Transcript Technological Tools and Their Application in the Practice of

I Simposio de Rehabilitacion Cardiovascular
Fundacion Cardiovascular
Dr. Jorge Kaplan Meyer
Nuevas Direcciones en Rehabilitacion
Cardiovascular
Carmen M. Terzic M.D., Ph.D.
Profesor y Jefe Departamento de Medicina Fisica y
Rehabilitacion
Co-Director Rehabilitacion Cardiovascular
Mayo Clinic, Rochester, MN, USA
Cardiac rehab requires investment in space,
equipment, and personnel.
Programs may charge > $100 USD
per patient hour to recovery these costs.
Cardiac Rehab Participation Rates US
• Rates of 13 - 41% for men and 7 - 22% for
women reported in various regional and
national surveys (1)
• Wide range of participation rates (2-4)
• States: 7% (Idaho) to 56% (Nebraska)
• Centers: Higher performers, 70-85%
(1) Suaya. Circulation 2007 Oct 9;116(15):1653-62.
(2) Pack. Circulation 2013 Aug 6;128(6):590-7
(3) Goel. Circulation 2011 May 31;123(21):2344-52
(4) Grace. Arch Intern Med 2011;171(3):235-241.
Comparison:
Minnesota
Population = 5,457,000
Number of Centers = 131
Density = 0.04 million/center
All South America
Population = 374,741,346
Number of Centers = 160
Density = 2.3 million/center
Cortes-Bergoderi M et al. J Cardiopulm Rehabil Prev 2013;33:33-41
Worldwide Mobile Ecosystem
Smartphones, mobile PCs, tablets, and
mobile routers with cellular connection
750 million
mobile PCs, tablets, and
mobile router subscriptions
5.6 billion
smartphone subscriptions
Mobile PCs, tablets, and
mobile router subscriptions
Smartphone subscriptions
November 2013 Ericsson Mobility Report 7
Worldwide Smartphone Use
www.eMarketer.com
Smartphone App Use
Our Mobile Planet by Google
Preventive Cardiology Perspective on Apps
Track Your Workout
Eating Right
Healthy Habits
Preventive Cardiology Perspective on Apps
Diabetes
Blood Pressure Monitoring
Smoking Cessation
Smartphone App Use
• As of July 2014
• Apple App Store
• More than 1,350,000 unique apps available
• More than 85 billion downloads to date
• Google Play
• More than 1,300,000 apps available
• “Health and Fitness” category
• ~37,000 unique apps available for download (Apple Only)
• By 2016  44 billion apps downloaded (Apple and Android)
• ~6 apps downloaded for every person in the world!
West J. et al. J Med Internet Res. 2012;14(3):e72.
STATISTA: http://www.statista.com/statistics/270291/popular-categories-in-the-app-store/
Behavior Change and Mobile Technology
Do Apps/Devices Improve Health?
• Systematic review of 26 unique
studies examining the use of
based devices to improve
pedometer
Reduced BMI
factors blood pressure
risk
Reduced
• xInterventions
ranged
from 4 weeks to
No change in
cholesterol
26 weeks
• Populations included:
• Healthy active
• Sedentary
• Hypertension
• COPD
• MI patients
• Neuromuscular disease
• Diabetes
• Pre- and Post-menopausal
• Known CAD
 Increased physical activity (+2491 steps/day)
Bravata DM et al. JAMA. 2007;298(19):2298-2304.
Do Apps/Devices Improve Health?
• Systematic review of 9 studies that
examined the use of pedometer
based devices to increase physical
activity
• Interventions ranged from 4 weeks
to 52 weeks
• Populations included:
• Diabetes
• AA breast cancer survivors
• Overweight/Obese
 Increased physical activity (+3249 steps/day)
• Sedentary
• Hypertension
 Decreased body weight (-1.4 kg (3.14 lbs))
• Pre- and Post menopausal
Richardson CR et al. Ann Fam Med. 2008;6:69-77.
What about Video Games?
AKA – “Exergames”
What about Video Games?
Not just for kids anymore…
Virtual exercise studios?
Importance of Promoting Physical Activity
after ACS
• International survey of 15,486 patients from 39
countries
• Surveyed
average
of 53 months
after MI
The
answer
is cardiac
rehabilitation
• 46% of patients reported decreased activity
• 34% of patients reported increased activity
• 20% of patients reported unchanged activity
Editorial:
Changing medical culture to promote physical activity in
secondary prevention of coronary artery disease
Thomas G. Allison, PhD, MPH
Stewart R et al. European Heart Journal (2013) 34, 3286–3293
Geographic Distribution of Physical Activity
Post-MI
Stewart R et al. European Heart Journal (2013) 34, 3286–3293
Electronic Patches (‘Smart Skin’)
• Stick-on electronic patch for health
monitoring
• “Smart Skin” microfluidic
construction bends/flexes with skin
• Stretchable Li-ion battery
• Reversible biaxial stretchability up to
300% with stable power output
• Current capabilities:
•
•
•
•
•
ECG
EEG
Temperature
Motion (accelerometry)
Wireless data transmission
University of Illinois at Urbana-Champaign / Northwestern University
Bodyguardian – Preventice
• FDA approved wireless
biometric skin sensor
•
•
•
•
•
ECG
Heart rate variability
Respiratory rate
Activity level
Body position
• Wireless data transmission
• Detects, records, and
transmits clinical grade
measurements
• Developed in conjunction
with a scaleable wireless
network platform for remote
patient monitoring
“Smart” Contact Lens?
iBGStar
• Blood glucose meter plug-in
for iPhone
• Free iBGCStar Diabetes
Manager app which tracks:
• Blood glucose
• Carbohydrate intake
• Insulin dose
What about cholesterol?
Cardiac Rehabilitation
New Models
• Do not require expensive centers
• Patients do not need to travel to center
• Home-based CR – connected to providers
• Someone is on the other end listening
• Can create virtual classes through Skype
• Mobile technology CR – self-contained
• All feedback is built into the application
Care Assessment Platform
Smartphone-based Cardiac Rehabilitation
Heart 20;100:1770-7914
The Design
• Secondary
Prevention
• PatientCentered:
•
•
Cardiac
Rehabilitation
Patients
Monitoring
Feedback
Daily Tasks and
Educational
Material
The Feasibility Design
Patients s/p
PCI for ACS
Three Months
Mayo Clinic CR
Usual Mayo
Clinic CR
(n=19)
Usual Mayo
Clinic CR plus
DHI-enhanced
CR (n=25)
After Three
Months Mayo
Clinic CR
Usual PostCR Care
(n=11)
Usual Post-CR
Care plus DHI
Intervention
(n=15)
Results – Risk Factor Reduction during CR
15
CR+DHI
CR Alone
10
Exercise
Capacity (ml
O2/kg/min)
5
0
-5
-10
Diet Score
BMI (kg/m2)
*
*
Weight, kg
Dartmouth
QOL
-15
-20
*
Systolic Blood
Pressure
(mmHg)
15
10
5
Post CR+DHI
Post CR
Weight, kg
Systolic
Blood
Pressure
(mmHg)
0
-5
-10
*
-15
-20
*
Widmer, RJ, et al. CATR. 2015
Proportion Rehospitalized/ED Visit
Results – Reduction in Re-hospitalizations/
ED Visits
*
*
During CR + DHI
Post CR + DHI
During CR - DHI
Post CR - DHI
Log-Rank *p<0.05
Time to Event (days)
Widmer, RJ, et al. CATR. 2015
Risk Score Assessment
Social Network
eLearning Programs
Remote Monitoring: Devices
Dashboard
Patient list
Novel Cardiac Rehabilitation Delivery
Advantages
• Large percentage of population has access to
remote technology (smart phone or tablet)
• Generally good coverage
• Low cost delivery
• 7 days per week, 24 hour per day access
• Standardization of processes
• Mass customization
Novel Cardiac Rehabilitation Delivery
Challenges
• Development (proceeding rapidly) versus
validation (way behind)
• Long-term adherence and impact not proven
• Financial model/reimbursement not established
Cardiovascular Rehabilitation
Paradigm Shift
No CR
“Home” CR
Traditional CR
Current Paradigm
No CR
”Home” CR
Traditional CR
Future Paradigm
Cardiovascular Rehabilitation
Paradigm Shift
No CR
New Model of
CR Delivery
Future-Future Paradigm
“There will never be another generation that does
not know about the internet”
– Bill Gates
• Preguntas
Novel Cardiac Rehabilitation Delivery
Mobile Technology-based Cardiac Rehabilitation
• Evolution of technology tools
• Pedometers
• Internet based tools
• Physiologic measurement tools
• Smart phone based tools
Care Assessment Platform
Smartphone-based Cardiac Rehabilitation
Heart 20;100:1770-7914
5 Emerging Insights into
Cardiovascular Rehabilitation
1. Cardiac rehabilitation (CR) is standard of care
2. CR is an asset for readmission prevention
3. Standard CR cannot meet current demands
4. New models of CR delivery are here
5. CR can be applied to non-CV patient groups
Cardiac Rehabilitation
Non-CV Groups
• Transplant
• (Heart, Heart-Lung)
• Transplant Proc 2007 Nov;39(9):2776-7. (Kidney)
• Transplant Proc 2011 Oct;43(8):3021-4. (Liver)
• CKD
•
•
•
•
J Am Soc Hephol 2006;17:1175-80.
Eur J Prev Cardiol 2014 Sep;21(9):1125-33.
Am Heart J 2005 Dec;150(6):1140-6.
J Ren Care 2010 May;36 Suppl 1:154-62.
• Cancer:
• J Cancer Surviv 2010;4:87–100.
• Curr Sports Med Rep 2009 Jul-Aug;8(4):176-81.
Putting it All Together
Disease Prevention
Disease Management
Self Care
Wellness & Fitness
Healthcare
Information
Safety Reminders
Medical Reminders
Lifestyle Monitoring
Telecoaching
Assisted Living Apps
Social Care
Health Care
Medicine
Adherence
Moderated
Support Groups
Supported
Discharge
Personal Alarms
Chronic Disease
Management
Dementia Monitoring
(GPS/Location Services)
Professional,
Supported Care
Vital Sign
Monitoring
Overview
• Scope of the mobile health (mHealth) ecosystem
– Focus on smartphone applications (Apps)
• The role of mobile apps in Behavior Change
• Health / Fitness Gadgets and Games
• What’s next?
Worldwide Smartphone Use
Our Mobile Planet by Google
Overview
• Scope of the mobile health (mHealth) ecosystem
– Focus on smartphone applications (Apps)
• The role of mobile apps in Behavior Change
• Health / Fitness Gadgets and Games
• What’s next?
Role of Apps in Behavior Change
Predisposing Factors
– Knowledge / Information
– Beliefs / Attitudes / Values
– Confidence or Motivation
Enabling Factors
– Teaching a Skill
– Providing a Service
– Tracking Behavior
Behavior
Change
Reinforcing Factors
– Social Network
– Encouragement / Coaching
– Self Evaluation
West JH et al. J Med Internet Res. 2012;14(3):e72.
Role of Apps in Behavior Change
90%
Predisposing
Enabling
Reinforcing
80%
70%
60%
50%
40%
30%
3,336 apps reviewed for the
potential to influence behavior
change based on the PrecedeProceed Model (PPM)
20%
10%
0%
Only 1.86% apps included all 3 factors!
West JH et al. J Med Internet Res. 2012;14(3):e72.
Do Apps/Devices Improve Health?
-2.9 (6.4)
-4.6 (10.1)
-2.0 (4.4)
-2.9 (6.4)
-1.3 (2.9)
-1.3 (2.9)
-1.1
-0.8
-0.5
-0.5
• 6 month RCT examining
-1.6
-1.1
efficacy of Smartphone App for
weight loss
-0.9
-0.7
• 128 participants randomized
to
-1.2
-0.9
3 groups
• Smartphone app
• Website
support
Need
to convert
this data
• Paper diary
-0.3
-0.4
to a bar graph
Carter MC et al. M Med Internet Res. 2013;15(4):e32.
Role of Apps in Behavior Change
• Theory-based interventions have been shown to be
effective in changing behavior
• Unfortunately, most current apps do not include or
only partially include theoretical constructs
• Important to recognize limitations of apps in
generating desired outcomes
• Be realistic about expectations for behavior change
Overview
• Scope of the mobile health (mHealth) ecosystem
– Focus on smartphone applications (Apps)
• The role of mobile apps in Behavior Change
• Health / Fitness Gadgets and Games
• What’s next?
Jawbone – Upmove / UP24 / UP3
(www.jawbone.com)
Cost
$129.99
Up24
Distance Steps
 Yes
 Yes
Stairs
Calories
Sleep
Heart
Rate
X
 Yes
 Yes
 Yes Wireless sync
(barcode
scanner &
nutrition
database)
App/Online
to mobile
Up3 only device or
computer
“UP” program
Instant
Feedback
X
Fitbit –
(www.fitbit.com)
Cost
Distance Steps
$129.99  Yes
Charge
 Yes
Stairs
Calories
Sleep
Heart
Rate
X
 Yes
 Yes
 Yes Wireless sync
(barcode
scanner &
nutrition
database)
App/Online
to mobile
Up3 only device or
computer
“UP” program
Instant
Feedback
X
Withings – Pulse O2
(www.withings.com)
Cost
$119.95
Distance Steps
 Yes
Stairs
Calories
Sleep
 Yes  Yes With partner  Yes
app
Heart
Rate
App/Online
 Yes Wireless sync
to Withings
Fitness Ecosystem with
multiple
partners
Instant
Feedback
Onscreen
Do Apps/Devices Improve Health?
• Systematic review of 26 unique
studies examining the use of
based devices to improve
pedometer
Reduced BMI
factors blood pressure
risk
Reduced
• xInterventions
ranged
from 4 weeks to
No change in
cholesterol
26 weeks
• Populations included:
• Healthy active
• Sedentary
• Hypertension
• COPD
• MI patients
• Neuromuscular disease
• Diabetes
• Pre- and Post-menopausal
• Known CAD
 Increased physical activity (+2491 steps/day)
Bravata DM et al. JAMA. 2007;298(19):2298-2304.
Do Apps/Devices Improve Health?
• Systematic review of 9 studies that
examined the use of pedometer
based devices to increase physical
activity
• Interventions ranged from 4 weeks
to 52 weeks
• Populations included:
• Diabetes
• AA breast cancer survivors
• Overweight/Obese
 Increased physical activity (+3249 steps/day)
• Sedentary
• Hypertension
 Decreased body weight (-1.4 kg (3.14 lbs))
• Pre- and Post menopausal
Richardson CR et al. Ann Fam Med. 2008;6:69-77.
Overview
• Scope of the mobile health (mHealth) ecosystem
– Focus on smartphone applications (Apps)
• The role of mobile apps in Behavior Change
• Health / Fitness Gadgets and Games
• What’s next?
“Some people will sit down and ask, ‘what is it?’
but others ask, ‘what can I do with it?’
– Steve Jobs
Stay Current with New Technologies
• www.active.com
• www.pcmag.com
• www.digitaltrends.com
Take Home Message
• New Apps / Devices / Gadgets are coming out all the
time – the patient needs to find what works for them
(and actually use it!)
• Accuracy of “fitness” gadgets can have a large +/-.
− Best when used to identify long-term trends in behavior change
within an individual
• Be realistic about expectations for behavior change
• In general, the App / Device / Gadget should be:
1.
2.
3.
Easy to use
Provide timely feedback
Stimulate motivation (stimulate behavior change!)
Technological Tool and Their Application in
Preventive Cardiology:
Smartphone Apps, Gadgets, Video Games, and More…
Thomas P. Olson, PhD
[email protected]
“There will never be another generation that does
not know about the internet”
– Bill Gates
Behavior Change and Mobile Technology
Role of Apps in Behavior Change
• Effectiveness will depend on:
1.
2.
3.
4.
5.
6.
Ability to stimulate motivation
Ease of use
Engagement of social network
Feedback
Frequency of use
Information content
Cowan LT et al. Health Ed Behav. 2012;40(2):133-139.
Are Fitness Gadgets Accurate?
Lee JM et al. Health Fit J. 2014;18(4):16-21.
Nike+ - Fuel Band
Cost
$99.00
Distance Steps
 Yes
 Yes
Stairs
Calories
Sleep
Heart
Rate
X
 Yes
X
X
App/Online
Instant
Feedback
Wireless sync Lights show
progress for
to mobile
NikeFuel goal
device or
computer Nikeplus
Shine
Misfitwearables
Cost
$119.95
Distance Steps
X
 Yes
Stairs
Calories
Sleep
Heart
Rate
X
 Yes
 Yes
X
App/Online
Instant
Feedback
Wireless sync Tap to see
with Shine app lights showing
progress
towards goal
What about Video Games?
Sony PlayStation Move
Fastest growing iOS and Android Markets
by Active Devices (%)
xxxxxxxxxx
xxxxxx
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Outcomes in Cardiac Rehabilitation
1996 AHCPR Guidelines
1. Smoking cessation
2. Lipid management
3. Weight control
4. Blood pressure control
5. Improved exercise tolerance
6. Symptom control
7. Return to work
8. Psychological well-being/stress management
Meeting Risk Factor Goals
How Cardiac Rehabilitation Can Promote
Secondary Prevention
• Patient education
• Diet, exercise, smoking, weight control
• Partner with physicians
• Check-list of medications
• Feedback on blood pressure at sessions
• Review lipid tests with patients
• Review home blood sugar and blood
pressure records
What about Video Games?
Microsoft Kinect (Xbox 360)
What about Video Games?
Nintendo Wii