Improving Adherence to Exercise in Patients With Heart Failure Through Internet‐based Self‐management

To the Editor: Acquisition and maintenance of healthy behaviors in patients with heart failure (HF) is vital from the viewpoints of mobility, mortality, quality of life, and healthcare costs. One effective management method for heart failure that has been recognized in the past decade is exercise.1–3 Despite well-known positive effects of exercise for improving health, studies of home-based exercise programs indicate low adherence rates to exercise protocol.4 To educate patients with HF about the importance of exercise, to motivate them to commit to regular home-based exercise, and to maintain this healthy habit, an Internet-based self-management program (e-health) was developed and its effectiveness tested. This program consisted of provision of relevant information and exercise protocol posted on a publicly accessible Web site, daily recording form of vital signs and amount of daily exercise on a secure Web site that healthcare professionals can monitor, and monthly feedback on the record from healthcare professionals using e-mail. The following hypotheses were tested. Patients with HF using e-health (the treatment group) will have a high adherence rate (>75%)5 to exercise; will increase their amount of exercise; and will improve blood pressure (BP), body mass index (BMI), and illness-specific symptoms such as dyspnea and fatigue. A randomized, controlled trial with a 1-year intervention (e-health) was conducted. Assessments were made three times at 6-month intervals in participants' homes. A convenience sample of 40 older adults (≥65) with New York Heart Association Class II and III HF participated in the study. Adherence rates were obtained from monitoring daily records on the secure Web site. Information regarding exercise (breathing exercises, stretching, walking, and moderate exercise such as stationary biking, swimming, and golf) was obtained from self-report during the assessments and was verified using the daily record. Amount of exercise was obtained using a four-level nominal scale. Illness-specific symptoms were measured using the Chronic Heart Failure Questionnaire.6 For statistical analyses, multivariate linear models were used based on collected numeric end points measured across time. The analyses of binary end points collected across time used logistic models fit using generalized estimating equation methodologies. By the end of the intervention, five participants from the control group (CG) were lost due to HF and three from the treatment group (TG) for reasons other than HF, leaving 13 subjects in the CG and 19 in the TG. The mean adherence rate to exercise was 88.9% of the intervention period (365 days with Internet connection). Regarding baseline amount of exercise, both groups were comparable for all types of exercises. During the year, the TG increased the amount of exercise for all types of exercise, whereas the CG did not show any changes. At the 1-year follow-up, the amount of exercise for the two groups varied for all types of exercises. For example, numbers of participants who exercised every day were 11 for TG versus two for CG for breathing exercise (P<.001), 10 for TG versus five for CG for stretching (P=.02), 10 for TG versus four for CG for walking (P=.005), and three for TG versus 0 for CG for moderate exercise (P=.015). Specific details are shown in Table 1. At follow-up, lower diastolic BP was observed for both groups (P<.001). Systolic BP was significantly higher than at baseline for the CG (P=.004), whereas it was significantly lower in the TG (P=.003). At baseline, men and women in the TG were obese (mean body mass index (BMI)=30.1 and 32.1, respectively) and men in the CG were overweight (mean BMI=28.9). BMI fell (P=.023) over the year only in women in the TG. Statistically significant improvements in dyspnea (P=.003) and fatigue (=.005) were observed in the TG after 1 year, whereas CG remained the same or worsened. Summing up, the study found that older adults with HF had a high adherence rate of 85% to Web-based recording and 89% to an exercise program. The former finding is parallel to what was found (84%) in a prior study on e-health management system.7 Because a high adherence rate to prescribed healthy behaviors is the basis for successful self-management of chronic illnesses, application of e-health is recommended. Major factors of program success were availability of a simple form for daily recording of self-management activities by patients, better understanding of the causal relationship between health behaviors and health consequences, awareness of healthcare professionals monitoring their records, and access to regular personal evaluation from healthcare professionals. Internet-based health promotion systems will be ubiquitous in the near future. This study provided evidence for effective use of e-health by home-based older adults with HF. Further studies should provide the basis for generalization of these results. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Funded by the National Institute on Aging. Author Contributions: All authors contributed to the letter. Sponsor's Role: None.