Cardiac Rehaband TelehealthEvidence 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

7 literature reviews in the past 3 years

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

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

50 years of research

• 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

“In sum, the body of literature shows CR…impacts both morbidity and mortality”5

-Williams et al. 2006

Well established clinical efficacy

CMS FY 2015 to include COPD readmissions

• $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

February 19, 2014

“CMS has announced it will expand Medicare coverage for cardiac rehabilitation services to patients with stable, chronic HF.”

Cost effective for everyone

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…?

“25 years of evidence-based use and equivalence” 21

• 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

Alternative CR history starts with the Heart Manual

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 studiesMetric 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 Automated

referral system

Tablet based education

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