Telehealth-based cardiac rehabilitation: A solution to the problem of access?

The benefits of cardiac rehabilitation (CR) following a cardiac event are well established. ¹ Participation in a CR programme reduces cardiovascular risk factors, improves quality of life, increases adherence to cardioprotective medications and decreases morbidity and mortality. ¹ Importantly, these benefits have been demonstrated to be the same regardless of programme duration, ² whether they are delivered by a generalist or specialist, ² and whether they are delivered in a hospital or at home. ³ Much of CR is delivered in a face-to-face, group-based setting, in a model that has not changed over the past two decades. ⁴

Despite the clear benefits of these programmes, substantial challenges remain. Globally, uptake of CR following a cardiac event is between 15–30%, ⁵ with a recent paper indicating that only 25% of people have even a minimum level of secondary prevention after a cardiac event, including appropriate medications, lifestyle advice and referral to CR. ⁶ Access to these programmes is limited by many factors, including distance to the providing centre, feelings of embarrassment that participants have about taking part in group exercise sessions and language barriers. ⁵ It has been suggested that programmes that are delivered remotely, such as telehealth-based programmes might overcome these barriers. ⁷ Systematic reviews have shown the benefits of telehealth programmes when compared to usual care.^7,8 However, what has been unknown is whether telehealth programmes are as effective at reducing cardiovascular risk factors and improving quality of life as the traditional, face-to-face model of CR.

In their paper in this issue of the European Journal of Preventive Cardiology, Huang and colleagues undertook a systematic review of 15 papers, reporting nine randomised controlled trials (RCTs). ⁹ These RCTs compared a telehealth intervention to face-to-face CR. In this nicely conducted review, the results indicate that there was no difference between the telehealth interventions and face-to-face CR in terms of exercise capacity, weight, blood pressure, lipid profiles, smoking, quality of life and psychosocial state. These encouraging findings suggest that there are alternatives that are non-inferior to the face-to-face model of care. This is of great relevance because Internet access is increasing exponentially, such that almost half of the world’s population now has Internet access ¹⁰ and 72% of people in a recent survey stated that they had sought health information on the Internet in the preceding year. ¹¹ Indeed, up to a third of US adults have gone online to find a diagnosis before consulting a health care professional. ¹¹

The changing face of technology brings hope that new models of care might effectively enable people who do not currently access CR to participate. This might equally apply in low and middle income countries, which have had very low access to face-to-face services. The term ‘leapfrogging’ has been used to describe how technology is helping to bypass traditional barriers of access that these countries face. ¹² Technology may be utilised to overcome barriers of distance and time and could help to provide information translated into other languages. It could also potentially overcome personal embarrassment that people may feel about participating in a face-to-face programme. ⁵

However, together with opportunities that technologies bring there are challenges. All health-related websites are not created equal and there is an overwhelming amount of poor, inaccurate or even dangerous information available on the Internet. ¹³ Disparity still occurs between those of higher socio-economic status and those of lower socio-economic status. ¹¹ Since cardiovascular disease often affects older people, it is worth noting that specific challenges exist for older people in gaining access to the Internet. This may be in relation to cost of devices, cost of downloading digital data, visual acuity and fear of making mistakes, which might ‘break’ the computer. ¹⁴

Newer models of care, such as mobile app-based interventions, show considerable promise in increasing options to improve access. A recent RCT that compared mobile app-based CR to face-to-face CR demonstrated significant gains in risk factor reduction in both arms of the study. ¹⁵ Moreover, there was significantly greater adherence and completion in the mobile app group, ¹⁵ which is of great interest when we consider the low uptake and adherence to a face-to-face model of care.

Mobile apps have enormous potential to improve health. There are over 43,000 health-related apps listed in the iTunes store. ¹⁶ Although the quality of these apps is generally low, there is potential to use existing apps to facilitate risk factor reduction. A chief barrier to use of existing apps is the difficulty in identifying which ones are appropriate, due to cataloguing limitations on the app distribution platforms. There are some sites that strive to list recommended and tested health-related apps, for example, the NHS Health Apps Library. ¹⁷ While at present there are only a few apps listed that are suitable for risk factor reduction in cardiovascular disease, this is an area that will undoubtedly improve as demand to access suitable apps grows.

Another area that deserves exploration is the use of social media to deliver CR. A vast number of social media sites exist, for example, Twitter and Facebook. Access to social media accounts for 25% of time spent online. ¹⁰ One third of older adults using the Internet will use it to access Facebook or Linkedin. ¹¹ Social media have not yet been robustly tested, although show promise in areas such as smoking cessation ¹⁸ and social media-based models of care could provide a low cost adjunct to other services to increase consumer engagement. The solution to ensuring equitable access to CR is likely to be multi-faceted and the findings that telehealth is non-inferior to face-to-face CR ⁹ gives us confidence that telehealth-based options are an important part of the overall package of CR strategies.