Benefits of eCR

Technology has been used for chronic disease management more broadly, and studies generally have demonstrated positive effects on patients’ health outcomes. For instance, a recent review showed that delivery modalities such as videoconferencing, webconferencing and text messaging were equally effective and sometimes superior to usual care for chronic disease management.3 Studies have also documented patient acceptance and satisfaction. Moreover, in a systematic review of cost-effectiveness studies, electronic delivery of chronic disease management was shown to be cost-saving from the healthcare system and insurance provider perspectives in the majority of included studies.4 A recent systematic review of eCR showed that participation in eCR was related to significantly greater programme adherence when compared with usual care.5

This most recent trial by Varnfield et al2 provides support for smartphone-based CR specifically as a feasible and effective delivery modality. In particular, they provide striking evidence that eCR significantly improves CR utilisation when compared with traditional CR. The high rates of CR adherence were particularly compelling, given that population-based research has demonstrated that participation in each additional CR session is associated with 1% less mortality.6 Daily exercise, which was objectively assessed with the smartphone accelerometer, was also very high, although physical activity in the traditional CR group was not reported. Also of note were the psychosocial benefits observed, which may be attributed to the integration of relaxation audio recordings within the smartphone applications. Key outcomes were maintained postprogramme. Finally, the authors also make compelling inferences regarding potential cost-savings and lives saved with greater implementation.

How eCR could address the dearth of CR globally

The use of smartphones to increase CR reach is particularly promising due to the high penetration of mobile technology. Currently, it is estimated there are 5 billion mobile users around the globe.7 This penetration is expected to increase to an estimated 7 billion mobile subscribers worldwide, representing 95% of the world's population.7 In LMICs where the burden of CR is greatest, the penetration of mobile devices is estimated at 78% of global subscriptions.7

Arguably, eCR holds the greatest potential to increase reach in high-income countries, due to evidence, health human resource capability and financial capacity. Trials to date on eCR demonstrating benefit have been conducted in high-income countries. Ministries of Health and health insurance companies must be informed of these findings so that funding for these alternative models is provided.

In LMICs, given CR is only available in 23% of countries but the penetration of mobiles is high, eCR holds the promise of feasibility, reach, affordability and effectiveness. Before implementation, clearly eCR models must be adapted to the realities of LMICs. Particular consideration should be given to the type of healthcare provider available to deliver the programme, as well as regional differences in risk factors. For instance, patients may engage in sufficient physical activity from active transport and occupational activity, and therefore the focus on exercise may require tailoring. Additionally, availability of medications to control blood pressure and lipids may be limited or they may be unaffordable, and thus again the eCR programme should be appropriate to the setting.

Other considerations

Other considerations to be tackled before broad implementation of smartphone-based CR include: (1) ensuring programmes incorporate all the core CR components; (2) consideration of the types of healthcare providers delivering the programme; (3) safety; (4) dose; and (5) degree of interpersonal contact. With regard to the former, the British Association of Cardiovascular Prevention and Rehabilitation,8 among other CR societies, have published standards which are fairly consistent globally. The eCR model developed by Varnfield et al2 does include many of the components; however, optimal medication use for risk factor control and medication adherence were not considered nor was smoking cessation or return to work. Finally, there was no mention of communication of entry or exit assessments with primary care providers for purposes of continuity.

Second, Varnfield et al2 did not report the type of healthcare provider providing the initial assessment or the weekly mentorship. Closely related to the third issue is whether there is a physician overseeing the programme who could be consulted in instances of clinical complexity or where safety issues arise. CR guidelines from national societies recommend a multi-disciplinary team offer CR. This ensures expertise within the CR team to address all risk factors (eg, smoking cessation, medical therapy for blood pressure and lipid reduction, depression assessment and treatment) to effectively deliver adult education, while ensuring safety. While there is no evidential basis for the disciplinary composition of CR, the trials on which the evidence for the impact of CR in decreasing mortality delivered CR with multi-disciplinary teams. While many of the core components can be built into a smartphone platform, expertise in all the core CR areas should be sustained where affordable.

With regard to the fourth issue of dose, currently it is unknown what minimum dose of CR is required to achieve optimal patient health outcomes. It is known that there is a dose–response relationship between CR adherence and improved outcomes.6 Varnfield et al2 developed a 6-week programme and demonstrated positive effects. With eCR, there is the potential to more easily individually-tailor the duration of a patient's programme depending on his or her needs and preferences. It may also be more affordable to offer programmes of longer duration to achieve greater benefits and support maintenance of behaviour changes.

On a related note, the optimal degree of patient contact with healthcare providers is also unknown, and could be individually-tailored in eCR. Varnfield et al2 offered 15-min telephone interaction with a ‘mentor’ once weekly. Consideration and testing are required regarding the mode of this interaction (video vs audio only), type of healthcare provider, and frequency of these contacts. With eCR, patients can self-guide through the components of the programme, at their own pace and according to their own risk factors and learning needs. However, other patients may desire contact with healthcare providers to maintain motivation, address anxiety and seek information.

In conclusion, the study by Varnfield et al2 provides more compelling, initial evidence that smartphone-based CR can improve utilisation, and results in health outcomes similar to supervised CR programmes. The potential of eCR is great, particularly in low-resource settings, and rural and remote areas lacking infrastructure; however, no feasibilities studies in these contexts exist to date. Prior to eCR implementation, further consideration should be given to consensus and testing of minimum standards. Finally, large-scale pragmatic randomised controlled trials powered for a primary outcome of mortality will be required to establish the case for eCR.