Heart Disease and Stroke Prevention: Mobile Health (mHealth) Interventions for Treatment Adherence among Newly Diagnosed Patients
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) recommends mobile health (mHealth) interventions to improve treatment adherence among patients recently diagnosed with cardiovascular disease. Included studies showed improvements in medication adherence, outpatient follow-up, and adherence to self-management goals.
The full CPSTF Finding and Rationale Statement and supporting documents for Heart Disease and Stroke Prevention: Mobile Health (mHealth) Interventions for Treatment Adherence among Newly Diagnosed Patients are available in The Community Guide Collection on CDC Stacks.
Intervention
mHealth interventions for treatment adherence use mobile devices to deliver self-management guidance to patients who have been recently diagnosed with cardiovascular disease.
Content must be accessible through mobile-phones, smartphones, or other hand-held devices. Interventions must include one or more of the following:
- Text-messages that provide information or encouragement for treatment adherence
- Text-message reminders for medications, appointments, or treatment goals
- Web-based content that can be viewed on mobile devices
- Applications (apps) developed or selected for the intervention with goal-setting, reminder functions, or both
Interventions also may include the following:
- An interactive component (i.e., patients enter personal data or make choices) that gives patients personally relevant, tailored information and feedback
- Mobile communication or direct contact with a healthcare provider
- Web-based content to supplement text-message interventions
About The Systematic Review
The CPSTF uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision-makers with additional, effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to cardiovascular disease prevention.
Gandhi S, Chen S, Hong L, Sun K, Gong E, Li C, et al. Effect of mobile health interventions on the secondary prevention of cardiovascular disease: systematic review and meta-analysis. Canadian Journal of Cardiology 2017; 33:219-31.
The systematic review and meta-analysis included 27 randomized controlled trials (search period through January 2016). The CPSTF finding is based on results from the published review, additional information from the subset of studies, and expert input from team members and the CPSTF.
Study Characteristics
Following are characteristics of studies from the subset of 12 studies from high-income countries.
- Studies were of short duration (median 6 months).
- Interventions used mobile phones (10 studies) or smartphones (2 studies).
- Studies provided web-based content that was accessible through smartphones (2 studies) or served as a supplement to text messages (2 studies).
- Studies used text messages for information or motivation (4 studies), as reminders (4 studies), or both (2 studies).
- Mobile content was tailored based on patient inputs (2 studies), or personalized without patient inputs (4 studies).
- Three studies offered contact or appropriate follow-up with a healthcare provider.
- Studies were conducted in the United States (4 studies), Australia (2 studies), New Zealand (2 studies), Norway (1 study), Spain (1 study), France (1 study), and Canada (1 study).
- All 12 of the subset studies (and 25 of the 27 studies in the full meta-analysis) were conducted among patients with a recent diagnosis of cardiovascular disease.
- Patients were recruited at the time of initial hospitalization (6 studies), or when they were referred to an outpatient cardiac rehabilitation program (6 studies).
Summary of Results
The systematic review and meta-analysis included 27 studies.
- Adherence to medications improved significantly (9 studies).
- Adherence to treatment (i.e., one or more medications, clinical care follow-up, or risk factor management recommendations) improved significantly (15 studies).
- Conclusions about intervention effects on additional outcomes related to changes for cardiovascular disease risk factors (i.e., blood pressure, lipids, smoking cessation), morbidity, and mortality were limited by the small numbers of studies and mixed, or inconsistent, results.
The CPSTF examined results from a subset of 12 trials conducted in high-income countries.
- Adherence to medications improved significantly (3 studies).
- Adherence to treatment (i.e., one or more medications, clinical care follow-up, or risk factor management recommendations) improved significantly (6 studies).
- Two additional studies reported improvements in medication adherence using objective measures (1 study) or self-reported outcomes (1 study). A third study reported improvements in treatment adherence.
Summary of Economic Evidence
A systematic review of economic evidence has not been conducted.
Applicability
While additional research is warranted, the CPSTF finding is likely applicable to the use of these interventions in U.S. healthcare settings for adults recently diagnosed with cardiovascular disease.
Evidence Gaps
Gandhi et al. suggested additional research and evaluation be completed to answer the following questions and fill existing gaps in the evidence base.
- Are interventions based on smartphone apps more or less effective than interventions based on text messaging?
- Are mobile health interventions effective when used for older patients (>65 years), who may have less familiarity with mobile devices and content?
- Are mobile health interventions, especially smartphones, effective for patients of lower socioeconomic status, given potential limitations in access to data or current technologies?
The CPSTF further identified the following evidence gaps as areas for future research (What are evidence gaps?):
- Do studies that use objective measures report outcomes equal to or greater than studies that use self-reported data?
- Are interventions effective in helping patients adhere to medications and self-management goals over longer periods of time (1-2 years)?
- Are interventions effective in reducing morbidity, mortality, and healthcare use associated with cardiovascular disease?
- What factors influence intervention effectiveness?
- Use with or without in-person counseling or contact?
- Patients’ sex, race, ethnicity, or socioeconomic status?
- Length of time since cardiovascular disease diagnosis?
- Use of current smartphone capabilities such as access to social support?
Implementation Considerations and Resources
- Given the range of adherence demands on patients at this time (new treatment regimens, appointments for follow-up and rehabilitation, and adoption of new lifestyle and self-management goals) mobile health interventions may be most useful and effective during the initial management period of patients with a new diagnosis.
- Improved adherence might reduce the number of in-person clinical care appointments needed to achieve control of cardiovascular disease risk factors.
- Text messages may be a source of distraction for patients engaged in other activities.
- The rapid evolution of mobile device technology is likely to provide newer studies with opportunities for substantially enhanced or personalized message content and interactivity.
- Neubeck et al. (2015) provides a useful review of smartphone apps used to prevent and manage cardiovascular disease. The review describes intervention characteristics associated with patient uptake including credible, sourced, clear, and concise messaging, and personalized content with feedback, rewards, and positive reinforcement.
- The Million Hearts Initiative includes tools and resources to help organize health system and public health improvement strategies for prevention and management of cardiovascular disease risk factors.
- Implementers should understand state policies regarding application of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to electronic communications with patients.
Crosswalks
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.