Editor's Note: In the video below, Dr Widmer provides an overview of the investigational app developed by the Mayo Clinic.
Rehab via Smartphone
Bernard J Gersh, MB, ChB, DPhil: Hello. I am Bernard Gersh from the Mayo Clinic. With me are my colleagues, Drs Amir Lerman and Jay Widmer, who are going to talk about a rather fascinating smartphone patient-oriented application for cardiovascular rehabilitation. Cardiovascular rehabilitation is a proven measure that is very beneficial in secondary prevention and is very much underutilized. That is one of the needs. Jay, could you begin by telling us exactly what the device is and what the goal of this study is?
Robert J Widmer, MD, PhD: Thanks, Dr Gersh. We set out with the intent to use American Heart Association (AHA)/American College of Cardiology (ACC) secondary-prevention guidelines along with some Mayo expertise and condense it into an online and smartphone-based application. The goal was to disseminate this information to different patients throughout the Mayo Clinic area in an effort to improve compliance and adherence to cardiac rehabilitation.
Dr Gersh: Amir, you had looked at this before in primary prevention and identified some issues in relation to outpatients and distance and so on. Could you elaborate on that?
Amir Lerman, MD: We looked at this in primary prevention in patients with low Framingham risk scores. They were engaged in this to maintain their health. These are patients who had at least one to two risk factors. They used this application for about 90 days. In 90 days we saw a significant reduction in weight (body-mass index), blood pressure, and an overall reduction in Framingham risk score just by using the application.
Dr Gersh: The application was then extended into secondary prevention. Can you tell us more about this specific application?
Dr Widmer: The application is designed such that patients are taken through a brief educational session lasting about 15 minutes when they first log in. Then the patients insert their cardiovascular disease metrics. They put in their blood pressure and their weight. We are trying to engage behavior-change theory so that the patients understand where they stand from a prevention standpoint, where they need to go, and how they will get there. They put in their own information and we ask them to log in daily information on blood pressure, weight, and so forth. They also have educational tasks.
Dr Gersh: I have about 40 apps in my iPhone. I love apps, but I never use them. How does this differ from having people go to cardiovascular rehabilitation every day and having someone else take their weight and blood pressure and tell them they are not doing well?
No Parking Required
Dr Widmer: That's a great point. One of the biggest factors that keeps people away from Mayo Clinic cardiac rehabilitation is parking. If we can translate the Mayo Clinic cardiac rehabilitation experience to patients in the surrounding communities, we hope that we can enhance the benefit of secondary prevention. We know from Mayo Clinic data that if patients adhere to one cardiac rehabilitation session per week for the three-month period, they have a 50% reduction in all-cause mortality.
Dr Gersh: I would have thought that the major problem was weather, not parking, given the way the winter has been. Please continue telling us how the app used.
Dr Widmer: The patients log in on a daily basis. When they engage in their own care and are relearning things that are enforced in cardiac rehabilitation, we see more significant improvements in lifestyle change over that three-month time, which is carried on beyond cardiac rehabilitation.
Dr Gersh: How many patients did the study involve?
Dr Widmer: The actual study included 44 patients (nonrandomized), and 25 participants who used the personal health assistant were compared with participants who did not use the personal health assistant.
Dr Gersh: Why wasn't it randomized?
Dr Widmer: This was essentially a pilot feasibility study, to test and make sure that we could implement the technology, that we had the right application design and metrics, that we could do this at Mayo Clinic, and that we would have compliance.
Dr Gersh: Did this include in-house sessions as well?
Dr Widmer: Both groups of patients underwent the usual cardiac rehabilitation. The group that used the personal health assistant had that added benefit of the application and a 30-minute education session at the beginning.
Reduced Weight and Hospitalizations
Dr Gersh: And what were the results?
Dr Widmer: It was very interesting. We actually had a pretty benign cardiovascular risk factor profile at the beginning, a little bit of obesity and a little bit of uncontrolled glucose.
Dr Gersh: These were patients with known cardiovascular disease?
Dr Widmer: Yes, after percutaneous coronary intervention for acute coronary syndrome. The results showed that at the end of 90 days, we had significant reductions in weight (as measured in kg), significant reductions in systolic blood pressure, and an improvement in quality of life. Of note, when we did the chart review to verify all of the data, we found that there was a 40% reduction in emergency-department visits and rehospitalizations in the group that used the personal health assistant.
Dr Gersh: That is an extraordinary statistic. I wouldn't have expected that. I would have expected a reduction in weight and in other things, but not [emergency-department] visits.
Dr Lerman: The [emergency-department] visits were not the primary goal, but it came out in the study. If you improve the overall quality and the exercise of these patients and they have the knowledge at home and can see their status every day, it prevents some of them from coming to the [emergency department]. They know where they are. They know their medical information.
We underestimate the lack of accessibility of patients to medical care. If we live close to tertiary care, for us it's obvious, but most of the people in the United States don't live with access to medical care. Most of the information that we obtain in daily life is through the internet and smartphone applications. It's not a novel concept. Everything that we do in our daily life is now electronic.
Essentially we took all of the information that we give the patients in written or oral presentations and turned it into an application. A strong element of this application is social networking. Patients can communicate with each other. We give information—what is a healthy portion of food or where they can exercise—that we think patients know but they actually don't.
Dr Gersh: With the smartphone app, they have the ability to communicate with others who are in the same rehabilitation program?
Dr Widmer: Yes.
The Magnitude of Benefit
Dr Gersh: What's particularly attractive from the standpoint of where we're situated (at Mayo) is that we're a huge tertiary referral care center surrounded by a large number of rural communities (even our CCU STEMI network is a network of 28 hospitals, 27 of which are rural). Tell me about the magnitude of the change. You said that they lost more weight and the blood-pressure control was better.
Dr Widmer: We saw about a 4-kg reduction in body weight. There was stagnant weight change in the group that did not use the personal health assistant.
Dr Gersh: Four kg in three months. That's not trivial.
Dr Widmer: We also saw about a 10- to 12-mm-Hg drop in systolic blood pressure. On the quality-of-life index, there was about a twofold increase in the patients who used the personal health assistant. We saw some trends toward an improvement in physical-activity metrics, such as exercise capacity, minutes of physical activity, and dietary information.
Dr Gersh: Let me just ask you something that may sound like a somewhat trite or supercilious question. What time of the year did this take place, or was it across the year?
Dr Widmer: It was across the year.
Dr Gersh: I would have thought there would be differences. It's not easy to come in during the winter months.
Dr Lerman: That's why we think accessibility is a big issue. There are more smartphones than people in the world. They are using a lot of information. The combination of science-based and knowledge-based application is what brought them in. Another element that will be implemented in the future is a reward. There is a strong element of reward for individuals who participate. The reward can be a reduction in insurance rates if they participate. This can encourage people to participate in this kind of an application.
Dr Gersh: It's like Pavlov's dog. Do what I tell you and I'm going to give you a bone.
Dr Lerman: There are a lot of data on the strong effect of reward.
Here to Stay or Gone Tomorrow?The Magnitude of Benefit
Dr Gersh: That makes sense. I suppose the other question is like all new apps and fads, how will this play out over time? You talk about a three-month study. What do you think this will look at in six to 12 months or 18 months? This has been the problem with weight loss. It is achieved but it's not maintained.
Dr Widmer: It's a good question. We have followed the same cohort of patients for up to six and 12 months out. These changes do persist. The use of the application was only for a three-month study, so we don't have a way to chart their ongoing use of the application. That obviously will go down. One way that we can keep it accessible and applicable as physicians is by engaging the patients in the social network, by engaging them in blogging, and having patients feel that they don't need to come in and see us every three months. We are giving them advice for cardiovascular prevention. That keeps them connected with the tertiary center and keeps them feeling comforted and out of the [emergency department].
Dr Gersh: It's fascinating. It makes us realize we are in a very new technological world. When you were talking, I was thinking about home international normalized ratio (INR) monitoring.
Dr Lerman: There are some elements to this application to remind patients to take their medication. If you had a patient who had a stent and you want to make sure that the patient is taking clopidogrel every day, the patient is going to have a medicine box on the application to make sure that they are taking their medication. If they don't, they get a reminder. We know that almost 50% of patients stop taking their statin.
Dr Gersh: That is fascinating as well. I heard the other day that the commonest cause of drug-resistant hypertension is people not taking their drugs. Talk about a simple but effective tool. Could you wrap up for us? Where do you plan to go with this?
Dr Widmer: We have a randomized clinical trial going on now. We are halfway through with recruitment and expect to wrap up sometime in the summer. We are working on different modules for heart failure. We are continuing our work on primary prevention in larger groups. We are trying to establish a digital and mobile health center at Mayo so that we can implement this in our care.
Dr Gersh: If you can have an impact on readmission rates for heart failure, what a contribution that would be.