Cardiac telerehabilitation: A novel cost-efficient care delivery strategy that can induce long-term health benefits

Assessment of Physical Activity by Wearable Technology During Rehabilitation After Cardiac Surgery: Explorative Prospective Monocentric Observational Cohort Study

Background

Wearable technology is finding its way into clinical practice. Physical activity describes patients’ functional status after cardiac surgery and can be monitored remotely by using dedicated trackers.

Objective

The aim of this study was to compare the progress of physical activity in cardiac rehabilitation by using wearable fitness trackers in patients undergoing coronary artery bypass surgery by either the conventional off-pump coronary artery bypass (OPCAB) or the robotically assisted minimally invasive coronary artery bypass (RA-MIDCAB). We hypothesized faster recovery of physical activity after RA-MIDCAB in the first weeks after discharge as compared to OPCAB.

Methods

Patients undergoing RA-MIDCAB or OPCAB were included in the study. Each patient received a Fitbit Charge HR (Fitbit Inc, San Francisco, CA) physical activity tracker following discharge. Rehabilitation progress was assessed by measuring the number of steps and physical activity level daily. The physical activity level was calculated as energy expenditure divided by the basic metabolic rate.

Results

A total of 10 RA-MIDCAB patients with a median age of 68 (min, 55; max, 83) years and 12 OPCAB patients with a median age of 69 (min, 50; max, 82) years were included. Baseline characteristics were comparable except for body mass index (RA-MIDCAB: 26 kg/m²; min, 22; max, 28 versus OPCAB: 29 kg/m²; min, 27; max, 33; P<.001). Intubation time (P<.05) was significantly lower in the RA-MIDCAB group. A clear trend, although not statistically significant, was observed towards a higher number of steps in RA-MIDCAB patients in the first week following discharge.

Conclusions

RA-MIDCAB patients have an advantage in recovery in the first weeks of revalidation, which is reflected by the number of steps and physical activity level measured by the Fitbit Charge HR, as compared to OPCAB patients. However, unsupervised assessment of daily physical activity varied widely and could have consequences with regard to the use of these trackers as research tools.

Cost-Utility Analysis of Home-Based Telerehabilitation Compared With Centre-Based Rehabilitation in Patients With Heart Failure

BACKGROUND

Whilst home-based telerehabilitation has been shown non-inferior to traditional centre-based rehabilitation in patients with chronic heart failure, its economic sustainability remains unknown. This study aimed to investigate the cost-utility of a home-based telerehabilitation program.

METHODS

A comparative, trial-based, incremental cost-utility analysis was conducted from a health care provider's perspective. We collected data as part of a multi-centre, two-arm, non-inferiority, randomised controlled trial with 6 months follow-up. There were 53 participants randomised to either a telerehabilitation program (consisting of 12 weeks of group-based exercise and education delivered into the home via online videoconferencing) or a traditional centre-based program. Health care costs (including personnel, equipment and hospital readmissions due to heart failure) were extracted from health system records, and calculated in Australian dollars using 2013 as the base year. Health utilities were measured using the EuroQol five-dimensional (EQ-5D) questionnaire. Estimates were presented as means and 95% confidence intervals (CIs) based on bootstrapping. Costs and utility differences were plotted on a cost-effectiveness plane.

RESULTS

Total health care costs per participant were significantly lower in the telerehabilitation group (-$1,590, 95% CI: -2,822, -359) during the 6 months. No significant differences in quality-adjusted life years (0, 95% CI: -0.06, 0.05) were seen between the two groups.

CONCLUSIONS

Heart failure telerehabilitation appears to be less costly and as effective for the health care provider as traditional centre-based rehabilitation.

Rationale and design of randomized controlled trial protocol of cardiovascular rehabilitation based on the use of telemedicine technology in the Czech Republic (CR-GPS)

BACKGROUND

Cardiovascular diseases remain the most common causes of death in the world. Instructions for secondary prevention recommend multifaceted approach in cardiovascular diseases risk management. Center-based physical exercise training is considered as an important integral part of cardiac rehabilitation (CR). Despite all recognized benefits CR brings, active interest of patients remains low in many countries, including the Czech Republic. That is why there is a need to focus on more effective patients' participation in CR with respect to their preferences and needs. One of possible approaches is using telemonitoring guidance based on obtaining data via technological equipment during home exercise training. The aim of this study is to compare effectiveness of both center- and home-based exercise training with focus on participants' physical fitness and quality of life.

METHODS/DESIGN

This randomized control trial intends to monitor cardiorespiratory health indicators and quality of life of patients diagnosed with a coronary artery disease (CAD) at the University Hospital Brno, Czech Republic. These patients will be randomly separated into 2 groups-a regular outpatient group (ROT) and an intervention training group (ITG). Both groups undergo a 12-week rehabilitation training program. The ROT group will undergo center-based exercise trainings in the hospital and receive feedback and support directly by their coach. The ITG group will be telemonitored during exercise training in their home environment via a wrist sport tester and Internet application.All patients will be supposed to exercise at 70% to 80% of their heart rate reserve obtained from cardiopulmonary exercise test (CPX). The primary outcome is to measure and compare physical fitness values assessed at baseline and after 12 weeks of training. Physical fitness is expressed as peak oxygen uptake assessed by the CPX test. The secondary outcomes are patients, training adherence, and their quality of life.

DISCUSSION

This trial focuses on an up-to-date topic. As there have not been any similar trials in the Czech Republic yet, we expect it to bring great benefits not only for our hospital in Brno. In the long term, this method seems to be low-cost for all participants and brings a lot of benefits for those patients, who are for many reasons unable to participate in center-based CR provided by hospitals and other health care centers. Physical exercise therapy brings good results in reducing cardiovascular risk factors and improves its global impact. Thanks to its simplicity, it is expected to increase patients' training adherence as well.

Effects and costs of real-time cardiac telerehabilitation: randomised controlled non-inferiority trial

Objective

Compare the effects and costs of remotely monitored exercise-based cardiac telerehabilitation (REMOTE-CR) with centre-based programmes (CBexCR) in adults with coronary heart disease (CHD).

Methods

Participants were randomised to receive 12 weeks of telerehabilitation or centre-based rehabilitation. REMOTE-CR provided individualised exercise prescription, real-time exercise monitoring/coaching and theory-based behavioural strategies via a bespoke telerehabilitation platform; CBexCR provided individualised exercise prescription and coaching via established rehabilitation clinics. Outcomes assessed at baseline, 12 and/or 24 weeks included maximal oxygen uptake (V̇O₂max, primary) modifiable cardiovascular risk factors, exercise adherence, motivation, health-related quality of life and programme delivery, hospital service utilisation and medication costs. The primary hypothesis was a non-inferior between-group difference in V̇O₂max at 12 weeks (inferiority margin=−1.25 mL/kg/min); inferiority margins were not set for secondary outcomes.

Results

162 participants (mean 61±12.7 years, 86% men) were randomised. V̇O₂ max was comparable in both groups at 12 weeks and REMOTE-CR was non-inferior to CBexCR (REMOTE-CR-CBexCR adjusted mean difference (AMD)=0.51 (95% CI −0.97 to 1.98) mL/kg/min, p=0.48). REMOTE-CR participants were less sedentary at 24 weeks (AMD=−61.5 (95% CI −117.8 to −5.3) min/day, p=0.03), while CBexCR participants had smaller waist (AMD=1.71 (95% CI 0.09 to 3.34) cm, p=0.04) and hip circumferences (AMD=1.16 (95% CI 0.06 to 2.27) cm, p=0.04) at 12 weeks. No other between-group differences were detected. Per capita programme delivery (NZD1130/GBP573 vs NZD3466/GBP1758) and medication costs (NZD331/GBP168 vs NZD605/GBP307, p=0.02) were lower for REMOTE-CR. Hospital service utilisation costs were not statistically significantly different (NZD3459/GBP1754 vs NZD5464/GBP2771, p=0.20).

Conclusion

REMOTE-CR is an effective, cost-efficient alternative delivery model that could—as a complement to existing services—improve overall utilisation rates by increasing reach and satisfying unique participant preferences.

Comparative Effectiveness of Disease Management With Information Communication Technology for Preventing Hospitalization and Readmission in Adults With Chronic Congestive Heart Failure

OBJECTIVES

Critical appraisal of all available evidence regarding the role of noninvasive communication technology for improving patient survival and reducing hospital admissions in adults with chronic heart failure (HF).

DESIGN

Systematic literature review and grading of the quality of evidence according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group approach.

SETTING AND PARTICIPANTS

Four databases were searched in March 2018 to find 2 high-quality meta-analyses and published and unpublished data from 58 randomized controlled trials (RCTs) that compared noninvasive communication technology with usual care in community-dwelling adults with HF.

MEASURES

Direct meta-analysis of aggregate data with random effects models.

RESULTS

Moderate-quality evidence suggests that there are no differences in all-cause mortality between telemonitoring and usual care, whereas complex telemonitoring that includes transmission of patient parameters and analysis by health care professionals decreases all-cause mortality (relative risk [RR] 0.78, 95% confidence interval [CI] 0.62, 0.99; 2885 people in 12 RCTs). Moderate-quality evidence suggests that telemonitoring prevents HF-related hospitalizations (RR 0.74; 95% CI 0.62, 0.88; 4001 people in 11 RCTs). Moderate-quality evidence suggests that structured telephone support decreases all-cause mortality (RR 0.86; 95% CI 0.77, 0.97; 9535 people in 24 RCTs) and HF-related hospitalizations (RR 0.83; 95% CI 0.73, 0.94; 7030 people in 16 RCTs). Use of a mobile personal digital assistant prevents HF-related hospitalizations (RR 0.58; 95% CI 0.44, 0.77; 674 people in 3 RCTs). The evidence regarding the comparative effectiveness of specific telecommunication devices is insufficient. The results from many completed studies are not available.

CONCLUSIONS

Clinicians should offer noninvasive monitoring with communication technology applications to all HF patients. Future research should examine comparative effectiveness of technology applications in patient subpopulations.

A pilot study of daily telemonitoring to predict acute exacerbation in chronic obstructive pulmonary disease

BACKGROUND

Exacerbations of COPD (ECOPD) are important events in the course of COPD and they accelerate the rate of decline of lung function, and exacerbations requiring hospitalization are associated with significant mortality. Therefore, developing approaches of prevention and early treatment of ECOPDs are of special clinical interests. One of such approaches is telecare, including home telemonitoring.

MATERIAL AND METHODS

Daily telemonitoring of HR, BP, SpO₂ and spirometry was performed. Variables were compared using the bootstrap-boosted inference tests: the paired t-test or Wilcoxon signed rank test, depending on data normality, and categorical variables were compared using exact McNemar's test.

RESULTS

Nineteen patients were included to the study. We observed significant decrease in SpO₂ 7 days preceding ECOPD (P = 0.007; Pbootstrap-boosted = 0.005) and increase in number of events of day-to-day decrease in oxygen saturation >4% in the period of 7 days preceding ECOPD versus reference period (P = 0.02).

CONCLUSIONS

Oxygen saturation telemonitoring would be successfully used in predicting ECOPD. Recording of day-to-day decrease in oxygen saturation >4% as alarming events would be effective approach which would be easily implemented in telemonitoring devices, however this outcome should be further validated in larger size samples.