Outcomes of a smartphone-based application with live health-coaching post-percutaneous coronary intervention

Abstract

Background: The interval between inpatient hospitalization for symptomatic coronary artery disease (CAD) and post-discharge office consultation is a vulnerable period for adverse events.

Methods: Content was customized on a smartphone app-based platform for hospitalized patients receiving percutaneous coronary intervention (PCI) which included education, tracking, reminders and live health coaches. We conducted a single-arm open-label pilot study of the app at two academic medical centers in a single health system, with subjects enrolled 02/2018-05/2019 and 1:3 propensity-matched historical controls from 01/2015-12/2017. To evaluate feasibility and efficacy, we assessed 30-day hospital readmission (primary), outpatient cardiovascular follow-up, and cardiac rehabilitation (CR) enrollment as recorded in the health system. Outcomes were assessed by Cox Proportional Hazards model.

Findings: 118 of 324 eligible (36·4%) 21-85 year-old patients who underwent PCI for symptomatic CAD who owned a smartphone or tablet enrolled. Mean age was 62.5 (9·7) years, 87 (73·7%) were male, 40 of 118 (33·9%) had type 2 diabetes mellitus, 68 (57·6%) enrolled underwent PCI for MI and 59 (50·0%) had previously known CAD; demographics were similar among matched historical controls. No significant difference existed in all-cause readmission within 30 days (8·5% app vs 9·6% control, ARR -1.1% absolute difference, 95% CI -7·1-4·8, p = 0·699) or 90 days (16·1% app vs 19·5% control, p = 0.394). Rates of both 90-day CR enrollment (HR 1·99, 95% CI 1·30-3·06) and 1-month cardiovascular follow up (HR 1·83, 95% CI 1·43-2·34) were greater with the app. Weekly engagement at 30- and 90-days, as measured by percentage of weeks with at least one day of completion of tasks, was mean (SD) 73·5% (33·9%) and 63·5% (40·3%). Spearman correlation analyses indicated similar engagement across age, sex, and cardiovascular risk factors.

Interpretations: A post-PCI smartphone app with live health coaches yielded similarly high engagement across demographics and safely increased attendance in cardiac rehabilitation. Larger prospective randomized controlled trials are necessary to test whether this app improves cardiovascular outcomes following PCI.

Funding: National Institutes of Health, Boston Scientific.

Clinical trial registration: NCT03416920 (https://ichgcp.net/clinical-trials-registry/NCT03416920).

Keywords: Apps; Digital health; Outcomes; Smartphone.

Conflict of interest statement

Declaration of Competing Interest The study was supported by an investigator-initiated grant to P.N. from Boston Scientific. The sponsor had no role in the design of this study, and did not have a role in the execution, analyses, interpretation of the data, or decision to submit results for publication; however, company representatives were permitted to review and comment on the manuscript prior to submission. P.N. also reports investigator-initiated grants from Apple, Amgen, AstraZeneca, and Novartis; he is a scientific advisor to Apple, Genentech, Novartis, AstraZeneca, Forsite Labs and Blackstone Life Sciences, and he reports spousal employment and equity in Vertex. S.W. reports grants from Amgen, Arena, AstraZeneca, Bristol Myers Squibb, Daiichi Sankyo, Eisai, Eli Lilly, Janssen, Merck and Sanofi-Aventis and consulting fees from ARENA, AstraZeneca, Aegerion, Allergan, Angelmed, Boehringer-Ingelheim, Boston Clinical Research Institute, Bristol Myers Squibb, Daiichi Sankyo, Eisai, Eli Lilly, Icon Clinical, Janssen, Lexicon, Merck, Servier, St Jude Medical, and Xoma. S.W. also reports personal membership in the TIMI Study Group which receives institutional research grant support through Brigham and Women's Hospital as well as spousal employment in Merck.

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Figures

Fig. 1

Weekly app engagement. Patients’ interaction with the app decreased gradually over time but the overall rate was stable amongst patients who engaged early (within first 30 days). Engagement peaked at 4.35 days in the first week and gradually decreased to 2.73 days by the last week of the study period. (Engagement = a day with completion of at least one task; Week = 7-day period starting from enrollment).

Fig. 2

A smartphone app and longitudinal cardiovascular care. (a) Two-fold increase in attendance of cardiac rehabilitation intake and (b) two-fold increase in 1-month outpatient cardiovascular follow up in the intervention group. Error bars represent confidence intervals. (MGB = Mass General Brigham).

Fig. 3

Use of a smartphone app and readmission rates post-PCI. No significant difference in (a) all-cause readmissions or (b) cardiovascular readmission to MGB facilities at either 30- or 90-days post-PCI. Error bars represent confidence interval.