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Abstract
Cardiovascular disease (CVD) is the leading cause of global mortality. Two forms of CVD are acute coronary syndromes (ACS) and heart failure (HF). Patients with either are prone to repeat hospitalisations, which are detrimental to both patients and the healthcare system. Traditional care models are suboptimal in preventing readmissions. Mobile health interventions (MHIs) are attractive due to the computing power and convenience of the smartphone.
Firstly, the literature regarding MHIs in CVD is systematically reviewed and meta-analysed. MHIs improved medication adherence in ACS patients and hospitalisation rates in HF patients. The review noted limitations of published trials and identified features of successful MHIs, which were incorporated into the design of a novel smartphone app-based model of care (TeleClinical Care, TCC). TCC allows home measurement of blood pressure, heart rate and weight by patients. The readings are automatically transmitted to a central server, where clinicians can identify abnormalities and intervene accordingly.
A pilot RCT comparing TCC and usual care (UC) to UC alone was performed (n=164). Patients using TCC had fewer readmissions at 6 months (41 vs. 21, hazard ratio 0.51, P= 0.015), and were more likely to be adherent with medications (75% vs. 50%, P= 0.001) and complete cardiac rehabilitation (39% vs. 18%, odds ratio 2.9, P= 0.02) compared to patients in the control arm.
A process evaluation of the RCT was subsequently undertaken, which identified several contributory factors to TCC’s success, such as a helpful orientation protocol for team members, and high background rates of HF outreach service and cardiologist follow-up in both trial arms. Via a series of interviews, methods to improve the future delivery of TCC were identified, particularly relating to its integration into mainstream healthcare.
Patterns of smartphone ownership among cardiac inpatients were also examined. Age, sex, diagnosis, and private health insurance subscription influenced smartphone ownership. These data will help identify patients who may be excluded from MHIs.
The thesis contains a cost-effectiveness model of TCC if applied widely. When enrolment exceeds 237 patients, TCC will reduce healthcare costs relative to UC, resultant to readmission prevention. Enrolment of 500 patients is projected to save $100,000 annually.
In conclusion, TCC is demonstrated as a feasible, beneficial, safe, and cost-effective intervention for patients with CVD.
