From the 2021 HVPAA National Conference
Francoise Marvel (Johns Hopkins Hospital), Erin Spaulding (Johns Hopkins), William Yang, George Yung, Seth Martin
Among the 1 million patients in the United States hospitalized yearly with acute myocardial infarction (AMI), nearly 1 in 6 experience a 30-day hospital readmission. Approximately 75% of these readmissions are potentially preventable. The Center for Medicare and Medicaid services and American College of Cardiology suggest utilizing best practices including pre-discharge planning, education, and adherence support, to save millions of dollars from unnecessary healthcare utilization and readmission penalties. Digital health presents opportunities to re-engineer the hospital discharge process, but these programs disproportionately engage participants that are younger, healthier and of higher socioeconomic status. This digital divide makes inclusivity of underserved populations a priority, as these patients are at higher risk of poor health outcomes. To demonstrate the potential benefit of digital health on health equity, we present a case study of an underserved patient with multiple cardiovascular risk factors and social barriers to healthcare, who was given access to a digital health program and improved her health status post-AMI.
A 55-year-old woman with undiagnosed familial hypercholesterolemia, premature coronary artery disease with previous AMI, pre-diabetes, tobacco use, physical inactivity, diet heavy in fried and processed foods, and morbid obesity. She had previously been incarcerated, earned ~$31,000 annually working night shifts at Walmart, and had been uninsured for several years. She had never received preventive care to address her cardiac risk factors. She was admitted with substernal chest pain, diagnosed with an inferior ST-elevation MI, and had two drug-eluting stents placed in her right coronary artery. While hospitalized, she was enrolled in the Myocardial infarction, COmbined-device, Recovery Enhancement (MiCORE) Study. At the time of enrollment, she owned a flip phone and had never used a smartphone. She was provided with a digital health program (Figure 1) including: (1) an iPhone preloaded with a smartphone application (“Corrie”; Figure 2) designed to engage patients in guideline-directed medical treatment, (2) an Apple Watch for tracking heart rate and steps, and reminders about medications, appointments, and (3) a wireless blood pressure monitor. She was trained in-person for 25 minutes on how to use the technology.
With the help of reminders from Corrie, she tracked adherence to her cardiac medications and follow-up appointments with her primary care physician and cardiologist. She monitored her step count and increased her exercise to climbing stairs and/or walking 3–5 miles daily. She learned more about cardiovascular health and her recent diagnosis through brief, easy to understand and visually engaging educational videos. She also changed her lifestyle, as recommended in the videos, by quitting smoking, reducing fast and fried foods, eating heart healthy foods and reducing her soda intake by half. At 30 days, and at an interview conducted 2.4 years after enrollment, she was continuing healthy daily habits, avoiding both post-AMI complications and short interval hospital readmission.
In summary, this case illustrates the potential for a well-designed digital health program to improve underserved patient access to guideline-directed treatment, support in AMI recovery, and promote high value care and outcomes.