Introduction
Coronary heart disease (CHD) affects over 2.3 million people in the UK.1 There is a very large cost to both the individual, in terms of loss of quality of life, and to society, in terms of healthcare costs and loss of productivity. It has been estimated that the cumulative cost of cardiovascular disease (CVD) to the UK economy is in the region of £30 billion annually,2 through direct service provision, lost productivity and informal care.3 The acute and ongoing management of individuals with CHD has been outlined in many national and international guidelines,4 and acknowledges the importance of cardiac rehabilitation (CR) in the care pathway of these individuals. CR is commonly a structured and supervised package of care that supports individuals with CHD to achieve their best possible levels of physical, psychological and social function.5–7
Many national and international guidelines on management of CHD acknowledge the importance of CR in the care pathway, including the National Institute for Health and Care Excellence (NICE) clinical guideline 172 on myocardial infarction (MI),8 94 on unstable angina and non-ST segment elevation MI9 and guideline 108 on chronic heart failure.10 The CVD outcomes strategy (2013) set an ambitious target for 65% of people discharged from hospital with a primary diagnosis of acute MI or a surgical revascularisation to be offered CR.11
Despite national guidance, the most recent National Audit of Cardiac Rehabilitation indicates that only 51% of eligible patients actually receive CR.12 There also appears to be unacceptable variation in uptake (30%–90%) across the UK, underpinned by complex reasons; some related to the organisation and system of delivery13 and others to patients’ individual choice. Factors related to rehabilitation non-attendance that have been identified comprised employment commitments, difficulties with transport, lack of time, distance to travel to rehabilitation and embarrassment related to attending rehabilitation.14–16 There appears to be some consensus around barriers that argue for the development of alternative formats and modes of rehabilitation delivery, so that access is broadened.17 Currently within practice, the ‘Heart Manual’18 and the ‘Angina Plan’19 are alternative paper-based home rehabilitation options, but are not widely delivered. Studies have shown that most patients with CHD who are still working would prefer a home-based CR programme.20 Interestingly, CR delivered either as a supervised or facilitated self-delivered programme has equivalent positive outcomes.21 The audit also identified that 33% of patients do not complete a CR programme and the most cited reason for attrition or failure to complete group-based CR is the need to have ‘return to work’.12
There is considerable interest in digital health as a means of delivering healthcare for individuals with long-term conditions, where a standard intervention is delivered in a way that is not geographically or time constrained. An increasing proportion of retired people are using the internet, reflecting the typical rehabilitation population. In the UK, 79% and 76% of men and women aged between 65 and 74 years respectively had used the internet within the previous 3 months.22 Among adults aged 75+ years, internet use increased from 19.9% to 40.5% from 2011 to 2017 (ie, 3% a year).22
Studies carried out across Europe and North America have investigated the efficacy of web-based interventions for those with heart disease.23–26 The largest was reported in 201226; however, it was not a comprehensive rehabilitation programme (as defined by the Department of Health’s commissioning pack27 and recruited participants with a broad range of CVDs). Reid et al 24 reported on a Canadian study which recruited exclusively people postprimary percutaneous coronary revascularisation (percutaneous coronary intervention (PCI) or angioplasty) who were offered a physical activity intervention that was web based. The paper reported a benefit in the intervention arm not observed in the control arm, suggesting the potential value of web-based interventions in this population. The Cochrane review of internet-based interventions for the secondary prevention of CHD, published in 2015, suggested that there was some evidence to support improvements in health-related quality of life and behaviour change, but there was insufficient evidence to draw firm conclusions.28
The University Hospitals of Leicester (UHL) NHS Trust has developed a web-based CR programme (‘ACTIVATE YOUR HEART’, www.activateyourheart.org.uk). This online programme was developed over a number of years, and has been tested in two small studies. The first was a pilot randomised controlled trial (RCT) in patients with angina managed exclusively in primary care.29 Encouragingly, the data demonstrated improvements in angina symptoms, objectively measured physical activity and levels of anxiety and depression, compared with the control group. A second single cohort observational study collected pilot data from patients attending CR at UHL, which identified significant improvements (p<0.05) in depression, exercise capacity and quality of life (n=106). Interestingly 65% of patients reported that they would not otherwise have attended CR.30 This has formed the basis of a case study on the NICE website (http://www.nice.org.uk/usingguidance/sharedlearningimplementingniceguidance/examplesofimplementation/eximpresults.jsp?o=718), encouraging the use and exploration of alternative forms of delivery.
The use of the internet permits greater flexibility of CR delivery, as patients are able to complete their programme at a place and time that suit them. It is also capable of reaching a wider population, especially those patients who live in rural areas.31 Studies have highlighted how web-based interventions can also help improve knowledge for patients with chronic health conditions.32 There may also be benefits to the service, releasing capacity for CR specialists to manage more complex patients in conventional hospital classes, as well as providing additional choice for those unwilling to do standard CR.33