A Systematic Review of Personalized Health Applications through Human–Computer Interactions (HCI) on Cardiovascular Health Optimization

Abstract

Abstract

Introduction: Currently, the deployment of human–computer interactive technologies to provide personalized care has grown and immensely taken shape in most healthcare settings. With the increasing growth of the internet and technology, personalized health interventions including smartphones, associated apps, and other interventions demonstrate prowess in various health fields, including cardiovascular management. This systematic review thus examines the effectiveness of various human–computer interactions technologies through telehealth (mainly eHealth) towards optimizing the outcomes in cardiovascular treatment. Methods: A comprehensive search of MEDLINE, EMBASE, and CINAHL databases using key terms was conducted from 2000 to November 2021 to identify suitable studies that explored the use of human–computer interaction technologies to provide a personalized care approach to facilitate bolstered outcomes for cardiovascular patients, including the elderly. The included studies were assessed for quality and risk of bias, and the authors undertook a data extraction task. Results: Ten studies describing the use of a mix of personalized health app (mHealth) interventions were identified and included in the study. Among the included studies, nine of them were randomized trials. All of the studies demonstrated the effectiveness of various personalized health interventions in maximizing the benefits of cardiovascular disease treatment. Conclusions: Personalized health application interventions through precision medicine has great potential to boost cardiovascular disease management outcomes, including rehabilitation. Fundamentally, since each intervention’s focus might differ based on the disease and outcome preference, it is recommended that more research be done to tailor the interventions to specific disease and patient outcome expectations.

1. Introduction

Over time, progress on eradicating cardiovascular disease has been ascertained through various approaches, including adopting lifestyle modifications, such as modifications in diet, tobacco smoking, physical exercise, and other evidence-based therapies, proposed to modify recognizable and common at-risk phenotypes of cardiovascular complications [1]. Despite traces of success, the prevention and cure of various cardiovascular health conditions remain elusive, presumably due to the imprecise deep phenotyping of patients, which would be vital in characterizing the disease subgroups. Given the statistics, the magnitude of cardiovascular health issues is devastating. It remains the leading cause of deaths and mortalities globally, accounting for approximately 32% of the total global deaths, likely to hit 23.6 million deaths by 2030 [2]. Owing to the growing concern, medicine and public health have witnessed a radical change that has seen the introduction of various human–computer interactions inventions to support personalized health, also known as precision medicine, to optimize cardiovascular health outcomes. The human–computer interaction (HCI) is any form of user-centered design technology that provides insight into usefulness, usability, and fit of technology into daily human life [3]. Precision medicine is an integrative approach to vascular disease management confined to personalized human genetics, lifestyle, and exposures in determining disease phenotypes, thus overcoming the limitation of reductionism medicine, which assumes that all patients with similar disease signs exhibit common pathophenotypes and therefore should be treated similarly. According to scientists, cardiovascular disease complications have continued to rise due to poor medication adherence and persistence, increasing re-hospitalization, morbidity, and mortality [4]. To this course, the personalized health applications approach is ideally the solution. The most common human–computer interaction technologies widely applied are the mHealth technology [5], which has interestingly been associated with improving treatment adherence and persistence through behavioral interventions. Although there is no standard definition, mHealth has also been referred to as a part of electronic health (eHealth), telemedicine, and telehealth, ideally supported by mobile devices such as patient monitoring devices, mobile phones, personal digital assistants, and wireless devices [5].

One fundamental reason for the increased incorporation of these personalized health applications is their portability, instant access to information, and various cost-effective models for chronic disease [6]. For the patients, Evans and colleagues identify that the telehealth apps have proved effective in the self-management of the disease, giving every individual the capacity to manage the symptoms and treatment, alongside physical and psychological consequences and lifestyle changes associated with living with this disease condition [7]. For instance, the elderly with cardiac health issues could benefit from empowerment by engaging in physical exercise to minimize cardiac arrest, encouragement to quit smoking, maintain a diet, and even watching their weight.

Previous reviews have summarized various impacts of mHealth as a tool for improving treatment adherence for chronic condition patients like stroke, obstructive pulmonary disease, and diabetes. A recent review of observational studies and controlled trials attributed to the importance of mHealth technology in facilitating medication adherence for chronic disease cases. However, a robust study is still needed to support the evidence on the effectiveness of the various HCI applied. Besides, a meta-analysis study of randomized controlled trials demonstrates the impact of mobile phone text messaging as one effective way of actualizing precision medicine for this case. To this knowledge, although literature exists, there is still a need for higher quality evidence for the applicability of mHealth in personalized healthcare delivery. Thus, this systematic review is conducted to fill the literature gap on the effectiveness of various personalized health applications through technology to maximize cardiovascular health outcomes. It reviews various types of mHealth tools applicable for both patients and care providers to maximize medication adherence and management of the cardiovascular disease.

2. Methods

2.1. Search Strategy

Initially, a data search was done on available literature from high-quality medical online libraries like PubMed (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus (EMBASE). The medical subject headings (MeSH) were used to identify the key terms. Under “cardiovascular disease and telehealth’ the search generated 53 sources with the guidance of the MeSH list for MEDLINE. The search string ‘telehealth’ AND ‘cardiovascular disease’ was used for PubMed, and similar MeSH terms were used to generate sources in CINAHL. For EMBASE, Boolean operator terms like ‘telemedicine, telehealth, OR telecardiology, OR personalized care, OR personal medication or cardiovascular diseases were all applied.

2.2. Study Selection

Two investigators reviewed the titles and abstracts of the selected study. Data collection was done by one of the authors (JAM) and then rechecked and evaluated by the other (SQ) to confirm accuracy. The two investigators then screened the studies through full-text analysis to arrive at the final decision, and reasons for exclusion were recorded.

Inclusion and Exclusion Criteria

The inclusion criteria were based on the following article characteristics: articles published in English, published between 2011 and 2021, and completed randomized controlled trials on patients with cardiovascular issues that assessed the impact of mHealth telehealth interventions on adherence to cardiovascular disease treatment.

The exclusion criteria involved studies that were not RCTs or with control groups, abstract only articles, articles published before 2000, and non-English publications, as well as studies that had irrelevant information on telemedicine or did not mention anything close to mHealth or personal health applications interventions on cardiovascular disease treatment.

2.3. Data Extraction and Analysis

Full-text articles relevant for inclusion were retrieved and independently screened by the authors. The irrelevant records that did not meet the inclusion criteria were excluded, and a full-text analysis of the relevant results was done to finalize appropriate studies. The following information was retrieved from the included studies and analyzed: first author, publication year, study design, participant sample size, intervention tool, and outcome measurements. The various health applications were considered effective if they reported statistically significant health behavioral changes and outcomes.

2.4. Risk of Bias

The risk of bias assessment for the articles included was done by the authors using a modified version of the Scottish Intercollegiate Guidelines Network (SIGN) checklist for the randomized controlled trials [8]. The checklist was used to grade the evidence levels of each study. The evaluation items were divided into seven categories as listed: random sequence generation (selection bias), allocation concealment (selection bias), blinding of participants (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting, and other bias. Each of the domains was classified as having low, moderate, high, or unclear risk.

3. Results

3.1. Study Selection Process

The literature search resulted in 527 records from the databases. Then, 340 documents were excluded due to duplication in the initial screening. The remaining 187 were screened for title and abstract, leaving only 77 for full-text review. In the end, 67 records were excluded, and only the remaining 10 that met the inclusion criteria were considered. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart of the study selection process is presented in Figure 1 below [9].

3.2. Characteristics of Included Studies

The key characteristics of the studies included are summarized in Table 1. All the included studies except one (n = 9) were randomized controlled trials, with the exception being a survey. The studies were studies published between 2011 and 2021. Two of the studies were conducted in the U.S.A [10,11] and two in Finland [12,13], and the rest we conducted per region including India [14], Belgium [15], China [16], Spain [17], China and India [18] combined, and finally the Kaiser Permanente health plan regions (Northwest, Hawaii, and Georgia) [19]. The longest study duration was 12 months. Two studies had a larger sample size (n = more than 1000). Four studies had a medium participants population (between 100 and 999), while the rest had a smaller number of participants. All the included studies had a higher retention rate of 80 to 100%. Of the 10 included studies in this systematic review, the critical theme items relating to health behaviors include physical activity, dietary change, adherence to medication therapy, and other significant study attributes.

3.3. Risk of Bias of the Included Study

The methodological quality of the 10 included studies was evaluated using the SIGN checklist framework, and results were summarized using the risk of bias table of the RevMan 5.4 software. The risk of bias assessment results is depicted in the figure below (Figure 2). Overall, the methodological quality of the included studies was moderate. Even if very few studies reported a low risk of bias, most of the studies showed a high risk of bias in more than two categories. Some studies failed to provide enough information necessary to enable a complete assessment of their risk of bias (unclear risk of bias). Besides, blinding for the participants was also difficult to conduct in some studies.

3.4. Thematic Synthesis of Results

3.4.1. Telehealth (mHealth App) Interventions

The interventions were categorized by the actual personalized health applications, the duration for intervention, and the app functioning, either educating, reminding, or monitoring. The intervention period varied between 12 weeks and 12 months. In monitoring, mHealth apps used varied methods of data sharing and feedback. The input data included body weight, step count, physical activity, blood pressure/systolic blood pressure, quality of life, medication intake and adherence, diet, and smoking status. The feedback types included automatic feedback generated by the intervention applications, data center algorithms, or healthcare providers via telephone, short messages service, or physical presence. On education, the contents included disease information, various measurement methods, medication and dietary measures, exercising, and any other relevant lifestyle patterns, which were tailored via SMS, written forms, or internet platforms. The reminders also focused on monitoring, medication, and lifestyle modification delivered through the apps, SMS, or cellphone calls.

3.4.2. Effectiveness of App Interventions

The telehealth interventions’ effectiveness was evaluated based on behavioral, physiological, and psychological outcomes. The studies also measured the acceptance and user satisfaction levels of the HCI devices applied. On the physiological outcomes, three studies reported objective physical activity levels. Mobile-based mHealth interventions were compared with the usual care, amongst which the studies demonstrated a significant outcome between the intervention and control groups. There were different tools used to measure physical activity for these studies. One study used the 6-minute walk test, [13] an abridged 12-item version of the Intrinsic Motivation Inventory [12], and daily step count [10]. For instance, Martin et al. [10] observed that the population that received text message reminders walked close to 2534 daily steps more than those who did not get the text messages reminders (95% CI: 1318–3750; p < 0.001). Similarly, Frederix et al. [15] reported in the intervention group a significant increase of the daily steps from the baseline to week 6 and week 24 of the follow-up, unlike in the control group, where there was a decline after the six weeks of follow-up. On the outcomes on anxiety levels, smoking cessation, quality of life, and medication adherence, the study by Blasco et al. [17] found no significant difference between the control and intervention groups. However, the study reported a significant improvement in cardiovascular risk profiling in the telemonitoring group than the control group.

Nonetheless, a study by Vollar et al. [19] reporting medication adherence reported a significant change regarding medication reminders. In particular, patients subjected to automated phone calls showered a lower nonadherence rate. The IVR+ and IVR interventions increased adherence to statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers than the usual care. Similarly, McGillicuddy et al.’s [11] study on medication adherence showed great improvement. For example, compared to the standard care control group, the mHealth intervention group exhibited significant improvements in medication adherence and significant reductions in clinic-measured systolic blood pressures across the monthly evaluations. On the other hand, Fang et al. [16], also showed the significance of mHealth interventions towards medication adherence. According to his studies, the results reported that the SMS and SMS + ML groups had better cumulative adherence than the phone group. Hence, short message service and messaging applications, such as Micro Letter (ML), are effective means of providing discharged patients with reminders and coronary artery disease-related health information.

Again, for the quality-of-life outcomes, a study by Frederix et al. [15] reported that participants in the intervention group depicted a significant improvement in their physical subscale of the perceived health-related quality life from the baseline to the end of the study period (calculation by Friedman’s test; U = 2407, Z = 2.805, p = 0.01). Additionally, Tian et al. [18] also assessed the quality of life associated with the effectiveness of mHealth intervention. The study aimed at establishing the effectiveness of a simplified cardiovascular management program in improving the care and clinical outcomes of patients. According to the study results, compared with the control group, the intervention group had a 25.5% (p < 0.001) higher net increase in the primary outcome of the proportion of patient-reported antihypertensive medication use pre-and post-intervention. Two other studies also assessed the user satisfaction and acceptance of the mHealth apps and devices, owing to their effectiveness in CVD treatment. Studies by Feinberg et al. [14] showed higher approval to the interventions. Based on the study results, 92% were willing to receive mHealth advice, 94% favored mobile medication reminders, and 70.3% and 73% preferred voice calls over short messaging service (SMS) for delivering health information and medication reminders, respectively. The other study by McGillicuddy et al. [11] also showed the acceptability and feasibility of the mHealth systems. For instance, based on the studies, results showed a significant adherence to the mHealth prototype technology on the management of systolic blood pressure, accrediting its use by both patients and physicians.

4. Discussion and Conclusions

4.1. Discussion

In this systematic review, we attempted to explore various ways through which personalized health applications through human–computer interactions positively optimize the outcomes of cardiovascular disease medication. Personalized care is a person-specific treatment approach tailored to the particular patient’s characteristics, such as epigenetic, microbiome, genome, and lifestyle characteristics, among others, whose complexity can be captured in the medicine network to improve treatment outcomes based on personal preference [20]. Thus, this article analyzes the effectiveness of various human–computer interaction mechanisms (mobile-app-based and internet technology-based mechanisms) that are used to provide personalized care to boost the medication outcomes for cardiovascular patients. The application functions were monitoring, reminding, or educating on cardiovascular disease management. Integrating technology to interface with personalized patient approaches and outcomes through human–computer interaction platforms like telehealth, eHealth, or mHealth is currently a significant clinical research initiative. This attaches to the ubiquity of the precision technological interfaces with multiple capabilities of bolstering cardiovascular health outcomes. For instance, health app technologies and smartphones have shown the potential to make healthcare delivery more personalized, better, affordable, and accessible, and mHealth is in this light as illustrated by the outcomes of included studies.

Characteristics of the included studies showered that most of the interventions used short messages service with a personalized text message content approach towards a positive result to health outcomes of smoking cessation, medication adherence, and physical activity improvement. Generally, studies indicated that SMS as a mHealth tool was very effective in improving the outcomes of cardiovascular disease treatments programs for such patients [21]. Other than SMS, mobile applications also provided significant functions towards improving personalized health outcomes of CVD patients. For the records, Urrea et al. [22], for instance, supported those mobile applications can significantly help collect and analyze real-time data and offer interactivity, gaming, and feedback. In line with other studies indicating that the design of the HCI apps on cardiovascular disease management should be based on behavioral change and cater to such individuals’ needs [23]. The effectiveness of HCI programs was evaluated on the impact of the various interventions on health outcomes of the coronary disease patient outcomes within multiple levels like physical activity, cardiovascular risk factors, psychological health status, and clinical events. Some studies also used questionnaires in evaluating medication adherence.

Precisely for this review, studies have immensely demonstrated how human–computer interactions have been used to optimize healthcare through telemedicine through various applications. Dominantly, mHealth has been used in various interventions, with the support of other devices like mobile smartphones or iPhones. The apps on multiple occasions have been used to propel medication reminders through SMS and voice calls. Some of the mHealth interventions even included smartphone games as a model to facilitate behavioral change to motivate physical activity for enhanced cardiovascular disease treatment outcomes. In one particular study, Paldán et al. [13] discussed one of the mHealth mobile intervention software (TrackPAD) called TENALEA used to motivate and monitor walking through step counting to enhance the quality of life of peripheral arterial disease patients. The other technology-based tools like the Interactive voice recognition calls (IVR regular and IVR advanced) used in conjunction with EMR were also discussed. Its potential to boost adherence to chronic disease medication was highlighted.

Nevertheless, the findings from the included studies highlight various ways through which personalized health applications on cardiac rehabilitation have benefited cardiovascular disease patients, including the elderly. Cardiac rehabilitation encompasses multiple measures to provide cardiac patients with optimized physical and psychological support to prevent the disease from progressing to fatality. Across the population, cardiac rehabilitation is achieved through three main measures that include psychological interventions, physical activity (exercise), and lifestyle modification. In this connection, a study conducted by Heran et al. [24] analyzing 47 randomized studies on exercise-based cardiac rehabilitation and usual care found that exercise-based cardiac rehabilitation generally reduced cardiovascular morbidity and mortality (RR 0.87 (95% CI 0.75, 0.99) and 0.74 (95% CI 0.63, 0.87) as well as hospital admission rates (RR 0.69 (95% CI 0.51, 0.93)). Supportive studies also asserted that clinic and home-based forms of cardiac rehabilitation proved effective for clinical and health-related quality of life outcomes with heart failure [25]. Regarding exercise training or physical activity, Pollock et al. [26] attributed to the importance of resistance training in cardiac rehabilitation. Resistance exercise is training as stretching and flexibility activities focused on improving muscular endurance and strength.

Additionally, patients with atrial fibrillation (AF) showed positive effects through a regular and moderate physical training exercises. Cardiac rehabilitation has also been linked with a reduction of time in arrhythmia of patients diagnosed with persistent atrial fibrillation. Segev et al. also reported the positive impacts of coordinated exercise training for improved outcomes in the elderly with cardiovascular disease conditions. Based on the results in the intervention group, 70% of patients adhered to the program, with significant improvement post-intervention in the Timed Up and Go (p  <  0.01) and the Balance Error Scoring System (p  <  0.05) tests. In the control group, no changes were made. Hence, the study recommended that cardiac rehabilitation include training and other routine cardiac rehabilitation programs to realize better health outcomes for elderly patients diagnosed with cardiovascular disease. Thus, from a general perspective, the renowned advantages of personalized health applications on cardiac rehabilitation in elderly patients include medication adherence, which forms an essential part of the treatment and prevention of cardiovascular diseases.

Personalized health application has been used to bolster capacities of attaining solutions for medication adherence to maximize cardiovascular health outcomes. The other advantage is smoking cessation, mainly achieved through cognitive-behavioral and pharmacological digital interventions. Again, for the elderly, diabetes management is an added advantage attached to precision healthcare. According to Mathur and colleagues, glycemic management has been identified as significant for risk control in cardiovascular prevention for people with diabetes mellitus, especially the elderly [27]. To mention, there has already been a tremendous evolution in the usage of continuous glucose monitoring through subcutaneous glucose sensors, smart insulin pens, automatic pumps, and decision support systems. Related to the same parameters is the advantage of weight loss management. According to scientists, weight gain or obesity is strongly attached to cardiovascular health conditions, including heart failure and arteriosclerosis [28]. Thus, guidelines on cardiovascular treatment and prevention signify the potential of weight loss in overweight patients. This is ascertained through lifestyle changes like physical activity and a healthy diet.

4.2. Limitations

There were some notable limitations of this systematic review. One major limitation of the study is the inclusion of studies with relatively smaller sample size and a limited follow-up time, making their inclusion less impactful and highly reliable in determining the effectiveness of personalized health apps (mHealth) in cardiovascular medicine. Another limitation was that the article was biased towards randomized studies, which implied that most of the studies consulted were RCTs except one. This meant that the study focused on theoretical evidence to assess the impacts of personalized health applications while ignoring the potentials of other evidence provided with other sources.

5. Conclusions

This systematic review highlights the impacts of personalized health applications through human–computer interaction attributes to maximize positive outcomes for cardiovascular disease patients. The overall findings of this review point out the potential importance of telehealth or telemedicine, or mHealth technologies, in care management for CVD patients. It also provides evidence to cardiovascular care when these personalized health apps are deployed. Thus, it attributes to the world’s understanding of the importance of technologies, especially in improving the overall care delivery system. This study therefore is summarized by suggesting a futuristic development for the provision of medication through human–computer-based interfaces, alongside training for both the patients (elderly) and the caregivers, to enhance cardiovascular health treatment and management.

Author Contributions

Both the authors S.Q. and J.A.M. contributed equally in the literature review and writing and drafting the manuscript. S.Q. is responsible for fund acquisition. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not Applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures and Table

Figure 1. PRISMA TABLE.

Figure 2. Risk of bias graph; (Red Circles indicating High Risk of Bias, while Green Circles Indicate Low Risk of bias).

Table 1

Characteristics of included studies.

Author & Year	Country	Study Design	No. of Participants	Intervention	Follow up Duration	Measurement Methods	Results/Outcomes	Limitations	Conclusion
Feinberg et al., 2017	India	Survey	262	mHealth (mobile phone use in healthcare)	NA	IBM-SPSS version 20 was used for data analysis. Kolmogorov–Smirnov tests were used to identify variable normality. Relevant variables with statistical significance of p < 0.10 were identified using Chi-square tests for categorical covariates, Kruskal–Wallis test for non-continuously distributed covariates, and independent sample t-tests for continuously distributed covariates. Logistic regression was used to investigate the relationship between these variables and mobile phone usage characteristics. A p-value ≤0.05 was considered statistically significant.	92% were willing to receive mHealth advice;94% favored mobile medication reminders;70.3% and 73% preferred voice calls over short messaging service (SMS) for delivering health information and medication reminders, respectively. 85.9% would send home recorded information on their blood pressure, weight, medication use, and lifestyle to a doctor.	Over-presentation of high economic status in the sample affected generalizability for other population sectors.Study also used convenience sampling and a limited sample size that affect its generalizability to represent the whole population.	Majority of the population approved the use of mHealth interventions, with preference of further investigation on mHealth use as educational tool to manage cardiovascular disease
Höchsmann et al., 2019	Finland	RCT	36 (45–70 years)	mHealth app (smartphone game as a behavioral change technique)	24 weeks	Intrinsic physical activity (PA) motivation was assessed with an abridged 12-item version of the Intrinsic Motivation Inventory (IMI) before and after the intervention.Adherence to the game-proposed PA recommendations during the intervention period was assessed in the intervention group via the phone-recorded game usage data	Intrinsic PA motivation (IMI total score) increased significantly in the intervention group (+6.4 (SD 4.2; p < 0.001) points) while it decreased by 1.9 (SD 16.5; p = 0.623) points in the control group.The usage data revealed that participants in the intervention group used the game for an average of 131.1 (SD 48.7) minutes of in-game walking and for an average of 15.3 (SD 24.6) minutes of strength training per week, implying a significant positive association between total in-game training (min) and change in IMI total score (beta = 0.0028; 95% CI 0.0007–0.0049; p = 0.01).	The study lacked an objective measure of records of any additional physical activity (PA) beyond phone recorded PA. These periods without phone wear likely led to an underestimation of unknown magnitude of the true number of daily steps.	Study shows that a novel smartphone exergame that incorporates established motivational elements and personalized PA recommendations in the storyline can generate significant increases in intrinsic PA motivation in inactive individuals with type 2 diabetes
Paldán et al., 2021	Finland	RCT	46	mHealth app (mobile intervention software-TrackPAD)	3 months	The distance covered in the 6-minute walking test using the TENALEA software.The PAD-related peripheral arterial disease quality of life (PAD-QoL) was assessed by the PAD-QoL questionnaire at baseline and follow-up.	The intervention group (n = 19) increased their mean 6-min walking distance (83 m, SD 72.2), while the control group (n = 20) decreased their mean distance after 3 months of follow-up (–38.8 m, SD 53.7; p = 0.01). The peripheral arterial disease–related quality of life increased significantly in terms of “symptom perception” and “limitations in physical functioning.” Users’ feedback showed increased motivation and a changed attitude toward performing supervised exercise training.	There were weaknesses of the general gestural concept resulting from advanced age of the user groups who are inexperienced in using mHealth. Since the study designed a platform for both iOS and Android, some technical issues occurred due to the different technical implementations of the provider.	The mobile intervention TrackPAD was linked to a change in prognosis-relevant outcome measures combined with enhanced coping with the disease
Vollmer et al., 2014	Kaiser Permanente health plan regions (Northwest, Hawaii and Georgia)	RCT	21,752 (above 40 years)	Interactive voice recognition calls (IVR regular and IVR advanced).IVR participants received automated phone calls when they were due or overdue for a refill. IVR+ participants received these phone calls, plus personalized reminder letters, live outreach calls, EMR-based feedback to their primary care providers, and additional mailed materials.	12 months	A modified version of the Proportion of Days Covered (PDC) was used to measure medication adherence as the primary measure.EMR was used to capture age, race, gender, and healthcare utilization for diabetes and CVD, as well as BP and lipid levels.	IVR+ and IVR interventions increased adherence to statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) compared with usual care (1.6 to 3.7 percentage points).Adherence to ACEIs/ARBs was also significantly higher for IVR+ relative to IVR participants.Among statin users, IVR+ participants had significantly lower low-density lipoprotein (LDL) levels at follow-up compared with UC (Δ = −1.5; 95% CI, −2.7 to −0.2 mg/dL); this effect was seen mainly in those with baseline LDL levels >100 mg/dL (Δ = −3.6; 95% CI, −5.9 to −1.3 mg/dL).	A substantial number of participants were never reached by phone, thus diluting delivery and potentially the effectiveness of the IVR intervention. Indeed, the IVR+ intervention was designed largely in recognition of this limitation, although the incremental effect of the added IVR+ components was also small/	Technology-based tools, in conjunction with an EMR, can improve adherence to chronic disease medications and measured cardiovascular disease risk factors.
Fang & Li, 2016	China	RCT	280 outpatients, including 200 men (71.42%) and 80 women (28.58%) ranging in age from 38 to 69 years.	mHealth technologies (short message service, short message service + Micro Letter, and phone).	6 months	Study used the four-item dichotomous Morisky Medication Adherence Scale (MMAS) to assess drug compliance.	Results showed that the SMS and SMS + ML groups had better cumulative adherence (lower MMAS scores) after six months compared to the phone group. The SMS + ML group had better cumulative adherence (lower MMAS scores) after six months compared to the SMS group.	Study limitations are that it required access to a cellular data network, literacy, and the ability to use a smart phone.	Short message service and messaging applications, such as Micro Letter, are effective means of providing discharged patients with reminders and coronary artery disease-related health information. Implementation of a short message service + Micro Letter program can improve outpatient adherence to medication.The use of smart-phone communication technologies increased adherence to medications in patients with CAD.
Frederix et al., 2015	Belgium	RCT	140 (intervention group; n = 70) or to conventional cardiac rehabilitation alone (control group; n = 70)	Internet based, patient-tailored telerehabilitation program with short message service (SMS)	24 weeks	The primary outcome measure was peak aerobic capacity (VO2 peak), measured during maximal cardiopulmonary exercise testing with breath-by-breath gas exchange analysis at baseline and after 6 and 24 weeks (Jaeger MS-CPX).	Mean aerobic capacity increased significantly in intervention group patients (n = 69) from baseline (mean 22.46, SD 0.78 mL/[min*kg]) to 24 weeks (mean 24.46, SD 1.00 mL/[min*kg], p < 0.01) versus control group patients (n = 70), who did not change significantly (baseline: mean 22.72, SD 0.74 mL/[min*kg]; 24 weeks: mean 22.15, SD 0.77 mL/[min*kg], p = 0.09). Between-group analysis of aerobic capacity confirmed a significant difference between the intervention group and control group in favor of the intervention group (p < 0.001). At 24 weeks, self-reported physical activity improved more in the intervention group compared to the control group (p = 0.01) as did the global HRQL score (p = 0.01).	The telerehab was designed to recruit broad cardiac patient population but ended up with minority of patient participants, thus reducing the generalizability of the findings for the chronic heart failure patients.	Study showed that comprehensive tele rehabilitation program can lead to a bigger improvement in both physical fitness (VO2 peak) and associated health-related quality of life (HRQL) compared to center-based cardiac rehabilitation alone.
Blasco et al., 2012	Spain	RCT	203	Patients randomized to the TMG were temporarily provided with an automatic sphygmomanometer, glucose lipid meter, and cellular phone.	12 months	Outcome measures were resting BP, body mass index(BMI), smoking status, LDL-c, and glycated hemoglobin A1c (HbA1c), all measured at the initial and final visits for comparison. Smoking status was determinedby self-report and confirmed by a 1-step cotinineimmunoassay in urine	Telemonitoring (TMG) patients were more likely (RR 1.4;95% CI 1.1–1.7) to experience improvement in cardiovascular risk factors profile than control patients (69.6% vs. 50.5%, p 0.010).TMG patients achieved treatment goals for BP (62.1% vs. 42.9%, p0.012) and HbA1c (86.4% vs. 54.2%, p 0.018), with no differences insmoking cessation or LDL-c. Body mass index was significantly lower in TMG (0.77 kg/m2 vs.0.29 kg/m2, p 0.005).		A telemonitoring program, via mobile phone messages,appears to be useful for improving the risk profile in acute coronary syndrome (ACS) survivorsand can be an effective tool for secondary prevention, especially foroverweight patients.
Martin et al., 2015	U.S.A, Marylland	RCT	48	Automated mHealth tracking technology (digital physical activity tracking was performed using the Fitbug Orb, a wearable, display-free, triaxial accelerometer that pairs with low-energy Bluetooth with compatible smartphones) linked with smart texting system	6 months	The primary outcome measure was the mean change in accelerometer-measured daily step count assessed from baseline through phase I and II.	The phase I change in activity was non significantly higher in unblinded participants versus blinded controls by 1024 daily steps (95% confidence interval [CI], −580 to 2628; p = 0.21). In phase II, participants receiving texts increased their daily steps over those not receiving texts by 2534 (95% CI, 1318 to 3750; p < 0.001) and over blinded controls by 3376 (95% CI, 1951 to 4801; p < 0.001).	The study had a limited sample size, hence, it best interpreted as exploratory evidence rather or a pilot trial study. The study also used adult smartphone participants thus making its generalizability uncertain.	An automated tracking-texting intervention increased physical activity with, but not without, the texting component. In ambulatory cardiology patients who are smartphone users, a novel mHealth intervention coupling smart texts to digital tracking significantly increased near-term physical activity.
Tian et al., 2015	China & India	RCT	2086	Android-powered app (Simplified Cardiovascular management Study; SimCard)	12 months	The primary outcome was the net difference between groups in the change in the proportion of patient-reported antihypertensive medication use.The outcomes were assessed with data collected during baseline and post intervention surveys from all high-risk individuals in both intervention and control villages in a standardized manner.	In comparison with the control group, the intervention group had a 25.5% (p < 0.001) higher net increase in the primary outcome of the proportion of patient-reported antihypertensive medication use pre- and post-intervention.There were also significant differences in certain secondary outcomes: aspirin use (net difference: 17.1%; p < 0.001) and systolic blood pressure (–2.7 mm Hg; p = 0.04	This study was not able to evaluate the effectiveness of different components or specific measures of the simplified cardiovascular management program, e.g., any given lifestyle modification or prescription of appropriate medication. Additionally, the imbalances of two baseline characteristics (history of coronary heart disease and history of diabetes mellitus) in India could have potentially affected the outcome assessment.	The results indicate that the simplified cardiovascular management program improved quality of primary care and clinical outcomes in resource-poor settings in China and India. Larger trials in more places are needed to ascertain the potential impacts on mortality and morbidity outcomes.
McGillicuddy et al., 2013	U.S.A	RCT	20	Prototype mHealth technology (A smartphone enabled medication adherence and BP self-management system).The prototype mHealth system consisted of a wireless GSM electronic medication tray, a wireless Bluetooth-enabled BP monitor, and a smartphone.	3 months	Medication adherence was examined using a 2 (treatment group: mHealth, SC) × 4 (time: pre-intervention, 1, 2, and 3 months) repeated measures analyses of variance (ANOVA).Resting BP was examined using a 2 (treatment group: mHealth, SC) by 4 (time: pre-intervention, 1, 2, and 3 months) repeated measures ANOVA.	Compared to the standard care control group (SC), the mHealth intervention group exhibited significant improvements in medication adherence and significant reductions in clinic-measured systolic blood pressures across the monthly evaluations. Physicians made more anti-hypertensive medication adjustments in the mHealth group versus the standard care group (7 adjustments in 5 patients versus 3 adjustments in 3 patients) during the 3-month trial based on the information provided in the weekly reports.	All the study subjects were recruited from a single transplant center which jeopardizes its generalizability. Besides, the randomly assigned groups differed significantly in age and adherence prior to the intervention raises questions about the validity of the conclusions. Finally, those who chose to participate in the mHealth-based RCT might be predisposed to a more positive attitude toward mHealth and thereby introduce a positive bias.	These data support the acceptability and feasibility of the prototype mHealth system. Further trials with larger sample sizes and additional biomarkers (e.g., whole blood medication levels) are needed to examine efficacy and effectiveness of the system for improving medication adherence and blood pressure control after kidney transplantation over longer time periods.

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