A Digital Health Intervention in Acute Myocardial Infarction

From the 2021 HVPAA National Conference

Erin Spaulding (Johns Hopkins), Francoise Marvel (Johns Hopkins Hospital), Vinayak Bhardwaj, Matthias Lee, William Yang, Ryan Demo, Jie Ding, Jane Wang, Helen Xu, Lochan Shah, Daniel Weng, Jocelyn Carter, Maulik Majmudar, Eric Elgin, Julie Sheidy, Renee McLin, Jennifer Flowers, Valerie Vilarino, David Lumelsky, Rongzi Shan

Background

Thirty-day readmissions among patients following acute myocardial infarction (AMI) contribute to the United States healthcare burden of preventable complications and costs. Digital health interventions (DHIs) may improve patient healthcare self-management and outcomes.

Objective

We aimed to (1) determine if AMI patients using a DHI have lower 30-day all-cause readmissions than a historical control group, (2) establish cost-effectiveness of the DHI, and (3) evaluate patient activation and DHI use at 30 days post-discharge among patients in the DHI group.

Methods

This nonrandomized controlled trial, conducted at four hospitals from 2015-2019, included 1,064 AMI patients (DHI n=200, historical control n=864). The DHI (Figures 1 and 2) consisted of a smartphone application, smartwatch, and blood pressure monitor to engage patients in guideline-directed care during hospitalization and 30 days post-discharge via (1) medication reminders, (2) vital sign and activity tracking, (3) education, and (4) outpatient care coordination. The Patient Activation Measure<sup>®</sup> assessed patient knowledge, skills, and confidence for healthcare self-management. Propensity score-adjusted Cox proportional hazard models estimated hazards for all-cause 30-day readmission, measured through administrative databases, between the two groups. A Markov model was used to explore the cost-effectiveness.

Results

Following propensity score adjustment, baseline characteristics were well-balanced between the DHI vs control patients (standardized differences <0.07), including a mean age of 59.3 vs 60.1 years, 30% vs 29% Women, 70% vs 70% White, 54% vs 54% with private insurance, 61% vs 60% patients with a NSTEMI, and 15% vs 15% with high comorbidity burden. DHI participants were predominantly in the highest levels of patient activation for healthcare self-management (mean score 71.7±16.6 at 30 days). There was a median of 213 (IQR: 393) application interactions per participant, consisting of: number of blood pressure, heart rate, weight, mood, and step count recordings; number of medications tracked; and number of educational articles and videos viewed over the study period. The DHI group had fewer all-cause 30-day readmissions than the control group (6.5% vs. 16.8%, respectively). After adjusting for hospital site and a propensity score inclusive of age, sex, race, AMI type, comorbidities, and six additional confounding factors, the DHI group had a 52% lower risk for all-cause 30-day readmissions (aHR: 0.48; 95% CI: 0.26-0.88; Figure 3). The DHI reduced costs and increased QALYs on average, dominating standard care in 99.7% of simulations in the probabilistic analysis. Based on the assumption that the DHI costs $2,750 per patient, use of the DHI leads to a cost-savings of $7,319 per patient compared to standard care alone.

Conclusions

Our results suggest that in AMI patients the DHI may be associated with high patient activation for healthcare self-management and lower risk of all-cause unplanned 30-day readmissions. This study also demonstrates that this DHI is cost-saving through the reduction of risk for all-cause readmission following AMI.

Clinical Implications

This DHI improved quality of care by supporting post-AMI recovery, from early during hospitalization to home, through behavior change strategies and evidence-based patient self-management.

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