Target Audience and Preferences Related to an Australian Coronary Heart Disease Specific Mobile App: A Mixed Methods Study

Testing the Effect of a Smartphone App on Hospital Admissions and Sedentary Behavior in Cardiac Rehabilitation Participants: ToDo-CR Randomized Controlled Trial

BACKGROUND

People with coronary heart disease are at an increased risk of morbidity and mortality even if they attend cardiac rehabilitation. High sedentary behavior levels potentially contribute to this morbidity. Smartphone apps may be feasible to facilitate sedentary behavior reductions and lead to reduced health care use.

OBJECTIVE

We aimed to test the effect of a sedentary behavior change smartphone app (Vire app and ToDo-CR program) as an adjunct to cardiac rehabilitation on hospital admissions and emergency department (ED) presentations over 12 months.

METHODS

A multicenter, randomized controlled trial was conducted with 120 participants recruited from 3 cardiac rehabilitation programs. Participants were randomized 1:1 to cardiac rehabilitation plus the fully automated 6-month Vire app and ToDo-CR program (intervention) or usual care (control). The primary outcome was nonelective hospital admissions and ED presentations over 12 months. Secondary outcomes including accelerometer-measured sedentary behavior, BMI, waist circumference, and quality of life were recorded at baseline and 6 and 12 months. Logistic regression models were used to analyze the primary outcome, and linear mixed-effects models were used to analyze secondary outcomes. Data on intervention and hospital admission costs were collected, and the incremental cost-effectiveness ratios (ICERs) were calculated.

RESULTS

Participants were, on average, aged 62 (SD 10) years, and the majority were male (93/120, 77.5%). The intervention group were more likely to experience all-cause (odds ratio [OR] 1.54, 95% CI 0.58-4.10; P=.39) and cardiac-related (OR 3.26, 95% CI 0.84-12.55; P=.09) hospital admissions and ED presentations (OR 2.07, 95% CI 0.89-4.77; P=.09) than the control group. Despite this, cardiac-related hospital admission costs were lower in the intervention group over 12 months (Aus $252.40 vs Aus $859.38; P=.24; a currency exchange rate of Aus $1=US $0.69 is applicable). There were no significant between-group differences in sedentary behavior minutes per day over 12 months, although the intervention group completed 22 minutes less than the control group (95% CI -22.80 to 66.69; P=.33; Cohen d=0.21). The intervention group had a lower BMI (β=1.62; P=.05), waist circumference (β=5.81; P=.01), waist-to-hip ratio (β=.03, P=.03), and quality of life (β=3.30; P=.05) than the control group. The intervention was more effective but more costly in reducing sedentary behavior (ICER Aus $351.77) and anxiety (ICER Aus $10,987.71) at 12 months. The intervention was also more effective yet costly in increasing quality of life (ICER Aus $93,395.50) at 12 months.

CONCLUSIONS

The Vire app and ToDo-CR program was not an outcome-effective or cost-effective solution to reduce all-cause hospital admissions or ED presentations in cardiac rehabilitation compared with usual care. Smartphone apps that target sedentary behavior alone may not be an effective solution for cardiac rehabilitation participants to reduce hospital admissions and sedentary behavior.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12619001223123; https://australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619001223123.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2020-040479.

Health information needs and dissemination methods for individuals living with ischemic heart disease: A systematic review

OBJECTIVES

This review aimed to identify the health information needs and preferred approaches to receive health information of individuals with Ischaemic Heart Disease (IHD).

METHODS

A systematic review was conducted. Relevant literature, published in English (January 2011 to October 2021), was identified across six databases. Guided by Coulter et al.'s framework for developing patient information materials, thematic analysis was performed. The findings were presented in tables and prose.

RESULTS

Fifty-nine studies were included. Eleven themes summarised the information needs of individuals with IHD. Each theme was supported with subthemes. Forty-five studies included information on preferred methods of dissemination.

CONCLUSIONS

Our review has characterised the diverse information needs of individuals living with IHD and dissemination methods for outreach to this population. Such insights inform healthcare providers in formulating patient-centred educational interventions to empower patients to undertake successful behavioural modification.

PRACTICE IMPLICATIONS

Patient education should be personalised and delivered according to individuals' risks for IHD and modifiable risk factors. The use of web-based dissemination of patient education has gained popularity among healthcare providers but sub-optimal adherence to these web-based interventions limits behavioural modification. Adding elements of in-person patient education session to complement web-based interventions may be more propitious to effecting behavioural modification.

The effect of a game-based mobile app 'MyHeartMate' to promote lifestyle change in coronary disease patients: a randomized controlled trial

Aims

Secondary prevention reduces coronary heart disease (CHD) progression. Traditional prevention programs including cardiac rehabilitation are under-accessed, which smartphone apps may overcome. To evaluate the effect of a game-based mobile app intervention (MyHeartMate) to improve cardiovascular risk factors and lifestyle behaviours.

Methods and results

Single-blind randomized trial of CHD patients in Sydney, 2017-2021. Intervention group were provided the MyHeartMate app for 6 months. Co-designed features included an avatar of the patient's heart and tokens earned by risk factor work (tracking, challenges, and quizzes). The control group received usual care. Primary outcome was self-reported physical activity [metabolic equivalents (METs), Global Physical Activity Questionnaire] and secondary outcomes included lipid levels, blood pressure (BP), body mass index, and smoking. Pre-specified sample size was achieved (n = 390), age 61.2 ± 11.5 years; 82.5% men and 9.2% current smokers. At 6 months, adjusted for baseline levels, the intervention group achieved more physical activity than control (median difference 329 MET mins/wk), which was not statistically significant (95% CI -37.4, 696; P = 0.064). No differences occurred between groups on secondary outcomes except for lower triglyceride levels in the intervention [mean difference -0.3 (95% CI -0.5, -0.1 mmoL/L, P = 0.004)]. Acceptability was high: 94.8% of intervention participants engaged by tracking exercise or BP and completing missions; 26.8% continued to engage for ≥30 days. Participants (n = 14) reported the app supported tracking behaviours and risk factors, reinforcing and improving self-care confidence, and decreasing anxiety.

Conclusion

A game-based app proved highly acceptable for patients with CHD but did not improve risk factors or lifestyle behaviours other than triglyceride levels.

Effect of an mHealth self-help intervention on readmission after adult cardiac surgery: Protocol for a pilot randomized controlled trial

Aim

To describe a protocol for the pilot phase of a trial designed to test the effect of an mHealth intervention on representation and readmission after adult cardiac surgery.

Design

A multisite, parallel group, pilot randomized controlled trial (ethics approval: HREC2020.331‐RMH69278).

Methods

Adult patients scheduled to undergo elective cardiac surgery (coronary artery bypass grafting, valve surgery, or a combination of bypass grafting and valve surgery or aortic surgery) will be recruited from three metropolitan tertiary teaching hospitals. Patients allocated to the control group with receive usual care that is comprised of in‐patient discharge education and local paper‐based written discharge materials. Patients in the intervention group will be provided access to tailored ‘GoShare’ mHealth bundles preoperatively, in a week of hospital discharge and 30 days after surgery. The mHealth bundles are comprised of patient narrative videos, animations and links to reputable resources. Bundles can be accessed via a smartphone, tablet or computer. Bundles are evidence‐based and designed to improve patient self‐efficacy and self‐management behaviours, and to empower people to have a more active role in their healthcare. Computer‐generated permuted block randomization with an allocation ratio of 1:1 will be generated for each site. At the time of consent, and 30, 60 and 90 days after surgery quality of life and level of patient activation will be measured. In addition, rates of representation and readmission to hospital will be tracked and verified via data linkage 1 year after the date of surgery.

Discussion

Interventions using mHealth technologies have proven effectiveness for a range of cardiovascular conditions with limited testing in cardiac surgical populations.

Impact

This study provides an opportunity to improve patient outcome and experience for adults undergoing cardiac surgery by empowering patients as end‐users with strategies for self‐help.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000082808.

Evaluating mobile health technologies: does the traditional randomized controlled trial serve our needs?

Mobile health technologies are increasingly used by cardiovascular nurses and allied health clinicians to support behaviour change and self-care in patients. Randomized controlled trials provide rigorous methodology for evaluation but progress slowly, so the technology is often outdated by completion. A helpful modification to the trial design includes identification of the behaviour intervention principles involved and concurrently track in-app usage data, allowing updates to be made. These data collected alongside user experiences enables analysis of effects on outcomes and determination of the relative influence of component parts. Cardiovascular and mental health mHealth strategies are used to exemplify these recommendations.

A Behavioral Change Smartphone App and Program (ToDo-CR) to Decrease Sedentary Behavior in Cardiac Rehabilitation Participants: Prospective Feasibility Cohort Study

BACKGROUND

Cardiac rehabilitation participants are encouraged to meet physical activity guidelines to reduce the risk of repeat cardiac events. However, previous studies have found that physical activity levels are low and sedentary behavior is high, both during and after cardiac rehabilitation. There is potential for smartphone apps to be effective in reducing sedentary behavior, although among the few studies that have investigated smartphone apps in cardiac rehabilitation, none targeted sedentary behavior.

OBJECTIVE

This study aims to evaluate the feasibility of a behavioral smartphone app (Vire) and a web-based behavior change program (ToDo-CR) to decrease sedentary behavior in cardiac rehabilitation participants.

METHODS

Using a single-center, pre-post design, participants were recruited by nursing staff on admission to cardiac rehabilitation. All eligible participants installed the Vire app, were given a Fitbit Flex, and received the 6-week ToDo-CR program while attending cardiac rehabilitation. The ToDo-CR program uses personalized analytics to interpret important behavioral aspects (physical activity, variety, and social opportunity) and real-time information for generating and suggesting context-specific actionable microbehavioral alternatives (Do's). Do's were delivered via the app, with participants receiving 14 to 19 Do's during the 6-week intervention period. Outcome measures were collected at 0, 6, and 16 weeks. The assessors were not blinded. Feasibility outcomes included recruitment and follow-up rates, resource requirements, app usability (Unified Theory of Acceptance and Use of Technology 2 [UTAUT2] questionnaire), and objectively measured daily minutes of sedentary behavior (ActiGraph) for sample size estimation. Secondary outcomes included functional aerobic capacity (6-min walk test), quality of life (MacNew Heart Disease Health-Related Quality of Life Questionnaire), anxiety and depression (Hospital Anxiety and Depression Scale questionnaire), BMI, waist circumference, waist-to-hip ratio, and blood pressure.

RESULTS

Between January and May 2019, 20 participants were recruited consecutively. One-third of people who commenced cardiac rehabilitation were eligible to participate. Other than declining to take part in the study (15/40, 38%), not having a smartphone was a major reason for exclusion (11/40, 28%). Those excluded without a smartphone were significantly older than participants with a smartphone (mean difference 20 [SD 5] years; P<.001). Participants were, on average, aged 54 (SD 13) years, mostly male (17/20, 85%), and working (12/20, 67%). At 6 weeks, 95% (19/20) of participants were assessed, and 60% (12/20) of participants were assessed at 16 weeks. Participants were relatively satisfied with the usability of the app (UTAUT2 questionnaire). Overall, participants spent 11 to 12 hours per day sitting. There was a medium effect size (Cohen d=0.54) for the reduction in sedentary behavior (minutes per day) over 16 weeks.

CONCLUSIONS

The use of a behavioral smartphone app to decrease sitting time appears to be feasible in cardiac rehabilitation. A larger randomized controlled trial is warranted to determine the effectiveness of the app.