Heart Disease and Stroke Prevention: Mobile Health (mHealth) Interventions for Treatment Adherence among Newly Diagnosed Patients

The CPSTF uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision-makers with additional, effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to cardiovascular disease prevention.

Gandhi S, Chen S, Hong L, Sun K, Gong E, Li C, et al. Effect of mobile health interventions on the secondary prevention of cardiovascular disease: systematic review and meta-analysis. Canadian Journal of Cardiology 2017; 33:219-31.

The systematic review and meta-analysis included 27 randomized controlled trials (search period through January 2016). The team examined a subset of 12 studies from the systematic review that were conducted in high-income countries and abstracted supplemental information about study, intervention, and population characteristics.

The CPSTF finding is based on results from the published review, additional information from the subset of studies, and expert input from team members and the CPSTF.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review and meta-analysis included 27 studies.

• Adherence to medications improved significantly (9 studies).
• Adherence to treatment (i.e., one or more medications, clinical care follow-up, or risk factor management recommendations) improved significantly (15 studies).
• Conclusions about intervention effects on additional outcomes related to changes for cardiovascular disease risk factors (i.e., blood pressure, lipids, smoking cessation), morbidity, and mortality were limited by the small numbers of studies and mixed, or inconsistent, results.

The CPSTF examined results from a subset of 12 trials conducted in high-income countries.

• Adherence to medications improved significantly (3 studies).
• Adherence to treatment (i.e., one or more medications, clinical care follow-up, or risk factor management recommendations) improved significantly (6 studies).
• Two additional studies reported improvements in medication adherence using objective measures (1 study) or self-reported outcomes (1 study). A third study reported improvements in treatment adherence.

A systematic review of economic evidence has not been conducted.

While additional research is warranted, the CPSTF finding is likely applicable to the use of these interventions in U.S. healthcare settings for adults recently diagnosed with cardiovascular disease.

Gandhi et al. suggested additional research and evaluation be completed to answer the following questions and fill existing gaps in the evidence base.

• Are interventions based on smartphone apps more or less effective than interventions based on text messaging?
• Are mobile health interventions effective when used for older patients (>65 years), who may have less familiarity with mobile devices and content?
• Are mobile health interventions, especially smartphones, effective for patients of lower socioeconomic status, given potential limitations in access to data or current technologies?

The CPSTF further identified the following evidence gaps as areas for future research (What are evidence gaps?):

• Do studies that use objective measures report outcomes equal to or greater than studies that use self-reported data?
• Are interventions effective in helping patients adhere to medications and self-management goals over longer periods of time (1-2 years)?
• Are interventions effective in reducing morbidity, mortality, and healthcare use associated with cardiovascular disease?
• What factors influence intervention effectiveness?
  • Use with or without in-person counseling or contact?
  • Patients’ gender, race, ethnicity, or socioeconomic status?
  • Length of time since cardiovascular disease diagnosis?
  • Use of current smartphone capabilities such as access to social support?

• Following are characteristics of studies from the subset of 12 studies from high-income countries.
  • Studies were of short duration (median 6 months).
  • Interventions used mobile phones (10 studies) or smartphones (2 studies).
  • Studies provided web-based content that was accessible through smartphones (2 studies) or served as a supplement to text messages (2 studies).
  • Studies used text messages for information or motivation (4 studies), as reminders (4 studies), or both (2 studies).
  • Mobile content was tailored based on patient inputs (2 studies), or personalized without patient inputs (4 studies).
  • Three studies offered contact or appropriate follow-up with a healthcare provider.
  • Studies were conducted in the United States (4 studies), Australia (2 studies), New Zealand (2 studies), Norway (1 study), Spain (1 study), France (1 study), and Canada (1 study).
• All 12 of the subset studies (and 25 of the 27 studies in the full meta-analysis) were conducted among patients with a recent diagnosis of cardiovascular disease.
• Patients were recruited at the time of initial hospitalization (6 studies), or when they were referred to an outpatient cardiac rehabilitation program (6 studies).
• Four U.S. studies provided limited information on patient demographic characteristics, and none provided stratified analyses of effectiveness by socioeconomic status, or race/ethnicity. None of the studies evaluated intervention effectiveness among older patients (>65 years).

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

Gandhi S, Chen S, Hong L, Sun K, Gong E, Li C, et al. Effect of mobile health interventions on the secondary prevention of cardiovascular disease: systematic review and meta-analysis. Canadian Journal of Cardiology 2017; 33:219-31.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Subset of Included Studies conducted in High-Income Nations (as identified by the World Bank)

Blasco A, Carmona M, Fernandez-LozanoI, et al. Evaluation of a telemedicine service for the secondary prevention of coronary artery disease. J Cardiopulm Rehabil Prev 2012; 32: 25-31.

Antypas K, Wangberg SC. An Internet- and mobile-based tailored intervention to enhance maintenance of physical activity after cardiac rehabilitation: short-term results of a randomized controlled trial. J Med Internet Res 2014; 16: e77.

Chow CK, Redfern J, Hillis GS, et al. Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease: a randomized clinical trial. JAMA 2015; 314: 1255-63.

Dale LP, Whittaker R, Jiang Y, et al. Improving coronary heart disease self-management using mobile technologies (Text4Heart): a randomized controlled trial protocol. Trials 2014; 15: 71.

Lounsbury P, Elokda AS, Gylten D, et al. Text-messaging program improves outcomes in outpatient cardiovascular rehabilitation. Int J Cardiol Heart Vasc 2015; 7: 170-5.

Maddison R, Pfaeffli L, Whittaker R, et al. A mobile phone intervention increases physical activity in people with cardiovascular disease: results from the HEART randomized controlled trial. Eur J Prev Cardiol 2015; 22: 701-9.

Pandey AK, Choudhry NK. Improving adherence to exercise regimens post-MI through a novel text message reminder system. Can J Cardiol 2014; 30 (10 suppl): S178-9.

Pandey A, Choudhry N. AREST MI: adherence effects of a comprehensive reminder system for post-myocardial infarction secondary prevention. J Am Coll Cardiol 2015; 65 (10 suppl): A1384.

Park LG, Howie-Esquivel J, Chung ML, Dracup K. A text messaging intervention to promote medication adherence for patients with coronary heart disease: a randomized controlled trial. Patient Educ Couns 2014; 94: 261-8.

Quilici J, FugonL, Beguin S, et al. Effect of motivational mobile phone short message service on aspirin adherence after coronary stenting for acute coronarysyndrome. Int J Cardiol 2013; 168: 568-9.

Varnfield M, Karunanithi M, Lee CK, et al. Smartphone-based home care model improved use of cardiac rehabilitation in post myocardial infarction patients: results from a randomized controlled trial. Heart 2014; 100: 1770-9.

Widmer RJ, Allison T, Lerman L, Lerman A. The augmentation of usual cardiac rehabilitation with an online and smartphone-based program improves cardiovascular risk factors and reduces rehospitalizations. J Am Coll Cardiol 2014; 63: a1296.

Included Intervention Studies conducted in Other Nations

Chen S. The influence of strengthening health education on declining the rate of recurrence and stroke. Journal of Qiqihar University of Medicine 2011; 32: 2515-6.

Dike Sha, Yao Y. Impact of Web-based health management model on quality of life of patients after coronary artery stenting. J Nurs Sci 2014; 15: 84-6.

Fu X. Effect of We-chat platform information support on medicine compliance of patients who underwent carotid artery stenting [in Chinese]. Nurs J Chin PLA 2015; 12: 43-6.

Hong L. The observation of We Chat improvement on self-efficiency of patients who received the carotid artery stent implantation [in Chinese]. Chin Dig Med 2015; 6: 54-6.

Huang M. Impact of text messaging service on medication compliance in patients after percutaneous coronary intervention. Shanghai Nurs 2011; 4: 17-20.

Khonsari S, Subramanian P, Chinna K, et al. Effect of a reminder system using an automated short message service on medication adherence following acute coronary syndrome. Eur J Cardoiovasc Nurs 2015; 14: 170-9.

Li B. The effect of transitional care on the anticoagulant therapy compliance among discharged patients undergoing cardiac valve surgery [in Chinese]. Chin Nurs Manag 2014; 12: 1278-81.

Liu Y. The effect of transitional care on the anticoagulant therapy compliance among discharged patients undergoing cardiac valve surgery. Chin J Nurs 2015; 6: 660-5.

Pan X. Influence of SMS and telephone interviews education on rehabilitation of discharged patients after coronary intervention. Chin Nurs Res 2013; 18: 1871-2.

Shen L. Application of video information technology on health education for stroke patients. Nurs Recov 2015; 14: 10-2.

Tian M, Ajay VS, Dunzhu D, et al. A cluster-randomized, controlled trial of a simplified multifaceted management program for individuals at high cardiovascular risk (Sim Card Trial) in rural Tibet, China, and Haryana, India. Circulation 2015; 132: 815-24.

Wang L. Use of an app on rehabilitation follow-up for patients who received PCI [in Chinese]. Cardiovasc Dis J Integr Trad Chin West Med 2014; 12: 33-4.

You M, Ding Q, Yin P. The influence of health education messages on the compliance of anticoagulant therapy after heart valve replacement. Hushi jinxiuzazhi 2013; 28: 73-4.

Zeng Y, Liu S. Relative involvement of short-message intervention on smoking cessation of patients received percutaneous coronary intervention [in Chinese]. J Qilu Nurs 2014; 9: 121-2.

Zhang. Effect of follow-up ways on the occurrence rate of cardiac event and survival qualities of CHD patients. Chin J PHM 2014; 5: 758-9.

Implementation Resources

• CDC’s Division for Heart Disease and Stroke Prevention developed an implementation resource to help communities and health systems implement telehealth interventions to improve chronic diseases, including cardiovascular disease.

Refer to the existing systematic review for information about the search strategy:

Gandhi S, Chen S, Hong L, Sun K, Gong E, Li C, et al. Effect of mobile health interventions on the secondary prevention of cardiovascular disease: systematic review and meta-analysis. Canadian Journal of Cardiology 2017; 33:219-31.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• Given the range of adherence demands on patients at this time (new treatment regimens, appointments for follow-up and rehabilitation, and adoption of new lifestyle and self-management goals) mobile health interventions may be most useful and effective during the initial management period of patients with a new diagnosis.
• Improved adherence might reduce the number of in-person clinical care appointments needed to achieve control of cardiovascular disease risk factors.
• Text messages may be a source of distraction for patients engaged in other activities.
• The rapid evolution of mobile device technology is likely to provide newer studies with opportunities for substantially enhanced or personalized message content and interactivity.
• Neubeck et al. (2015) provides a useful review of smartphone apps used to prevent and manage cardiovascular disease. The review describes intervention characteristics associated with patient uptake including credible, sourced, clear, and concise messaging, and personalized content with feedback, rewards, and positive reinforcement.
• The Million Hearts Initiative includes tools and resources to help organize health system and public health improvement strategies for prevention and management of cardiovascular disease risk factors. Broader strategies outlined in these resources identify potential opportunities to incorporate mobile health interventions.
• Implementers should understand state policies regarding application of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to electronic communications with patients.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Improve cardiovascular health in adults — HDS-01
• Reduce coronary heart disease deaths — HDS-02
• Reduce stroke deaths — HDS-03
• Increase control of high blood pressure in adults — HDS-05
• Increase cholesterol treatment in adults — HDS-07