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Scientific Review

A Structured Review of Commercially Available Cardiac Rehabilitation mHealth Applications Using the Mobile Application Rating Scale

Meddar, John M. MS; Ponnapalli, Aditya MS; Azhar, Rimsha MS; Turchioe, Meghan Reading PhD, MPH, RN; Duran, Andrea Tiana PhD, MPhil, MS; Creber, Ruth Masterson PhD, MSc, RN

Author Information
Journal of Cardiopulmonary Rehabilitation and Prevention: May 2022 - Volume 42 - Issue 3 - p 141-147
doi: 10.1097/HCR.0000000000000667
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Coronary heart disease affects over 18.2 million American adults,1 and accounts for high morbidity and mortality. Cardiac rehabilitation (CR) is a multicomponent, comprehensive, 3- to 6-mo program designed to improve cardiovascular health after a significant cardiac event.2 Attendance of CR programs for ≥25 sessions is linked to reduced mortality,3 disability,4,5 hospital readmission,6,7 and improved quality of life.4,5 However, CR has been grossly underutilized, with <30% of eligible cardiac patients participating in CR in the United States.8 Patients who are most at risk of having cardiovascular events are also at highest risk of facing significant barriers to accessing center-based CR,9,10 including older adults and minorities.11 Commonly reported barriers to CR include parking and driving costs, absence of accessible forms of transportation,12 lack of insurance, program costs, inflexibility in work schedule,13,14 and women with caregiving responsibilities.15

The coronavirus disease-2019 (COVID-19) pandemic expedited the use of technology to expand CR among vulnerable groups.16–18Ad hoc technology platforms were put in place to limit in-person contact of center-based CR programs. While technology-driven CR has been in operation before onset of the pandemic, curbing transmission of COVID-19 required cessation of all center-based CR programs, globally,16–20 and there is ongoing implementation of remote, home-based CR programs delivered using telehealth21–24 and mobile health applications (mHealth apps). The quality and functionality of existing mHealth apps for CR have not been systematically appraised. The present review aims to identify and systematically evaluate the quality and functionality of existing commercially available mHealth apps for CR using validated methods for the review and evaluation of commercially available apps.25

METHODS

SYSTEMS SEARCH AND SELECTION

In February 2020, we conducted a systematic app search to identify commercially available mHealth apps for CR. We performed our search in two of the most widely used commercial mobile apps stores: Apple iTunes Appstore (using Appshopper for iOS apps) and Google Play Store (Android apps). Six search terms were used to query relevant CR apps: “cardiac rehabilitation,” “heart disease and remote therapy,” “heart failure exercise,” “heart therapy and cardiac recovery,” “cardiac recovery,” and “heart therapy.”

Three rounds of app screening were conducted, applying strict inclusion and exclusion criteria in each round. During the first round, app titles were screened against three exclusion criteria: not in English, primarily games, and unrelated to cardiac health. In the second round, app titles and descriptions were screened against four exclusion criteria: not patient-facing, vital sign monitoring and informational content only, diagnostic, and unrelated to CR. In the third round, we downloaded the remaining apps and evaluated them against our final four exclusion criteria: unable to be accessed, above price point threshold ($10), duplicates not removed from previous rounds, and unrelated to CR. Apps >$10 were excluded to ensure that we only reviewed apps that were accessible to a broad majority of the population.

MEASURES OR RATING TOOLS

Apps were assessed along three different scales measuring quality,26 functionality,27 and adherence to evidence-based guidelines.28 First, three reviewers (J.M., A.P., and R.A.) reviewed five randomly chosen apps concurrently on both iOS and Android platforms to ensure that all reviewers gained adequate understanding of the scale and achieved consensus, which was confirmed by calculating interrater reliability (IRR). After achieving an acceptable IRR of 0.85, the remaining apps were independently reviewed by a minimum of two reviewers.

To evaluate quality, we used the Mobile App Rating Scale (MARS), which provides a 5-point Likert scale (1 = inadequate, 2 = poor, 3 = acceptable, 4 = good, and 5 = excellent) across four domains: Engagement (entertainment, interest, customization, interactivity, and target group), Functionality (performance, ease of use, navigation, and gestural design), Aesthetics (layout, graphics, and visual appeal) and Information (accuracy of app description, goals, quality and quantity of information, visual information, credibility, and evidence base). The MARS has four additional subscales scores, which calculates a total mean score for each of these key measures. Additionally, the MARS includes a subjective quality score, the perceived effects score based on user knowledge, attitude, and intention, and a behavior change score (assessing the likelihood of behavior change).

To evaluate functionality, we used the IQVIA functionality scale from the IQVIA Institute for Healthcare Informatics report.27 The scale consists of seven main functionality categories and four subcategories. These categories assess the ability of the app to inform, instruct, record, display, guide, remind/alert, and communicate. There are four additional subscales for functionality; these assess the ability of the app to intervene, evaluate, share, and collect. While the MARS functionality subscale focuses on the performance, aesthetics, and ease of use of an app, the IQVIA functionality criterion focuses on capturing how many distinct features the app provides.

Finally, we mapped the content of the apps to the core components of CR, as recommended by a joint scientific statement released by the American Heart Association (AHA) and the American Association of Cardiovascular and Pulmonary Rehabilitation.21,28 The five recommended components of CR include the following: patient assessment, nutritional counseling, risk factor management (lipids, blood pressure, weight, diabetes mellitus, and smoking), psychosocial interventions (depression, anger), and physical activity counseling and exercise training. We evaluated whether mHealth apps for CR offer a feature to monitor each core component of CR, with the exception of psychosocial interventions.21,28 We excluded the psychosocial component of CR with the underlying assumption that many CR apps may not yet be inclusive of features that monitor psychosocial risk factors. Additionally, apps did not need to monitor a minimum number of components to be included in the review. We assumed most apps had varying levels of functionality to address most of the core components of CR reviewed. The composite guidelines identify six behavior changes: daily weighing, checking extremities for edemas, performing physical activities, eating a low-salt diet, taking medications as prescribed, attending doctor's appointments as scheduled, and monitoring cardiac health symptoms daily.

RESULTS

DESCRIPTIVE CHARACTERISTICS

Across the two platforms (Android Google Play and Apple iTunes Appstore), we identified 3121 potentially relevant apps, of which 273 were included after the first round of title screening. After our second round of screening, of which 54 were included, 9 apps met our final inclusion criteria. The flow diagram (Figure 1) provides a detailed overview of the selection process and categories for exclusion. Most apps were excluded because they were unrelated to CR (n = 2719), not available in English (n = 107), or were games (n=22).

F1
Figure 1.:
Selection process and categories for exclusion. Abbreviations: CR, cardiac rehabilitation; MARS, Mobile App Rating Scale.

Table 1 presents a full list of the included apps and their characteristics. All the included apps were free to download and most apps were updated within the last year (78%). The average consumer star rating of all the apps was 3.9, with a range of 2-5. Most of the apps were found on both platforms (Google Play and Apple), with the exception of a few apps such as My Cardiac Coach, My Health Check, and Heart Failure Log, which were only available on Apple. Most of the apps were installed between 100 and 10 000+ times, while Qardio had >100 000 installations. There was no information on the number of installs provided on My Cardiac Coach and Heart Failure Log. All nine apps had publicly available privacy policies.

Table 1 - Description of Included Apps
Names Star
Rating
Installs Version Release
Year
Country Cost,
US $
In-App
Cost, US $
Platform IQVIA
Score
My Cardiac Coach 2 NA 2.2.7 2016 US Free Free Apple 10
Love My Heart For Women 5 100+ 2.0 2018 US Free Free Apple and Google 10
Heart Failure Storylines 3.7 1000+ 7.17 NA US Free Free Apple and Google 8
Flaredown for Chronic Illnesses 3.9 10 000+ 1.0.4 2014 US Free Free Apple and Google 7
Heart Care 3.8 1000+ 1.0.3 NA US Free Free Apple and Google 7
Heart Failure Log 5 NA 1.0 2016 US Free 3.99 Apple 6
Qardio 4.6 100 000+ 1.88 2012 US Free Free Apple and Google 6
Sanket Life 4 10 000+ 6.2 NA India Free Free Apple and Google 5
My Health Check 3.8 10 000+ 1.0.7 NA US Free Free Apple 4

MARS APP QUALITY SCORES

Table 2 presents the four main subscale scores (engagement, functionality, aesthetics, and information), overall quality score, subjective quality score (satisfaction), and app-specific health behavior score from the MARS. The MARS overall median score was 3.4 out of 5, and the overall scores for all the apps were ≥3.0, indicating high quality. Across all apps, out of the four subscales, functionality had the highest overall average score of 3.8 and aesthetics had the lowest overall average score of 3.4. The My Cardiac Coach app had the highest average MARS score of 4.5. The second highest average MARS app was Love My Heart for Women with a score of 4.1.

Table 2 - Mobile Application Rating Scores
Name Engage Function Aesthetic Information Satisfaction Behavior Change Overall
My Cardiac Coach 4.9 4.4 4.5 4.2 4 4.5 4.5
Love My Heart For Women 4.3 4.1 4.1 3.9 4.3 4.0 4.1
Heart Failure Storylines 3.9 4.1 3.8 3.5 4.0 4.0 3.9
Qardio 3.5 4.1 4.0 3.3 3.3 3.6 3.7
Heart Care 3.0 3.9 3.3 3.0 3.5 4.0 3.4
My Health Check 3.4 3.2 2.8 3.1 3 3.5 3.2
Sanket Life 2.7 3.8 3.2 3.0 3.3 3.3 3.2
Heart Failure Log 3.0 3.1 2.5 3.0 3.6 3.0 3.1
Flare Down for Chronic Illnesses 2.7 3.2 2.8 2.8 3.0 3.5 3.0

FUNCTIONALITY

Table 1 and Figure 2 illustrate the IQVIA functionality scores of the apps. The average functionality score and median number of functionalities were 7, and 45% of the apps were <7. The average IQVIA functionality score of the apps was also 7. The Love My Heart for Women and My Cardiac Coach apps had the highest functionality scores among reviewed apps, with an IQVIA score of 10, followed by Heart Failure Health Storyline with a functionality score of 8. Love My Heart for Women and My Cardiac Coach apps were the only apps that provide guidance on user-entered information. All of the nine apps were able to record and capture data by the user. The majority of the apps were able to send alerts/reminders (n = 6, 67%) and share data (n = 7, 78%). Some of the apps such as Love My Heart for Women and My Cardiac Coach were able to give instructions or guidelines to the user. All the apps are able to collect data and display the data in a form of graphs, tables, or reports. The Sanket Life app collects data, shares data, but does not evaluate or intervene data. Sending reminders and alerts to the patients with CR is considered a valuable feature of an app. The apps that were able to send alerts/reminders were Love My Heart for Women, Heart Failure Log, Flaredown for Chronic Illness, Heart Failure Storylines, and My Cardiac Coach.

F2
Figure 2.:
Functionality of included apps based on the IQVIA Institute for Healthcare Informatics scores. This figure is available in color online (www.jcrpjournal.com).

AMERICAN HEART ASSOCIATION GUIDELINES FOR CARDIAC REHABILITATION

Table 3 illustrates included apps that were evaluated based on the AHA guidelines for CR.2 The most common CR self-care behavior evaluation included physical activity and daily monitoring of the cardiac health symptoms, blood pressure, heart rate, blood sugar, cholesterol, etc (n = 8, 89%), followed by attending doctor's appointment (n = 5, 56%), following a low-salt diet and medication adherence (n = 4, 44%), followed by checking ankles and extremities for swelling (n = 1, 11%). The app that addressed all self-care behavior was My Cardiac Coach, which was developed by the AHA. While most apps were not explicitly designed for CR, many included functionalities centered around AHA core CR components.

Table 3 - Apps Mapped to the Core Components of Cardiac Rehabilitation
Core Components
Patient Assessment Nutritional Counseling Risk Factor Management Physical Activity, Counseling, and Exercise Training
Titles AHA CR
Behavior:
Extremities
Checking
AHA CR
Behavior:
Symptoms
Monitoring
AHA CR Behavior:
Diet Management
AHA CR
Behavior:
Medication
Management
AHA CR
Behavior:
Doctor's
Appointment
AHA CR Behavior: Physical
Activity
Total
Score
Heart Failure Storylines 6
My Cardiac Coach 6
Heart Care 4
Love My Heart For Women 4
Heart Failure Log 3
My Health Check 3
Flaredown for Chronic Illnesses 2
Sanket Life 2
Qardio 2
Abbreviations: AHA, American Heart Association; CR, cardiac rehabilitation.

DISCUSSION

This review systematically evaluated the quality and functionality of existing commercially available mHealth CR apps.25 The quality and functionality of the included apps for mobile CR was high, with three apps performing the best across three categories of quality, functionality, and consistency with evidence-based clinical guidelines. The apps, My Cardiac Coach, Heart Failure Storylines and Love My Heart For Women, demonstrated a broad range of CR-related functionalities to facilitate remote monitoring of cardiac symptomatology, including monitoring of heart rate, cholesterol levels, medication adherence, physical activity, diet, and weight, in addition to consulting with physicians. In a previous study, Heart Failure Health Storylines was found to be the top-performing app for heart failure using the same quality and functionality scales, and was highlighted for its ability to track multiple heart failure symptoms simultaneously.25 The Qardio app was also empirically assessed in two peer-reviewed articles.29 The two studies reported that the Qardio app demonstrated good reliability, and was found to have high usability,29 and overall quality,30 thus was recommended for patients with cardiovascular disease.

Early evidence suggests that technology-driven CR could be effective or complementary in delivering CR.31,32 A recent meta-analysis reporting on the efficacy of mHealth-driven CR found that it was effective at increasing adherence across a range of CR outcomes, though a diversity of intervention types were used, including fixed telephone-landlines, websites, and short message service.33 Similarly, other meta-analyses revealed that use of mHealth was noninferior to center-based CR,34 and was effective at increasing adherence to CR programs by promoting physical activity and social support and boosting motivation.35 However, the latter study highlighted that mHealth technologies used to deliver CR were still in the initial stages of implementation and required further investigation to ascertain effectiveness.35

High-quality apps, especially when free or low-cost, could play an integral role in expanding access to CR for vulnerable populations that face barriers to in-person CR, including those in rural areas, without health insurance, and with limited access to transportation. Commercially available CR apps can supplement in-person CR and could expand the scope of access to CR for many patients with cardiovascular disease who would benefit from it.36 A recent national initiative led by the Centers for Disease Control and Prevention and Centers for Medicare & Medicaid Services, aimed at preventing 1 000 000 heart attacks in 5 yr, found that improving CR participation rates to 70% could save 25 000 lives and prevent 180 000 hospitalizations.37

Most of the apps evaluated had features for entering, storing, and graphically displaying user-entered data, while a minority had features centered on informing and coaching. Further advancement and refinement of CR apps should include the ability to inform and coach patients on making important behavioral changes to improve their health. Additionally, app developers should strive to address salient barriers to CR. For example, since older age is associated with barriers to accessing CR,38 app developers should integrate gerontological design principles, specifically related to visual impairment and simplified user interface design and functionality to support patients who may have limited technology experience and cognitive deficits.39–41 For instance, interface designs that are easy to use and forgiving of user errors can be helpful in boosting ease of use for older adults.41 Integrating MARS functionality measures in app development and technology acceptance models such as the Technology Acceptance Model42 and the Health Information Technology Acceptance Model,43 which are frameworks rooted in enhancing behavioral intentions to use technology, into app development could improve sustained engagement and self-monitoring when using mHealth CR apps.44 A study showed that iteratively refining mHealth apps for CR by integrating user feedback was effective at improving usability.45 Using a user-centered approach could support desired functionalities and usability by participants for optimal use of mHealth apps for CR.

With lower uptake of CR among women, CR app developers should design apps using content, layouts, and aesthetics graphs that are tailored for women. For example, the Love My Heart for Women app achieved high scores for functionality and quality in this review, while also being aesthetically appealing to women. This is consistent with other studies, which have led women-only focus groups to elucidate usability and acceptability principles that will increase usage of mHealth by women.46,47 Low educational level and psychosocial factors are also barriers to CR uptake.38 As such, mHealth CR apps should be designed to be accessible for a range of literacy levels so that it does not impede progress toward behavioral change and sustained participation. Additionally, CR app developers should consider intrinsic barriers such as low self-efficacy and motivation because they are leading reasons for not sustaining engagement in CR programs.48

The study findings are timely considering the recent scaling up of digital health throughout the COVID-19 pandemic. The pandemic has expanded opportunities to leverage diverse digital modalities, including text-messaging, mobile apps, and teleconferencing for the purposes of telerehabilitation and have historically been used across a spectrum of clinical domains. For instance, mHealth-supported telerehabilitation has been used in specialties like pulmonology, to monitor various components of rehabilitation for conditions such as COVID-19, asthma, chronic obstructive pulmonary disease, and cystic fibrosis.49–51 Likewise, specialties such as surgery have used mHealth-supported telerehabilitation to remotely monitor patients, as they rehabilitate from major surgical procedures such as arthroplasty, spinal surgery, and hip fractures.52–55 The use of app-facilitated telerehabilitation in neurology has proven to be noninferior or effective in helping to manage neurological conditions such as chronic back pain, strokes, and cerebellar ataxias.56–59 Increased adoption of technology by patients and rapid scaling of the digital health landscape may further propel telerehabilitation forward and democratize participation in telerehabilitation for individuals who have previously been excluded.60

STRENGTHS AND LIMITATIONS

A strength of this study was the rigorous methodology that was applied to evaluate app quality using the MARS, which has been used in several prior app reviews for heart failure,25 mindfulness,61 weight loss management,62 rheumatology,63 drug-drug interactions,64 and pain management.65 Findings of this study should be interpreted in the context of several limitations such as not including the psychological dimensions to CR.28 Promoting sustained engagement in CR requires consideration of psychological factors such as stress levels and emotional well-being as essential elements to prolonged participation.66 Future studies examining apps for CR should also evaluate the psychological dimension of CR, including addressing depression, motivation, and possibly anxiety about participating in CR. Second, only apps in English were included in the review. It is likely that high-quality apps in other languages were excluded from our evaluation. Third, app evaluation was not conducted by patients using CR. Involving patients in future app reviews is recommended when possible.67,68 Additionally, some apps may have not been commercially accessible for review because they were being used in clinical trials or they required prescription or enrollment in a particular health care network or insurance plan.

CONCLUSION

In this review we identified several CR apps currently available on the commercial market that are of high quality. Further refinement and development of apps are needed to address quality, functionality, clinical guidelines adherence, and barriers to CR uptake. Overall, there are growing opportunities for home-based mHealth that can be provided through high-quality, low-cost mHealth applications, which could boost participation and expand access to CR to substantially alleviate the burden of congenital heart disease.

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Keywords:

cardiac rehabilitation; cardiovascular disease; mHealth; rehab; telerehabilitation

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