What Do Patients Talk About? A Qualitative Analysis of Online Chat Sessions with Health Care Specialists During a "Virtual" Cardiac Rehabilitation Program.

INTRODUCTION: Cardiac rehabilitation programs (CRPs) are effective at reducing cardiovascular disease (CVD) risk, yet attendance in these programs remains low due to geographic constraints. In a previously conducted randomized trial we demonstrated that a virtual CRP (vCRP) delivered over the Internet reduced risk for CVD. The current investigation has reviewed the online chat sessions between participants and healthcare providers (HCP) to describe the content of discussions during the vCRP intervention. MATERIALS AND METHODS: Participants were recruited from two geographically isolated areas in British Columbia, Canada without in-person CRP or a cardiologist serving the area. The vCRP, among other elements, included scheduled one-on-one chat sessions with a dietician, exercise specialist, and nurse to mimic standard CRP consultations. The chat sessions were reviewed for content and themes. Multiple chat sessions between participants and a single care provider were also analyzed to describe how chat content progressed through multiple sessions. RESULTS: A total of 38 participants participated in the vCRP intervention. From the 122 chat sessions between participants and HCP during the vCRP, the main themes identified were Managing Health and Lifestyle, Continuity of Care, and Getting Care from a Distance. Within each theme, sub-themes were also identified. CONCLUSIONS: The vCRP chat sessions fulfilled the role of face-to-face consultations with HCP that are standard in hospital-based CRP and addressed patient concerns, facilitating remote patient-provider interaction and covering topics on exercise, diet, and positive behavior changes to limit risk factors for future heart problems.

Healing healthcare in Canada: a shared agenda for healthcare quality and sustainability.

Sullivan et al. make a compelling argument that a "coalition of the willing" must seize the nettle and create a national agenda and the capacity for quality leadership in Canadian healthcare. While there is reason to believe that Canada could benefit from such an agenda, there is also evidence that, if done incorrectly, such an agenda could be expensive and counterproductive. To increase the likelihood that a national quality agenda will contribute to the creation of a sustainable and effective healthcare system, it will be important to understand potential pitfalls and to incorporate approaches that have enabled leading organizations to achieve success. It will be key to create a shared vision of healthcare that focuses on the health needs of our population and engages stakeholders broadly.

Assessment of an Interactive Digital Health-Based Self-management Program to Reduce Hospitalizations Among Patients With Multiple Chronic Diseases: A Randomized Clinical Trial.

Importance: Digital health programs may have the potential to prevent hospitalizations among patients with chronic diseases by supporting patient self-management, symptom monitoring, and coordinated care. Objective: To compare the effect of an internet-based self-management and symptom monitoring program targeted to patients with 2 or more chronic diseases (internet chronic disease management [CDM]) with usual care on hospitalizations over a 2-year period. Design, Setting, and Participants: This single-blinded randomized clinical trial included patients with multiple chronic diseases from 71 primary care clinics in small urban and rural areas throughout British Columbia, Canada. Recruitment occurred between October 1, 2011, and March 23, 2015. A volunteer sample of 456 patients was screened for eligibility. Inclusion criteria included daily internet access, age older than 19 years, fluency in English, and the presence of 2 or more of the following 5 conditions: diabetes, heart failure, ischemic heart disease, chronic kidney disease, or chronic obstructive pulmonary disease. A total of 230 patients consented to participate and were randomized to receive either the internet CDM intervention (n = 117) or usual care (n = 113). One participant in the internet CDM group withdrew from the study after randomization, resulting in 229 participants for whom data on the primary outcome were available. Interventions: Internet-based self-management program using telephone nursing supports and integration within primary care compared with usual care over a 2-year period. Main Outcomes and Measures: The primary outcome was all-cause hospitalizations at 2 years. Secondary outcomes included hospital length of stay, quality of life, self-management, and social support. Additional outcomes included the number of participants with at least 1 hospitalization, the number of participants who experienced a composite outcome of all-cause hospitalization or death, the time to first hospitalization, and the number of in-hospital days. Results: Among 229 participants included in the analysis, the mean (SD) age was 70.5 (9.1) years, and 141 participants (61.6%) were male; data on race and ethnicity were not collected because there was no planned analysis of these variables. The internet CDM group had 25 fewer hospitalizations compared with the usual care group (56 hospitalizations vs 81 hospitalizations, respectively [30.9% reduction]; relative risk [RR], 0.68; 95% CI, 0.43-1.10; P = .12). The intervention group also had 229 fewer in-hospital days compared with the usual care group (282 days vs 511 days, respectively; RR, 0.52; 95% CI, 0.24-1.10; P = .09). Components of self-management and social support improved in the intervention group. Fewer participants in the internet CDM vs usual care group had at least 1 hospitalization (32 of 116 individuals [27.6%] vs 46 of 113 individuals [40.7%]; odds ratio [OR], 0.55; 95% CI, 0.31-0.96; P = .03) or experienced the composite outcome of all-cause hospitalization or death (37 of 116 individuals [31.9%] vs 51 of 113 individuals [45.1%]; OR, 0.57; 95% CI, 0.33-0.98; P = .04). Participants in the internet CDM group had a lower risk of time to first hospitalization (hazard ratio, 0.62; 95% CI, 0.39-0.97; P = .04) than those in the usual care group. Conclusions and Relevance: In this study, an internet-based self-management program did not result in a significant reduction in hospitalization. However, fewer participants in the intervention group were admitted to the hospital or experienced the composite outcome of all-cause hospitalization or death. These findings suggest the internet CDM program has the potential to augment primary care among patients with multiple chronic diseases. Trial Registration: ClinicalTrials.gov Identifier: NCT01342263.

Innovation in the North: are health service providers ready for the uptake of an internet-based chronic disease management platform?

Remote and rural regions in Canada are faced with unique challenges in the delivery of primary health services. The purpose of this study was to understand how patients and healthcare professionals in northern British Columbia might make use of the Internet to manage cardiovascular diseases. The study used a qualitative methodology. Eighteen health professionals and 6 patients were recruited for a semi-structured interview that explored their experience in managing patients with cardiovascular disease and their opinions and preferences about the use of the Internet in chronic disease management. Key findings from the data suggest that a) use of the Internet helps to maintain continuity of care while a patient moves through various stages of care, b) the Internet may possibly be used as an educational tool in chronic disease self-management, c) there is a need for policy development to support Internet-based consultation processes, and d) while health providers endorse the notion of electronic advancement in their practice, the need for secure and stable electronic systems is essential.

The experiences of patients undertaking a 'virtual' cardiac rehabilitation program.

Cardiac rehabilitation programs (CRP) are medically supervised, multidisciplinary programs that provide secondary prevention aimed at addressing risk factors and improving lifestyle behaviours for patients following an acute cardiac event. CRPs have been demonstrated to be a cost-effective and evidence-based mechanism to improve patient outcomes, but despite the known benefits of these programs, uptake remains poor. Poor attendance has been linked to many factors, but geographical accessibility is a key concern, since many CRPs are limited to hospitals in urban areas. The widespread availability of the Internet has made it possible to provide virtual health services to populations that may have previously been hard to access. This paper examines the qualitative findings from a 16-month mixed methods randomized controlled trial examining the impact of a virtual CRP (vCRP). The vCRP was revealed to be an accessible, appropriate, convenient and effective way to deliver cardiac rehabilitation services, with patients experiencing both clinical improvements and a high level of satisfaction. To understand the experience of patients undertaking the vCRP, semi-structured interviews were undertaken with a purposive sample of 22 participants. An analysis of the qualitative interviews revealed that the vCRP improved participants' access to healthcare professionals, supported them to make healthy choices, and enhanced feelings of accountability due to greater surveillance. Barriers to participation, such as computer literacy, and general perceptions of a vCRP were also examined. Further investigation into the use and long-term effectiveness of virtual programs across a broader range of healthcare settings is warranted, particularly in those with multiple chronic diseases and those located in rural and remote communities.

Improving access to cardiac rehabilitation using the internet: a randomized trial.

Cardiac rehabilitation (CR) is essential for secondary prevention, yet only 10%-30% of eligible patients attend as geographical proximity is a major barrier. We evaluated a 'virtual' CR program (vCRP) delivered by the Internet to patients in small urban and rural areas. In our study, in-patients (n=78) with acute coronary syndrome or post-revascularization were randomized to usual care (UC) or vCRP. The vCRP was a four-month program that included heart rate monitoring; physiologic data capture; education sessions; ask-an-expert sessions; and chat sessions with a nurse, exercise specialist and dietitian. Participants were assessed at baseline and four months, and followed for another 12 months. The primary outcome was change in maximal time on the treadmill stress test (MTT) between groups adjusted for age, sex, diabetes status and Internet use for health information. The vCRP resulted in a greater increase in MTT by 45.7 seconds (95% CI: 1.0, 90.5) compared to usual care (p=0.045). Cholesterol levels and dietary quality improved in the vCRP compared to the UC group. Participants perceived the vCRP to be an accessible, convenient and effective way to received healthcare. Eleven (30%) and 6 (18%) participants in the UC and vCRP groups, respectively, had cardiovascular-related events (p=0.275). In conclusion, the vCRP was safe and effective and resulted in sustainable risk reduction without the requirement of face-to-face visits and directly monitored exercise.

Prevalence and characteristics of home Internet access in patients with cardiovascular disease from diverse geographical locations.

BACKGROUND: Patients living outside of urban centres do not have access to the same level of care as patients in cities. The use of the Internet has been suggested as a possible resolution to this geographic inequity. OBJECTIVE: To identify the determinants of Internet use in patients with cardiovascular disease and the patterns of use. METHODS: Cardiac inpatients of an urban tertiary and a northern regional hospital in British Columbia were invited to participate. Patients who could not speak English or who had mental impairment were excluded. Consenting patients were interviewed regarding demographics and home Internet use. RESULTS: A total of 294 patients participated. The mean (+/- SD) age was 64.0+/-12.7 years. Most participants were men (68%) of European ancestry (77%) with some postsecondary education (57%). All geographical regions of British Columbia were represented. A total of 66% of patients had home Internet access. In rural areas, 47% of patients had access to the Internet (P=0.020 compared with nonrural areas). Eighty-four per cent of patients with Internet access had a high-speed connection, 55% reported using the Internet daily and 23% used it more than once per week. Accessing health information from the Internet was reported by 70% of patients. CONCLUSION: These data indicate a high prevalence of Internet use among English-speaking cardiac patients and a strong desire to obtain health information using the Internet. Health care organizations can take advantage of the Internet to develop and evaluate the delivery of cardiac services to patients in their homes, particularly to patients in rural and remote communities.