Telehealth interventions versus center-based cardiac rehabilitation: It’s time to strengthen the evidence

Abstract

Despite evidence from trials and meta-analysis that cardiac rehabilitation 'works', only 15-30% of eligible patients participate. 1 This causes many to lament: why don't more patients get referred to and use cardiac rehabilitation programs?Using telehealth to deliver cardiac rehabilitation has been proposed as an innovative way of improving patient uptake, choice and access. 2,3 The systematic review of telehealth cardiac rehabilitation programs by Huang et al. 2 ostensibly provides more justification for the utilization of telehealth cardiac rehabilitation. However, the review actually draws attention to significant limitations about the credibility of current evidence supporting telehealth cardiac rehabilitation. We suggest that the included trials use of out-dated technology, short follow-up points and trial heterogeneity make it difficult to draw conclusions regarding the effectiveness of telehealth versus center-based cardiac rehabilitation programs.Only two of the nine included trials utilized the internet or email and no trials examined text messaging interventions. Telephone support was used in seven of the trials reviewed. Remarkably, none of the trials included dated from after 2007 -the year the iPhone was first introduced. It is difficult to make credible comparisons with the modern day from such dated trials in an area subject to rapid technological change and advances.In regard to follow-up, four of the included trials did not collect follow-up data beyond 12 weeks -only two included trials collected data beyond 12 months. While the goal of cardiac rehabilitation is to support patients to recover from their cardiac event, an equally important goal is to prevent future cardiac events. Studies with such short-term follow-up periods are unlikely to detect the long-term effects of cardiac rehabilitation -which meta-analysis indicates are likely to accrue only after two to five years. 4 The heterogeneity in this review is high; there is evidence of substantial clinical heterogeneity (e.g. different study populations and phases of rehabilitation) and methodological heterogeneity (e.g. different technologies used and exercise patterns). Haung et al. 2 could have better managed these variations and the statistical heterogeneity they contribute to by using a random effects statistical model to pool all of the study data (random effects model was used for total cholesterol data only). The random effects model, unlike the fixed effects model, does not assume that these diverse interventions have a single shared and identical underlying effect size despite their many differences. 5 As these models can produce different results, this reliance on the more naı¨ve fixed effects model is problematic.Is telehealth cardiac rehabilitation a compelling alternative to center-based cardiac rehabilitation? We suggest that strengthening our evidence should be urgently prioritized. Instead of reiterating the message that 'telehealth cardiac rehabilitation interventions works' and/or is comparable to center-based cardiac reha...

Cardiac Rehabilitation in German Speaking Countries of Europe—Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH—Part 2

“…In some tele-CR studies, exercise training was defined as “activities that the patient could perform alone at home, such as walking around” and occasionally, patients were supported by trained personel in the tele-CR group [ 321 , 322 , 323 , 324 , 325 , 326 , 327 , 328 ]. This methodological heterogeneity [ 321 , 322 , 323 , 324 , 325 , 326 , 327 , 328 ] precludes generalization of study results [ 346 , 347 , 348 , 349 ]. In addition, predominantly low-risk patients have been evaluated in tele-CR studies so far, and there are no standards for selecting patients that are suitable for tele- or home-based-CR.…”