Abstract
BackgroundDespite its efficacy and cost-effectiveness, exercise-based cardiac rehabilitation is undertaken by less than one-third of clinically eligible cardiac patients in every country for which data is available. Reasons for non-participation include the unavailability of hospital-based rehabilitation programs, or excessive travel time and distance. For this reason, there have been calls for the development of more flexible alternatives.Methodology and Principal FindingsWe developed a system to enable walking-based cardiac rehabilitation in which the patient's single-lead ECG, heart rate, GPS-based speed and location are transmitted by a programmed smartphone to a secure server for real-time monitoring by a qualified exercise scientist. The feasibility of this approach was evaluated in 134 remotely-monitored exercise assessment and exercise sessions in cardiac patients unable to undertake hospital-based rehabilitation. Completion rates, rates of technical problems, detection of ECG changes, pre- and post-intervention six minute walk test (6 MWT), cardiac depression and Quality of Life (QOL) were key measures. The system was rated as easy and quick to use. It allowed participants to complete six weeks of exercise-based rehabilitation near their homes, worksites, or when travelling. The majority of sessions were completed without any technical problems, although periodic signal loss in areas of poor coverage was an occasional limitation. Several exercise and post-exercise ECG changes were detected. Participants showed improvements comparable to those reported for hospital-based programs, walking significantly further on the post-intervention 6 MWT, 637 m (95% CI: 565–726), than on the pre-test, 524 m (95% CI: 420–655), and reporting significantly reduced levels of cardiac depression and significantly improved physical health-related QOL.Conclusions and SignificanceThe system provided a feasible and very flexible alternative form of supervised cardiac rehabilitation for those unable to access hospital-based programs, with the potential to address a well-recognised deficiency in health care provision in many countries. Future research should assess its longer-term efficacy, cost-effectiveness and safety in larger samples representing the spectrum of cardiac morbidity and severity.
Highlights
Cardiac rehabilitation (CR) is widely recognised as playing a critical role in optimising recovery in cardiac patients, with metaanalyses demonstrating reduced cardiac and all-cause mortality, fewer cardiovascular related events, less re-hospitalisation and shorter length of stay. [1,2,3] CR has been shown to be a highly cost effective form of secondary prevention. [2,4]limited accessibility and low participation levels present persistent challenges in almost all countries where CR is available
The system provided a feasible and very flexible alternative form of supervised cardiac rehabilitation for those unable to access hospital-based programs, with the potential to address a well-recognised deficiency in health care provision in many countries
In Australia as few as one in five of those who are clinically eligible complete CR, [5,6] with a figure of approximately one in three in the United Kingdom, and comparably low figures have been reported for the United States
Summary
Cardiac rehabilitation (CR) is widely recognised as playing a critical role in optimising recovery in cardiac patients, with metaanalyses demonstrating reduced cardiac and all-cause mortality, fewer cardiovascular related events, less re-hospitalisation and shorter length of stay. [1,2,3] CR has been shown to be a highly cost effective form of secondary prevention. [2,4]limited accessibility and low participation levels present persistent challenges in almost all countries where CR is available. While poor referral practices mitigate against participation, [8,9] and older patients [8], females [8], or those with more clinical complications [8,9,10] participate in or complete programs at lower rates, there are more immediate access barriers which have been consistently reported These include living further from or taking longer to travel to a program, [8,9] or being unable to drive. Despite this improved understanding of barriers to participation, studies reporting possible solutions have been much less numerous This is despite strong calls for the exploration of more flexible CR programs [11], including the observation that ‘‘the potential for embracing novel methods and the latest technology are rarely exploited’’ [12] and the fact that those living in rural and remote locations with the least access to conventional CR have higher levels of cardiac morbidity and mortality than those in metropolitan areas. There have been calls for the development of more flexible alternatives
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