Effects of ehealth-based interventions on adherence to components of cardiac rehabilitation a systematic review

Abstract

Objective The aim of this study was to determine the effects of eHealth-based interventions on patient adherence to components of cardiac rehabilitation (CR).

Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guided this review. Medline, CINAHL, Embase, and Cochrane Library databases were searched for studies published from January 1996 to December 2017. All studies were included in which eHealth-based components of CR and its effects on patient adherence were measured. Because this review included a heterogeneous group of study designs, the authors qualitatively described the effect of eHealth on adherence into a narrative approach.

Results A total of 1520 studies were identified, with 1415 excluded after screening. Of the remaining 105 studies, 90 were excluded after full text assessment, leaving 15 studies for analysis. Most (11) of the 15 studies reported on medication adherence. Other studies focused on adherence to diet, physical activity, vital signs, weight, step counts, smoking, and fluid restriction. The type of eHealth used also varied, ranging from telemonitoring and web-based applications to telephone calls. Of the 15 studies, 7 reported significant improvements with eHealth-based components of CR on adherence.

Discussion and Conclusion This review summarizes the effects of eHealth on components of CR and revealed variations in measurement and evaluation methods. The telemonitoring and web-based applications for self-care behaviors were most effective in promoting adherence. The measurement of adherence should be based on an explicit definition of adherence and should be measured with validated scales tested in the CR population.

Coronary artery disease is the most frequent cause of death.1 Given the burgeoning population of patients with cardiovascular disease, effective treatment modalities for secondary prevention are urgently needed. According to the European Society of Cardiology, cardiac rehabilitation (CR) is one intervention repeatedly shown to be effective in the secondary prevention of cardiovascular disease,2 including a 20% to 30% reduction in hospital readmissions and a 15% to 31% reduction in all-cause and cardiac mortality.3 International guidelines recommend that CR should focus on health, lifestyle change, modification of risk factors, and psychosocial well-being.4,5 Despite the well-established benefits of CR, challenges occur in maximizing these benefits, such as lack of accessibility, referral, and adherence.6 Unfortunately, as many as 80% of the eligible population do not enroll in CR. Furthermore, adherence in center-based programs is low, and dropout rates are high.7,8 Poor adherence has been associated with those with lower educational level, lack of social support, high burden of family responsibilities, economic challenges, lack of or limited healthcare insurance, and lower age (<65 years).9,10 Novel approaches could reduce dropout rates and increase availability. Because home-based CR has been shown to be as effective as traditional center-based CR, it could be an option for patients who have difficulty accessing a program.11–13

eHealth is the use of information and communication technologies to facilitate improving health. eHealth is an effective approach for disseminating health information and behavioral interventions via technology and the Internet. eHealth also has the potential to educate one on one, at a convenient time and place for the patient. Advantages to eHealth include an individualized learning environment at a lower cost than hospital-based interventions.14,15 eHealth can provide patient assessment, physical activity promotion, nutritional and tobacco counseling, weight management, dyslipidemia and hypertension monitoring, and psychosocial support.16 There has been increasing attention to eHealth-based CR as an alternative or complement to traditional CR programs.17 The World Health Organization has acknowledged the supportive role of eHealth-based methods.18 Video education for self-care,19 tele-monitoring,20–22 telephone support,23 and mhealth (mobile technology/text messages and website support)24 have been shown to have a positive effect on self-care behaviors in CR programs.

Cardiac rehabilitation is a multicomponent strategy consisting of 3 phases. Phase 1 typically takes place in the inpatient setting during recovery from a cardiac event. Phase 2 is typically held in a hospital-based outpatient facility with patients attending weekly sessions, and phase 3 includes health maintenance by the patient in the home. Phase 2 includes an individualized treatment plan, exercise prescription, education classes, and assistance with risk reduction (eg, tobacco dependence and hyperlipidemia). The third phase of CR requires independent maintenance of risk factor modification and management by patients, with periodic physician evaluation.25 Novel interventions have the potential to enable components of CR to be accessible and economical and decrease risk factors, similar to traditional, phase 2 programs.26 However, there are concerns that adherence to components of CR via eHealth-based interventions may be affected by numerous barriers, such as lack of time and motivation of the patient, technical problems, and technological literacy.27–29 To understand the effectiveness of eHealth-based interventions in CR, it would be useful to determine the current state of knowledge of eHealth use, in respect to acceptability of its components by evaluating adherence.