AHA Science Advisory on Digital Technology in Cardiac Rehabilitation
In this podcast series, moderator Seth S. Martin, MD, MHS, examines key practice-changing clinical trials and explores the future of cardiovascular medicine, including the development of cutting-edge technologies, innovative approaches to implementing prevention guidelines, and more.
In this podcast episode, Dr Seth Martin interviews Jessica Golbus, MD, about the Science Advisory from the American Heart Association on digital technology in cardiac rehabilitation, including the development, evaluation, and integration of digital technology, and the critical importance of health equity. They also discuss the role of the clinician in matching patients with the appropriate technology.
Additional Resource:
Golbus JR, Lopez-Jimenez F, Barac A, et al; Exercise, Cardiac Rehabilitation and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Quality of Care and Outcomes Research; and Council on Cardiovascular and Stroke Nursing. Digital technologies in cardiac rehabilitation: a science advisory from the American Heart Association. Circulation. 2023;148(1):95-107. doi:10.1161/CIR.0000000000001150
Seth Martin, MD, MHS, is a Preventive Cardiologist and a Professor of Medicine in the Division of Cardiology, Department of Medicine, at Johns Hopkins University School of Medicine. He is the Director of the Advanced Lipid Disorders Program and Digital Health Lab at the Ciccarone Center for the Prevention of Cardiovascular Disease. He is also the Center Director and the Principal Investigator of the mTECH Center, part of the AHA Health Tech and Innovation Network (Baltimore, MD).
Jessica Golbus, MD, is a clinical instructor in the Division of Cardiovascular Medicine at the University of Michigan and specializes in heart failure, heart transplantation, and mechanical circulatory support (Ann Arbor, MI).
TRANSCRIPTION:
Speaker 1:
Hello, and welcome to Cardio Care Now, a special podcast series led by Dr Seth Martin. Dr Martin is a cardiologist and an associate professor at Johns Hopkins University School of Medicine in Baltimore, Maryland. The views of the speakers are their own and do not reflect the views of their respective institutions or Consultant360.
Seth Martin:
Welcome back to the Cardio Care Now podcast series. We are really lucky to have joining us today as our expert guest, Dr. Jessie Golbus from the University of Michigan. Dr. Golbus is a cardiologist and a heart failure expert at the University of Michigan, and I've had the pleasure of collaborating with Dr. Golbus in the AHA Health Tech and Innovation Network where our teams at Michigan and Hopkins have had a really deep interest in cardiac rehabilitation and looking into technology as a way to increase access to cardiac rehab. So one of the reasons we're particularly lucky to have Dr. Golbus joining us is she recently led American Heart Association Scientific Advisory on the topic of digital technologies in cardiac rehab. So I'm looking forward to picking Dr. Golbus's brain around this advisory and really deeply exploring this topic of the intersection of technology and cardiac rehab. So welcome, Dr Golbus.
Jessica Golbus:
Thanks so much, Dr. Martin for having me here today. It's really a pleasure to join you and to be able to dive into this work, which I'm really excited and passionate about.
Seth Martin:
Thank you. Thank you so much. So just to kick things off, I think it is worth just talking to a high level about cardiac rehabilitation, what it is. I mean, in general, I know that you've had an interest in physical activity and exercise, and cardiac rehab really brings things together as a program for patients in the secondary prevention setting. But can you, just to level set for us, share with us what is cardiac rehab, what's the basic evidence and guideline recommendations around cardiac rehab?
Jessica Golbus:
Yeah. That's a great place to start. So cardiac rehab is a medically supervised exercise and lifestyle program for patients who have cardiovascular disease, so it is so much more than just exercise. It's education around different lifestyle behaviors that have been known to increase the risk of patients having a secondary cardiovascular event, so things like smoking cessation, for example, or nutrition. That's all an integral part of cardiac rehab and goes hand in hand with the supervised exercise component. And that supervised exercise is typically delivered as two to three sessions a week for as many as 12 weeks. And there's really robust data out there that supports the benefits in terms of morbidity and mortality for patients with cardiovascular disease. And so it has a class one recommendation from the AHA and the American College of Cardiology for many cardiovascular conditions given this strong evidence base to support benefits in our patients.
Seth Martin:
Yeah, absolutely. I mean, clearly, this is something that as clinicians, for patients who meet the qualifications for cardiac rehab, which basically is having a cardiovascular event or procedure such as having an MI status post PCI or CABG or bypass surgery, even chronic heart failure, Jessie, qualifies, which is one of those that's often forgotten, I guess, but having chronic stable heart failure for a few months. So there's a lot of, I mean, this is the kind of thing, whereas active clinicians, we're going to see patients that qualify for cardiac rehab all the time. It's really a comprehensive program. It has this core of exercise, but a comprehensive program that brings these key pieces together to mitigate the risk of recurrent events and to improve quality of life and longevity.
So I love the fact that it is such a well-established and evidence-based program. I honestly think in the future of medicine, we probably will have more and more organized programs like this that are tailored to certain patients and clinical conditions. But the challenge I guess, we've run into is that despite the evidence and despite so many patients who could benefit, the majority of patients don't participate in cardiac rehab. Can you shed a little more light on what the current state of affairs is and what some of the barriers have been?
Jessica Golbus:
Yeah, absolutely. So I love that you highlighted heart failure, which is obviously near and dear to my heart. To put it in perspective, depending on the numbers that you're looking at, anywhere from four to 6%, so incredibly low numbers, four to 6% of eligible heart failure patients participating in cardiac rehab. But that's really just one small subset of the population. So consistently it's been shown that women, older individuals, and some racial and ethnic minority groups are participating in cardiac rehab at rates far below those that would be expected, and also people living in certain communities, so particularly people in more rural communities. And I think that there are multiple reasons for why that's the case and it depends on the specific population, but it frankly comes down to issues of access. It is a commitment and it's often structured in a way that makes it difficult for people to attend cardiac rehab given some of their commitments.
So it's two to three times a week, you have to go to a cardiac rehab center, so your schedule has to allow you to go to the center. There has to be a center that's accessible, and frankly, issues of copays come up. And even though sometimes these are small, they add up over time because we're talking about 36 sessions here. And so the barriers differ by different populations, but certainly, there are really large swathes of the population that are not well represented in cardiac rehab. And really that's been the motivation for thinking about some of these alternative delivery models and some creative solutions to help address this gap.
Seth Martin:
Right. And it really seems like we're now at a time where the technology is there to allow us to re-engineer the delivery of cardiac rehab to make it so much more accessible to many, many more patients, and not necessarily to replace traditional cardiac rehab, but just to increase the access. And it may be that patients participate in a hybrid of both traditional and digital forms of cardiac rehab, but that we're now really making it more accessible to many more patients. So as part of this scientific advisory of the AHA that you led and was just recently published, the first section of that article looks at the landscape of digital technology. So maybe you could speak a bit more about that landscape and the future directions using technology. It's actually an area that's been investigated now, and explored for a number of years, but before the technology was a little more simplistic. And now with the acceleration of technology, there really is this exciting chance to really be able to scale up cardiac rehab.
Jessica Golbus:
Yeah, that's right. So I think to start out to level set, so when we're talking about digital technology, I just wanted to make sure that we were all operating under the same definition here because that has not been standardized. So in this particular piece, we use digital technology to refer to care delivered through the internet, wearable devices, and mobile applications as well as emerging computational methods, so things as artificial intelligence. So what we didn't focus on in this was telephone-only studies, and there's actually really robust evidence to support home-based cardiac rehab using the telephone. It was actually the focus of a separate scientific statement but is not what we focused on in this piece, so I just wanted to set that up upfront.
Seth Martin:
Yeah. That's a super helpful distinction. Thank you.
Jessica Golbus:
So one of the things that I really liked about how we thought about this article is that we took a really holistic approach to thinking about digital technology and thought about how it can be used to augment many different forms of cardiac rehab. So we thought of digital technology as an adjunct to in-person cardiac rehab. We thought about it how it can be used to facilitate asynchronous cardiac rehab, and then as an adjunct to synchronous real-time audiovisual cardiac rehab, so that's a situation where the patient may be at home and the cardiac rehabilitation team is in another facility, but then they're communicating in real-time. And so we thought about how digital technology can be used in all of those different formats.
Seth Martin:
Absolutely. I like how you broke that down there because it really is an opportunity to have these different pathways within which patients can engage with cardiac rehab that really best meets their needs, and the digital technology can fit in a different way. And so really it just increases the flexibility for the patients that we serve. So as we think around the development and evaluation and integration of digital technology, maybe you can go through some of the key pieces there because clearly we're moving beyond the telephone now and there's a lot of possibility here. So can you just highlight some of the key pieces that came out of our scientific advisory? And by the way, I would encourage everybody listening to check out after this conversation to really check out this scientific advisory. It has both the text content that was really carefully developed and edited right by all of our co-authors and yourself, as well as graphics that really highlight the key components that were worked on together with the AHA Graphics team. So I would encourage everyone to read the content, but can you pull out some of the key pieces there, Jessie?
Jessica Golbus:
Sure, absolutely. So I think just to start about where there is evidence supporting digital technologies and where we need more data, so maybe I can start there and then we can move on to some of the subsequent pieces, if that sounds all right.
Seth Martin:
Absolutely.
Jessica Golbus:
And I think that this really been led by your team as well at Hopkins, a lot of the work to summarize the evidence on digital technologies and that really nice review that you came out within 2021, but showed that generally digital technologies, while they're heterogeneous, have generally been shown to improve functional capacity in aggregate. And there have been other studies that have looked at the specific components of those digital interventions that have been most effective. But things like real-time feedback or correctional goal setting, for example, have been some of the studies that have been potentially most effective.
Generally, however, the studies have been small and proof of concept studies, so we're talking about studies that have less than a hundred patients. So again, most studies on aggregate have been effective, but heterogeneous, and I think that there are a couple of gaps that we highlighted that hopefully will motivate future studies. So the focus of using digital technology has been predominantly on physical activity and exercise training. But really this technology, I think the next step is to think about how we can integrate many of the other core components of cardiac rehab, so things like lipid or diabetes management, nutrition and smoking cessation into these digital platforms.
Seth Martin:
Yeah, absolutely. I totally agree. That's such a key point that we've had some of our patients that have participated in some human-centered design sessions and focus groups say that cardiac rehab is more than just a gym, although that's a very important component to exercise, it goes beyond that risk factors such as cholesterol, like you said, where we know there are huge gaps in actually implementing all the great therapies that we now have. And it's interesting to look back at the history of cardiac rehab. I've actually talked with our mutual colleague, Pat Dunn from AHA about this. And we've looked back at some older papers where it's interesting that LDL cholesterol, cholesterol is actually a key outcome of some of the early cardiac rehab literature. And that predated all the, not just statin, but non-statin therapy that we have now.
So we have such a strong ability to lower LDL cholesterol levels to prevent recurrent ASCVD events in the secondary prevention population, and cardiac rehab because it brings these key pieces together as part of a program, clearly exercise, although very important, is not going to be the sole treatment for cholesterol levels. And so it's a chance to really integrate those pieces, and I think it speaks to the need to use technology to help address that, as well as to integrate cardiac rehab programs with, if you have a lipid clinic at your institution to have collaboration coordination between the program. So I'm glad that you brought up risk factor modification because we really have a unique chance now with both the evolution of technology as well as the evolution of treatments for risk factors, including now beyond lipids therapies like GLP-1 where you can, not only improve someone's weight a substantial amount but also the risk factor profile across the board.
So there's really a great opportunity here to really, for cardiac rehab programs to have a strong emphasis on risk factors. Of course, patient education is really key there, and I think that the idea around patient education, particularly at an appropriate literacy level, also ties in with concepts around health equity. And you actually brought some of that up, Jessie, earlier in the conversation around health equity, and we do have that as a dedicated section in the scientific advisory. Do you want to maybe dive into that topic a little bit more about what some of our writing group's thoughts were around equity in cardiac rehab?
Jessica Golbus:
Yeah, that's great. I would love to highlight some of that work.
Seth Martin:
And also feel free to, I know I just brought forth quite a number of thoughts too, so feel free to respond to any of those too.
Jessica Golbus:
No, I think that's great. I think we can dive into equity here because I think that's a nice transition. And so I really highlighted how this concern about how rapidly advancing technology has the potential to exacerbate the exclusion of certain groups, introduce digital biases, and widen this digital divide, which is actually the opposite of what we want to do. By using digital technology, we want to increase access. And I think that there are unique issues that come up when you talk about digital technology. So there are issues of connectivity, affordability, and accessibility that have the potential to disenfranchise unique populations. So we're talking about older adults, frail patients, but also individuals with visual, auditory, and fine motor impairments. So for example, many smartwatches have very small screens, and potentially that could disenfranchise people with visual or fine motor impairment. So I think that our writing group thought a lot about these important issues.
And I think a couple of things that we talked about is really the role of the clinician in matching the patient with the technology. So not making it an impersonal solution where we just give people the technology and they are expected to be able to use it. We talked about one, selecting the right technology for the right patient. So maybe gravitating towards a mobile application that doesn't require a smartwatch if they have a visual impairment or a smartwatch with a much larger screen. And then also investing in human resources to onboard patients and also staff to ensure that everybody has the appropriate knowledge and competency to use the technology. So those were some of the things that our writing group talked about. We also have a really nice figure in the piece, which I'll direct everybody to that talks about the life cycle of equity center digital health and cardiac rehab. So it's not a one-and-done phenomenon, but appropriately developing and implementing these digital solutions and then having plans in place to reassess and ensure that we are achieving health equity.
Seth Martin:
Absolutely. And I'm hopeful that our conversation will inspire our colleagues who are listening to possibly step up and become a champion for equity and access to cardiac rehab in your own hospital or institution. And I think this science advisory will serve as a great resource, and I think we as well, Dr Golbus, myself, and our colleagues, can also serve as resources as you navigate conversations within your institution to really advocate. I think it's certainly just to start to see what's currently being done, but then to really start asking questions about what's possible to leverage technology. And at our institutions, we are both leveraging technology as part of cardiac rehab. And you mentioned there are certain aspects of it when you first start just around staff training, so I think we'd be happy to share our experience with those types of steps. But maybe that does start to get into implementation.
Why don't we talk some more about implementation? Obviously, there's an evolving landscape here with respect to reimbursement for cardiac rehab. During the pandemic there were certain changes that post-pandemic, there's now active legislation in the works to increase access to cardiac rehab, but ultimately it is about the value proposition for our patients, for hospitals, health systems, and for payers. So Jessie, what is that value proposition and what should folks that are first starting to develop an interest in this field look at in terms of implementing what they're in their own hospital or health system?
Jessica Golbus:
Yeah, thanks for highlighting that. So we really thought about this within the Quadruple Aim framework. So we thought about digital technology and cardiac rehab and its impact on population health, the patient experience, costs, and then work-life balance, and we really felt that this kind of fire and all four of those fronts. So first I think it's this idea of bringing new patients into your health system. So people that were previously underrepresented and center-based cardiac rehab now have the ability to potentially access care to reduce cardiovascular morbidity and mortality, reduce hospitalizations, and improve quality of life. I think we can all, as clinicians appreciate how valuable that is in and of itself. But I think that there's also value right there to health systems. I mean, you're now tying a group of patients to your health system that, perhaps, were not previously as connected, and so there are issues thereof reimbursement that are important to health systems and their sustainability.
I think the other value is thinking about how this changes the cost structure of cardiac rehab. So one of the limitations historically of center-based cardiac rehab has been issues of space and staff, and there's only so much exercise equipment. And so these digital technologies can potentially resolve many of those issues. And studies have suggested that these are at least as cost-effective as center-based cardiac rehab and may even prove to be more cost-effective. And then finally, I'll just highlight in terms of that implementation and value proposition piece. I think that it potentially has the ability to improve staff satisfaction. So thinking about how this can be delivered in flexible formats, in flexible times certainly has the ability to improve work-life balance for clinicians as well as patients. So I think that there are lots of reasons to be excited about digital technologies in cardiac rehab from a value proposition perspective.
Seth Martin:
Absolutely. Very well said. So the value proposition is really quite impressive and robust, but we are still on the leading edge of adopting digital technology in cardiac rehab, and so it really is an exciting future, the ability that it can really engage people in the context of their daily lives. And something that I think about is that it is a program, and then you graduate the program and then ultimately you go about living your daily life. And so the more that we can shift cardiac rehab to really engage people in the context of their daily lives outside of a center, I think the more that it could really build that long-term sustainability. And so just to reemphasize what we've said, this is not about replacing traditional cardiac rehab. Traditional cardiac rehab is very important, but as you said, there's limited equipment, there's a limited number of centers.
There's been literature to suggest that only about a third to a half of patients, even if all the eligible patients participated, would have the ability to participate in a center if we filled up all the center slots. So there's a need to find ways to scale up access to cardiac rehab, and digital technology really is paving the way for that as you've really illuminated today. So I wonder, as we come towards the close of the conversation, any additional thoughts that you wanted to make sure to share to inspire folks to read the science advisory and to really champion this type of program within their hospital and health system, any take-home points or resources that you want to leave our audience with?
Jessica Golbus:
Yeah. Well, I guess, one final point that I just wanted to make, and I think we've touched on this sporadically throughout our discussion, but we are not looking to replace center-based cardiac rehab, which is wonderful, and we're certainly not looking to replace the role of clinicians. Well, I think one of the things that we really highlight nicely and consistently throughout the piece is how digital technology can augment existing resources and make them go farther. How we can really make those clinician-patient relationships stronger, how we can leverage the data that's available to make those conversations more valuable to patients and augment the benefits that they see beyond that traditional cardiac rehabilitation period? So again, it's not about replacing, it's about using the technology to augment and extend what exists so that we can reach more patients and have a more meaningful impact. And so I just wanted to say that out loud because that was something that I really liked about the piece.
Seth Martin:
Absolutely. And it can become a contentious point that, especially for folks that have been part of the traditional world of cardiac rehab for a long time, it is a new way of thinking and approaching things, so it is important that we really respect the traditions of cardiac rehab while still trying to innovate using technology. So this is a great area for traditions to meet innovation. And to that end, I will say that to our listeners, there are active trials and really well-funded studies happening now through the American Heart Association as well as PCORI. Dr. Golbus and I are collaborating with Alexis Beatty and a team from UCSF as well as other institutions on a CORI, that's the Patient-Centered Outcomes Research Institute on a trial that's testing this kind of digital telehealth type of approach versus traditional cardiac rehab.
So there's going to be, in the coming years, more evidence to further drive this field forward, but even now, there's a chance to really start exploring this and taking action to leverage what we know and have on the technology side already within your hospital or health system. So if you're interested in, or have questions, feel free to reach out and follow up. And really thankful for your time today, Jessie, Dr Golbus, for joining us and sharing your insights on this topic. And just thankful for your tremendous leadership on this science advisory from AHA.
Jessica Golbus:
Well, thanks so much for having me. It's been a pleasure to be able to chat with you about this topic that we both think is so important.
Seth Martin:
Thank you so much.
Speaker 1:
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