Cardiac Rehab
and Telehealth
Evidence and innovations:
A systematic review
Richard Curry MS, PT, MBA
IEBC Conference April 4, 2014
“Cardiac rehabilitation is a
professionally supervised
program to help people recover
from heart attacks, heart
surgery, percutaneous coronary
intervention (PCI) procedures
such as stenting and
angioplasty…
…programs usually provide
education and counseling to
help heart patients increase
physical fitness, reduce cardiac
symptoms, improve health and
reduce the risk of future heart
problems, including heart
attack.” –AHA 2013-
Telehealth
“The use of electronic
communication to provide
and deliver a host of
health-related information
and health care services,
over large and small
distances”.
-American Telemedicine
Assocation-
So what could be the telehealth
alternatives…?
• Telephone
• Email
• mHealth
- SMS
- GPS
- accelerometers
- mobile apps
- wearable devices
• Web portals
- online tutorials
- web based diary
- medication tracking
- vitals monitoring
• Home monitoring
• Video Conferencing
Exsisting CR alternative literature
reviews
• 4 separate reviews of alterantive
cardiac rehab in 2013 alone
- mobile review1
- internet-based review2
- alternative model review3
-current/future review of CR4
• Economic review CR alternatives5
• Qualitative review (2011)6
• Recent home CR review (2011)7
7 literature
reviews in the
past 3 years
Alternative approaches
to cardiac rehab have
been looked at from
new technology, to cost
effectiveness, and home
based alternatives with
no negative effects and
at least equivalence
Well established clinical efficacy
• Between 24% to 20% decrease in
total mortality for MI 8,9
• 3 year survival rate of 95% vs 64% for
non cardiac rehab MI patients10
• CABG: 10 year follow up: less
cardiac events (18% vs 34%),
reduced hospitalizations11
• PCI: less cardiac events
(11.9% vs 32.2%)
reduced hospitalization
(18.6% vs 46%)12
50 years of
research
“In sum, the body of
literature shows
CR…impacts both
morbidity and
mortality”5
-Williams et al. 2006
Cost effective for everyone
• $10 for $16 billion13
• Lowest cost per Quality Adjusted
Life Year14
• Treats 4 patients for cost of 115
•Oct 2013: ROI of 7% over 2 years16
•Higher contribution margin
$2500 vs $80617
•In 3 years, CR patients contributed
$2.8 million to health system
CMS FY 2015 to
include COPD
readmissions
February 19, 2014
“CMS has
announced it will
expand Medicare
coverage for cardiac
rehabilitation
services to patients
with stable, chronic
HF.”
Systematic Review of economics for CR
• Wong W, Feng J, Pwee KH, Lim J (2012)5
• 16 articles included
•Supervised center-based CR highly cost-effective
•Home-based CR no different from center-based CR
•No difference between inpatient CR and outpatient CR
•Home-based programs saved costs compared to no CR
Important now more than ever…
timing, timing, timing
• ACO
• 30 day readmission
• Quality of care
• Continium and coordination of care
• CHF inclusion by Medicare for cardiac rehab
• Possible increase payment for CR by Medicare to $100/session
• Technology
…so cardiac rehab referral rates must be high, right..?
Cardiac rehab for MI stuck at 18% eligible
enrollment in the US?
• Lack of referral
• Patient demographics
• Patient non-compliance
• CR traditionally lo$$
leaders
• Location, access
• Limited models
• Reimbursement
Physicians refers=patient go
Systematic Review of
Physician Factors Affecting
CR Referral and Patient
Enrollment
(Ghis GL, et al 2013)18
17 articles reviewed
Cardiac Rehab attendance around the
world…
•
•
•
•
Australia 50%19
Sweden 40-45%20
UK 41% (76% cardiac bypass, 40% MI, 28% angio)
Italy 30% (75% cardiac bypass, 16% MI, 4% angio)
…besides national coverage, what else do these countries do…?
Alternative CR history starts with the
Heart Manual
• Developed in Scotland late 1980s
• Multi-disciplinary approach
• Home-based CR program
• Work books, diaries, record sheets
• Facilitator
• Recommended by WHO
• Used in UK, Australia, New
Zealand, Italy, Canada, Holland
“25 years of
evidence-based
use and
equivalence” 21
Systematic reviews of home-based CR
• Jolly K, (2005) reviewed 24 articles (Home vs center-based CR)22
- Home based CR for low-risk does NOT have inferior outcomes
• Blair J, et al (2011) reviewed 22 articles (Home vs hospital CR)7
- Home CR is a safe, viable and effective option
• Systematic review of the Heart Manual
Clark M, Kelly T, Deighan C (2010)21 reviewed 8 studies
- Manual as effective as hospital-based CR including cost
outcomes
History of studies used, modes of
telehealth
• First study included was from 198523 (Debusk R, et al)
• All but two of the studies done between 2000-201324-56
• 1st included internet-based program done in 2007
• 26 studies used telephone contact
9 utilized ECG monitoring 5 used web portals/internet-based
4 mHealth solutions
2 videoconferencing
Most common metrics in studies
Metric
Number of studies
Total cholesterol
12
Resting blood pressure
11
Body Mass Index
10
Traumatic brain injury
10
HDL
9
LDL
8
Triglycerides
8
Smoking status
8
SF-36
8
Max workload (METs)
8
Weight
7
Findings
• Significant evidence for telephone case management support
• No difference in outcomes comparing home-based approaches
to traditional cardiac rehab
• High quality evidence for comprehensive telehealth models
• Exercise only approaches lower quality studies, small groups.
• Internet-based outcomes positive results with high patient
satisfaction but insufficient evidence to support effectiveness
•3 published mHealth studies, only one was comprehensive CR
Discussion
• Comprehensive approach necessary
• Physician referral and encouragement is key
• Safe and effective alternatives available
• Cost effective alternatives available
• The more options, the more individualized the CR
• Initial assessment/ motivational interviewing for personalization
• Internet-based and mHealth approaches promising, more studies
needed
• Exercise models need more comprehensive and personalized
approach
US examples of innovations in CR
Cardiac rehab mobile app
Tablet based
education
Automated
referral system
What does the future hold for CR?
• Personalizing not just treatment but the approach (flexibility)
• Wearable devices and non-wearble (i.e. Ultra-Wide band)
• Less patient centered barriers
• Fine tuning, extending case management
• Patients with more responsibility, coaching not counseling
• Home-based is inevitable
• Profitable Phase II CR…? Measurable ROI…? Reimbursement…?
• Extension of models to COPD, CHF, CVA
Thank you