Revolutionizing access to cardiovascular care for 1.4 billion people - How mobile health apps and services evolved from 2016-2020 in China and its implications

doi:10.21203/rs.3.rs-3868917/v1

Background

Cardiovascular diseases (CVDs) create a large disease burden in China. The country’s large population and land mass make access to CVD care difficult. The virtual model of care provided through mobile health (mHealth) can improve access to care and management of chronic CVDs on a population level. The article aims to examine the evolution of mHealth coverage, patient usage, and service development and delivery for CVD on a national level and describe its potential to impact access to cardiovascular care in developing countries.

Methods

We collected data on mHealth platforms for telemedicine of CVDs in the Chinese market in 2016, 2017, 2019 and 2020 from platforms available to the general public. Factors affecting access to CVD care were analyzed including 1) longitudinal changes of mHealth services provided per region; 2) medical facility coverage rate per province by mHealth apps; 3) distribution of specific cardiovascular conditions being sought on mHealth apps; and 4) the flow of patients across geographies to receive telemedicine. Descriptive statistics were used.

Findings

45.8% of tertiary hospitals were accessible by mHealth apps in 2016, this grew at an average annual growth rate of 10.7% between 2016 to 2020. Regions with a higher economic level, population, percentage of elderly, and internet penetration, rather than CVD burden, had better mHealth coverage. 34% and 67% of patients consulted doctors outside of their own provinces in 2016 and 2020, respectively. Wealthiest areas of Beijing, Shanghai and Guangdong were the preferred destinations (57.1% in 2016, 38.4% in 2020) for patients seeking interprovincial care. The top 3 disease types were the common chronic CVDs of hypertension, coronary artery disease and arrhythmia.

Interpretation

The uniform functionality available across provinces and apps suggest a mature technological and health service infrastructure across Mainland China, where the widespread adoption of service delivery and offerings (such as payment, tracking, telemedicine, etc.) via mHealth apps show a step toward democratizing access to care across the country. The inter-provincial flow of patients to HCPs suggests poorer and resource-scarce areas are poised to benefit more while the burden on major cities can be ameliorated; We found regions that are traditionally underdeveloped and lacking in access to care had the most increase in services available. However, adequate technological infrastructure needs to be available and mobile technology widely adopted by patients and medical facilities.

Funding

None of the authors were paid by a company or other agency for the writing of this manuscript. This study was supported by the National High Level Hospital Clinical Research Funding grant awarded by the Chinese Academy of Medical Sciences to Wei Chen (grant nos.: 2022-PUMCH-B-0252 and 2022-PUMCH-C-069) for data analysis and interpretation.

Health sciences/Medical research

Scientific community and society/Scientific community

mHealth

telemedicine

access to care

cardiovascular disease burden

developing countries

Evidence before this study:

We searched Pubmed and Google Scholar from Jan 2016 to December 2022 using the search “mobile health”, “cardiovascular disease burden”, and “access to care”. We identified studies that addressed mHealth functions offered, clinical outcomes, and population based or real-world implications of the mHealth apps on cardiovascular disease. China bears the largest burden of cardiovascular diseases (CVDs) worldwide. There is an inverted pyramid in cardiovascular care with a large burden primary care and public health promotion but much resources are directed towards tertiary care for acute conditions. Many studies examining mHealth have focused on small scale or individual trials, functionality of the app and the problem of CVD burden being compounded by difficult access to care. Mobile health can be a valuable tool for managing chronic CVDs, especially in China. This article examined the evolution of mHealth coverage status, patient usage, and service development and delivery for CVD in China, and its potential to impact access to cardiovascular care in developing countries.

Added value of this study:

Our study examined mHealth apps in the context of an entire country/population rather than a single app or single center. The uniform functionality available across provinces and apps suggest a mature technological and health service infrastructure across China. The interregional flow of patients to healthcare professionals suggests poorer and resource scarce areas are poised to benefit more while the burden on major cities can to some extent be ameliorated. Deployment of mHealth apps nationally, and offering comprehensive services is a way to sustainably address difficult access to CVD care in different developing countries.

Implications of all the available evidence:

mHealth in cardiovascular care has well developed tools and documented benefits for specific CVDs. Wide implementation nationally can improve access to resource scarce areas. There is limited evidence of population outcomes on the various CVD sub-groups from mHealth apps. Future studies should examine the regulatory effect of mHealth on the broader population, cardiovascular implications such as incidence, awareness, treatment, or mortality, and ways to integrate mHealth with in-person care so mHealth becomes part of standard care. Furthermore, the concept of standard care in developing countries and developed countries should be separately examined.

Globally, heart disease has remained the leading cause of death for the last 20 years. Nearly 9 million people died from heart disease in 2019 worldwide.¹ In China, cardiovascular disease (CVD) is the leading cause of death and premature death,² where the absolute number of cardiovascular deaths increased by 46% between 1990 and 2013.³ The prevalent CVDs – hypertension, coronary heart disease, and chronic heart failure – need long-term monitoring and treatment.

The peculiarities of the Chinese healthcare system make the task of CVD disease management monumental and difficult, given a population of more than 1·4 billion,⁴ a land area of 9·6 million square kilometers, and a significant CVD disease burden. The inverted pyramid of the Chinese healthcare system focuses on treating acute CVDs in tertiary hospitals with resources concentrated at top hospitals.⁵ Meanwhile access to primary care needs improvement to guide the treatment of common chronic CVDs. Thus, many patients with CVD are not able to achieve timely diagnosis and appropriate treatment. For example, while hypertension prevalence is at 37·2%, awareness, treatment and control rates are at 36·0%, 22·9%, and 5·7%, respectively.⁶

There are various evident strategies for tackling the CVD burden in China. Previous studies have mentioned “making the most efficient use of available [resources] to maximize the benefits for the people – providing equal, accessible and quality healthcare to everyone”,⁷ and focusing on promotion and management of risk factors rather than only treating acute episodes.⁵ The difficulty lies in strengthening primary care and striking a balance between primary care and secondary and tertiary care.⁷ One report indicated that more coverage of in-person care does not necessarily lead to more service and better health, especially in rural areas.⁸

Incorporating technology to provide CVD care especially through mobile health (mHealth) and telemedicine can impact access to high quality care. In 2019 the WHO released guidelines on digital health, improving accessibility of medical care services.⁹ mHealth in the context of this paper is a method of telemedicine delivery classified under the WHO Digital Health Interventions 2·4·1–2·4·3,¹⁰ delivered by mobile applications between a healthcare professional and patient. The Chinese State Council issued the Internet Plus action plan in 2015,¹¹ and the Internet Plus Healthcare in 2018,¹² to use mHealth as a tool to increase accessibility and affordability of medical services across the country. Previous reports on Chinese mHealth have focused on functions, such as diagnosis support, treatment, rehabilitation, and education regarding heart diseases via smartphone apps.^13,14 However, there lacks information on how mHealth impacts access to care and disease management on a national level.

Examining the longitudinal changes of mHealth’s role in CVD management can help explain the impact of the technology on CVD burden in China and potentially other developing countries with similar healthcare characteristics. Therefore, the aim of this article is to: 1) describe the trajectory of mHealth services offered for cardiovascular care between 2016 and 2020 in China; 2) describe how mHealth services are being utilized in cardiovascular care; and 3) discuss the implications of mHealth on cardiovascular care access in resource-scarce regions and developing countries.

mHealth app selection

mHealth apps offering telemedicine services in China were sampled on publicly available platforms in 2016, 2017, 2019, and 2020 using the keyword “appointment making”. The two main types of mobile applications in China were sampled: stand-alone mobile apps and mini-programs. Mini-programs are apps embedded within another app, a feature allowing users to use a collection of apps without installing multiple applications on their smartphones.¹⁵ Stand-alone apps were obtained for Android and iOS operating systems. For Android, apps were sampled from the five top Android app stores, which accounted for more than three quarters of the market coverage,¹⁶ namely: MyApp (Tencent Technology (Shenzhen) Co., Ltd., Shenzhen, China), Baidu (Baidu, Beijing, China), 360 (Qihoo 360 Technology, Beijing, China), Huawei (Huawei Technologies Co. Ltd., Shenzhen, China), and Oppo (Guangdong Oppo Mobile Telecommunications Corp., Ltd., Dongguan, China).¹⁷ For iOS, Apple’s App Store (Apple Inc., Cupertino, CA, USA) was used to obtain apps. WeChat (Tencent Technology (Shenzhen) Co., Ltd., Shenzhen, China) was the source of the mini-programs.

Stand-alone apps or mini-programs (henceforth collectively referred to as mHealth apps unless otherwise specified) described above were evaluated based on a set on criteria for inclusion into this study. The mHealth apps had to be in Simplified Chinese language and provide services for Mainland China. We ensured apps provided services adhering to the definition of telemedicine – the provision of healthcare services at a distance,^18-²⁰ through the use of information and communication technology, where patient and providers are separated by distance.²¹ Apps providing purely non-care related services such as health monitoring, exercise, lifestyle management, medical science education, and over-the-counter drugs were excluded from the study. The apps were then evaluated to ensure the user can obtain access to cardiovascular care, as defined by 1) having the option to select telemedicine service from the division of cardiology or cardiac surgery – both online and offline appointments were included, and 2) being able to make a telemedicine appointment after registering in the app. The selection process is shown in Figure 1 and Table 1.

The initial identification, screening, and evaluation were completed by four authors with each app’s evaluation subsequently cross referenced by another evaluator to ensure accuracy. Where discrepancies existed, the app was discussed, and a consensus was reached, and the final decision was jointly approved by two other authors.

[Insert Figure 1.]

mHealth app evaluation – Categorization and characteristics of providers

We identified the characteristics of each app, hospital, and hospital location prior to further analysis. Each app was categorized by the operator or owner of the app into one of four categories- public hospital, private hospital, government, or private company. The number of hospitals each mHealth app provided access to were categorized as single, two to three, four to ten or more than ten. Each hospital that was available for telemedicine was then individually listed with duplicates removed. The hospitals were then tagged to a geographic location and hospital level (primary, secondary, and tertiary). Geographies were defined as one of thirty-one provinces, municipalities, or autonomous regions, henceforth collectively referred to as provinces. Taiwan, Hong Kong and Macau were not included in this study. The following data were identified for each geographic region – CVD burden, GDP per capita, population size, percentage of population older than 65 years old, percentage of population with college degree or above, and number of internet users – where possible for the years 2016, 2017, 2019, and 2020 (Supplementary Table 1).^2,22 When it was not possible to obtain data for the exact year, the most recent available value was used excluding all data prior to 2015 (Supplementary Table 2). Hospitals in China are categorized on a three-tier system based on factors including but not limited to staffing, bed count, specialties offered, and operations performed; with tertiary hospitals being the highest designation.²³.

mHealth app evaluation – Services offered

The services offered by each app was identified according to a previous study’s classification – reminders, appointment making, medical record, pharmacy, disease awareness, clinical decision support, discussion forum and medical education.¹⁷ Other telemedicine related functions were captured as well, including identity verification, doctor selection, and online payment.

mHealth app evaluation – Usage for access to CVD care

To investigate the real-world patient usage of mHealth apps in China, a large private mHealth app provider called HaoDF (HaoDF Online Corp., Beijing China) that provides medical service to up to 72 million patients was selected.²⁴ Deidentified app usage data via an open access data platform granted for scientific research was obtained.²⁵ App usage data for 2016 and 2020, included the following data elements – each episode of care’s diagnosis, date of consultation, patient’s city of residence, physician’s name and facility of physician.

Data analysis

This was a longitudinal descriptive study on mHealth apps. Descriptive statistics was used for reporting results. Various factors affecting access to CVD care were analyzed including: 1) longitudinal changes of mHealth services provided per region; 2) hospital coverage rate per province by mHealth apps; 3) distribution of specific cardiovascular conditions being sought on mHealth apps; and 4) the flow of patients across geographies to receive telemedicine.

Funding

None of the authors were paid by a company or other agency for the writing of this manuscript. This study was supported by the National High Level Hospital Clinical Research Funding grant awarded by the Chinese Academy of Medical Sciences to Wei Chen (grant nos.: 2022-PUMCH-B-0252 and 2022-PUMCH-C-069) for data analysis and interpretation.

Apps and mini-programs selection

In the initial sampled list there were 1590 mHealth apps in 2016 with this number increasing to 4742 in 2017, and then decreasing to 4233 and 3255 in 2019 and 2020, respectively (Table 1). The final number of platforms for CVD care were 207, 599, 403, and 425 in 2016, 2017, 2019, and 2020, respectively. The number of hospitals covered by mHealth apps consistently increased during the period of the study (1310, 1564, 1850, and 1970 in 2016, 2017, 2019, and 2020, respectively).

Table 1. App selection and screening

	2016	2017	2019	2020
Number of platforms in initial list, n	1590	4742	4233	3255
Unrelated to telemedicine	855	2757	2592	1694
Duplicates	316	859	619	669
Unique platforms, n	419	1126	1022	892
Non-existent/non-operational	128	340	378	298
Unable to realize telemedicine for CVD	71	135	157	105
Designed for doctors	6	15	65	47
Not in Mainland China and not in Simplified Chinese	7	37	19	17
Final platforms for CVD, n	207	599	403	425
Duplicates	77	216	214	292
Final hospital coverage list, n	1310	1564	1850	1970

Abbreviation: CVD = cardiovascular disease.

Of the different providers of mHealth apps, public hospitals and private companies consistently provided the highest numbers of mHealth apps across the duration of the study, with 77 and 108 mHealth apps in 2016, and 304 and 92 mHealth apps in 2020 respectively (Table 2). The range of coverage of mHealth apps from government and private company providers, collectively, showed 61·7% covered more than 10 hospitals in 2016, with this increasing to 85·6% by 2020. In 2016, over 80% of mHealth apps from government and private company providers covered one entire province or more, whereas in 2020, most mHealth apps the same providers covered only one city or hospital.

Table 2. mHealth app evaluation – Categorization and characteristics of providers

	2016	2017	2019	2020
mHealth apps by provider type, n
Public hospitals	77	232	224	304
Private hospitals	3	22	14	16
Government	19	86	24	13
Private company	108	259	141	92
Hospital(s) covered by mHealth apps*, n (%)
1 hospital	11 (8·6)	19 (5·5)	13 (8·0)	6 (5·7)
2-4 hospitals	3 (2·3)	12 (3·5)	17 (10·5)	1 (1·0)
5-10 hospitals	35 (27·4)	32 (9·4)	8 (4·9)	8 (7·7)
＞10 hospitals	79 (61·7)	279 (81·6)	124 (76·6)	89 (85·6)
Region(s) covered by mHealth apps*, n (%)
More than 2 provinces	51 (40·1)	115 (33·7)	49 (29·7)	26 (25·2)
1 province	51 (40·1)	108 (31·7)	19 (11·5)	18 (17·5)
1 city or 1 hospital	25 (19·8)	118 (34·6)	97 (58·8)	59 (57·3)

*Range of coverage – Each platform from public and private hospital providers represents one single hospital. We analyzed range of coverage for mHealth apps from government and private companies, collectively. Abbreviation: mHealth = mobile health; App = application

Hospitals available

In 2016, 2017, 2019, and 2020, the number of hospitals available via mHealth apps were 1310, 1564, 1850, and 1970 respectively, with all provinces having at least one facility providing telemedicine services. Between 2016 and 2020, Eastern China and Central China consistently had the highest number of hospitals providing telemedicine services while Northwestern China and Southwestern China consistently had the least (Table 3).

Table 3. Distribution of hospitals providing CVD care via mHealth apps in China

	2016	2017	2019		2020
Number of hospitals, n	1310	1564	1850		1970
Primary hospitals	23	26	27	29
Secondary hospitals	305	423	552		612
Tertiary hospitals	982	1115	1271		1329
Coverage rate of all available hospitals, %
Primary hospitals	0·1	0·1	0·1		0·1
Secondary hospitals	4·0	5·0	6·1		6·3
Tertiary hospitals	45·8	47·6	49·2		48·1
Coverage rate of provinces, %	100	100	100		100
Average number of hospitals in each province by geographic region, n
Eastern China	64·4	74	87·1		90·9
Southern China	39·7	46·3	56·7		62·7
Central China	62·3	78·7	93		98
Northern China	47·4	51·4	56·4		61
Northwestern China	18·4	26·8	33·4		35·2
Southwestern China	24·6	30·2	38·8		42
Northeastern China	33	42	48·3		53

Abbreviation: CVD = cardiovascular disease; mHealth = mobile health; App = application

Hospital distribution and geographical coverage of mHealth apps in China

Between 2016 and 2020, the number of hospitals providing telemedicine for CVD in China increased from 1310 to 1970, with an average annual growth rate of 10·7%. Provinces with the most hospitals accessible was Shanghai, Guangdong, and Henan in 2016 and 2020. The provinces with more than 100% growth rate in hospitals accessible via mHealth apps were Xinjiang, Xizang, Ningxia, and Gansu, Hunan, and Hainan, Jiangxi, and Yunan (Figure 2.); these had among the lowest GDP per capita in the nation. Provinces with the greatest increase in hospital number available via telemedicine were Shanghai, Hunan, and Guangdong- these were among the highest populated areas nationally.

The provinces with the highest hospital coverage rates of telemedicine were Beijing, Shanghai, and Liaoning, Shandong, Guangdong; these are located along the eastern coast of the country. While the provinces in Western China (Xinjiang, Xizang, Gansu, Yunnan) had the greatest increase in coverage rate (Figure 3).

[Insert Figure 2.]

[Insert Figure 3.]

Function analysis of Apps and mini-programs

Telemedicine was provided in all apps and mini-programs in our study. The other functions of hospital and third-party apps or mini-programs had some similarities (Table 4). Appointment making (84·7%), medical record (43·3%), disease awareness (20·5%), and reminders (15·1%) were the most common functions in 2020. In contrast, clinical decision support, discussion forums and medical education were rarely provided in the same app. Hospital platforms focused primarily on tracking patient medical history and disease awareness, while the third-party platforms focused on aspects of chronic disease management, such as online pharmacy.

Table 4. Services offered for CVD care by mHealth apps

	2016	2017	2019	2020
Functions apart from telemedicine, n (%)
Reminders	18 (8·6)	177 (29·4)	92 (22·8)	64 (15·1)
Appointment making	166 (79·0)	461 (76·6)	297 (73·5)	360 (84·7)
Record	100 (47·6)	364 (60·5)	154 (38·1)	184 (43·3)
Pharmacy	15 (7·1)	35 (5·9)	29 (7·2)	30 (7·1)
Disease awareness	105 (50.0)	263 (43.7)	126 (31.2)	87 (20.5)
Clinical decision support	15 (7·1)	23 (3·8)	0 (0)	1 (0·2)
Medical education	4 (1·9)	42 (7·0)	2 (0·5)	30 (7·1)
Discussion forum	12 (5·7)	26 (4·3)	6 (1·5)	1 (0·2)
Functions related to telemedicine, n (%)
Identity verification	175 (84·1)	590 (98·3)	400 (99·0)	421 (99·1)
Doctor selection	183 (88·0)	580 (96·7)	364 (90·1)	402 (94·6)
Online payment	143 (68·8)	413 (68·8)	261 (64·6)	358 (84·2)

Abbreviation: CVD = cardiovascular disease; mHealth = mobile health; App = application

Patient identity verification was required on both hospital and third-party platforms (84·1% in 2016 increasing to over 98% in 2017 and plateauing in the following years). Doctor selection availability was 88% in 2016 and 94·6% in 2020. Online payments were available in 84·2% of all mHealth apps in 2020.

Patient usage of telemedicine

Open access data from HaoDF was used to examine telemedicine usage for CVD in China. In 2016, there were 222,000 telemedicine cases for CVD and 177,000 cases in 2020. The most common diseases seen on telemedicine visits in 2016 were coronary heart disease, arrhythmia, and hypertension in order; and in 2020 were coronary heart disease, hypertension, and arrythmia. (Figure 4). Experienced doctors, such as chief physicians and associate chief physicians, were preferred by more than half of the patients (64% in 2016, 62% in 2020).

[Insert Figure 4.]

We analyzed patients' consultations with doctors outside their own provinces (Supplementary Table 3). The percentage increased from 34% in 2016 to 67·3% in 2020. Nearly half of inter-provincial consultations were to physicians from Beijing and Shanghai hospitals in 2016, these are also the areas with the first and second highest GDP per capita. In 2020 the inter-provincial consultations to Beijing and Shanghai was lower, at 30%, with regions ranked 3-10 and 21-31 in GDP per capita seeing an increase. Patients from less developed regions contacted doctors in more developed regions (Figure 5), with high percentages of patients domiciled in Xizang and Qinghai (92·2% in 2016, 94·3% in 2020 and 88·6% in 2016, 93·1% in 2020, respectively). Shanghai, Beijing, and Guangdong consistently had the lowest rate of consultations interprovincially their provinces.

[Insert Figure 5.]

This study revealed that mHealth apps can rapidly increase access to cardiovascular care for large populations in ways that physical facilities cannot. mHealth can address China’s CVD burden despite its geographic size and population. On the healthcare provider side, the absolute number and coverage rate of hospitals providing telemedicine service increased all over China. Apart from telemedicine, other services including reminders, medical records, online payments, pharmacy, disease education was available for self-management and patient-physician engagement in managing chronic CVDs. On the mHealth utilization side, patients with common CVDs – coronary heart disease, arrhythmia, and hypertension – most frequently used mHealth apps to receive care. Furthermore, utilization of these apps realized a large-scale virtual patient flow from poorer to more affluent regions. The findings from China can serve as a reference for developing or resource poor regions.

Coverage and services available

Common cardiovascular conditions seen on mHealth apps consistent with prevalence

The most common conditions addressed via telemedicine were hypertension, coronary artery disease, and arrhythmia – consistent with reports on epidemiological prevalence of CVDs in China.²⁶ The data reported in this study accounts for both initial and follow-up visits collectively. Usage numbers indicate that access to care for CVD patients increased, however whether the care delivered aligned with guidelines, and whether clinical outcomes were affected remain to be seen.

Public hospitals taking charge in providing mHealth services

In 2020, private hospitals and primary hospitals constituted the majority of medical institutions in China (66·5% private hospitals versus 33·5% public hospitals; 34·6% primary hospital, 29·4% secondary hospitals and 36·0% tertiary hospitals).²⁷ However, per the results of this study, this ratio was reversed for telemedicine where public hospitals and tertiary hospitals were the major providers. Although secondary and primary hospitals were a focal point for the government to improve the healthcare system, the main burden remained concentrated on public and tertiary hospitals. Similarly, for in-person clinical visits, about one-third of all public hospitals provided over 80% medical services, while tertiary hospitals provided 57·0% of medical services.²⁷ This preference towards tertiary care reflects the current imbalances within the Chinese healthcare system. Primary care facilities and private hospitals still have significant room to grow before taking full responsibility of diagnosing and treating common CVDs. The inverted pyramid of the Chinese cardiovascular care system is not sustainable.⁵ More attention should be paid to the burden brought by telemedicine to the doctors in these limited hospitals. Therefore, population-level strategies, primary care strengthening, hierarchical disease management – where different hospital levels treat based on disease severity and urgency – and doctors practicing at multiple sites allowing flow and communication of healthcare professionals between hospitals,²⁸ should be further popularized in the future.

mHealth Services becoming more comprehensive

In this study we found mHealth services offered are becoming more comprehensive. The recent shift to internet hospitals is driving the push toward comprehensive medical care.²⁹ One aspect is the delivery of medical care now including diagnosis, treatment, and continuous care, having started out as non-diagnostic consultations and reminders in the 2010s. Also, patients can be diagnosed, and have prescriptions refilled and delivered remotely. Supportive services are also becoming more comprehensive and consolidated with non-medical care services such as payment, physician selection, patient education, and health records mainly provided in individual applications.^13,17 The trend observed in this study is the consolidation of services on applications and uniformity across service platforms. Furthermore, during the period of this study, hospitals rather than technology providers made up the majority of the mHealth providers. The trends suggest patients can more easily see physicians at top-tier hospitals without needing to be physically present and imply a higher likelihood of reducing overcrowding by patients in top-ranked hospitals.³⁰

Socioeconomic implications

The trends observed indicate adoption of mHealth services occurs at a higher rate in poorer regions making them more likely to benefit in the coming years. The top 4 in growth rate were in provinces with the lowest GDP per capita. Populous provinces also have the top 4 increases in absolute number of mHealth hospital services.

mHealth apps can provide inter-region support from resource-rich areas to poorer areas. This is indicated by the flow of patients mainly from other provinces to Beijing, Shanghai, Guangdong, the areas with the most top-ranked hospitals (51 of the 100 top-ranked hospitals).³¹ The implications can carry over to other developing Asian countries with large populations, such as Indonesia, Philippines, and Bangladesh, where there is a similar trend of top-ranked cardiovascular care facilities residing in 3 main cities/states in the country.^32–34 In poorer areas having access to care via mHealth can help strengthen primary care to prevent and manage chronic conditions. mHealth can also provide a medium to disseminate cardiovascular health education and promotion to regions that often would not receive such information. This study provides evidence that mHealth as a medium of cardiovascular care delivery can alleviate the pressure on the healthcare system’s inverted pyramid of providers.⁵

Looking forward

The future development of mHealth should focus on regulation and quality. Regulation of mHealth services from the perspectives of information technology privacy and security,³⁵ provider licensing, and liability should be considered on all operating platforms. Across Asian developing countries, mHealth platforms can cover more than 10 million cardiovascular patients per jurisdiction, where not all are subject to clear regulation by local health ministries;^36,37 such is also the case in developed markets.³⁸ In China, since COVID-19, the number of internet hospitals has been rising.^29,39 Internet hospitals are regulated mHealth services provided by licensed medical facilities. Practicing physicians providing services on internet hospitals are regulated similar to physical hospitals or clinics and are subject to the same legal protections. Also ensuring states/provinces update licensure requirements allowing physicians to practice beyond their own province or state’s jurisdiction is important.⁴⁰

Furthermore, sufficient triaging infrastructure and patient education should be implemented to ensure appropriate use of the mHealth services. Telemedicine via mHealth apps can be helpful for chronic conditions, but still cannot fully replace initial visits and diagnosis. Patients should be guided and educated on when in-person or emergency care is needed.

To ensure continued democratization of healthcare via mHealth, seamless integration of payment with commercial and national health insurance is necessary. Per the study data collected, the majority of payments were out-of-pocket with few integrating with an insurance payer. The national government first highlighted the importance of covering fees during online diagnosis and treatment after the COVID-19 pandemic – a unique stimulation to mHealth development.⁴¹ Studies have shown that integrating private or national insurance policies with telemedicine services, especially in rural areas, and across regional jurisdictions, is crucial in maintaining usage and adoption can improve the usage rate and user-adherence or satisfaction.^40,42

Developing countries, resource poor markets, or countries with an imbalanced distribution of medical resources can refer to China’s mHealth adoption as a model. Specific technologies were available for the whole population that spearheaded the change. Even as a developing country or having regions with low GDP, internet access and mobile phone usage rates in adults was near universal.^43,44 Also, policies encouraging and hospitals willing to adopt mHealth services allowed comprehensive coverage thus providing easier access to the population, specifically in poorer regions. The technology we believe to be most important is hospital and mHealth connectivity thus providing access; this entails appointment-making and telemedicine. Appointment-making for an in-person consultation in a local or distant facility can provide assurance to be seen and prevent patients from making multiple trips. Telemedicine is also an important contributor however there must be staff for triaging, and payment and digital literacy from the patients and providers.

Limitations

The authors recognize limitations to this study. The data reported were from publicly available data rather than officially published reports. However, a range of platforms was selected to ensure the representativeness of the study. Second, this study describes the implications pertaining to access to care, not the impact of mHealth on CVD outcomes including incidence, awareness, treatment, and mortality rate. Third, the quality of services delivered across providers was not determined. Future studies can examine the impact of quality and outcomes from mHealth on a population level.

From 2016 to 2020, there was a shift in mHealth services from third-party platforms to hospital platforms targeting CVDs in China. The poorer regions had the largest growth rate and inter-province and regional care delivery especially were delivered remotely from resource rich areas. This appears to be a sustainable model for developing countries to democratize CVD care across large populous countries. A comprehensive service suite offered across most applications allows for more health equity in managing CVDs.

mHealth

Mobile health

CVD

Cardiovascular disease

GDP

Gross domestic product

App

Application

Acknowledgements:

We thank HaoDF Online Corp. for providing data on mHealth app usage. We thank Yu-Pei Ma, Dinan Li, Yi Lv, Meng-Di Fan, Jing Zhou for helping screen for mHealth apps on the app store. This study was supported by the National High Level Hospital Clinical Research Funding grant awarded by the Chinese Academy of Medical Sciences to Wei Chen (grant nos.: 2022-PUMCH-B-0252 and 2022-PUMCH-C-069) for data analysis and interpretation.

Declaration of interests:

The authors have no competing interests to declare.

Author’s contributions:

Conceptualization: Wei Chen, Hai Gao, Jeffrey Hsu

Data curation: Xiang Li, Fei Liu, Xiaohang Liu, Fuwei Jia, Cheng-Gang Wang

Formal analysis: Cheng-Gang Wang, Fei Liu, Xiaohang Liu, Ding-ding Zhang

Investigation: Yu Qiu, Fuwei Jia

Methodology: Zhili Jiang, Fuwei Jia

Project administration: Rongrong Ji

Software: Tawquir R. Nawaz

Supervision: Wei Chen, Hai Gao, Yong Zeng

Validation: Tawquir R. Nawaz, Jeffrey Hsu

Visualisation: Xiaohang Liu, Yu Qiu, Tawquir R. Nawaz

Writing – original draft: Yu Qiu, Wei Chen, Xiaohang Liu

Writing– review & editing: Tawquir R. Nawaz, Jeffrey Hsu, Hai Gao, Yong Zeng

Data sharing statement

Only data collected for the purpose of this study will be made available beginning 9 months and ending 36 months following article publication. Data will be shared with researchers who provide a reasonable request only to achieve the aims of the approved request. Requests should be directed to [email protected] or [email protected] to gain access and data requestors will need to sign a data access agreement.

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There is a conflict of interest The authors have no competing interests to declare.

Revolutionizing access to cardiovascular care for 1.4 billion people - How mobile health apps and services evolved from 2016-2020 in China and its implications

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Abstract

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Research in Context

Introduction

Methods

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Discussion

Conclusions

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References

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