Liverpool University Hospitals NHS: Cardiac Rehabilitation

Professor Michael Fisher, Dr Tom Rayner, iBSc. (Hons), MBChB., Kirstie Tew, MSc.

Executive Summary

Background

During the COVID-19 pandemic, the provision of face-to-face cardiac rehabilitation (CR) has been scaled back due to national lockdowns and social distancing rules. The clinical team felt that KiActiv® Health could be a valuable tool in addressing this service disruption to support eligible patients and empower them to optimise their recovery and prevent significant unintended long-term consequences.

Innovation

KiActiv® Health is a personalised and guided online behaviour change intervention that empowers participants to optimise everyday physical activity in the context of their condition. KiActiv®’s patented technology evaluates minute-by-minute physical activity data from a validated wearable monitor, which is displayed instantly in the user’s personalised online dashboard, and is available 24/7 to provide meaningful and actionable feedback. Patients are also supported remotely by phone calls with a dedicated KiActiv® Mentor at 6 key time points during the 12-week programme, to help them build an understanding of the value of their daily activities and the confidence to plan, monitor and improve. At the end of the 12-weeks, the patients retain access to their personal dashboard and activity monitor, enabling them to continue their self-management using the technology if desired.

Purpose/objective

The aim of this pilot study, was to provide a digital support service to patients who were not able to access CR, with the goal of promoting positive behaviour change and optimising physical activity in the context of their condition.

Methodology

Between September 2020 and April 2021, adult patients referred for CR at LUH were introduced to KiActiv® Health at their initial assessment by either a clinician or specialist CR Nurse who confirmed their eligibility and provided an activity monitor. The patient was then contacted by KiActiv® to ensure that they were eligible to take up the service, complete the enrolment process and arrange a start date. The 12-week KiActiv® Health programme began with a set-up call with a KiActiv® Mentor.

In addition to collecting objective physical activity data and qualitative data from 2-hours of Mentor calls, patients also completed validated self-report questionnaires (HADS and Dartmouth COOP) at their initial and final assessments.

Key Findings

  • Demographic: 17 people started the programme (14 Males, 3 Females), average age = 58 years, average BMI = 29.4 kg/m2, range of diagnoses leading to CR referral, range of comorbidities.
  • Completion: 82% of patients completed the 12-week programme.
  • Engagement: The use of the technology was excellent and included 92% of days being classed as having complete data sets. 79% of patients continued to engage with their KiActiv® technology beyond the initial 12-week programme.
  • PROMS: Statistically significant improvements were seen in self-reported Physical Fitness and Overall Health measured using the Dartmouth Coop Charts.
    • Improvements were seen in 8 of the 9 domains
    • 100% of patients improved in at least 1 domain
  • Mental Wellbeing:
    • 56% of patients showed an improvement in their scores for anxiety and 56% in their scores for depression, assessed using the HADS score
    • The mean symptom scores improved for both anxiety and depression, despite the majority of people being categorised as “normal” at baseline
  • Physical Activity Data: A large proportion of participants were able to improve their physical activity.
    • 93% of people improved their physical activity in 1+ dimension
    • 79% of people improved their physical activity in 3+ dimensions
    • 64% of people improved their physical activity in 4+ dimensions
    • The average increases in physical activity from baseline (i.e., physical activity dose) across an average of 67 complete days were:
      • Non-Sedentary Time: +58hrs 10mins (+32%)
      • Moderate Activity: +33hrs 43mins (+69%)
      • Moderate Bouts: +31hrs 27mins (+1004%)
      • Calorie Burn: +12,002kcals (+6%)
    • Based on the scientific evidence, the total dose of Moderate Activity of 33-hours and 43-mins reported here could produce changes in cardiorespiratory fitness (CRF) of 1.10 to 2.92 metabolic equivalents (METs). A 1 MET increase in CRF reduces all-cause and Coronary Heart Disease (CHD)/Cardiovascular Disease (CVD) mortality by 13% and 15%, respectively (Kodama et al., 2009), and as such, the improvement shown in the present analysis could equate to reductions in all-cause and CHD/CVD mortality anywhere from 14.3% to 38.0% and from 16.5% to 43.8%, respectively
  • Patient reported benefits included:
    • An increased awareness of physical activity and the value of everyday movement, with many clients shifting their perspective away from solely focusing on traditional exercise and recognise the importance of everyday movement too. Understanding the accessibility of everyday physical activity, where many had previously disregarded activity as unachievable and daunting
    • Feelings of empowerment, autonomous choice and self-management, which promote sustainable behaviour
    • Motivation to improve other health behaviours including improvements to their diet and consequential weight loss

Amongst the 3 patients who did not complete the full 12-week programme, 1 chose to withdraw stating that they did not have the want nor motivation to engage with the system. Two patients disengaged and did not respond to contact.

Conclusion

This pilot demonstrates the effectiveness of KiActiv® Health as a tool for supporting and encouraging patients to optimise their physical activity and recovery in the wake of a cardiac event, and to improve the management of heart failure.

The disruption caused by the COVID-19 pandemic to usual CR services has highlighted the appeal and accessibility to patients of this remote service, which suggests that it may similarly engage those patients unable or unwilling to attend current provisions going forward. The pilot was offered to phase-3 CR patients only but the results suggest that it can be equally successful with those requiring phase-4 CR and managing heart failure. The programme delivers person centred care at home and without the need to travel.

The 12-week KiActiv® Health programme is currently employed by the NHS in multiple pathways and can be scaled immediately across the country to offer eligible patients the support they need and deserve, as well as helping to manage growing waiting lists and reduce mounting pressure on CR services.

1st November 2021