Abstract
This report describes Destination Rehab, a novel virtual world-based cardiac rehabilitation program, which aims to increase cardiac rehabilitation access to underserved populations. We highlight the experience of a cardiac patient whose successful participation in the program allowed her to overcome significant psychosocial and access barriers to cardiac rehabilitation.
Key Words: cardiac rehabilitation, cardiovascular disease, health disparities, secondary prevention, social determinants of health
Abbreviations and Acronyms: CBCR, center-based cardiac rehabilitation; CR, cardiac rehabilitation; CV, cardiovascular; VW, virtual world; VWCR, virtual world-based cardiac rehabilitation
Central Illustration
Cardiac rehabilitation (CR) is an essential component of secondary prevention for patients after major adverse cardiac events. It integrates core components such as medical evaluation, prescribed exercise, and cardiovascular (CV) risk factor modification to improve CV outcomes.1 Despite these known benefits, it remains underused globally.1 Efforts to establish alternative models to center-based cardiac rehabilitation (CBCR), such as home-based CR programs, are essential to increase CR participation and achieve CV health equity.
Learning Objectives
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To increase awareness of existing disparities in cardiac rehabilitation participation driven by patient-, provider-, and systems-level barriers to access.
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To describe an alternative home-based model for delivery of cardiac rehabilitation to increase access through innovative virtual world technology.
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To highlight the positive impact of a virtual world-based cardiac rehabilitation program from a patient perspective.
Cardiac patients are often burdened by numerous barriers to participation in CBCR. Sociodemographic factors such as race/ethnicity, sex, and socioeconomic status also have an impact on CR enrollment and participation.2 Specifically, women are approximately 41% less likely to enroll in CR compared to men. Additionally, racial/ethnic minority groups are approximately 37% less likely to enroll in CR than their White counterparts. These disparities are attributed to various factors, including lower referral rates, transportation, and out-of-pocket costs not covered by insurance.2 As a potential avenue to overcome barriers to participation and broaden access to CR, our team designed and implemented Destination Rehab, a novel CR program delivered via innovative virtual world (VW) technology on the Second Life platform.3
Destination Rehab Overview
Destination Rehab offered an alternative to CBCR in the VW by simulating in-person experiences through an online persona or avatar. The VW platform afforded participation in the comfort of one’s home or any preferred location with access to broadband internet access.3,4 The program components were developed with input from community-based cardiac patients to enhance end-user receptivity and relevance. The program was piloted to evaluate its feasibility, acceptability, and effects on CV health outcomes.5 Patients engaged in weekly CV health education sessions and group virtual tours by CR clinicians and staff (Table 1). Embedded support groups allowed for real-time interaction between patients to reflect on the virtual world-based cardiac rehabilitation (VWCR) experience and how they implemented healthy lifestyle practices to their everyday lives. The VWCR program garnered excellent recruitment, retention, and attendance, with 93% of patients attending ≥1 session and 71% attending ≥75% of sessions.5 Participation rates were particularly high among women: 84% of women attended each session. There were improvements in CV health behaviors and risk factors (eg, physical activity and weight).5 Participants provided overwhelmingly positive feedback regarding accessibility, convenience, and social connectivity.
Table 1.
Virtual World Cardiac Rehabilitation Education Session Topics
| Session | Topic |
|---|---|
| 1 | Anatomy and physiology of the heart |
| 2 | Managing heart disease risk factors |
| 3 | Stress management and heart disease |
| 4 | Cardiac medications |
| 5 | Sexuality and heart disease |
| 6 | High blood pressure |
| 7 | Fitness concepts and implementation strategies (including fitness center tour with exercise physiologist) |
| 8 | Dining out the healthy way (including interactive restaurant tour with dietician) |
| All | Weekly peer social support group |
Patient Experience with Destination Rehab
“I think first thing is, you’ve got to have a made-up mind that this is what you want to do. You want to change your way of living if you want to live. Because if your heart’s not working then you’re not going to live.” This quote is from Mrs W, an inspirational participant in the Destination Rehab program. Mrs W is a 76-year-old African-American woman with chronic systolic heart failure who enrolled in Destination Rehab after percutaneous coronary intervention. Herein, we describe her challenges to participating in CBCR and how Destination Rehab, coupled with her tenacity and determination, improved her CV health. Her story illustrates the potential for VWCR programs to expand CR access to underserved populations.
Mrs W was already experienced with CBCR after multiple prior myocardial infarctions but was confronted with several systemic barriers to participation. Most cumbersome was the financial burden of CBCR, citing a US$50 out-of-pocket cost per session despite having 2 insurance policies. She also noted that the nearest CBCR program was 45 minutes away from her home, which required her to travel 90 minutes by bus (US$4 fare per session). Given the financial stress and transportation burden of CBCR participation, she became frustrated and did not return. When approached by our study team about participating in Destination Rehab, she was reluctant, but excited to try something new.
Upon starting the program, she did not have broadband internet access or a personal computer at home. Determined to participate, she approached her church leadership to request their access to the internet and was provided a laptop computer by the study team. With support from her pastor, she brought her laptop to the church each week to engage in the sessions (Figure 1). This mitigated the cost burden and was an easier alternative to the long commute to the CBCR program. Given her minimal experience with computers and the internet, she received technical support from the study team to ensure that she would be comfortable with the technology and navigation in the VW platform. She also received assistance from family and fellow church members to connect to the platform for timely attendance at sessions. Demonstrating her dedication and perseverance, she noted, “I didn’t give up. I got on. I didn’t miss my classes. No. I enjoyed that. I really did.” She was initially awed by the platform, stating, “It was just like little people walking around and going into the library and going to the beach. And oh! I just couldn’t believe the things I was seeing. Sit down and having classes. They talked to you about your heart and stuff. It was just unreal.” She described learning about practical exercise tips and a healthy diet, and she felt that the program improved her quality of life.
Figure 1.
Virtual World-Based Cardiac Rehabilitation Platform
Mrs W (left) and her avatar (right) in the virtual world–based cardiac rehabilitation platform Destination Rehab during a peer support group session.
Mrs W also received excellent reports during her outpatient cardiology follow-up visits. Her cardiologist was impressed with her progress and informed the study team that he was certain the program facilitated her recovery and may have saved her life. She also recalled how the peer support group inspired her to change some health behaviors listening to other participants share their personal experiences in adopting healthier lifestyles (Videos 1 and 2). She was intrigued by the virtual sessions and asserted that she would eagerly join a similar program if one were to become available. Overall, she expressed that the program positively influenced her health and well-being.
Conclusions
Destination Rehab provided a platform for CR that mitigated many traditional barriers to participation while maintaining critical aspects of CBCR. The ease of participation reflected by excellent attendance rates demonstrates the potential scalability of Destination Rehab to reach under-resourced patients overwhelmed by barriers to CBCR access. Expanding broadband internet access to socioeconomically disadvantaged patients may help bridge the digital divide. Future studies should continue to assess the effectiveness of VWCR as an alternative approach to CBCR to improve CV outcomes for diverse patient populations, including those in resource-limited communities.
Funding Support and Author Disclosures
This study was supported by the Mayo Clinic Center for Innovation, Mayo Clinic Center for Translational Science Activities (UL1TR000135), Mayo Clinic Department of Cardiovascular Medicine, and Mayo Clinic Center for Health Equity and Community Engagement Research. Ms. Content has been supported by the Mayo Clinic Post-Baccalaureate Research Education Program (NIGMS 5R25GM075148-15) and Mayo Clinic Center for Regenerative Medicine and Michael S. and Mary Sue Shannon Foundation. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Acknowledgments
The authors thank the participants in the Destination Rehab Program, the staff for support, and all study team members for their assistance with the program through support of patient connectivity, lectures, support groups, and formative evaluation.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Mrs W’s Avatar Participating in a Peer Support Group
Mrs W’s Avatar Participating in a Peer Support Group
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Mrs W’s Avatar Participating in a Peer Support Group
Mrs W’s Avatar Participating in a Peer Support Group