Randomized Trial of a Virtual Cardiac Rehabilitation Program Delivered at a Distance via the Internet

Abstract

With an aging population in many Western countries and increases in risk factors such as obesity, the number of patients with cardiovascular diseases (CVDs) is increasing. 1 These patients are at greater risk of subsequent events, comorbidities, and premature mortality, therefore effective and ongoing management is needed to reduce this risk. Cardiac rehabilitation programs (CRPs) are effective at improving lifestyle behaviors and reducing risk factors in patients with CVD, as well as reducing CVD events and premature mortality, while being cost-effective.2-5 As a result, the American Heart Association, and others, have highlighted participation in CRP as an essential element of secondary prevention in patients with CVD. [6][7][8] Despite the known benefits of CRP, as little as 10% to 30% of eligible patients attend these programs. [9][10][11][12][13] The majority of these programs are limited to hospitals in large urban areas with geographical accessibility as one of the main barriers to attendance.14,15 Lack of access is more pronounced for patients in rural areas that do not have CRP, 16,17 although risk factors such as smoking and obesity are higher in rural populations 18 resulting in a greater rate of hospitalizations than urban populations.19 Home-based CRP have been developed to address the accessibility issue, and a review of these studies found no difference to hospital-based CRP with respect to improvements in CVD risk. 20 However, these programs generally consist of a mix of on-site exercise sessions, clinic or home visits, telephone calls from staff, and diaries, which still require patients to attend some sort of clinic and therefore do not accommodate patients in outlying areas.The proliferation of low-cost communications technology, such as the Internet, has opened up an array of opportunities for patient communication while bridging geographic distance. The Internet holds great promise in improving access to healthcare services as it is ubiquitous, requires little infrastructure and cost, and is readily scalable to large populations. Despite the enthusiasm for technology supported healthcare services, the evidence to support such use in cardiac rehabilitation is limited to pilot studies. [21][22][23][24] As a result, a recent American Heart Association Presidential Advisory has called for more robust research to test the feasibility and effectiveness of Internet-based CRP. 25 Our goal therefore, was to test the clinical effectiveness of a virtual CRP (vCRP) delivered exclusively using Internet-based technology. Local Challenges in ImplementationA common challenge to the implementation of CRP is the cost of their implementation despite having been demonstrated to be cost-effective.5 This challenge also holds true for technology-based solutions. Although several communication technology mediums exist (telephone, video-conferencing, and telemonitoring), we chose to use a web-based program delivered through the Internet as it is (1) commonly available in people's homes, (2) requires less capital exp...

Evaluation of a Web-Based Tailored Nursing Intervention (TAVIE en m@rche) Aimed at Increasing Walking After an Acute Coronary Syndrome: A Multicenter Randomized Controlled Trial Protocol

“…Two RCTs testing Web-based interventions in ACS patients measured an objective physical activity outcome (steps per day or exercise capacity) and reported serious adverse cardiac or mortality events requiring hospitalization per treatment group [28,29]. Reid et al reported four hospitalisations for chest pain and no deaths in the experimental group, and six hospitalisations for chest pain, one for cardiac surgery and two deaths in the control group during 12 months of follow-up [28] Lear et al reported three (9%) major cardiac events (e.g., revascularisation, stroke, and death) in the experimental group, and six (16%) in the control group during 16 months of follow-up [29]. These data suggest that fewer serious adverse cardiac or mortality events are found in favor of Web-based experimental groups, and too few events occur to plan mortality as a primary or secondary outcome within a feasible timeframe.…”

“…The other two RCTs tested nontailored interventions measuring the primary outcome of exercise capacity compared with usual care [29,30]. One RCT found a significantly greater increase in a proxy outcome of exercise capacity, maximal time on treadmill, in favor of the experimental group [29].…”

“…One RCT found a significantly greater increase in a proxy outcome of exercise capacity, maximal time on treadmill, in favor of the experimental group [29]. In contrast, the other RCT found no difference between groups in treadmill-measured peak oxygen uptake, despite finding significantly greater increases in a subjective secondary outcome of self-reported physical activity in favor of the experimental group [30].…”

“…In contrast, the other RCT found no difference between groups in treadmill-measured peak oxygen uptake, despite finding significantly greater increases in a subjective secondary outcome of self-reported physical activity in favor of the experimental group [30]. Considering these four RCTs, the content of the Web-based interventions tested were sufficient to increase steps per day [27,28] and maximal time on treadmill [29], but the exercise intensity was insufficient to increase peak oxygen uptake [30]. No RCTs tested Web-based interventions, with or without tailoring, in ACS patients performing insufficient physical activity.…”

The Learning Healthcare System and Cardiovascular Care: A Scientific Statement From the American Heart Association

“…For example, Web-based delivery of a virtual cardiac rehabilitation program was safe and effective for CVD risk reduction. 172 Similarly, mobile messaging was associated with greater physical activity and weight loss. 173 These early successes have prompted the ongoing development of other mobile applications to improve health-related behaviors such as smoking cessation and medication adherence.…”