Apps? Wearables? Probing Mobile Tech’s Potential to Boost Cardiac Rehab

DUBAI, United Arab Emirates—Technology in the form of social media, smartphone apps, or wearable devices might be able to help shift cardiovascular risk in the population, particularly among patients with established heart disease, although understanding what works and what doesn’t will take time.

That’s the takeaway from a session held here at the 2018 World Congress of Cardiology & Cardiovascular Health, which highlighted the promise inherent in using technology to reach patients outside of the clinic.

One presenter described efforts to enhance traditional cardiac rehabilitation by designing a Facebook group that encouraged behavioral change and participation in cardiac rehab among patients with established heart disease. Another talked about the development of an intervention based on an app that would help patients at high risk for CVD or established disease to monitor their risk level and make positive changes.

And a third presenter tackled the rise of wearable devices, concluding that there are more questions than answers about what their impact might ultimately be on patient outcomes.

“I’m very impressed with the high level of interest that now exists with mobile technology and also the variety of technologies that are out there,” Sidney Smith Jr, MD (University of North Carolina at Chapel Hill), who attended the session, told TCTMD.

However, he added, “I believe there’s a great need for verification of their efficacy. I think we’re just getting into a phase where we can understand what works and what doesn’t work.”

Social Media to Aid Cardiac Rehab

Although progress has been made in bringing down rates of death due to coronary heart disease, there remains a need for effective secondary prevention, according to Robyn Gallagher, PhD, RN (University of Sydney Susan Wakil School of Nursing and Midwifery, Australia), who started off the session. After an MI, patients often struggle with reducing various risk factors and with getting recommended levels of physical activity, she said.

“Cardiac rehabilitation provides effective support for behavior change and has class I evidence, but cardiac rehabilitation has a big problem in the way it is supporting patients because a lot of people don’t attend,” Gallagher said, noting that the effectiveness of the intervention is weakened by poor participation. The reason people don’t go “is primarily related to the way it’s delivered,” she said. “Fixed locations, limited times, and inflexible methods of delivery limit participation.”

Tapping into social media, which can be accessed at any time from any place and allows patients to engage with other users, might be one approach to overcome those limitations, and research by Gallagher and others laid the groundwork for the development of a prototype Facebook-based intervention called Heart Team. This was a closed group for patients with coronary heart disease that provided information and a forum for discussion on secondary prevention topics as well as encouragement to attend cardiac rehab.

Compared with traditional cardiac rehab, the Facebook intervention was not as time-consuming and offered more flexibility in work time, Gallagher said, but uptake was slow and engagement was cautious. Participants indicated that the group was easy to use and understand, that they felt encouraged to go to cardiac rehab, and that they would recommend the group to others, but they also said there was not enough interaction.

“I do think this is the future,” Gallagher said. “We’re just at the beginning, because social media is less resource intensive, scalable, [and] easily adapted for low health literacy and different languages.”

Risk Modification With an App

In another presentation, Lis Neubeck, PhD, RN (Edinburgh Napier University, Scotland), discussed the possibility of using a specially designed app to modify cardiovascular risks in patients with a high risk for CVD or existing disease.

The ability to evaluate existing health apps, which are generally of poor quality, is made difficult because of the disparity in the time it takes to plan and conduct a study (several years) and the time it takes to develop an app (about 18 weeks), Neubeck said. “It’s really important we start to think about principles within apps rather than the individual app,” she said, so specific technologies can be replaced without having to dismantle any system designed to handle the information.

Several studies have already evaluated the use of mobile apps for secondary prevention of CVD, and most, Neubeck pointed out, have evaluated complex interventions with multiple facets, making it hard to determine what aspect is having a benefit.

Her team is currently conducting the CONNECT study, a single-blind RCT in 930 high-risk patients or those with established CVD recruited from general practice. The intervention involves using a consumer-directed app and website integrated with the primary care electronic health record. Outcomes, which are not available yet, include changes in risk-factor levels, quality of life, e-health literacy, and economic and process evaluations.

Neubeck said that she thinks mobile apps can add to the suite of available options for modifying cardiovascular risk. “And in fact . . . we believe that mobile apps are best used to augment traditional cardiac rehab and will reduce morbidity for cardiovascular disease if used as an adjunct to cardiac rehab,” she explained.

What the ideal technology will be even a few years from now remains unclear. “Because the technology is developing so rapidly and so readily, we cannot say we are going to use one thing,” according to Neubeck. “We’ve got to think about the patient’s journey through the system and make the technology replaceable, because at the rate it’s evolving it’s almost unimaginable what we’ll have in 5 or 10 years.”

What About Wearables?

In another presentation during the session, Mariachiara Di Cesare, PhD (Middlesex University London, England), reviewed the role of wearable technology like wristbands, smartwatches, and fitness trackers in helping modify cardiovascular risk in the population, starting off by saying that she ended up with more questions than solutions.

As an example, she discussed wearable devices for detecting A-fib, of which there are many. Multiple RCTs and prospective cohort studies suggest that in general these technologies have high sensitivity and specificity, but there are limitations, Di Cesare said. Most studies are performed in ideal settings under supervision, involve automated algorithms that are not necessarily the ones used in final products released to the public, and include highly selected patient populations.

Are we ready to take action, to use that information? And do we have a system that is in place to take action? Mariachiara Di Cesare

There’s also a question about whether the healthcare system is prepared for the flood of data coming from this technology, she said.

“Are we ready? Are we ready to take action, to use that information? And do we have a system that is in place to take action?” Di Cesare asked.

As a cautionary note, she pointed to telehealth, which has been shown to be effective but has not been widely adopted. The more complex an innovation, the less likely it is to be successfully adopted, scaled up, spread, and sustained, she said.

For wearables, there are still unresolved questions about whether the data are reliable enough, whether the system and physicians are prepared to take action based on the data, and whether the new technologies can be used in a sustainable way.

“I think, honestly, that if we want to bring technology to another step . . . we need to first answer these questions—because, again, the technology is there—and then design whatever intervention we believe can support the cardiovascular health of the population,” Di Cesare said.

Neubeck said during her presentation that “wearable technology is the way of the future.” But she also expressed some concerns about what can happen when too much data are being collected on an individual—when cameras placed in public can detect changes in vital signs, for instance.

It takes very few data points in order to reidentify somebody. . . . So cybersecurity is a huge concern in this area. Lis Neubeck

“We’ve got to think about those implications for what happens if everybody knows everything about you,” Neubeck said. “It takes very few data points in order to reidentify somebody. . . . So cybersecurity is a huge concern in this area.”

Speaking to mobile technology in general, Smith said he thinks it “is really going to help on a variety of levels in changing patients’ behaviors, understanding what they’re doing, and responding to the patients in a very personal way.”

For example, there is some ongoing work being done on pills that contain microchips that allow physicians to know how often their patients are taking their medicine. That could be helpful in determining whether a patient has resistant hypertension or is simply being noncompliant, Smith said.

“I think the great opportunities [in mobile health] are with blood pressure and with heart rhythms and, I hope, adherence to medical therapy,” he said, “but if these apps that are measuring things are accompanied with the ability to communicate, then you really take it to the next level.”