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Effects and costs of real-time cardiac telerehabilitation: randomised controlled non-inferiority trial
Open accessAbstract
Objective: Compare the effects and costs of remotely monitored exercise-based cardiac telerehabilitation (REMOTE-CR) with centre-based programmes (CBexCR) in adults with coronary heart disease (CHD). Methods: Participants were randomised to receive 12 weeks of telerehabilitation or centre-based rehabilitation. REMOTE-CR provided individualised exercise prescription, real-time exercise monitoring/coaching and theory-based behavioural strategies via a bespoke telerehabilitation platform; CBexCR provided individualised exercise prescription and coaching via established rehabilitation clinics. Outcomes assessed at baseline, 12 and/or 24 weeks included maximal oxygen uptake (V̇O 2 max, primary) modifiable cardiovascular risk factors, exercise adherence, motivation, health-related quality of life and programme delivery, hospital service utilisation and medication costs. The primary hypothesis was a non-inferior between-group difference in V̇O 2 max at 12 weeks (inferiority margin=−1.25 mL/kg/min); inferiority margins were not set for secondary outcomes. Results: 162 participants (mean 61±12.7 years, 86% men) were randomised. V̇O 2 max was comparable in both groups at 12 weeks and REMOTE-CR was non-inferior to CBexCR (REMOTE-CR-CBexCR adjusted mean difference (AMD)=0.51 (95% CI −0.97 to 1.98) mL/kg/min, p=0.48). REMOTE-CR participants were less sedentary at 24 weeks (AMD=−61.5 (95% CI −117.8 to −5.3) min/day, p=0.03), while CBexCR participants had smaller waist (AMD=1.71 (95% CI 0.09 to 3.34) cm, p=0.04) and hip circumferences (AMD=1.16 (95% CI 0.06 to 2.27) cm, p=0.04) at 12 weeks. No other between-group differences were detected. Per capita programme delivery (NZD1130/GBP573 vs NZD3466/GBP1758) and medication costs (NZD331/GBP168 vs NZD605/GBP307, p=0.02) were lower for REMOTE-CR. Hospital service utilisation costs were not statistically significantly different (NZD3459/GBP1754 vs NZD5464/GBP2771, p=0.20). Conclusion: REMOTE-CR is an effective, cost-efficient alternative delivery model that could—as a complement to existing services—improve overall utilisation rates by increasing reach and satisfying unique participant preferences.
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“Home-based cardiac telerehabilitation using wearable sensors is equivalent or better than centre-based rehabilitation and can increase access to cardiac rehabilitation and reduce the cost”
From Smart wearable devices in cardiovascular care: Where we are and how to move forward (2021) · cites this paper as [85]
In the citing paper
“A non-inferiority, randomized trial comparing REMOTE-CR — a real-time, remote telerehabilitation platform that includes the use of a chest-worn wearable sensor (BioHarness 3, Zephyr Technology, USA) — with a centre-based programme showed that REMOTE-CR was associated with less sedentary time at 24 weeks and was more cost-effective than the centre-based programme85.”
From Smart wearable devices in cardiovascular care: Where we are and how to move forward (2021) · cites this paper as [85]
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“The authors demonstrated that the intervention was an effective and cost-effective delivery model that could potentially improve overall CR utilisation rates by increasing reach and satisfying unique participant preferences.30”
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Long-Term Outcomes of Digital Cardiac Rehabilitation
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“Following 8-week and 12-week CR program whether in-person or remote model, the HRQL scores were increased in all domains of physical and mental composites both, indicating the overall equivalence in HRQL between groups was expected, concurring with other previous reports [29, 30].”
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“Scores range from 0 to 27 and are categorized as mild (5-9), moderate (10-14), moderately severe (15-19), and severe (20-27).”
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Itoh, H., Amiya, E., Jimba, T., Shimbo, M., Narita, K., Taya, M., Kadokami, T., Yasu, T., Oka, H., Sogawa, M., et al. (2024) · IJC Heart & Vasculature · doi:10.1016/j.ijcha.2024.101421 · Cited by 5
“Historical controls in this study exhibited a lower baseline exercise capacity than that shown in several previous studies [17,20,30], whereas there were similar reports of equivocal baseline exercise capacity [31,32].”
Karthijekan, K., & Cheng, H. Y. (2022) · PLoS ONE · doi:10.1371/journal.pone.0270800 · Cited by 6
“To achieve a power of 1-β = 0.8 with a significance level of 0.05 (two sides) and account for 14% of the attrition rate [27] of the previous study, a total of 150 participants will be recruited in this study.”
InfluentialNishitani‐Yokoyama, M., Shimada, K., Fujiwara, K., Abulimiti, A., Kasuya, H., Kunimoto, M., Yamaguchi, Y., Tabata, M., Saitoh, M., Takahashi, T., et al. (2023) · Cardiology Research · doi:10.14740/cr1530 · Cited by 6
“The other is a semi-synchronous method in which the patient data are uploaded to an online application, and medical professionals access these data as appropriate [14, 15].”
Apple Watch-guided diagnosis of AVNRT in a pregnant woman—A case report and literature review
Hawryszko, M., Sławiński, G., Kozłowski, D., & Lewicka, E. (2022) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2022.985421 · Cited by 6
Agyei, E. E. Y. F., Ekpezu, A. O., & B, H. O.-K. A. (2024) · JMIR Cardio · doi:10.2196/49515 · Cited by 6
“The implementation of praise included individualized feedback to manage outcomes [27,28], motivational messages [29,33,41], personalized feedback on progress [33,40,42,45], and performance [18,26,34].”
BackgroundMethodAdvances in Cardiac Telerehabilitation for Older Adults in the Digital Age: A Narrative Review
Liu, T., Zou, J., Geng, Q., & Liu, J. (2024) · Heart and Mind · doi:10.4103/hm.hm-d-23-00080 · Cited by 5
Loschi, T. M., Baccan, M. D. T. A., Pereira, E. C., Dellabarba, T. D. L. C., Boteon, A. P. C. D. S., & BOTEON, Y. L. (2025) · World Journal of Hepatology · doi:10.4254/wjh.v17.i10.110856 · Cited by 5
Candelaria, D., Redfern, J., Zecchin, R. P., Brown, R., Freene, N., Fukumori, S., Gallagher, R. D., Gauci, S., Goodman, A., Hicks, D., et al. (2026) · Heart Lung and Circulation · doi:10.1016/j.hlc.2026.05.008 · Cited by 8
Self-citationExercise Prescription in Cardiac Rehabilitation
Staroń, A., Wolszakiewicz, J., & AlSulaimi, M. (2022) · MDPI eBooks · doi:10.3390/books978-3-0365-2029-2 · Cited by 8
Effective interventions and features for coronary heart disease: a meta-analysis
Agyei, E. E. Y. F., Miettunen, J., & B, H. O.-K. A. (2023) · Behaviour and Information Technology · doi:10.1080/0144929x.2023.2213342 · Cited by 5
Yamashita, R., Sato, S., SAKAI, Y., Tamari, K., Nozuhara, A., Kanazawa, T., Tsuzuku, S., Yamanouchi, Y., Hanatani, S., Nakamura, T., et al. (2024) · Journal of Physical Therapy Science · doi:10.1589/jpts.36.128 · Cited by 5
Quality care in ST-segment elevation myocardial infarction
Liu, E.-S., Hung, C. C., Chiang, C.-H., Tsai, Y.-C., Fu, Y.-J., Ko, Y.-L., Wang, C.-L., Lai, W.-Y., Tsai, F.-T., Kuo, F.-Y., et al. (2022) · Journal of the Chinese Medical Association · doi:10.1097/jcma.0000000000000687 · Cited by 5
“73,74 However, their efficacy in maintaining long-term behavioral changes remains a concern.”
Farklı Fizyoterapi ve Rehabilitasyon Alanlarında Telerehabilitasyon
Rabia, K. U. M., & Pehlivan, E. (2022) · Bandırma Onyedi Eylül Üniversitesi Sağlık Bilimleri ve Araştırmaları Dergisi · doi:10.46413/boneyusbad.1077637 · Cited by 5
Socioeconomic Inequalities and Predictors of Cardiac Rehabilitation Referral
Rocha, A., Azevedo, L. F., Freitas, A., & Silva‐Cardoso, J. (2023) · American Journal of Physical Medicine & Rehabilitation · doi:10.1097/phm.0000000000002270 · Cited by 5
“26 The COVID-19 pandemic has placed limitations on mobility and social contact, thereby highlighting the significance of alternative models and technologies for the delivery of CR services.”
BackgroundYoshihara, R., Kitamura, M., Ishihara, K., Kanejima, Y., & Izawa, K. P. (2024) · Heart and Mind · doi:10.4103/hm.hm-d-24-00005 · Cited by 5
Jabakhanji, S. B., Sørensen, J. R., Carney, R. M., Dickens, C. M., Dempster, M., Gallagher, J., Caramlau, I. O., & Doyle, F. (2022) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2022.110747 · Cited by 5
Røe, C., Bautz‐Holter, E., Anđelić, N., Søberg, H. L., Nugraha, B., Gutenbrunner, C. M., Boekel, A., Kirkevold, M., Engen, G., & Lü, J. (2022) · Archives of Rehabilitation Research and Clinical Translation · doi:10.1016/j.arrct.2022.100197 · Cited by 7
“Median (IQT): 52 (41-78) EQ-5D (global) at 6 mo follow-up”
Stathi, A., Withall, J., Greaves, C. J., Thompson, J. L., Taylor, G. T., Medina‐Lara, A., Green, C., Snowsill, T., Johansen‐Berg, H., Bilzon, J., et al. (2022) · Public Health Research · doi:10.3310/mqbw6832 · Cited by 6
Bashar, N., Aamdani, S. S., Khalid, S., Aziz, N., Sattar, S., Samad, Z. Z., & Kamal, A. K. (2025) · BMJ Open · doi:10.1136/bmjopen-2024-094425 · Cited by 6
Flores‐Sandoval, C., Sibbald, S. L., Ryan, B. L., Adams, T. L., Suskin, N., McKelvie, R. S., Elliott, J. B., & Orange, J. B. (2024) · Canadian Journal on Aging / La Revue canadienne du vieillissement · doi:10.1017/s0714980824000102 · Cited by 4
“For instance, exercise-based programs monitored remotely were found to be comparatively effective to centre-based exercise programs, resulting in savings in program delivery costs and increased patient accessibility (Maddison et al., 2019).”
Trache, D., Șerbănoiu, L. I., Bistriceanu, M. I. A., Olteanu, G., Andronic, O., Călin, L., & Busnatu, Ș. (2025) · Medicina · doi:10.3390/medicina61040635 · Cited by 4
“Moreover, it improves adherence through flexible, remote monitoring, reducing logistical barriers while remaining a cost-effective alternative to in-hospital rehabilitation [17,18].”
Participation and Progression of Hybrid Rehabilitation following Lung Transplantation
Carson, R., Cordi, C., Campisi, E. S., Moss, S., Trask, A., Zhu, K., Gottesman, C., Ferreira, M. D. P., de Mori, T. A., & Wickerson, L. M. (2025) · Clinical Transplantation · doi:10.1111/ctr.70185 · Cited by 4
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Liu, Y., Wang, X., Li, J., Huang, X., Yu, J., & Chen, M. (2025) · European Journal of Cardiovascular Nursing · doi:10.1093/eurjcn/zvaf195 · Cited by 4
Semphuet, T., Jianramas, N., Nissapatorn, V., Sivakorn, C., Pereira, M. D. L., Ratnarathon, A. C., Salesingh, C., Jaiyen, E., Chaiyakul, S., Piya-amornphan, N., et al. (2024) · Heliyon · doi:10.1016/j.heliyon.2024.e40453 · Cited by 4
Pierucci, A., de Almeida, N. S., Lemes, Í. R., Milanez, V. F., Oliveira, C. B., Winkelströter, L. K., de Abreu, M. A. M. M., Nakagaki, W. R., & Toledo, A. C. C. G. (2024) · Computer Methods and Programs in Biomedicine · doi:10.1016/j.cmpb.2024.108551 · Cited by 4
Lahtinen, M., Kaakinen, P., Jansson, M. M., Paalimäki‐Paakki, K., Virtanen, M. A., Kerimaa, H., Kivelä, K., Oikarinen, A., Rajala, M., Hylkilä, K., et al. (2025) · European Journal of Cardiovascular Nursing · doi:10.1093/eurjcn/zvae154 · Cited by 4
Yang, Y., Qiao, Y., Chen, W., & Yang, L. (2025) · BMJ Open · doi:10.1136/bmjopen-2024-088111 · Cited by 5
ME3CA: A Cognitive Assistant for Physical Exercises that Monitors Emotions and the Environment
Rincon, J. A., Costa, Â., Nováis, P., Julián, V., & Carrascosa, C. (2020) · Sensors · doi:10.3390/s20030852 · Cited by 4
“With this data, the REMOTE-CR gives real-time advice to improve the exercise performance as well as build an historic that the user’s can access through the web portal.”
MethodBatool, T., Neven, A., Smeets, C. J. P. P., Scherrenberg, M., Dendale, P., Vanrompay, Y., Adnan, M., Ross, V., Brijs, K., Wets, G., et al. (2022) · Journal of Transport & Health · doi:10.1016/j.jth.2022.101344 · Cited by 4
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“Two studies [29,31] compared the effectiveness of home-based programs vs.”
BackgroundMethodInfluentialNabutovsky, I., Breitner, D., Heller, A., Scheinowitz, M., Klempfner, Y., & Klempfner, R. (2022) · JMIR Cardio · doi:10.2196/36947 · Cited by 4
“RCR has been shown to improve exercise adherence, increase physical activity level, and reduce the relative cost of treatment [6,7].”
Background
Metadata
- Authors
- Maddison, R., Rawstorn, J. C., Stewart, R. A. H., Benatar, J., Whittaker, R., Rolleston, A., Jiang, Y., Gao, L., Moodie, M., Warren, I., Meads, A., & Gant, N.
- Affiliations
- Deakin University (AU)
- Auckland City Hospital (NZ)
- University of Auckland (NZ)
- The Centre for Health (New Zealand) (NZ)
- Corresponding author
- Rawstorn, Jonathan Charles
- ORCID
- Venue
- Heart
- Publisher
- BMJ
- Published
- 2018-08-27
- Volume
- 105
- Issue
- 2
- Pages
- 122-129
- ISSN
- 1355-6037 (ISSN-L)
- 1468-201X
- PMC
- PMC6352408
- OpenAlex
- W2889374857
- Cited by
- 320
- References
- 32
- Citations by year
- 2026: 27 · 2025: 47 · 2024: 52 · 2023: 55 · 2022: 59 · 2021: 36 · 2020: 25 · 2019: 14 · 2018: 5
- FWCI
- 15.13
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by-nc
- Locations
- Heart (publishedVersion, cc-by-nc)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- Own your potential (DEAKIN) (submittedVersion)
- Figshare (submittedVersion, cc-by-nc)
- HighWire Press Open Archive (submittedVersion)
- Funders
- Auckland Medical Research Foundation
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
- Keywords
- cardiac telerehabilitation, coronary artery disease, exercise-based cardiac rehabilitation, VO2max, sedentary behavior, cardiovascular risk factors, health-related quality of life, drug costs, non-inferiority, behavioral strategies, exercise adherence, motivation, New Zealand
- MeSH terms
- Coronary Disease, Cost-Benefit Analysis, Exercise Therapy, Female, Humans, Male, Middle Aged, New Zealand, Quality of Life, Rehabilitation Centers, Treatment Outcome, Telemedicine, Internet
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