How health technology helps promote cardiovascular health outcomes

Health technology in the hands of cardiac patients — helpful, hindrance, or hesitate to say?

Cardiovascular disease (CVD) is a leading cause of death and hospital admissions in Australia.1 Almost a third of patients will have a recurrence such as myocardial infarction (MI), stroke, heart failure and death within 5 years.2 Reductions of at least 80% in these events can be achieved through secondary prevention behaviours, including taking cardioprotective medications as prescribed, ceasing smoking, increasing physical activity and consuming a healthy diet.3 The most comprehensive and proven of strategies to support secondary prevention is cardiac rehabilitation. This is an evidence-based, cost-effective method to reduce CVD deaths, assist recovery and promote secondary prevention through reduction of cardiovascular risk factors.

The strength of secondary prevention success in cardiac rehabilitation ultimately depends on patients’ awareness, willingness and capacity to make lifestyle changes and to engage in the required behaviours. Patients must have a strong commitment to their health to sustain secondary prevention behaviours for the rest of their lives, often without direct evidence of benefit, as CVD is asymptomatic in the majority of cases.3 However, cardiac rehabilitation is widely underutilised, with less than a third of eligible patients attending the sessions and dropout rates estimated at 25%. In the absence of support, many patients struggle with sustaining the requisite behaviours.

Medications are a prime example of this struggle. Less than two-thirds of patients are reported to persist with all prescribed medications by 1 year following MI.4 The reasons given for discontinuation are largely self-determined, emphasising the importance of the patients’ understanding and engagement.5 Similar issues are present for most secondary prevention behaviours. At 6 months after MI, 27% of patients smoked, 26% consumed an unhealthy diet and 59% did not exercise enough.3 The key reasons identified for patients’ struggles are a lack of awareness that treatments must be long term to achieve effective prevention, and forgetting to follow recommendations.5 Patient education is necessary, but specialised support is often required for sustained behaviour change. Technology, particularly mobile technology, offers a solution for support for long term behaviour change and may also augment existing secondary prevention programs, such as cardiac rehabilitation.

Adoption of mobile technologies, such as mobile phones, smart phones and tablets that provide internet access, has been widespread in Australia.6 Rapid growth in popularity and technological advances have also occurred in wearable devices for tracking behaviours, such as fitness activities, that connect with mobile phones. These technologies and related applications can efficiently enable long term support for patients and provide memory prompts for behaviours. However, there has been such rapid evolution of technologies that we ask: are health technologies helpful, a hindrance, or should we hesitate to say?

Are health technologies helpful?

The evidence indicates that well designed and often simple technologies can improve patient outcomes in multiple cardiovascular risk factors.7 The most consistent evidence of benefit from health technologies is for coronary heart disease compared with other cardiovascular diseases.8 Simple short-message service (SMS) interventions delivered regularly can improve awareness and prompt actions, which may otherwise be forgotten. Text messages double the odds of adhering to medications and the Australian TEXT ME program has improved cardiovascular disease risk factor profiles.9 Emerging evidence indicates that many more risk factors may also be addressed through text messages and mobile phone apps, and potentially decrease dropout from cardiac rehabilitation.8,10 In addition, wearable activity trackers provide reliable information on steps and time spent in moderate to vigorous physical activity, which can be monitored, used for goal-setting and shared with treating doctors.11

There may be a temptation to assume that health technology is not applicable to cardiac patients because of their older age and lack of experience; however, such patients may be more ready and willing to use health technology than previously suspected. At least two-thirds of cardiac patients (67%) use the internet and at least half (50%) use mobile technologies for health, with higher rates of acceptance of health technology in cardiac rehabilitation participants (74%).12

Are health technologies a hindrance?

Several key issues hinder uptake and complicate recommendations for patient-facing technology in regular clinical practice. There is a proliferation of publicly available health technologies suitable for cardiac patients, particularly mobile phone apps, alongside a paucity of research-based evidence to support selection.7 Quality too is generally low, and popularity is a poor indicator. For instance, an evaluation of patient engagement, quality and safety of 1046 health care-related, patient-facing apps for chronic disease found that only 43% (iOS, Apple) and 27% (Android, Google) were actually likely to be useful.13 A recent review of mobile phone interventions for secondary prevention of cardiovascular disease did not identify any intervention that resulted in a negative impact, but six of the 28 interventions reviewed had no benefit.8 Owing to the poor quality of the studies included, it is difficult to distinguish the features that independently predict success; however, the use of text messaging, telemonitoring and interaction may have been important. In a similar way, popular weight loss apps do not incorporate successful behaviour change techniques and many have inaccurate content. The motivation of app developers must be carefully considered given the rise of pro-smoking apps disguised as educational games. At best, patients may experience no benefits from using health technology, and at worst, patients may question and disregard credible advice given by health professionals. Patients have few sources of advice for selection and use of health technologies, as physicians, like patients, have varying capacity and interest in using them. Previous experience, education, confidence and interaction with early adopters to understand how to interface with the health app and with the patient using the app are all required for success.14 Patients who are older, have little or no prior experience with technology and who have lower levels of education are less likely to be interested and have lower expectations of success or benefit from using technology for their health.12 The same could be argued for health professionals. This is important because, for health technologies that do prove useful, positive staff attitudes may offset the lower levels of expertise or interest present in older people and in those with lower education.

Should we hesitate to say?

The rapid advances in health technology, the mass of publicly available apps and programs, and the inability of research to keep pace are major factors affecting our ability to definitively determine whether health technologies are a help or a hindrance. These factors make it difficult to identify the technologies that are evidence-based and free from unintended negative consequences.15 However, there are a few shortcuts. For instance, there is no single repository for patient-based health technologies for cardiovascular secondary prevention, nor is there an accrediting or regulatory system for quality or effectiveness. There has been some attempt to catalogue apps, but the process is slow and apps are often modified by the time of publication. Regulation of health technologies, such as mobile phone apps, is poorly developed. A balance is needed between two polar possibilities: government regulation, as used for implanted medical devices, which is rigorous but slow and expensive; and self-regulation by technology companies through checklist certification, which is dependent on the company ethics.16 App stores such as those of Apple and Google currently vet apps sold in their stores, but the emphasis is on security, not on the quality or credibility of the app.17 Ultimately consumers must decide. One shortcut to ensuring credible content is to only use or recommend health technologies and health apps developed by reliable institutions, such as the Heart Foundations of Australia, Britain and Canada. However, the gains in credibility and time-saving from using this shortcut occur at a trade-off in diversity, innovation and personalisation for patients.

A principles-based approach may be more appropriate and feasible to discriminate the features of technology that encourage consumer uptake and promote appropriate behaviour change effectively. These principles have been highlighted for apps for the secondary prevention of CVD in a recent review12 and are relevant to most health technologies. Key elements to consider include simplicity, credibility of content, behaviour change components, real-time tracking, reward system, personalisation, social features and attention to privacy of data collected. A positive, but discerning attitude to patient-facing health technology is required, much the same as with any new health treatments, to maximise patient outcomes and ensure equitable access. Regular screening to identify effective health technology has become a necessary component of health professional life, equivalent to keeping up to date with effective medications and techniques. Evidence-based practice was introduced to medical curricula to help ensure the most effective treatment for an individual patient. Likewise, it is now time to introduce screening and selection systems for health technologies into health professional education.

In summary, the evidence suggests that mobile technologies will improve access to and participation in secondary prevention activities, but careful consideration is needed to ensure that the most effective and acceptable technologies are incorporated into patient care.