A Smartphone-Based Model of Care to Support Patients With Cardiac Disease Transitioning From Hospital to the Community (TeleClinical Care): Pilot Randomized Controlled Trial

Background

Patients hospitalized with acute coronary syndrome (ACS) or heart failure (HF) are frequently readmitted. This is the first randomized controlled trial of a mobile health intervention that combines telemonitoring and education for inpatients with ACS or HF to prevent readmission.

Objective

This study aims to investigate the feasibility, efficacy, and cost-effectiveness of a smartphone app–based model of care (TeleClinical Care [TCC]) in patients discharged after ACS or HF admission.

Methods

In this pilot, 2-center randomized controlled trial, TCC was applied at discharge along with usual care to intervention arm participants. Control arm participants received usual care alone. Inclusion criteria were current admission with ACS or HF, ownership of a compatible smartphone, age ≥18 years, and provision of informed consent. The primary end point was the incidence of unplanned 30-day readmissions. Secondary end points included all-cause readmissions, cardiac readmissions, cardiac rehabilitation completion, medication adherence, cost-effectiveness, and user satisfaction. Intervention arm participants received the app and Bluetooth-enabled devices for measuring weight, blood pressure, and physical activity daily plus usual care. The devices automatically transmitted recordings to the patients’ smartphones and a central server. Thresholds for blood pressure, heart rate, and weight were determined by the treating cardiologists. Readings outside these thresholds were flagged to a monitoring team, who discussed salient abnormalities with the patients’ usual care providers (cardiologists, general practitioners, or HF outreach nurses), who were responsible for further management. The app also provided educational push notifications. Participants were followed up after 6 months.

Results

Overall, 164 inpatients were randomized (TCC: 81/164, 49.4%; control: 83/164, 50.6%; mean age 61.5, SD 12.3 years; 130/164, 79.3% men; 128/164, 78% admitted with ACS). There were 11 unplanned 30-day readmissions in both groups (P=.97). Over a mean follow-up of 193 days, the intervention was associated with a significant reduction in unplanned hospital readmissions (21 in TCC vs 41 in the control arm; P=.02), including cardiac readmissions (11 in TCC vs 25 in the control arm; P=.03), and higher rates of cardiac rehabilitation completion (20/51, 39% vs 9/49, 18%; P=.03) and medication adherence (57/76, 75% vs 37/74, 50%; P=.002). The average usability rating for the app was 4.5/5. The intervention cost Aus $6028 (US $4342.26) per cardiac readmission saved. When modeled in a mainstream clinical setting, enrollment of 237 patients was projected to have the same expenditure compared with usual care, and enrollment of 500 patients was projected to save approximately Aus $100,000 (approximately US $70,000) annually.

Conclusions

TCC was feasible and safe for inpatients with either ACS or HF. The incidence of 30-day readmissions was similar; however, long-term benefits were demonstrated, including fewer readmissions over 6 months, improved medication adherence, and improved cardiac rehabilitation completion.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618001547235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375945

High-intensity interval training for patients with coronary artery disease: Finding the optimal balance

BACKGROUND

The optimal characteristics of high-intensity interval training (HIIT) for patients with coronary artery disease (CAD) within cardiac rehabilitation (CR) are unclear. We assessed a HIIT protocol designed to balance patient safety, efficacy and enjoyment.

METHODS

Twenty-nine patients with CAD completed 6-weeks (× 2 sessions per week) of HIIT within outpatient (phase 2) CR. HIIT comprised 15 repetitions × 30-seconds cycling at ∼85-90% maximum heart rate, interspersed with 30-seconds of active recovery. Key outcomes covered patient safety, efficacy (peak aerobic capacity, body composition, blood pressure and vascular function), and patient adherence and enjoyment.

RESULTS

No cardiovascular-related adverse events were reported in relation to HIIT sessions. Patients showed significant improvement in peak aerobic capacity (mean +12%, p < 0.001, effect size d = 0.38), blood pressure (brachial systolic -7mmHg, p < 0.001, d = -0.59) and total body fat (-4%, p < 0.001, d = -0.49). Central adaptations were prominent (aortic systolic BP -5mmHg, p = 0.001, d = -0.50; visceral fat -10%, p = 0.001, d = -0.41). Patient enjoyment of training was high (5.5 out of 7 using the Exercise Enjoyment Scale) and measures of affective state improved following training (assorted p < 0.018).

CONCLUSIONS

This HIIT protocol appears safe, effective and enjoyable for patients with CAD within CR. Improved aerobic fitness, blood pressure and body fat levels were observed indicating improved cardiovascular-risk. High patient enjoyment and improved mood suggest the HIIT could be sustainable for patients in the longer-term.

Evaluation of an mHealth-Based Adjunct to Outpatient Cardiac Rehabilitation

A pilot study was conducted to determine if a smartphone-based adjunct to standard care could increase the completion rate of a cardiac rehabilitation program (CRP). Based on historical completion rates, 66 participants who were about to commence a hospital-based CRP were randomized so that half received three devices embedded with near-field communication, namely, a smartphone [pre-installed with an application (app) designed specifically for cardiac rehabilitation], portable blood pressure monitor, and weight scale while completing the CRP. The completion rate among participants who were randomized to the intervention group was 88%, compared to 67% in the control group ( = 0.038). This combined with the week-to-week frequency with which participants in the intervention group measured their blood pressure ( 5/week) demonstrated the ability of the intervention to increase the proportion of patients who completed the CRP. No significant differences were found between the treatment groups for the measurements taken at baseline and prior to discharge from the CRP. A statistically significant correlation ( = 0.472; = 0.013) was found between the average time participants walked each day (as estimated via the smartphone app) and participants' six minute walking distance (6MWD) before they were discharged from the CRP (a clinically validated measurement).

Spindle cell tumour with glandular elements: an unusual ileal neoplasm

This report describes a tumour in the ileum with clinical features initially suggestive of a gastrointestinal stromal tumour (GIST). Histopathological examination revealed a biphasic tumour in which the spindle cell component showed immunohistochemical evidence of smooth muscle differentiation but without the characteristic profile of a GIST. A well-differentiated epithelial component was also present, comprising glandular structures with immunohistochemical features suggestive of Mullerian differentiation. Similar glandular differentiation has been described in uterine leiomyomas but not, to our knowledge, in tumours associated with the small bowel. None of the characteristic mutations of GISTs were identified in this case. There were no overt features of malignancy but, because of the unusual nature of the case, we assessed the biological behaviour as uncertain.

Effect of misoprostol on concentrations of prostaglandins in synovial fluid

The effect of misoprostol, a synthetic analogue of prostaglandin E, on prostaglandin concentrations in synovial fluids was investigated in a randomised placebo controlled, double blind study. The synovial fluid concentrations of prostaglandin E1, 6-keto-prostaglandin F1 alpha, and thromboxane B2 were measured at the beginning and end of a 24 hour period in 25 patients with effusions of the knee joint. During this period the patients were treated with diclofenac (50 mg every eight hours) and either misoprostol (400 micrograms) or placebo every 12 hours. The concentrations of prostaglandin E and 6-keto-prostaglandin F1 alpha were not significantly altered during treatment. There was an unexpected significant reduction in thromboxane B2 concentrations in the group treated with misoprostol (within group analysis). Although the mean concentration with misoprostol was about half the mean concentration with placebo, this difference was not statistically significant in the between group analysis. These results indicate that misoprostol is unlikely to exert a proinflammatory effect or to interfere with the prostaglandin mediated effects of non-steroidal anti-inflammatory drugs. The significant decrease in thromboxane B2 concentrations in the misoprostol treated group suggests that misoprostol may exert an anti-inflammatory effect.