==== Front JMIR Mhealth Uhealth JMIR Mhealth Uhealth JMU JMIR mHealth and uHealth 2291-5222 JMIR Publications Toronto, Canada v8i11e17957 33245286 10.2196/17957 Review Review Implementation of Telerehabilitation Interventions for the Self-Management of Cardiovascular Disease: Systematic Review Dias Casimiro Chen Si-Yu Olsen Sara Chappell Grant Subedi Narayan MPHhttps://orcid.org/0000-0002-8752-22441School of Exercise and Nutrition SciencesFaculty of HealthDeakin University221 Burwood HighwayBurwood VictoriaMelbourne, 3125Australia61 404745397nsubedi@deakin.edu.au Rawstorn Jonathan C PhD1https://orcid.org/0000-0002-9755-7993 Gao Lan PhD2https://orcid.org/0000-0001-9734-1140 Koorts Harriet PhD1https://orcid.org/0000-0003-1303-6064 Maddison Ralph PhD1https://orcid.org/0000-0001-8564-5518 1 School of Exercise and Nutrition Sciences Faculty of Health Deakin University Melbourne Australia 2 School of Health and Social Development Faculty of Health Deakin University Melbourne Australia Corresponding Author: Narayan Subedi nsubedi@deakin.edu.au 11 2020 27 11 2020 8 11 e1795723 1 2020 17 3 2020 2 7 2020 15 7 2020 ©Narayan Subedi, Jonathan C Rawstorn, Lan Gao, Harriet Koorts, Ralph Maddison. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 27.11.2020.2020This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information, a link to the original publication on http://mhealth.jmir.org/, as well as this copyright and license information must be included.Background Coronary heart disease (CHD) is a leading cause of disability and deaths worldwide. Secondary prevention, including cardiac rehabilitation (CR), is crucial to improve risk factors and to reduce disease burden and disability. Accessibility barriers contribute to underutilization of traditional center-based CR programs; therefore, alternative delivery models, including cardiac telerehabilitation (ie, delivery via mobile, smartphone, and/or web-based apps), have been tested. Experimental studies have shown cardiac telerehabilitation to be effective and cost-effective, but there is inadequate evidence about how to translate this research into routine clinical practice. Objective This systematic review aimed to synthesize research evaluating the effectiveness of implementing cardiac telerehabilitation interventions at scale in routine clinical practice, including factors underlying successful implementation processes, and experimental research evaluating implementation-related outcomes. Methods MEDLINE, Embase, PsycINFO, and Global Health databases were searched from 1990 through November 9, 2018, for studies evaluating the implementation of telerehabilitation for the self-management of CHD. Reference lists of included studies and relevant systematic reviews were hand searched to identify additional studies. Implementation outcomes of interest included acceptability, appropriateness, adoption, feasibility, fidelity, implementation cost, penetration, and sustainability. A narrative synthesis of results was carried out. Results No included studies evaluated the implementation of cardiac telerehabilitation in routine clinical practice. A total of 10 studies of 2250 participants evaluated implementation outcomes, including acceptability (8/10, 80%), appropriateness (9/10, 90%), adoption (6/10, 60%), feasibility (6/10, 60%), fidelity (7/10, 70%), and implementation cost (4/10, 40%), predominantly from the participant perspective. Cardiac telerehabilitation interventions had high acceptance among the majority of participants, but technical challenges such as reliable broadband internet connectivity can impact acceptability and feasibility. Many participants considered telerehabilitation to be an appropriate alternative CR delivery model, as it was convenient, flexible, and easy to access. Participants valued interactive intervention components, such as real-time exercise monitoring and feedback as well as individualized support. The penetration and sustainability of cardiac telerehabilitation, as well as the perspectives of CR practitioners and health care organizations, have received little attention in existing cardiac telerehabilitation research. Conclusions Experimental trials suggest that participants perceive cardiac telerehabilitation to be an acceptable and appropriate approach to improve the reach and utilization of CR, but pragmatic implementation studies are needed to understand how interventions can be sustainably translated from research into clinical practice. Addressing this gap could help realize the potential impact of telerehabilitation on CR accessibility and participation as well as person-centered, health, and economic outcomes. Trial Registration International Prospective Register of Systematic Reviews (PROSPERO) CRD42019124254; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=124254 heart diseasescardiac rehabilitationtelerehabilitationimplementation sciencesmartphonesystematic review ==== Body Introduction Cardiovascular diseases (CVDs) are a leading cause of clinical (ie, death and disability), health, and economic burden globally, accounting for approximately 31% (17.9 million) of total deaths each year [1-3]. Coronary heart disease (CHD), including myocardial infarction (MI) and angina, is the most common and burdensome form of CVD [4,5]. CHD accounts for a high proportion of all CVD deaths and more disability-adjusted life years than diseases such as cancer and diabetes [4-6]. Therefore, secondary prevention interventions that support CVD management are critical to reducing disease burden and health care expenditure. Cardiac rehabilitation (CR) is an essential component of secondary prevention for CHD that comprises coordinated, multifaceted interventions designed to improve physical, psychological, and social functioning [7-12]. CR includes medical evaluation, exercise prescription, cardiac risk factor modification, education, and counseling [13]. CR is safe, effective [14], and more cost-effective than no CR on overall health service expenditure [15-17]. Systematic reviews have shown that participation in center-based programs (ie, face-to-face delivery) reduces risks of hospital admissions and cardiac mortality, and improves health-related quality of life [14,18]. Despite these benefits, uptake and adherence of center-based CR are suboptimal [19-21]. Reasons for this are multifaceted [22-26], but accessibility-related factors, such as limited availability of programs, transportation, and parking, are prominent [22,24-28]. For these reasons, home-based delivery models have been tested to improve access and participation outside of clinical settings [29]. Home-based CR, which typically includes print resources, home visits, and/or telephone calls, has been shown to be as effective as center-based programs for improving health-related quality of life, CVD risk factors, and mortality [30]. However, few CR services offer home-based options (eg, less than one-quarter in the United Kingdom, United States, and Australia [30,31]). In addition, home-based programs are typically unable to provide the level of supervision, individualized coaching, and feedback from CR professionals that is common in center-based programs. Therefore, alternative delivery models that combine the accessibility of home-based programs with the comprehensive support of center-based CR are needed. The use of information and communication technologies (ICTs) to connect participants and CR professionals, which is termed cardiac telerehabilitation [32], has been investigated as an alternative. Systematic reviews have demonstrated the effectiveness of cardiac telerehabilitation for improving cardiovascular risk factors and health-related quality of life [33-37]. However, early telerehabilitation interventions were mostly limited to telephone counseling, which limits the types of rehabilitation support that can be provided [38]. Technological innovations including mobile phones, particularly smartphones, and mobile broadband [39,40] have enabled more flexible cardiac telerehabilitation interventions [36,41-43]. Recent studies using cutting-edge technologies, such as smartphones, mobile apps, and the internet, have demonstrated that cardiac telerehabilitation can deliver more comprehensive services [44], including individualized real-time exercise monitoring and coaching, similar to center-based programs [45]. Growing evidence indicates telerehabilitation could substantially broaden the benefits and impact of CR; however, most interventions have only been evaluated in controlled experimental settings (eg, [41-45]). There is little evidence to guide the successful, scalable, sustainable translation of telerehabilitation into real-world settings [46-48]; that is, there is a lack of studies that have tested telerehabilitation interventions when delivered by health care staff in routine clinical practice. Real-world implementation of an intervention is contextually dependent, influenced by individual (ie, personal characteristics), organizational (ie, hospital or service organization), community (ie, local government), and system-level (ie, government) factors, all of which are difficult to control in experimental designs [49]. Many public health interventions fail to be adopted or are less likely to be scaled and sustained when delivered in real-world settings, and the complexities and challenges involved in real-world implementation and scale-up are partly responsible for this lack of translational success [50]. A greater understanding of factors related to the implementation of interventions in practice settings is imperative for increasing population-level impact [51]. The purpose of this review was to synthesize research evaluating the implementation of cardiac telerehabilitation interventions when delivered in routine clinical practice. Methods Registration This review was registered in PROSPERO (International Prospective Register of Systematic Reviews) (CRD42019124254) before screening search results, and was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement [52,53]. Information Sources and Search Strategy Electronic databases—MEDLINE, Embase, PsycINFO, and Global Health—were searched between January 1990 and November 9, 2018, for studies that combined three concepts: telehealth, CVD, and implementation science. The search strategy was created for MEDLINE and modified for the other databases (see Multimedia Appendix 1). Eligibility and Study Selection Eligible studies were those that evaluated the implementation of cardiac telerehabilitation in routine clinical practice or assessed implementation outcomes of interest in experimental studies, including randomized and nonrandomized designs, among adults (aged ≥18 years) with CHD (ie, MI, angina, and coronary revascularization). Cardiac telerehabilitation interventions were defined as those with at least 50% of the program delivered via ICT, including any mobile phone (ie, feature phone or smartphone), web-based platforms, or wireless devices such as sensors. Implementation in routine clinical practice was defined as interventions delivered as part of existing CR services, without significant ongoing input from a research team. Experimental studies were included as we anticipated few studies examining real-world implementation, and experimental studies provide the next best available evidence to advance the field; eligibility was not limited to randomized controlled trials (RCTs) to allow the inclusion of translational studies that used alternative study designs. In addition to other criteria, eligible experimental studies were those that assessed constructs defined in a taxonomy of key constructs related to the effective implementation of evidence-based interventions, including acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability [54]. To acknowledge the importance of multiple stakeholder levels in successful implementation projects [55,56] and to meet the aims of this review, we assessed these constructs at the consumer (ie, participant), individual provider (ie, CR practitioner), and provider (ie, health care organization or institution) levels [54]. Constructs were defined as follows: Acceptability: satisfaction among implementation stakeholders with different aspects of the intervention, such as content, delivery, and complexity. Stakeholders included health care consumers, practitioners, and health care organization operational staff who participated in, delivered, and oversaw the provision of CR services, respectively. Adoption: rates of uptake or utilization of the intervention at the practitioner and/or health care organization level. Appropriateness: program suitability or compatibility at the health care consumer, practitioner, and/or health care organization level. Feasibility: practicability of the intervention for everyday use at the practitioner and/or health care organization level. Fidelity: delivery of the intervention as designed. Implementation cost: assessments of marginal cost, cost-effectiveness, or cost benefit. Penetration: the degree to which the intervention was institutionalized within health care organizations. Sustainability: continued delivery of the intervention beyond the study period, as well as characteristics of the implementation context that did or could influence the continuation of intervention delivery [54]. Feasibility and pilot studies were excluded from this review. To meet the aims of this review, it was important to include only interventions that had already undergone preliminary testing for feasibility and were considered by their respective authors as feasible for testing in the trial or delivery in practice. Conference abstracts, nonhuman studies, non-English-language papers, and grey literature were also excluded. Systematic reviews and study protocols were not eligible for inclusion; however, relevant systematic reviews were searched for eligible studies and cited where appropriate, and results articles were sought for relevant study protocols. Search results were exported to a reference manager, EndNote X8 (Clarivate), for duplicate removal, then transferred to Rayyan (Qatar Computing Research Institute) for screening [57]. Records were assessed by NS, verified by JR and HK, and underwent full-text review if the title or abstract identified the specified population and intervention components. Data Extraction Data describing eligibility, study design, participant and intervention characteristics, risk of bias, and outcomes of interest were extracted by NS using a standardized electronic form and verified by JR. Risk-of-Bias Assessment Risks of selection, performance, detection, attrition, reporting, and other biases in included experimental studies were assessed using the Cochrane risk-of-bias tool [58]. Risks of bias in nonrandomized cohort studies were assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies [59]. Risks of bias were assessed by NS and verified by JR. When available, risk-of-bias assessments were augmented with study protocols and clinical trial registrations. Data Synthesis A narrative synthesis of the data was carried out in this review. Results Study Selection In total, 2044 unique study reports were screened. From these, 21 underwent full-text review; 16 reports describing 10 studies (2250 participants in total) met the eligibility criteria and were included in the narrative synthesis [41-45,60-64]. Study selection is summarized in Figure 1. Figure 1 Summary of study selection process using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart. Characteristics of Included Studies Included studies were published between 2013 and 2018; studies were conducted in developed countries, including New Zealand [42,43,45], Australia [41,44], Canada [61], the Netherlands [60], Poland [63], and the United States [62]. One multi-country study was carried out in Spain, Germany, and the United Kingdom [64]. No eligible studies were identified that evaluated the effectiveness of the implementation of cardiac telerehabilitation in routine clinical practice. Of the 10 included studies, 9 (90%) used randomized controlled experimental designs [41-45,60-62,64], while 1 (10%) used an uncontrolled pre-post intervention design [63]. The mean age of study participants ranged from 55 to 65 years, and most participants were male (72%-93%). All studies recruited participants via hospitals or community-based CR centers. Detailed characteristics of the included studies (ie, study design, treatments, and primary and implementation outcomes) are presented in Multimedia Appendix 2. Cardiac Telerehabilitation Intervention Characteristics Out of 10 studies, 3 interventions (30%) were delivered using a mobile phone, smartphone, or web-based platform alone [41,61,62], while remaining interventions used combinations of web-based content, mobile phones or smartphones, and sensors. The most commonly targeted lifestyle risk factors were physical activity, diet, tobacco smoking, and medication adherence. Intervention duration ranged from 30 days [62] to 24 weeks [41-43] (see Multimedia Appendix 2). Most interventions (6/10, 60%) comprised a messaging component (eg, SMS or push notifications) [41,43-45,61,62] to educate or motivate participants to improve self-management behaviors. Out of 10 interventions, 7 (70%) enabled communication between providers and participants via a web-based program, mobile phone or smartphone, and/or telephone [42,44,45,60,61,63,64]. Out of 10 interventions, 6 (60%) included exercise monitoring [42,44,45,60,63,64], including 2 (20%) that provided live guidance [64] or real-time monitoring and coaching during exercise [45]. Out of 10 studies, 5 (50%) delivered telerehabilitation in combination with usual care (ie, center- or community-based CR) [41-43,45,60], 4 (40%) delivered cardiac telerehabilitation alone [44,61,62,64], and 1 (10%) delivered a hybrid intervention comprising center-based and telerehabilitation components [63] (see Multimedia Appendix 2). Risk of Bias in the Included Studies The quality of the included studies in the review varied (see Multimedia Appendix 2). Risk of bias was judged to be low in 6 out of 10 (60%) experimental studies [41-43,45,60,61] and high in 3 (30%) studies [44,62,64]. High risk of bias was judged due to incomplete outcome data and lack of blinding of participants and outcomes. The single nonrandomized study (1/10, 10%) had a high risk of bias due to lack of a control group, not identifying confounding factors, and inadequate reporting of follow-up time [63]. Implementation Outcomes Overview Included studies reported between three and six implementation outcomes. Appropriateness, acceptability, fidelity, adoption and feasibility, were assessed in 9 (90%), 8 (80%), 7 (70%), and 6 (60%), of the 10 studies, respectively; cost of intervention was assessed in only 4 (40%) studies, and penetration and sustainability were not assessed. Outcomes were predominantly assessed from a participant perspective, rather than from individual provider (ie, practitioner) or organizational perspectives. Implementation outcome findings are summarized below, with supporting data provided in Table 1 [41-45,60-71]. Table 1 Implementation outcomes for telerehabilitation interventions. Study author, year, and implementation construct Implementation outcomes Chow, 2015 [41,65] Acceptability SMS intervention acceptability was 90.9% (279/307); request to stop SMS was 2.3% (7/307) Adoption Focus groups reported high user engagement with saving and sharing SMS messages, receiving support from providers and family, and message personalization Appropriateness SMS was useful: 90.9% (279/307) SMS was easy to understand: 96.7% (297/307) SMS was motivating for change: 77.2% (237/307); especially for diet (249/307, 81.1%), exercise (223/307, 72.6%), and medication adherence (234/307,76.2%) Appropriateness of language used in SMS: 94.8% (291/307) Appropriateness of SMS frequency (4 times/week): 86.0% (264/307); timing : 89.9% (276/307, random timing was considered ideal); and 6-month duration: 77.2% (237/307) Feasibility Not assessed Fidelity 96.0% (338/352) of participants received all scheduled messages (analytic data) and read ≥75% of SMS messages: 95.4% (293/307 self-report survey respondents) Implementation cost US $0.10/SMS message (