Using Mobile Technology for Cardiac Rehabilitation: A Review and Framework for Development and Evaluation

Background I schemic heart disease (IHD) is the leading cause of death in the United States. Cardiac rehabilitation is an evidencebased, cost-effective, multidisciplinary program of individual patient risk factor assessment and management, exercise training, and psychosocial support for patients with heart disease that reduces mortality by 12% to 34% (Table 1). Cardiac rehabilitation is recommended by American Heart Association (AHA) and theAmericanCollege of Cardiology (ACC) Guidelines for patients after myocardial infarction (MI), percutaneous coronary intervention (PCI), or coronary artery bypass surgery (CABG). However, cardiac rehabilitation is dramatically underutilized, with only 14% to 31% of eligible patients participating. Barriers to participation include low referral rates, patient difficulty attending center-based rehabilitation sessions, and cost. Recently, an AHA Presidential Advisory called for a reengineering of cardiac rehabilitation to enhance access, adherence, and effectiveness. It is clear that new strategies are needed for the delivery of cardiac rehabilitation. Mobile technology has the potential to overcome barriers to access to cardiac rehabilitation and may be a useful tool for increasing participation. Mobile health provides the opportunity to improve access to health promotion interventions and has the unique advantage of being able to influence health behaviors in real-time. Of smartphone users, 86% have used their mobile phone to access just-in-time information in the past month. Through mobile technology, a user can receive and interact with information, record and review data, receive automated feedback, and connect with other users or healthcare providers. Mobile health interventions also have the potential to reach a wide segment of the population. Among American adults, 91% own a mobile phone and 56% own a smartphone. Mobile health applications are increasingly popular, with 1 in 5 smartphone users having downloaded a mobile health application. Among minorities, a group with traditionally low participation in cardiac rehabilitation, evidence suggests that uptake of smartphones is high, and that minorities are more likely than nonminority populations to use their smartphones to access health information. In addition, those without home broadband internet access are using their smartphones to access the internet, suggesting that the mobile platform could have even greater penetration than a purely internet-based platform for reaching disadvantaged populations. While older adults are less likely than younger adults to use mobile technology, recent trends have shown significant increases in internet use and mobile phone ownership by older adults. Use of mobile phone applications can increase motivation and physical activity in generally healthy populations. Studies of mobile applications have shown a high degree of acceptability and reasonable efficacy for increasing physical activity and weight loss. In patients with diabetes, mobile applications for self-management have been shown to improve blood glucose control. These findings raise the possibility that mobile applications could be used for promoting physical activity and self-management among patients with IHD who are eligible for cardiac rehabilitation. However, little is known regarding the use of mobile applications for cardiac rehabilitation. As these mobile applications begin to emerge, it will be important to have a standard framework for their evaluation. In this review, we examine the existing literature on the use of mobile technology for cardiac rehabilitation and propose a framework for developing and evaluating mobile applications for cardiac rehabilitation.