Abstract
PURPOSE: Despite demonstrated benefits of cardiac rehabilitation and risk factor reduction, only 11% to 38% of eligible patients with cardiovascular disease (CVD) participate in cardiac rehabilitation programs. Women and older adults are particularly less likely to participate in cardiac rehabilitation. In an effort to broaden access to cardiac rehabilitation, the authors developed an alternative Internet-based program that allows nurse case managers to provide risk factor management training, risk factor education, and monitoring services to patients with CVD.
METHODS: The evaluation consisted of a randomized, clinical trial involving 104 patients with CVD, 53 of whom used the program as a special intervention (SI) for 6 months and 51 of whom received usual care (UC).
RESULTS: The results indicate that fewer cardiovascular events occurred among the SI subjects (15.7%) than among the UC subjects (4.1%) (P = .053), resulting in a gross cost savings of $1418 per patient. With a projected program cost of $453 per patient, the return on investment is estimated at 213%. More weight loss occurred in the SI group (-3.68 pounds) than in the UC group (+.47 pounds) (P = .003). The differences between the two groups in terms of blood pressure, lipid levels, depression scores, minutes of exercise, and dietary habits were not statistically significant.
CONCLUSION: An Internet-based case management system could be used as a cost-effective intervention for patients with CVD, either independently or in conjunction with traditional cardiac rehabilitation.
In 1995, after extensive review of the literature, the Agency for Health Care Research and Quality (AHCPR) determined that comprehensive cardiac rehabilitation services are beneficial for individuals with cardiovascular disease (CVD). 1 However, this expert panel also determined that cardiac rehabilitation services were highly underutilized, with only 11% to 38% of eligible patients participating in these programs. 1 Women and older adults are particularly less likely to participate in cardiac rehabilitation. 2,3 Furthermore, besides cardiac rehabilitation, there is little, if any, support for self-management training to reduce cardiac risk among patients with CVD 4,5 despite numerous clinical trials demonstrating that risk factor reduction reduces morbidity, mortality, and recurrent events while improving quality of life for these patients. 6,7 Moreover, because risk factor modification has the potential to reduce the number of expensive cardiac-related procedures, 6,7 it could have a significant impact on the ability of healthcare providers to conserve limited healthcare resources if provided to a larger proportion of patients with CVD.
Using current technology in an effort to enable more patients with CVD to access risk factor modification support services, the authors developed an Internet-based program that allows nurse case managers to provide risk factor management support, education, and monitoring services to patients with CVD. The use of the Internet allows patients to access the program from the comfort of their own home at a time of their own choosing and at their own pace. A related Internet database underlying the Web site enables the program to be customized on the basis of patients' risk factors and other demographic variables.
Although the program is delivered via the Internet, the case manager remains the key component of the system, interacting with patients electronically via secure communication lines within the program using a format similar to e-mail. Ideally, this case manager is the same person the patient sees during routine office visits or during traditional cardiac rehabilitation, someone who already has a close, working relationship with the patient's physician. This imparts a very real human feel to what otherwise could be perceived as a cold, impersonal computerized intervention.
In addition, the program facilitates the development of a supportive online community of patients with CVD and their families through discussion groups and voluntary exchanges of e-mail addresses. Other components of the program include online assessments, interactive education modules, dynamic self-monitoring tools, and separate interfaces for other healthcare providers including patients' physicians, dietitians, and psychologists.