Accepted for/Published in: JMIR mHealth and uHealth
Date Submitted: Jan 23, 2020
Date Accepted: Jul 15, 2020
Implementation of Telerehabilitation Interventions for the Self-management of Cardiovascular Disease: A Systematic Review
ABSTRACT
Background:
Coronary heart disease (CHD) is a leading cause of disability and deaths worldwide. Secondary prevention (including cardiac rehabilitation; CR) is crucial to improve risk factors, reduce disease burden and disability. Accessibility barriers contribute to underutilization of traditional center-based CR programs; therefore, alternative delivery models, including cardiac telerehabilitation (delivery via mobile/smartphone and/or web-based application), have been tested. Experimental studies have shown cardiac telerehabilitation to be effective and cost-effective but there is inadequate evidence about how to translate this research into routine clinical practice.
Objective:
This systematic review aimed to synthesize research evaluating the effectiveness of implementing cardiac telerehabilitation interventions at scale in routine clinical practice—including factors underlying successful implementation processes—and experimental research evaluating implementation-related outcomes.
Methods:
Medline, Embase, PsycINFO and Global Health databases were searched from 1990 through 9 Nov 2018 for studies evaluating the implementation of telerehabilitation for the self-management of CHD. Reference lists of included studies and relevant systematic reviews were hand searched to identify additional studies. Implementation outcomes of interest included acceptability, appropriateness, adoption, feasibility, implementation cost, penetration and sustainability. A narrative synthesis of results was carried out. (PROSPERO CRD42919124254).
Results:
No included studies evaluated the implementation of cardiac telerehabilitation in routine clinical practice. Ten studies of 2250 participants evaluated implementation outcomes including acceptability (n=8), appropriateness (n=9), adoption (n=6), feasibility (n=6), fidelity (n=7), and implementation cost (n=4), predominantly from the participant perspective. Cardiac telerehabilitation interventions had high acceptance among the majority of participants, but technical challenges such as reliable broadband internet connectivity can impact acceptability and feasibility. Many participants considered telerehabilitation was an appropriate alternative CR delivery model as it was convenient, flexible and easy to access. Participants valued interactive intervention components such as real-time exercise monitoring and feedback, and individualized support. The penetration and sustainability of cardiac telerehabilitation, as well as the perspectives of CR practitioners and healthcare organizations, have received little attention in existing cardiac telerehabilitation research.
Conclusions:
Experimental trials suggest participants perceive cardiac telerehabilitation is an acceptable and appropriate approach to improve the reach and utilization of CR, but pragmatic implementation studies are needed to understand how interventions can be sustainably translated from research into clinical practice. Addressing this gap could help realize the potential impact of telerehabilitation on CR accessibility and participation, as well as person-centered, health, and economic outcomes. Clinical Trial: PROSPERO CRD2019124254
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