Virtual Healthcare Solutions for Cardiac Rehabilitation: A Literature Review (Preprint)

BACKGROUND In patients with cardiovascular disease, adherence to cardiac rehabilitation (CR) following a primary event has been demonstrated to improve overall health and quality of life, increase functional capacity, and decrease hospitalizations and mortality. Despite strong guideline recommendations, underutilization of CR remains a challenging problem in cardiovascular medicine, especially in underserved populations, who already have poorer health outcomes across a wide range of indicators. With the advent of new technologies such as wearable activity monitors (WAMs) or mobile apps running in smartphones and tablets (mHealth), healthcare professionals and researchers have looked at incorporating these and related technologies into novel home-based virtual CR programs to improve uptake and participation. OBJECTIVE This literature review summarizes the current state of the art in use of mHealth, WAMs, and other multi-component technologies deployed in support of home-based virtual CR. METHODS The methodology for this literature review was adapted from published guidance on methods for systematic literature reviews by Cochrane (Cochrane Handbook for Systematic Reviews of Interventions). Results were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. RESULTS The search identified a total of 2,094 records, of which 113 were eligible for qualitative analysis. A wide variety of virtual CR solutions were implemented in the 113 included studies, (1) multi-component interventions with multiple technologies integrated into a comprehensive CR solution in 48 studies (42.5%), (2) WAMs (e.g., Fitbit, Actigraph, Apple wristwatch) in 27 studies (23.9%), (3) web-based communications solutions and (4) mobile apps running on smartphones and tablets (mHealth), both in 19 studies (16.4%). Functional capacity was the most frequently reported aggregate primary outcome category (k=37, 32.7%), followed by user adherence/compliance (k=35, 31.0%), physical activity (k=27, 23.9%), and quality of life (k=14, 12.4%). Studies included in this review provided an overall mixed assessment of the efficacy of virtual CR in either attaining significant improvements over baseline, or in attaining significant improvements in outcomes compared with conventional hospital-based cardiac rehabilitation. Less than half of the included studies—47 out of 113 (41.6%)—reported a significant result for a primary outcome. A total of sixteen studies reported significant between-group improvements in primary outcomes of virtual CR vs. usual hospital-based CR; nine of these were studies utilizing multi-component interventions, six used mHealth and one reported on use of WAMs. CONCLUSIONS Efficacy outcomes with virtual CR sometimes, but not always, improve on the center-based CR outcomes, however, superior clinical efficacy may not necessarily be the only outcome of interest. The promise of virtual CR includes the potential for increased user adherence and longer-term patient engagement. If virtual CR solutions can improve adherence/compliance of cardiac patients, that would be a significant justification for using this technology.