Cardiac rehabilitation outcomes in a conventional versus telemedicine-based programme

Abstract

We studied patients who were eligible for phase II cardiac rehabilitation. Rehabilitation was delivered either conventionally or by telemedicine using videoconferencing. There were 226 participants: 173 at the conventional site and 53 at the telemedicine site. At baseline, blood pressure, anthropometric measurements, lipid profiles, activity levels, dietary intake and behaviours were assessed. Assessments at baseline were repeated after 12 weeks, at the end of the rehabilitation programme. There were no significant differences (P > 0.05) in the change from baseline to post-programme values between the conventional and the telemedicine groups. The results show the suitability of telemedicine for delivering cardiac rehabilitation for risk factor modification and exercise monitoring to patients who otherwise would not have access to it.

Introduction

Cardiac rehabilitation programmes contain different components to decrease cardiovascular risk, improve on healthy behaviours and help individuals live a more active lifestyle. The programmes include assessments at baseline and counselling in areas such as nutrition, risk factor management and exercise training.^1,2 Enrolment and adherence to these programmes can improve overall health and quality of life by increasing physical activity, helping in lifestyle modifications, and reducing symptoms and re-infarction.^2–8 Although cardiac rehabilitation programmes can decrease mortality by 25% and reduce risk factors, enrolment rates are low with only 10–25% of eligible patients attending.^1,5,9,10 The reasons for lack of enrolment are multi-factorial and include location, beliefs, transportation, access to health professionals and cost. Although cardiac disease is a significant problem throughout the world, cardiac rehabilitation programmes are mostly found in hospitals in large urban areas. This makes it more difficult for patients to access the programmes and the cardiologists.¹¹

Telemedicine offers patients an opportunity to receive health care within their own community, which may be advantageous for several reasons, including the existence of a current support system, reduced cost of travel, ability to take educational courses and the possibility of early disease diagnosis.¹² Studies have shown that telemedicine is a valuable tool for improving patient care, decreasing the number of physician visits and connecting physicians with their patients, especially with reaching patients who may otherwise not have access to health-care professionals.^8,13–15

To date, the application of telemedicine in cardiac rehabilitation has been relatively limited. However, results from one previous study suggest that home-based exercise rehabilitation using telemedicine is feasible and effective for certain categories of heart patients.¹⁶ We have conducted a feasibility study to compare changes in cardiovascular disease risk factors (e.g. blood pressure, body mass index and lipid profiles) between a telemedicine-delivered cardiac rehabilitation programme and a conventional cardiac rehabilitation programme.

Methods

The participants were a convenience sample of 226 patients who were eligible for phase II cardiac rehabilitation, including those who had had coronary artery bypass graft surgery (CABG), percutaneous transluminal coronary angioplasty (PTCA) or another transcatheter procedure (e.g. PTCI), myocardial infarction (MI) or valve surgery. Participants received phase II cardiac rehabilitation between January 2006 and December 2009. They received either conventional cardiac rehabilitation (n = 173) or telemedicine-delivered cardiac rehabilitation (n = 53). The telemedicine-supported rehabilitation was located in a rural setting that was 240 km (or 2.5 hours) from the conventional cardiac rehabilitation at an urban location. Prior to the study, conventional phase II cardiac rehabilitation was not available to patients in the rural location. The study was approved by the appropriate ethics committees and all participants provided their written informed consent.

Participants in both cardiac rehabilitation programmes had scheduled appointments at baseline, mid-programme (usually after 6 weeks) and post-programme (usually after 3 months). Prior to any appointments all participants initially attended an orientation session where an explanation of the cardiac rehabilitation programme was provided, paperwork was distributed and time was allotted for questions. At the conclusion of the orientation session patients scheduled their baseline appointment.

Baseline appointment

The baseline appointment began with an exercise physiologist. The exercise physiologist was responsible for measuring and recording each patient's cardiovascular disease risk factors, including resting blood pressure, anthropometric measurements (height and weight), lipid profile, and current physical activity patterns. The exercise physiologist then conducted an exercise test to establish baseline functional capacity. Information from the exercise test was also used to establish the starting exercise duration and intensity for each patient. After this, patients met a registered dietician who reviewed their dietary intake patterns. Dietary and stress questionnaires were scored by the dietician. The dietician also provided dietary suggestions and strategies for modifying dietary intake. Finally, patients met a cardiologist to discuss their medical condition, possible limitations, and to decide risk factor reduction goals (e.g. increase energy expenditure, decrease systolic blood pressure). At the conclusion of the baseline appointment patients scheduled their exercise orientation appointment.

Exercise programme

At the exercise orientation appointment, patients met an exercise physiologist. The exercise physiologist employed evidence-based guidelines^17,18 to guide the design, implementation, progression and monitoring of the exercise programme for each patient. In general, the exercise programme goals for frequency, intensity and duration of exercise were 4–7 days/week, a rating of perceived exertion (RPE) of 11–13 on a scale of 6 to 20, and 20–60 min/day, respectively. The exercise programmes were also designed to take account of patient preferences. Supervised exercise took place each Monday, Wednesday and Friday. Throughout the cardiac rehabilitation programme patients were supervised during exercise sessions and monitored via portable telemetry, pulse oximetry, blood pressure and RPE. The machines used for exercise included recumbent steppers, arm ergometers, cycle ergometers, elliptical cross-trainers and a treadmill.

Mid-point evaluation

At the mid-point of the cardiac rehabilitation programme patients visited a cardiologist again for a review of their medical conditions. In addition, the cardiologist and patient discussed the progress being made toward individual goals, such as the management of cardiovascular disease risk factors that had contributed to the cardiac event.

Post-programme appointment

The post-programme appointment duplicated the procedures of the baseline appointment. Patients again had meetings with an exercise physiologist, registered dietician and cardiologist. The same cardiovascular disease risk factors measured at baseline were also measured at the post-programme appointment. At the end of the post-programme appointment a plan was made to transfer the patient to a home-based exercise programme or supervised phase III cardiac rehabilitation programme.

Telemedicine

Each site had two large screen video displays and two videoconferencing units (Polycom VSX 5000, Polycom Inc) that could be controlled remotely. In addition, each site had one video visualizer camera (Canon RE-350, Canon USA Inc) that could be used to display medical information or educational materials to the patient. One set of equipment was located in the exercise room (Figure 1), while the second set was located in the private room used for consultation (Figure 2). Telecommunication between the locations was via a T-1 connection.

Figure 1

(a, b) Use of telemedicine for patient exercise prescription and supervision

Figure 2

(a, b) Use of telemedicine for cardiologist-patient appointments

Patients at both cardiac rehabilitation programmes completed similar appointments. However, telemedicine was incorporated at various stages throughout the programme for the telemedicine supported facility.

The senior exercise physiologist provided daily guidance to the junior exercise physiologist at the telemedicine-supported rehabilitation site on matters pertaining to exercise testing and exercise programming (Figure 1). Telemetry at the telemedicine-supported site was also monitored by an exercise physiologist at the conventional rehabilitation site;

Baseline and post-programme appointments between the registered dietician and patients at the telemedicine-supported site were conducted by telemedicine. An on-site dietician was not available to patients at the telemedicine-supported site;

All appointments at baseline, mid-point and post-programme between cardiologist and patients at the telemedicine-supported site were conducted by telemedicine (Figure 2). A cardiologist was otherwise unavailable to patients at the telemedicine-supported site, although this programme was located in a hospital setting and physicians were immediately available in the event of an emergency.

Statistical analysis

The statistical analysis was performed using a standard package (SPSS, version 12.0). The mean differences in conventional cardiac rehabilitation and telemedicine-supported cardiac rehabilitation between baseline and post-programme were assessed using paired t-tests. The mean differences in the change of health outcome variables between conventional and telemedicine-supported cardiac rehabilitation were assessed using independent t-tests.

Results

Baseline and post-programme descriptive data for patients at both the conventional cardiac rehabilitation programme and telemedicine-delivered cardiac rehabilitation programme are summarized in Table 1. Attendance was similar (P > 0.05) between the conventional cardiac rehabilitation programme (83%) and the telemedicine-based cardiac rehabilitation programme (81%). There were no significant differences (P > 0.05) for the change from baseline systolic and diastolic blood pressure values at the telemedicine-delivered site, see Table 2. There were no significant differences (P > 0.05) for the change from baseline fat or triglyceride values at the telemedicine-delivered site. However, there were significant improvements (P < 0.05) in body mass index, energy expenditure, stress, total cholesterol, HDL and LDL cholesterol from baseline at the telemedicine-delivered site. There were no significant differences (P > 0.05) for the change in body mass index in the conventional cardiac rehabilitation group. There were no significant differences (P > 0.05) for change from baseline to post programme in systolic blood pressure values at the conventional cardiac rehabilitation site. On the other hand, there were significant improvements (P < 0.05) in diastolic blood pressure, energy expenditure, fat, stress, total cholesterol, triglyceride, HDL and LDL cholesterol from baseline to post-programme at the conventional cardiac rehabilitation site.

Table 1

Participant characteristics

	Conventional (n = 173)		Telemedicine (n = 53)
	Baseline	12 weeks	Baseline	12 weeks
Mean age, y (SD)	67 (11)		68 (9)
Sex, %
Men	58		55
Women	42		45
Ethnicity
Caucasian, %	58		47
Hispanic, %	34		34
Native American, %	9		19
Phase 2 referral conditions
CABG, %	20		19
Myocardial infarction, %	21		26
PTCA/other, %	52		47
Post-valve, %	6		8
Medication history
Antihypertensive, %	89	87	94	93
Antidepressant, %	13	11	10	10
Antidiabetic, %	19	18	21	23
Hyperlipidaemic, %	94	96	90	87
Thyroid, %	9	9	9	9
Current smoker, %	11		9

CABG, coronary artery bypass graft surgery

PTCA/other, percutaneous transluminal angioplasty or other transcatheter procedure, e.g. PTCI

Table 2

Mean values for outcome variables (SD) at baseline and 12 weeks for patients in the two groups

	Time	Conventional (n = 173)	Telemedicine (n = 53)
Body mass index, kg/m²	Baseline	27.8 (4.5)	28.1 (4.5)
Body mass index, kg/m²	12-week	27.7 (4.3)	27.6 (4.2)*
Stress score⁺	Baseline	13.8 (6.4)	12.8 (6.6)
Stress score⁺	12-week	10.2 (6.1)*	10.0 (5.7)*
Dietary intake score⁺⁺	Baseline	11.4 (5.9)	9.0 (5.3)
Dietary intake score⁺⁺	12-week	9.7 (6.0)*	8.3 (4.4)
Energy expenditure, kcal/week	Baseline	209 (307)	307 (359)
Energy expenditure, kcal/week	12-week	1181 (676)*	1225 (664)*
Systolic BP, mmHg	Baseline	121 (16)	124 (17)
Systolic BP, mmHg	12-week	120 (15)	121 (15)
Diastolic BP, mmHg	Baseline	77 (8)	76 (9)
Diastolic BP, mmHg	12-week	74 (8)*	73 (8)
Total cholesterol, mg/dL	Baseline	153 (43)	149 (41)
Total cholesterol, mg/dL	12-week	140 (26)*	138 (26)*
HDL, mg/dL	Baseline	41.0 (10.9)	39.8 (10.6)
HDL, mg/dL	12-week	44.2 (9.3)*	43.8 (10.1)*
LDL, mg/dL	Baseline	87.9 (36.2)	89.2 (35.1)
LDL, mg/dL	12-week	73.4 (20.2)*	76.7 (19.6)*
Triglycerides, mg/dL	Baseline	128 (58)	111 (45)
Triglycerides, mg/dL	12-week	106 (41)*	103 (36)

*Denotes P < 0.05 for the change from baseline to 12 weeks

⁺Stress questionnaire [Risk: Low (0–14); Moderate (15–18); High (19+)]

⁺⁺Dietary intake questionnaire [Risk: Low (0–14); Moderate (15–18); High (19+)]

There were no significant differences (P > 0.05) in the changes from baseline to post-programme values between conventional cardiac rehabilitation and telemedicine- delivered cardiac rehabilitation for any of the measured variables.

Discussion

The purpose of the present study was to compare changes in cardiovascular disease risk factors between telemedicine-delivered cardiac rehabilitation and conventional cardiac rehabilitation. Both groups showed positive, and similar, changes in various risk factors from baseline to post-programme. Moreover, risk factor changes for both groups in the present study were similar to those commonly reported in the literature following participation in a phase II cardiac rehabilitation exercise programme.¹⁹ These findings suggest that telemedicine can be used to deliver cardiac rehabilitation effectively to patients who otherwise would not have access to such programmes.

A primary goal of cardiac rehabilitation is to slow or even reverse the progression of cardiovascular disease. By doing this, patients can reduce the risk of heart disease mortality and decrease their chances of recurrent cardiac events.¹ With a structured exercise programme, patients are able to increase their energy expenditure. The present study found that energy expenditure increased significantly from baseline in both conventional and telemedicine-delivered groups, and was 1181 and 1225 kcal/week respectively at the end of the programme. Meeting a threshold of 1000 kcal/week is associated with a 10–20% reduction in coronary heart disease event rate.²⁰

Regular aerobic exercise has been shown to improve glucose control and reduce the risk factors associated with cardiovascular disease, such as blood lipid profiles.²¹ Blood lipid changes for both programmes in the present study were consistent with findings reported elsewhere.^22,23 HDL-cholesterol levels for the conventional group and the telemedicine group both increased by 4.1 mg/dL respectively from baseline to post-programme. It has been reported that for every 1 mg/dL increase in HDL-cholesterol, the risk of a coronary heart disease event is reduced by 1% among men and almost 3% among women.²³ Triglyceride levels also decreased in both the conventional and telemedicine groups by 22 mg/dL and 8 mg/dL, respectively. A slight increase in triglyceride plasma concentrations (1 mg/dL) has been associated with an increased cardiovascular risk of 32% in males and 76% in women. Cardiac rehabilitation programmes which decrease triglyceride levels will decrease the overall cardiovascular risk.²⁴

Although previous studies have shown that telemedicine is useful in teaching, monitoring and providing support to patients at a distance, there have been very few studies of telemedicine being used to deliver cardiac rehabilitation. One study of telemedicine to deliver home-based cardiac rehabilitation found it to be both feasible and safe.¹⁶ An Internet-based programme also reported positive findings for the secondary prevention of cardiovascular disease.²⁵ The results from the present study suggest that telemedicine is a useful way to deliver cardiac rehabilitation. Our findings are similar to other studies in which telemedicine-delivered health care has been employed for risk factor modification.^14,16,25

There were some limitations to the present study. The participants were a convenience sample and an adequately powered and randomized, controlled design would have strengthened our findings, and made them more generalizeable. Results beyond three months are also required to ascertain the long-term benefits of a telemedicine-delivered cardiac rehabilitation programme. Finally, it would be helpful to explore the effectiveness of telemedicine in modifying additional cardiovascular disease risk factors such as cardiorespiratory fitness and inflammation. In summary, the promising findings of the present study justify future randomized controlled research trials to explore the effectiveness of telemedicine-based cardiac rehabilitation programmes.

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