Peer Review of “Use of Smartphone Apps for Improving Physical Function Capacity in Cardiac Patient Rehabilitation: Systematic Review”

Background Despite 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 Findings We 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 Significance 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. Future research should assess its longer-term efficacy, cost-effectiveness and safety in larger samples representing the spectrum of cardiac morbidity and severity.

Most eligible patients do not participate in traditional clinic-based cardiac rehabilitation (CR) despite well-established benefits. Novel approaches to overcome logistic obstacles and increase efficiencies of learning, behavior modification, and exercise surveillance may increase CR participation. In an observational study, the feasibility and utility of a mobile smartphone application for CR, Heart Coach (HC), were assessed as part of standard care. Ultimately, innovative CR models incorporating HC may facilitate better CR usage and value. Twenty-six patients enrolled in CR installed HC. Over the next 30 days, they were prompted by HC to complete a daily "task list" that included medications, walking, education (text and videos), and surveys. Cardiac rehabilitation providers monitored each patient's progress through a HC-based Web dashboard and also sent them personalized feedback and support. Completion of the tasks and feedback (qualitative and quantitative) from patients and clinicians were tracked. Patients engaged with HC 90% of days during the study period, with uniformly favorable impact on compliance and adherence. Eighty-three percent of patients reported a positive/very positive HC experience. Providers reported that HC enhanced their provision of therapy by improving communication, clinical insight, patient participation, and program efficiency. Integrating a mobile care delivery platform into CR was feasible, safe, and agreeable to patients and clinicians. It enhanced patient perceptions of CR care and physician perceptions of the CR caregiving process. Mobile-enabled technologies hold promise to extend the quality and reach of CR, and to better achieve contemporary accountable care goals.

The purpose of this study was to determine the feasibility and acceptability of utilizing a smartphone based application to monitor compliance in patients with cardiac disease around discharge. For 60 days after discharge, patients' medication compliance, physical activity, follow-up care, symptoms, and reading of education material were monitored daily with the application. 16 patients were enrolled in the study (12 males, 4 females, age 55 ± 18 years) during their hospital stay. Five participants were rehospitalized during the study and did not use the application once discharged. Seven participants completed 1–30 days and four patients completed >31 days. For those 11 patients, medication reminders were utilized 37% (1–30-day group) and 53% (>31-day group) of the time, education material was read 44% (1–30) and 53% (>31) of the time, and physical activity was reported 25% (1–30) and 42% (>31) of the time. Findings demonstrated that patients with stable health utilized the application, even if only minimally. Patients with decreased breath sounds by physical exam and who reported their health as fair to poor on the day of discharge were less likely to utilize the application. Acceptability of the application to report health status varied among the stable patients.