for productivity gains arising from health system redesign; however, under the Australian activity-based funding, it is unlikely that these gains will result in cost savings. Secondary care use mitigation is an area of promise for telehealth; however, many studies have not demonstrated overall cost savings due to the cost of administering and monitoring telehealth systems. Alternate funding models from telehealth systems have the potential to save the health system money in situations where the consumers pay out of pocket to receive services. Telementoring has had minimal economic evaluation; however, in the long term it is likely to result in inadvertent cost savings through the upskilling of generalist and allied health clinicians.

Conclusions

Health services considering implementing telehealth should be motivated by benefits other than cost reduction. The available evidence has indicated that although telehealth provides overwhelmingly positive patient benefits and increases productivity for many services, current evidence suggests that it does not routinely reduce the cost of care delivery for the health system.

Cost-utility analysis of home-based cardiac rehabilitation as compared to usual post-discharge care: systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Determining cost-utility differences between home-based cardiac rehabilitation (HBCR) on the one hand, and usual post-discharge care (UC) on the other, can improve resource-allocation in healthcare settings.

AREAS COVERED

In June 2019, PubMed, Web of Science, Scopus, and Cochrane library were searched for randomized controlled HBCR trials. Standardized mean differences (SMDs) of cost and quality-adjusted life years (QALYs) between HBCRs and UCs were calculated using random effect models. Heterogeneity was assessed by inconsistency index (I2) and publication bias by funnel plot and Egger's regression test. Thirteen articles, representing 2,992 participants, were deemed representative for final analysis. In the meta-analysis, a significant difference with respect to QALYs favored HBCR, while no significant cost difference was observed between HBCR and UC. However, subgroup-analysis of trials with different follow-up durations revealed somewhat different results, and HBCR was found to be significantly better with regard to both cost and QALYs for patients with heart failure. Cost-utility analysis categorizing interventions as 'dominant', 'effective', 'doubtful', and 'dominated', found HBCRs dominant.

EXPERT OPINION

Although HBCR tended to be superior compared to UC in this review, larger and more robust trials addressing specific patients groups are needed for definitive results.

Economic evaluation protocol for a multicentre randomised controlled trial to compare Smartphone Cardiac Rehabilitation, Assisted self-Management (SCRAM) versus usual care cardiac rehabilitation among people with coronary heart disease

INTRODUCTION

It is important to ascertain the cost-effectiveness of alternative services to traditional cardiac rehabilitation while the economic credentials of the Smartphone Cardiac Rehabilitation, Assisted self-Management (SCRAM) programme among people with coronary heart disease (CHD) are unknown. This economic protocol outlines the methods for undertaking a trial-based economic evaluation of SCRAM in the real-world setting in Australia.

METHODS AND ANALYSIS

The within-trial economic evaluation will be undertaken alongside a randomised controlled trial (RCT) designed to determine the effectiveness of SCRAM in comparison with the usual care cardiac rehabilitation (UC) alone in people with CHD. Pathway analysis will be performed to identify all the costs related to the delivery of SCRAM and UC. Both a healthcare system and a limited societal perspective will be adopted to gauge all costs associated with health resource utilisation and productivity loss. Healthcare resource use over the 6-month participation period will be extracted from administrative databases (ie, Pharmaceutical Benefits Scheme and Medical Benefits Schedule). Productivity loss will be measured by absenteeism from work (valued by human capital approach). The primary outcomes for the economic evaluation are maximal oxygen uptake (VO₂max, mL/kg/min, primary RCT outcome) and quality-adjusted life years estimated from health-related quality of life as assessed by the Assessment of Quality of Life-8D instrument. The incremental cost-effectiveness ratio will be calculated using the differences in costs and benefits (ie, primary and secondary outcomes) between the two randomised groups from both perspectives with no discounting. All costs will be valued in Australian dollars for year 2020.

ETHICS AND DISSEMINATION

The study protocol has been approved under Australia's National Mutual Acceptance agreement by the Melbourne Health Human Research Ethics Committee (HREC/18/MH/119). It is anticipated that SCRAM is a cost-effective cardiac telerehabilitation programme for people with CHD from both a healthcare and a limited societal perspective in Australia. The evaluation will provide evidence to underpin national scale-up of the programme to a wider population. The results of the economic analysis will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12618001458224).

Patients' needs and perspectives for using mobile phone interventions to improve heart failure self-care: A qualitative study

AIMS

To explore heart failure patients' needs and perspectives for using mobile health technology at home before developing a mobile phone-based heart failure self-care intervention.

DESIGN

A qualitative interview study.

METHODS

Purposive sampling was used to conduct semi-structured individual interviews with patients diagnosed with chronic heart failure (N = 20). Data were collected from November 2018 - May 2019. All interviews were audio-recorded and transcribed verbatim and data were analysed using qualitative content analysis.

RESULTS

The four themes that emerged from the interviews were as follows: 'The demand for reliable and customized health information', 'Valuable features of mobile phone applications', 'Barriers to adopting mobile health service', and 'Expected benefits of using mobile health technology'. Participants in this study required personalized health-related information and reminders for improving their self-care behaviours. However, while difficulties in using mobile phone applications posed the main obstacle, users expected mobile health services to improve their overall quality of life.

CONCLUSION

Despite mobile phone technology's potential benefits for effective self-care strategies at home, there were some obstacles such as security issues, application costs, and the need for user friendly designs and reliable information for patients' optimal use.

IMPACT

This study highlights that healthcare professionals should consider patients' needs and preferences to promote the acceptability of mobile health technology. This study's findings can guide the future design and implementation of mobile health interventions for improving self-care among patients with heart failure.

Cardiac Rehabilitation During Quarantine in COVID-19 Pandemic: Challenges for Center-Based Programs

Because of the coronavirus disease 2019 (COVID-19) epidemic, many cardiac rehabilitation (CR) services and programs are stopped. Because CR is a class I level A recommendation with clinical benefits that are now well documented, the cessation of CR programs can lead to dramatic consequences in terms of public health. We propose here a viewpoint of significant interest about the sudden need to develop remote home-based CR programs both in clinical research and in clinical care routine. This last decade, the literature on remote home-based CR programs has been increasing, but to date only clinical research experiences have been implemented. Benefits are numerous and the relevance of this approach has obviously increased with the actual health emergency. The COVID-19 crisis, the important prevalence of smartphones, and high-speed Internet during confinement should be viewed as an opportunity to promote a major shift in CR programs with the use of telemedicine to advance the health of a larger number of individuals with cardiac disease.

Cardiac telerehabilitation as an alternative to centre-based cardiac rehabilitation

Multidisciplinary cardiac rehabilitation (CR) reduces morbidity and mortality and increases quality of life in cardiac patients. However, CR utilisation rates are low, and targets for secondary prevention of cardiovascular disease are not met in the majority of patients, indicating that secondary prevention programmes such as CR leave room for improvement. Cardiac telerehabilitation (CTR) may resolve several barriers that impede CR utilisation and sustainability of its effects. In CTR, one or more modules of CR are delivered outside the environment of the hospital or CR centre, using monitoring devices and remote communication with patients. Multidisciplinary CTR is a safe and at least equally (cost-)effective alternative to centre-based CR, and is therefore recommended in a recent addendum to the Dutch multidisciplinary CR guidelines. In this article, we describe the background and core components of this addendum on CTR, and discuss its implications for clinical practice and future perspectives.

Effect of Smartphone-Enabled Health Monitoring Devices vs Regular Follow-up on Blood Pressure Control Among Patients After Myocardial Infarction: A Randomized Clinical Trial

IMPORTANCE

Smart technology via smartphone-compatible devices might improve blood pressure (BP) regulation in patients after myocardial infarction.

OBJECTIVES

To investigate whether smart technology in clinical practice can improve BP regulation and to evaluate the feasibility of such an intervention.

DESIGN, SETTING, AND PARTICIPANTS

This study was an investigator-initiated, single-center, nonblinded, feasibility, randomized clinical trial conducted at the Department of Cardiology of the Leiden University Medical Center between May 2016 and December 2018. Two hundred patients, who were admitted with either ST-segment elevation myocardial infarction or non-ST-segment acute coronary syndrome, were randomized in a 1:1 fashion between follow-up groups using smart technology and regular care. Statistical analysis was performed from January 2019 to March 2019.

INTERVENTIONS

For patients randomized to regular care, 4 physical outpatient clinic visits were scheduled in the year following the initial event. In the intervention group, patients were given 4 smartphone-compatible devices (weight scale, BP monitor, rhythm monitor, and step counter). In addition, 2 in-person outpatient clinic visits were replaced by electronic visits.

MAIN OUTCOMES AND MEASURES

The primary outcome was BP control. Secondary outcomes, as a parameter of feasibility, included patient satisfaction (general questionnaire and smart technology-specific questionnaire), measurement adherence, all-cause mortality, and hospitalizations for nonfatal adverse cardiac events.

RESULTS

In total, 200 patients (median age, 59.7 years [interquartile range, 52.9-65.6 years]; 156 men [78%]) were included, of whom 100 were randomized to the intervention group and 100 to the control group. After 1 year, 79% of patients in the intervention group had controlled BP vs 76% of patients in the control group (P = .64). General satisfaction with care was the same between groups (mean [SD] scores, 82.6 [14.1] vs 82.0 [15.1]; P = .88). The all-cause mortality rate was 2% in both groups (P > .99). A total of 20 hospitalizations for nonfatal adverse cardiac events occurred (8 in the intervention group and 12 in the control group). Of all patients, 32% sent in measurements each week, with 63% sending data for more than 80% of the weeks they participated in the trial. In the intervention group only, 90.3% of patients were satisfied with the smart technology intervention.

CONCLUSIONS AND RELEVANCE

These findings suggest that smart technology yields similar percentages of patients with regulated BP compared with the standard of care. Such an intervention is feasible in clinical practice and is accepted by patients. More research is mandatory to improve patient selection of such an intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02976376.

Secondary prevention through comprehensive cardiovascular rehabilitation: From knowledge to implementation. 2020 update. A position paper from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology

Secondary prevention through comprehensive cardiac rehabilitation has been recognized as the most cost-effective intervention to ensure favourable outcomes across a wide spectrum of cardiovascular disease, reducing cardiovascular mortality, morbidity and disability, and to increase quality of life. The delivery of a comprehensive and 'modern' cardiac rehabilitation programme is mandatory both in the residential and the out-patient setting to ensure expected outcomes. The present position paper aims to update the practical recommendations on the core components and goals of cardiac rehabilitation intervention in different cardiovascular conditions, in order to assist the whole cardiac rehabilitation staff in the design and development of the programmes, and to support healthcare providers, insurers, policy makers and patients in the recognition of the positive nature of cardiac rehabilitation. Starting from the previous position paper published in 2010, this updated document maintains a disease-oriented approach, presenting both well-established and more controversial aspects. Particularly for implementation of the exercise programme, advances in different training modalities were added and new challenging populations were considered. A general table applicable to all cardiovascular conditions and specific tables for each clinical condition have been created for routine practice.

Effect of eHealth cardiac rehabilitation on health outcomes of coronary heart disease patients: A systematic review and meta-analysis

AIMS

To evaluate the effects of eHealth cardiac rehabilitation (CR) on health outcomes of coronary heart disease patients and to identify programme design, which may lead to more effective health benefits.

DESIGN

A systematic review and meta-analysis following Cochrane Handbook for Systematic Reviews of Interventions.

DATA SOURCES

Medline, EMBASE, CLNAHL, Web of Science, Scopus, PsycINFO, Cochrane Central Register of Controlled Trails, PubMed and CNKI were searched over the period from 1806 to April 2019.

REVIEW METHODS

A systematic review and meta-analysis of randomized controlled trials to examine the effect of eHealth CR on health outcomes of coronary heart disease patients. We used RevMan 5.3 for risk of bias assessment and meta-analysis and GRADE software for generating findings.

RESULTS

In all, 14 trials with 1,783 participants were included. eHealth CR has significantly promoted duration of physical activity, daily steps, quality of life (QoL) and re-hospitalization. Using comparative analysis of programme design elements, including mode of delivery, intervention content, motivational strategies and social support, between the effective and ineffective eHealth CR, it was found that comprehensive empowerment strategies and follow-up care by tele-monitoring may be the crucial characteristics leading to more favourable treatment effect.

CONCLUSION

eHealth CR is effective in engaging patients in active lifestyle, improving QoL and reducing re-hospitalization. Future research needs to test the effects of comprehensive CR programmes by incorporating empowerment strategies and tele-monitoring as active components.

IMPACT

eHealth has been increasingly applied to increase accessibility and uptake of CR. Integrative evidence to indicate its effects on health outcomes is lacking. This review identified its positive effects on some behavioural, psychosocial and health service use outcomes. Together with insights about which programme design elements may positively shape the outcomes, this review informs the role and practice of cardiovascular nurses in promoting evidence-based eHealth CR.

Remote monitoring and telemedicine

Telemedicine and remote monitoring represent more than the communication of health data via a 'remote connection'. Modern systems can be stand-alone and can be equipped with the ability to acquire and summarize data in order to inform the patient, carer or health care giver. The information can be held locally or be shared with a health care centre. Contemporary telemedicine and telemonitoring solutions have shifted their focus, trying to work on a system which is ubiquitous, efficient and sustainable. Along with devices that collect and elaborate data, a new generation of plug and play sensors has also come to life, which with standardization can lower management costs and make introduction into practice more feasible. Multiple trials (TIM-HF, TEN-HMS and BEAT.HF) have reported varying outcomes, depending on the monitoring system and the background health care process. A special mention is necessary for home tele-rehabilitation programmes for patients with heart failure. Despite the progress obstacles remain, including adequate training, data ownership and handling and applicability to larger populations. This article will review contemporary advances in this area.