Using mHealth interventions to promote cardiovascular health

To the Editor:

Cardiovascular disease remains the leading cause of morbidity and mortality worldwide [1, 2]. It is therefore critical to identify innovative means of delivering care for patients with, or at risk for, heart disease. Mobile health (mHealth) interventions, including mobile applications and text messaging interventions (TMIs), utilize wireless devices to prevent, monitor, and treat medical conditions, and may represent an important innovation in of heart disease management [3]. mHealth interventions allow content (e.g., medication reminders, behavioral programs) to be delivered on demand, anytime and anywhere, to users, and these programs are available to an increasingly broad segment of the population. Indeed, over 95% of American adults own cellular phones, more than three-quarters own smartphones able to execute downloaded applications [4], and two-thirds of the world’s population own a mobile device [5]. Furthermore, many are eager to use their devices to help manage their health, with up to half of American smartphone owners having downloaded at least one health-related application [6]. TMIs are another, and the most researched [7], mode of mHealth intervention. TMIs may be particularly appealing given that they are low cost, do not require a smartphone, still hold the capacity to be personalized, and are broadly accessible [8, 9].

There is a growing literature on mHealth interventions in patients with existing heart disease [10]. They have been used to assist in monitoring key metrics and symptoms in patients with chronic heart disease such as heart failure [11]. Such programs often use mHealth technology as part of a monitoring system that allows direct transmission of important variables (e.g., blood pressure/weight) to health care teams in an effort to reduce decompensation and hospitalizations. Likewise, mobile applications to deliver cardiac rehabilitation are being developed and tested for those who have existing heart disease but cannot attend in-person rehabilitation programs [12]. Such applications may increase the reach of cardiac rehabilitation programs and increase individuals’ control over the timing, intensity, and duration of their use [13]. TMIs have also been used for remote cardiac rehabilitation and to provide self-management information in cardiac patients, with promising effects [14-16]. Overall, a systematic review of TMIs for health improvement and behavior change found that TMIs were effective on targeted outcomes/behaviors (mean effect size d=.33 [95% confidence interval .27-.39]; p<.001) but that studies were limited in terms of size, duration, and quality [8].

Along with providing benefit to those with existing heart disease, mHealth self-management interventions may also be helpful in prevention. Such programs have been used to modify cardiac risk factors, such as assisting with medication adherence in hypertension [17] and weight loss in overweight adults [18]. Furthermore, given the serious effects of psychological factors on prognosis in patients with heart disease, mHealth interventions focusing on mental health, either by helping to reduce distress or promote well-being [e.g., 19, 20, 21], also have the potential to provide cardiovascular benefits.

Given the potential benefits of these programs, funding agencies, such as the National Institutes of Health in the U.S., are increasingly interested in the development and testing of mHealth interventions to improve self-management of chronic conditions such as cardiovascular disease [22] and to more effectively and cheaply deliver health interventions to underserved populations [23] and low- and middle-income countries [24].

Despite the substantial excitement surrounding these mHealth interventions, it is important to critically evaluate their safety and impact. Data protection is of utmost importance, and though encrypted, firewalled, HIPPA-compliant text delivery systems exist, regulations around mHealth interventions (including mobile applications) are uneven. Furthermore, uniform HIPAA protection may not apply to personal health data in all contexts, raising important privacy concerns [25, 26]. There is an additional issue of mHealth interventions that appear to come from healthcare providers or to provide health benefits but may be driven by commercial interests.

In terms of impact, there are many existing mobile applications related to cardiovascular health promotion that have minimal or no evidence for their effectiveness [7]. Even among formally studied mHealth interventions, most studies have not yet shown an impact on major health outcomes [27, 28]. Also, though mHealth programs have the benefit of greater ease and reach, they do not have provide the benefits of a personal connection, and mHealth interventions should be part of an overall communication strategy between health providers and patients. Optimization of these treatments will likely be a slow, steady, iterative process, and will clearly require careful and critical evaluations in terms of efficacy, safety, and cost-effectiveness that neither stifle innovation nor jump too quickly to implement programs that are not yet effective.