Digital health interventions for older adults with heart failure: A scoping review of participant representation, engagement, and equity considerations.

Digital health interventions for older adults with heart failure: A scoping review of participant representation, engagement, and equity considerations - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. 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Learn more: PMC Disclaimer | PMC Copyright Notice Digit Health . 2026 Apr 13;12:20552076261438677. doi: 10.1177/20552076261438677 Search in PMC Search in PubMed View in NLM Catalog Add to search Digital health interventions for older adults with heart failure: A scoping review of participant representation, engagement, and equity considerations Kristina M Kokorelias Kristina M Kokorelias 1 Division of Geriatric Medicine, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada 2 Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada 3 KITE- Toronto Rehabiliation Sciences Institute, Toronto, ON, Canada 4 Rehabilitation Sciences Institute,Temerty Faculty of Medicine, University of Toronto, Toronto, ON Canada Find articles by Kristina M Kokorelias 1, 2, 3, 4, ✉ , Peter M Hoang Peter M Hoang 1 Division of Geriatric Medicine, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada 5 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada 6 Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada Find articles by Peter M Hoang 1, 5, 6 , Maira Khan Maira Khan 6 Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada Find articles by Maira Khan 6 , Maurita T Harris Maurita T Harris 7 Faculty of Liberal Arts, Wilfrid Laurier University, Waterloo, ON, Canada Find articles by Maurita T Harris 7 Author information Article notes Copyright and License information 1 Division of Geriatric Medicine, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada 2 Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada 3 KITE- Toronto Rehabiliation Sciences Institute, Toronto, ON, Canada 4 Rehabilitation Sciences Institute,Temerty Faculty of Medicine, University of Toronto, Toronto, ON Canada 5 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada 6 Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada 7 Faculty of Liberal Arts, Wilfrid Laurier University, Waterloo, ON, Canada ✉ Kristina M. Kokorelias, Division of Geriatric Medicine, Department of Medicine, Sinai Health System and University Health Network, 600 University Avenue, Toronto, ON M5G 1X5, Canada. Email: [email protected] Received 2025 Dec 30; Revised 2026 Feb 27; Accepted 2026 Mar 18; Collection date 2026 Jan-Dec. © The Author(s) 2026 This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( https://creativecommons.org/licenses/by-nc/4.0/ ) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage ). PMC Copyright notice PMCID: PMC13080154  PMID: 41993043 Abstract Objective To examine participant representation, engagement, and equity considerations in randomized controlled trials of digital health interventions for older adults living with heart failure, using the PROGRESS-Plus framework to assess reporting across key social determinants of health. Methods We conducted a scoping review following Joanna Briggs Institute methodology. Randomized controlled trials evaluating digital health interventions for older adults with heart failure were identified through systematic database searches. Data were extracted on participant characteristics, intervention features, engagement outcomes, and reporting across PROGRESS-Plus domains, including place of residence, race/ethnicity, occupation, gender/sex, religion, education, socioeconomic status, social capital, age, disability, sexual orientation, and health literacy. Results Fourteen studies (n = 5,959 participants) were included. Interventions commonly involved remote monitoring, telehealth, wearable devices, and web-based platforms. While overall engagement among enrolled older adults was generally high, reporting of equity-relevant characteristics was inconsistent. Race/ethnicity and education were variably reported, while socioeconomic status and rurality were often minimally described. Cognitive impairment was frequently an exclusion criterion, and digital literacy was rarely assessed using standardized measures. Sexual orientation and health literacy were not reported in any study. These gaps limit understanding of how digital health interventions reach and benefit socially and clinically diverse older adults. Conclusions Digital health interventions for older adults with heart failure demonstrate promising engagement but are characterized by limited and inconsistent reporting of equity-related factors. Greater attention to inclusive recruitment, standardized reporting across PROGRESS-Plus domains, and equity-informed intervention design is needed to ensure that digital innovations support diverse older adults living with heart failure. Keywords: heart failure, digital health, older adults, health equity, PROGRESS-plus, scoping review, participant representation Introduction Heart failure is one of the most prevalent chronic conditions among older adults and represents a major public health challenge due to its high rates of morbidity, frequent hospitalizations, and associated healthcare costs. 1 Effective management of heart failure requires ongoing monitoring, timely intervention, and active patient engagement in self-management behaviors, including adherence to complex medication regimens, daily symptom tracking, dietary and lifestyle modifications, and frequent communication with healthcare providers. 2 , 3 Traditional models of care often rely on episodic in-person visits and reactive management, which may be insufficient to address the dynamic and complex needs of older adults living with heart failure. 4 , 5 These limitations are further compounded by structural barriers, such as geographic distance from care centers, transportation challenges, and limitations in healthcare workforce availability, highlighting the need for innovative approaches to care delivery. 4 Digital health interventions, encompassing mobile health applications, wearable sensors, remote monitoring platforms, telehealth services, and interactive web-based programs, have emerged as promising strategies to address these challenges. 6 – 8 By providing continuous, real-time feedback, personalized guidance, and remote connectivity with healthcare providers, digital health technologies can facilitate more proactive, patient-centered management of heart failure. 7 For instance, remote monitoring systems can detect early signs of decompensation, mobile applications can support medication adherence and symptom tracking, and telehealth platforms can facilitate timely provider interventions. 9 Beyond individual-level benefits, these digital health interventions also offer potential system-level advantages, including reduced hospital readmissions, improved care delivery efficiency, and enhanced capacity for longitudinal data collection to inform population health strategies and predictive analytics. 10 – 12 Despite the promise of digital health interventions, their adoption and effectiveness are influenced by both participant characteristics and intervention design. 13 , 14 Older adults are a heterogeneous population with considerable variation in age, cognitive function, digital literacy, socioeconomic status, sex and gender, racial or ethnic identity, and geographic location. 15 These factors can affect access to technology, comfort and proficiency in using digital tools, engagement with interventions, and ultimately, health outcomes. 16 Existing literature suggests that many digital health interventions fail to adequately consider these differences, which may contribute to the underrepresentation of certain subgroups, reduced usability, and inequities in intervention impact. 17 For example, older adults with limited digital literacy or cognitive impairment may struggle to navigate complex interfaces, while those in rural or low-resource settings may lack reliable access to internet-enabled devices. 18 Similarly, interventions that do not account for culturally relevant content or language preferences may be less engaging for racially or ethnically diverse populations. 19 In addition to participant characteristics, intervention design features, including technology type, delivery mode, frequency of interaction, level of personalization, and integration with routine clinical care, play a critical role in shaping engagement and effectiveness. 20 , 21 Some interventions rely on passive monitoring (non-invasive), 22 whereas others require active participant input, which can differentially affect adherence. 23 Interventions delivered through multiple modalities, such as combining mobile applications with telehealth coaching or wearable sensors, may improve engagement by providing redundancy and flexibility. 24 Frequency of use and the intensity of feedback also influence whether older adults can sustain participation over time, highlighting the importance of user-centered design principles and iterative co-design processes in developing effective digital health solutions. 25 Given these considerations, there is a critical need to systematically examine how older adults are represented in research on digital health interventions for heart failure and to explore how intervention characteristics influence participation and engagement. While some reviews have examined the efficacy of digital health interventions for heart failure broadly, few have focused on the inclusion of diverse subgroups or explicitly addressed equity, accessibility, and usability concerns. Mapping this literature can illuminate gaps in representation, identify barriers to participation, and inform the design of interventions that are both effective and inclusive. Methodology This scoping review was carried out following the Joanna Briggs Institute (JBI) guidelines for scoping reviews, which provide a structured approach to mapping the breadth and nature of existing evidence. 26 The review was framed using the PROGRESS-Plus framework, which prioritizes examining interventions with attention to equity by considering factors that shape differences in health outcomes and opportunities among diverse populations. 27 PROGRESS-Plus is a widely used tool for examining social determinants of health across research studies. The domains include place of residence (e.g., urban, rural, or geographic location of participants), race/ethnicity (self-identified or reported population groupings), occupation (employment status or type of work), gender/sex (reported gender identity or biological sex), religion (religious affiliation where reported), education (highest level of formal education attained), socioeconomic status (income level, financial indicators, or area-level deprivation measures), social capital (social relationships, caregiver support, or community connectedness), age (age distribution or age-related subgroup reporting), disability (including cognitive or functional impairment), and the additional “Plus” factors of sexual orientation and health literacy. The protocol was registered on the Open Science Framework (osf.io/2a7hz) and was published (Citation Blinded for Review) . We report our methods and findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review (PRISMA-ScR) checklist (see Appendix A ). Ethical approval was not required for this scoping review, as it did not involve human participants or the collection of primary data. At the host institution, research ethics board approval was also unnecessary for the involvement of patient and family partners, since they were considered members of the research team rather than study participants. Formal consent was not obtained, as their participation was implied through their application to serve as partners. Review objective and questions The primary objective of the review was to map the literature on digital health interventions designed for failure management in older adults and to evaluate how the representation of diverse subgroups was described. The review also sought to describe the characteristics of these interventions and examine whether specific features influenced participation among older adults. The main review question focused on identifying the participants represented in digital health interventions for older adults with heart failure. Secondary questions explored how subgroups of older adults, differentiated by age, cognitive function, socioeconomic position, sex or gender, racial or ethnic identity, and geographic location, were included, and what characteristics of the interventions, such as technology type, delivery mode, and frequency of use affected engagement. Eligibility criteria Studies were eligible for inclusion if they involved adults aged 50 years and older diagnosed with heart failure. Although 65 years is typically used to define older adulthood, a lower threshold of 50 was applied to account for health equity considerations and evidence of accelerated aging in marginalized populations (e.g., HIV, Indigenous populations, and members of racially or socioeconomically disadvantaged groups) (Citation Blinded for Review) . 28 Eligible participants could reside in the community or in institutional or supportive care settings, provided the study specifically targeted heart failure management. The review focused on interventions that utilized digital health technologies, defined as platforms or tools that employ computing and telecommunications to deliver, enhance, or monitor healthcare services. Eligible interventions included mobile health applications, wearable devices, online platforms, remote monitoring systems, telemedicine integrated with patient portals, and other digital solutions designed to provide interactive and personalized care for heart failure management. Interventions are typically aimed at supporting symptom monitoring, medication adherence, self-care education, virtual consultations, or real-time clinical monitoring. Only studies conducted in high-income countries, as classified by the World Bank, were considered to ensure comparability in healthcare infrastructure, technology access, and intervention feasibility. 29 Eligible studies could be conducted in outpatient clinics, hospitals, rehabilitation centers, community programs, or home-based care settings. Studies from low- or middle-income countries were excluded due to significant differences in healthcare system capacity and digital infrastructure. The review also focused on how equity-related factors were reported, using the PROGRESS-Plus framework to assess whether studies considered characteristics such as place of residence, race or ethnicity, socioeconomic status, education, gender, and other relevant variables. 27 Only randomized controlled trials were included, as these study designs enabled rigorous evaluation of interventions and typically provided standardized reporting of participant characteristics, facilitating the assessment of equity-related variables. Eligible studies were peer-reviewed and published in English or capable of being translated into English using Google Translate. Studies reporting protocols, observational designs, quasi-experimental methods, qualitative-only findings, and conference abstracts were excluded. Search strategy A three-stage search strategy was used. 26 First, a preliminary search of MEDLINE (via PubMed) and CINAHL (via EBSCOhost) identified relevant studies, and keywords and index terms from these articles were analyzed to inform the development of a comprehensive search strategy. In the second stage, the full search was executed across MEDLINE, CINAHL, Embase, and Scopus, combining controlled vocabulary terms and free-text keywords related to digital health, heart failure, and older adults (See Appendix B ). RCT filters were applied where appropriate. A medical librarian reviewed the search strategy to ensure completeness and accuracy. In the third stage, reference lists of included studies and relevant systematic reviews were screened to identify additional studies. Only peer-reviewed studies published between January 1, 2005, and May 12, 2025, were included, reflecting the rapid growth and clinical adoption of digital health technologies. All retrieved records were managed in Covidence for deduplication and screening. 30 Study selection Before full screening, a pilot test was conducted to ensure consistent application of the inclusion and exclusion criteria. Two reviewers independently screened 25 randomly selected records, and the process was repeated until inter-rater reliability reached a Cohen’s kappa of 0.70 or higher. Discrepancies were discussed, and the criteria were refined as needed. Following the pilot, two reviewers independently screened all titles and abstracts, with studies deemed potentially eligible or unclear progressing to full-text review. Full texts were also independently reviewed by two reviewers, and disagreements were resolved through discussion or by consulting a third reviewer. Reasons for excluding studies at the full-text stage were documented, and the study selection process was summarized in a PRISMA-ScR flow diagram ( Figure 1 ). Figure 1. Open in a new tab Prisma Flow Diagram. Data extraction Data were independently extracted by two reviewers using a standardized form in Covidence, adapted from JBI methodology. The extraction tool incorporated PROGRESS-Plus domains to capture equity-relevant information, including participants’ age, sex or gender, race or ethnicity, socioeconomic status, education, digital literacy, language proficiency, comorbidities, cognitive or functional status, and other relevant characteristics. 27 Information about study design, setting, funding sources, recruitment strategies, and intervention features, including technology type, primary functions, delivery mode, duration, healthcare provider involvement, co-design elements, and efficacy, was also collected. Additionally, equity considerations were noted, such as whether the intervention was tailored to specific subgroups or included strategies to enhance digital inclusion, and whether outcomes were reported for different subgroups. Limitations and authors’ recommendations regarding equity were also extracted. The extraction form was piloted on a small subset of studies (n=2). Authors (n=2) were contacted when information was missing or unclear. A formal assessment of study quality or risk of bias was not conducted, as this was outside the scope of the review. As this study was a scoping review, a formal sex- and gender-based analysis was not performed, in accordance with JBI guidance for scoping reviews. 31 Data analysis and presentation Data were analyzed using both quantitative and qualitative descriptive methods. Quantitative data, including publication year, study setting, sample characteristics, and intervention features, were summarized using frequencies and proportions. Qualitative data were synthesized using deductive coding guided by PROGRESS-Plus domains, including place of residence, race or ethnicity, occupation, gender or sex, religion, education, socioeconomic status, social capital, and additional factors such as age, disability, sexual orientation, and health literacy. 27 The synthesis identified patterns in representation, intervention design, and equity-related reporting, highlighted gaps in the literature, and provided insight into how digital health interventions may either mitigate or exacerbate disparities among older adults with heart failure. Patient engagement strategy An integrated knowledge translation approach was applied in this scoping review. 32 The time commitment for the public partner was 2 hours per month, as confirmed and agreed upon in advance. Although patient engagement has not traditionally been part of scoping review methodology, there has been growing recognition of the value of including patient input in literature reviews. 33 Recruitment was facilitated through pre-existing relationships with the research team. Partnership procedures were co-developed in accordance with the CIHR Patient Engagement Framework. 34 High-level meeting minutes captured decisions, so no identifying information about partners’ experiences was collected. Results A total of 14 studies were included in this scoping review (see Figure 1 ). The majority of the studies (n=13, 93%) were randomized controlled trials (RCTs), with the remaining study using a mixed-methods approach. 35 Across all studies, the total number of participants was 5959. The sample sizes of the studies varied, ranging from 20 36 to 3124. 37 The mean sample size was 426. Almost all studies (n=13, 93%) were conducted in a Global North country or region. One study was conducted in Colombia. 38 The most heavily represented country in the global North was the United States of America, with five studies (36%) in this sample conducted there. 35 , 37 , 39 – 41 We summarize the studies in Table 1 . Overall, the included studies demonstrated substantial variability in the reporting of participant characteristics and equity-relevant variables. While digital health interventions for older adults with heart failure generally reported basic demographic information, detailed reporting across social determinants of health was inconsistent. Many PROGRESS-Plus domains were either minimally described or used as exclusion criteria rather than variables for analysis. The synthesis below summarizes key patterns of representation, intervention characteristics, and reporting gaps across included trials. Table 1. Study characteristics. Authors, year, country, study design Study objectives Methods for data collection Results Limitations Conclusions Diana M. Achury-Saldaña, Rafael A. Gonzalez, Angel Garcia, Alejandro Mariño, Wilson R. Bohorquez; 2024; Colombia; RCT To evaluate the efficacy of the ControlVit telemonitoring system as a complementary strategy in reducing hospital readmissions and deaths in patients with heart failure. Randomized allocation of adult outpatients with heart failure to intervention (ControlVit + standard care) or control (standard care) groups; data collected via mobile application (intervention group) and standard clinical follow-up; daily biometric and symptom data reviewed by clinicians; outcomes assessed over 6 months; statistical analysis with t-tests, χ 2 /Fisher’s exact, log-rank test, and Cox proportional hazards model. Intervention group had fewer readmissions for decompensated heart failure (3 vs 14; p = 0.0081) and fewer deaths (3 vs 11; p = 0.024). Single healthcare facility; calculated sample size based on composite outcome; structured follow-up in the control group may have reduced observed differences compared with less-structured outpatient follow-up. ControlVit is a useful complementary tool that reduces hospital admissions and deaths due to heart failure decompensation, enhances self-care, and improves continuity of care. Hazard ratio for combined outcome of readmission or death: 0.75 (95% CI 1.82–35.7; p < 0.011). Intervention improved monitoring, timely interventions, and education for self-care. Tariq Ahmed, Nihar R Desai, Yu Yamamoto, Aditya Biswas, Lama Ghazi, Melissa Martin, Michael Simonov, Ravi Dhar, Allen Hsiao, Nitu Kashyap, Larry Allen, Eric J Velazquez, F Perry Wilson; 2022; United States; RCT To assess whether providing prognostic information in heart failure leads to better treatment decisions, more suitable end-of-life care, and ultimately lower rates of hospitalization or mortality. Patients were randomly assigned to either the alert (intervention) group or the standard of care group using an internal random-number rule. The alert was developed using recommended methodologies through focus groups prior to the clinical trial. The primary outcomes assessed were 30-day hospital readmission and 1-year mortality. Median NT-proBNP levels were 3826 (1692-8241) pg/mL in the alert group, and 3867 (1663-8917) pg/mL in the usual-care group. 284 patients were admitted to the ICU group and 270 from the usual-care group. 367 patients in the alert group had a left ventricular ejection fraction of 40% or less, and 359 patients did in the usual-care group. The primary outcome occurred in 619 patients in the alert group and 603 in the usual-care group (p=0.89) Small sample size, short follow-up period, single-center study, limited generalizability, potential selection bias The REVEAL-HF trial, conducted in a high-risk hospitalized heart failure population, investigated whether 1-year prognostic knowledge influences clinical decisions and outcomes, but found no supporting evidence. Marie A Bakitas, J Nicholas Dionne-Odom, Deborah B Ejem, Rachel Wells, Andres Azuero, Macy L Stockdill, Konda Keebler, Elizabeth Sockwell, Sheri Tims, Sally Engler, Karen Steinhauser, Elizabeth Kvale, Raegan W Durant, Rodney O Tucker, Kathryn L Burgio, Jose Tallaj, Keith M Swetz, Salpy V Pamboukian; 2020; United States; RCT To evaluate the impact of a 16-week early palliative care telehealth intervention on quality of life, mood, overall health, pain, and healthcare resource utilization in patients with advanced heart failure. 2-site, single-blind RCT comparing effect of ENABLE CHF-PC with usual care. Outcome measures were collected via trained, blinded data collectors via telephone every 8 weeks, for a total of 48 weeks. Primary outcomes were: QOL via KCCQ, functional assessment via FACIT PAL-14, mood via HADS. At week 16, mean KCCQ score improved by 3.9 points in intervention group versus 2.3 points in the usual care group (d=0.07), and mean FACIT-Pal-14 score improved by 1.4 points in intervention group versus 0.2 in the usual care group (d=0.12). No relevant between group differences in mood Higher than expected data attrition at 16 weeks, multiple strategies to contact patients including incentives and repeated attempts, attrition influenced by illness, socioeconomic factors, and irregular healthcare access, some participants missed palliative consultation or sessions, reduced intervention dose may explain limited QOL and mood effects, overrecruited and adjusted analyses for missing data, exploring video consultations to improve accessibility Few palliative care programs exist in the southeastern United States, and underserved, rural, minority patients have limited access to guideline-concordant care. This trial addressed the gap by using a nurse-led telehealth model to deliver culturally tailored palliative care to heart failure patients who otherwise could not access such services. The study also highlights the potential influence of baseline quality of life in identifying populations most likely to benefit, and future research will examine patient factors and intervention components to optimize the timing and dose of palliative care. Roberto Antonicelli, Ilaria Mazzanti, Angela M. Abbatecola, Gianfranco Parati; 2010; Italy; RCT To evaluate the effect of telemonitoring on patients’ adherence to prescribed therapies, particularly beta-blockers, and to determine whether home telemonitoring reduces mortality and hospital readmission rates in elderly patients with chronic heart failure compared with standard specialized CHF team care. Patients were randomized to a control group who received standard care with routinely scheduled clnic visits from a CHF specialized team, or home telemonitoring group (TM) which were managed by the same specialized CHF team. TM group had significantly increased usage of beta-blockers, statins, and aldosterone receptor antagonists. The TM group also had reduced nitrate administration compared with baseline. The primary combined endpoint of mortality and hospital readmission for CHF at 12 months was significantly lower in the TM group than in the control group Small sample size, short follow-up This study demonstrated that a home-care model incorporating telemonitoring of key clinical parameters may offer valuable support in managing patients with CHF. Home telemonitoring was associated with increased use of beta-blockers at appropriate doses, suggesting that this approach reassured physicians about the safe use of these agents in this context. However, larger studies are needed to confirm these results. Our findings highlight the importance of monitoring relevant parameters in CHF patients in their daily lives, which can help optimize beta-blocker and other drug therapies. Aggie H. Balka, Wim Davidse, Paula van Dommelen, Ellen Klaassen, Kadir Caliskan, Pieter van der Burgh, Christina M. Leenders; 2008; Netherlands; RCT To determine whether a tele-guidance program could improve patient knowledge about heart failure, self-care practices, and overall quality of life. Participants with CHF were randomly assigned to standard care or tele-guidance. The tele-guidance group used a web platform for weekly educational sessions and remote interactions with heart failure nurses for 6 months. Outcomes were measured using validated questionnaires covering knowledge, self-care, quality of life, and depressive symptoms. There were no significant improvements found between both groups in primary outcomes, QoL, or self care behavior. The intervention group had significantly increased knowledge about heart failure (p<0.001). Short study duration, the intervention improved knowledge but did not affect self-care or quality of life, and the participants were a motivated and selected sample which may limit generalizability. Tele-guidance can effectively increase patient knowledge of heart failure but does not appear to improve self-care or quality of life in the short term. Further studies are needed to assess broader outcomes and longer-term impact. Palmira Bernocchi, Michele Vitacca, Maria Teresa La Rovere, Maurizio Volterrani, Tiziana Galli, Doriana Baratti, Mara Paneroni, Giuseppe Campolongo, Barbara Sposato, Simonetta Scalvini; 2005, UK, Germany, Netherlands; RCT To compare the effects of home telemonitoring, nurse telephone support, and usual care on outcomes in patients with chronic heart failure. Patients with heart failure were randomized to one of three groups: home telemonitoring (daily electronic transmission of weight, blood pressure, heart rate, and ECG via equipment installed at home), nurse telephone support (structured calls and support), or usual care. After 4 months, the intervention group could walk further than baseline, whereas the control group showed no improvement (p=0.0040). The median time to hsopitalization/death was 113.4 days in the intervention group compared to 104.7 days in the control group (p=0.0484). Other secondary outcomes were also significantly improved in the intervention group compared to the control group and stayed improved at the 6 month mark as well. Sample size was relatively modest; technology used was complex and may not reflect routine practice; patients were selected and may not represent all heart failure populations. Both telemonitoring and nurse-led support are viable alternatives to standard care for patients with heart failure and may reduce hospitalizations, though neither significantly reduced mortality compared with each other. Andreas Blomqvist, Maria Bäck, Leonie Klompstra, Anna Strömberg, Tiny Jaarsma; 2025; Sweden; RCT To test the recruitment rate, fidelity of implementation, and feasibility of outcomes for the Activity Coach app. Patients who were already using the existing mHealth tool Optilogg were recruited and randomized to either have their tool updated with the Activity Coach app or control group. Intervention was 12 weeks long and on weeks 1 and 12, participants wore an accelerometer daily to measure physical activity, as well as measuring HR-QoL via KCCQ and subjective goal attainment. Daily adherence to registering physical activity in Activity Coach app was 69% and weekly adherence was 88%. Mean goal attainment score was -1.0 for the control group, compared to 0.6 for the intervention group (p=0.001). The mean change in HR-QoL was -9 for control group versus 3 for the intervention group (p=0.027). There was a significant improvement in physical limitation scores (p=0.04). The average length of sedentary bouts increased by 27 minutes in the control group and decreased by 0.70 minutes in the intervention group. There was no significant difference in the mean light physical activity amount. Small sample size, short follow-up, potential selection bias, and limited generalizability due to recruitment challenges. The Activity Coach app appears feasible and acceptable as a supportive tool for older adults with heart failure, though further work is needed to optimize recruitment and adherence. Giuseppe Boriani, Antoine Da Costa, Aurelio Quesada, Renato Pietro Ricci, Stefano Favale, Gabriele Boscolo, Nicolas Clementy, Valentina Amori, Lorenza Mangoni di S. Stefano, Haran Burri; 2017; Europe & Israel; RCT To determine whether remote monitoring of patients with newly implanted CRT-D devices reduces mortality and hospitalizations compared to standard in-office follow-up, and to assess its impact on healthcare use and costs. Patients randomized within 8 weeks of CRT-D implant to remote monitoring (CareLink system) with alternating remote/in-office checks vs. standard in-office follow-up. Clinical events, healthcare utilization, and costs were collected prospectively, with adjudication by blinded committees. No significant differences were found in the primary endpoint of composite death and cardiovascular and device-related hospitalization between the control and intervention group, or in the individual components of the primary endpoint. There was a significant decrease in the amount of healthcare utilization by 38% in the intervention group (p<0.001), mainly in the number of in-office visits. Study ended early, limiting power to detect differences in primary endpoint; majority of patients recruited in Italy may affect cost generalizability; clinical management varied across centers; only limited device diagnostics (e.g., atrial fibrillation, thoracic impedance) were enabled. Remote monitoring of CRT-D patients was safe and feasible, but did not significantly reduce the composite clinical endpoint. It reduced travel-related patient costs and may lower healthcare costs, supporting its role as an efficient alternative to standard follow-up. Josiane J.J. Boyne, Hubertus J.M. Vrijhoef, Harry J.G.M. Crijns, Gerjan De Weerd, Johannes Kragten, Anton P.M. Gorgels; 2012; Netherlands; RCT To assess whether a tailored telemonitoring intervention improves quality of life, self-care, and clinical outcomes in heart failure patients compared with usual care. Patients were randomized to telemonitoring or usual care. The intervention included daily home monitoring of symptoms, weight, blood pressure, and heart rate using an electronic device, with data transmitted to nurses who provided individualized feedback. Follow-up lasted 12 months. Outcomes measured: quality of life, self-care behavior, mortality, and hospitalization. No significant difference in the mean time to first heart failure-related hospitalization (p=0.151). No differences in secondary endpoints, including duration of heart failure, having a pacemaker, and co-habiting, except for significantly decreased number of face to face contacts with the heart failure nurse (p<0.001). No significant difference in mortality (p=0.82) Underpowered for clinical outcomes; patients were relatively young and stable, which may have limited ability to detect effects; adherence to telemonitoring varied. Tailored telemonitoring was safe and feasible, but did not provide additional benefits over usual care in improving outcomes for this patient group. Darshan H. Brahmbhatt, Heather J. Ross, Mary O’Sullivan, Veronica Artanian, Brigitte Mueller, Kyle Runeckles, Chun-Po Steve Fan, Valeria E. Rac, Emily Seto; 2024; Canada; RCT To assess whether remote medication titration for patients with heart failure with reduced ejection fraction was more effective than usual care (UC). Patients were randomized to remote GDMT titration through the Medly heart failure program versus usual care. At 6 months, GDMT titration was completed in significantly more patients in the intervention group than the control (p=0.001). Remote titration required significantly fewer in-person visits (p=0.004) and remote visits (p=0.009). Median time to optimization was significantly shorter in the intervention group (3.42 months vs 5.47 months, p<0.001). There was no significant difference in the number of urgent clinic/emergency department visits. Single-center study in a specialized heart function clinic, patients and clinicians experienced with the Medly HFRPM platform, lack of blinding for clinicians and participants, potential bias in GDMT optimization decisions, health service utilization outside the institution based on patient-reported data, possible under-reporting of hospitalizations and other events, younger average patient age compared to typical HF cohorts, limited generalizability to other clinics and populations Remote titration of GDMT in heart failure with reduced ejection fraction proved effective, safe, and feasible, leading to a higher proportion of patients reaching target doses more quickly, without an increase in adverse events compared with usual care. Carly M. Goldstein, Emily C. Gathright, Mary A. Dolansky, John Gunstad, Anthony Sterns, Joseph D. Redle, Richard Josephson, Joel W. Hughes; 2014; USA; RCT To explore heart failure patients’ and caregivers’ views on integrating palliative care early in the course of illness, including preferences, barriers, and needs. Conducted focus groups and in-depth interviews with patients with advanced heart failure and their caregivers Overall adherence was 78% (76% in control vs 80% in intervention). Though telehealth reminders did not improve adherence, patient’s preferred the m-health approach Single geographic region; participants may not represent the full diversity of heart failure populations; possible selection bias toward those willing to discuss sensitive topics. Early palliative care integration in heart failure could address unmet emotional and informational needs, but implementation strategies must overcome barriers related to awareness and stigma. Leanne L. Lefler, Sarah J. Rhoads, Melodee Harris, Ashley E. Funderburg, Sandra A. Lubin, Isis D. Martel, Jennifer L. Faulkner, Janet L. Rooker, Deborah K. Bell, Heather Marshall, Claudia J. Beverly; 2018; USA; Mixed-methods study To test the feasibility and acceptability of a home telehealth program for heart failure patients, focusing on self-care management and early detection of deterioration. Patients were randomized to receive either standard care or telehealth support with daily biometric monitoring (weight, BP, HR, SpO 2 ) transmitted electronically to nurses. Outcomes included feasibility, adherence, patient satisfaction, and early clinical outcomes. Telehealth participants used the system consistently and reported high satisfaction. Nurses were able to detect early warning signs and intervene. Recruitment and retention were feasible. Small sample size; short follow-up; not powered for clinical outcomes; conducted in one region, limiting generalizability. A nurse-supported home telehealth program is feasible and acceptable in HF patients, with potential to improve early detection and management of worsening symptoms. Larger studies are needed. Daniel Sahlin, Babak Rezanezad, Marie-Louise Edvinsson, Erasums Bachus, Olle Melander, Sofia Gerward; 2022; Sweden; RCT To assess the feasibility and preliminary effectiveness of supplementing nurse case management with internet-connected telemonitoring in elderly patients with heart failure. Patients received either usual nurse case management or additional telemonitoring (daily weight, BP, HR, SpO 2 transmitted to a secure platform). Nurses reviewed data and contacted patients when abnormalities occurred. Data were collected over 6 months on clinical outcomes, healthcare utilization, and feasibility. The telemonitoring group had fewer unplanned HF hospitalizations and increased use of guideline-directed medications (e.g., β-blockers at appropriate doses). Patients and nurses reported the system was easy to use and helpful in care management. Small sample size; not randomized; limited generalizability; follow-up duration relatively short. Telemonitoring integrated into nurse case management appears feasible, acceptable, and may improve medication use and reduce hospitalizations, but larger trials are needed to confirm benefits. Marcia J. Wade, Akshay S. Desai, Claire M. Spettell, Aaron D. Snyder, Virginia McGowan-Stackewicz, Paula J. Kummer, Maureen C. Maccoy, Randall S. Krakauer; 2011; USA; RCT To evaluate the effect of adding Internet-connected telemonitoring to nurse case management on clinical outcomes in elderly patients with heart failure Participants were randomized to control group with case management or intervention group, involving telehealth system with case management. The primary outcome assessed at 6 months was composite all-cause hospitalization, ED visit, or death. There was no significant difference in the primary composite outcome. The intervention group had 42% less inpatient days than the year prior. Telehealth alerts from the intervention group required increased telephone contact, thus increasing the case managers’ workload. Small sample size, limited intervention time There was no significant difference in morbidity or mortality between the intervention group and control group, despite the effective implementation of the telehealth intervention. Open in a new tab Theme 1. Intervention characteristics and engagement There was variation in the type of intervention and in the degree of involvement of healthcare professionals with participants. The majority of the studies (n=8, 57%) used some form of remote home monitoring. 35 , 38 , 40 – 45 Four studies (28.5%) featured the use of an app-based intervention, 36 , 38 , 40 , 46 two used the telephone (14%), 39 , 47 one used a web-based platform (7%), 48 and one used a shared electronic health record (7%). 37 Four studies also used biometric monitoring as part of the intervention (28.5%). 35 , 38 , 43 , 45 Interventions varied in the intensity and structure of participant–provider interaction. Some programs relied primarily on passive monitoring with automated feedback, while others incorporated scheduled communication, real-time alerts, or active clinical review by healthcare professionals. Overall, the included studies did not consistently report detailed metrics describing interaction frequency, duration, or qualitative aspects of engagement, limiting the ability to compare intervention “dose” across trials. Nine of the studies (64%) 35 , 38 , 39 , 41 , 42 , 45 , 47 , 48 included interventions that involved regular feedback and interaction between healthcare providers and participants. Some studies with limited engagement from healthcare providers also showed beneficial outcomes, including higher medication optimization rates 46 and high adherence rates. 44 One study found that a majority of participants felt they had improved access to healthcare providers through remote care. 46 We summarize the interventions in Table 1 . Theme 2. Participant demographic representation Participants were predominantly male and reported higher levels of formal education where this information was available . Reporting of gender diversity was absent across all studies. The majority of the included studies (n=12, 86%) 35 – 39 , 42 – 48 reported participants’ sex/gender. All studies that reported participant sex had more men than women. In five studies, 38 , 42 , 45 , 46 , 48 men made up 60% or more of participants, with one study 45 reporting as high as 88% male participation. None of the studies in the sample reported on gender diversity in participants ( Tables 2 and 3 ). Table 2. Participant characteristics. Authors, year, country, study design Age range Mean age Sex/Gender Race/Ethnicity Socioeconomic indicators Education level Digital literacy Language proficiency Comorbidities Cognitive status Geographic setting Disability Sexual orientation Health literacy Diana M. Achury-Saldaña, Rafael A. Gonzalez, Angel Garcia, Alejandro Mariño, Wilson R. Bohorquez; 2024; Colombia; Randomized clinical trial NR 66 years (SD 11.9) overall; intervention 64.1 (SD 12.0), control 69.4 (SD 11.2) 71% men overall; intervention 21/70 female, control 19/70 female NR NR Elementary, high school, associate degree, or major degree; proportions reported in Table 1 Able to handle mobile devices (inclusion criterion) NR Arterial hypertension (44.3%), chronic kidney disease (37.9%), diabetes mellitus (27.9%), hypothyroidism (38%), obstructive sleep apnea (25.7%), COPD (12.9%), dyslipidemia (42%) NR Urban NR NR NR Tariq Ahmed, Nihar R Desai, Yu Yamamoto, Aditya Biswas, Lama Ghazi, Melissa Martin, Michael Simonov, Ravi Dhar, Allen Hsiao, Nitu Kashyap, Larry Allen, Eric J Velazquez, F Perry Wilson; 2022; United States; RCT NR Alert group: 76.5 (IQR 65-86) Alert group: 49.9% male, 50.1% female Usual care: 0.8% Asian, 20.4% Black, 8.6% Hispanic, 91.1% non-Hispanic, 70.8% White, 0.4% other ethnicity, 8.0% other race NR NR NR NR (alert group%, usual care %) NR Urban NR NR NR Usual care group: 77 (IQR 65-86) Usual care: 48.6% male, 51.4% female Usual care: `.4% Asian, 19.4% Black, 10.6% Hispanic, 88.6% non-Hispanic, 70.2% White, 0.9% other ethnicity, 8.9% other race Atrial fibrillation (48.6%, 50.7%), chronic kidney disease (41.4%, 40.6%), COPD (30.1%, 31.0%), type 2 diabetes (43.6%, 43.7%), depression (23.6%, 24.4%) Marie A Bakitas, J Nicholas Dionne-Odom, Deborah B Ejem, Rachel Wells, Andres Azuero, Macy L Stockdill, Konda Keebler, Elizabeth Sockwell, Sheri Tims, Sally Engler, Karen Steinhauser, Elizabeth Kvale, Raegan W Durant, Rodney O Tucker, Kathryn L Burgio, Jose Tallaj, Keith M Swetz, Salpy V Pamboukian; 2020; United States; RCT Intervention group: 50-89 Usual care: 50-92 Intervention group: 63.5 (SD 8.0) Intervention: 53.4% male Intervention: 44.2% White, 54.3% African American, 1.4% other Intervention group: 50.5% married/living with partner, 25.0% divorced/separated, 13.9% never married, 10.1% widowed. 9.1% employed, 39.4% retired/homemaker, 48.6% disability, 2.9% not employed. 93.8% protestant, 1.4% Catholic, 1.9% other, 2.9% none Intervention: 13.9% less than high school graduate, 39.4% high school graduate or GED, 29.3% some college or technical school, 13.9% college graduate, 3.4% graduate degree Able to complete telephone-administered baseline questionnaires English-speaking Charlson Comorbidity Index mean (SD) Intervention group: 3.2 (1.9) Usual care: 3.4 (1.9) Callahan Cognitive Screener score of 3 or more 72.1% intervention group in urban residence, 75.8% usual care group in urban residence Intervention group 48.6% NR NR Usual care: 64.1 (SD 9.1) Usual care: 53.1% male Usual care: 44.4% White, 54.6% African American, 1.0% other Usual care: 46.4% married/living with partner, 27.1% divorced/separated, 10.6% never married, 15.9% widowed. 5.3% employed, 44.9% retired/homemaker, 46.9% disability, 2.4% not employed. 88.9% Protestant, 4.3% Catholic, 3.4% other, 3.4% none Usual care: 14.5% less than high school graduate, 23.7% high school graduate or GED, 40.6% some college or technical school, 12.6% college graduate, 8.2% graduate degree Usual care 46.9% Roberto Antonicelli, Ilaria Mazzanti, Angela M. Abbatecola, Gianfranco Parati; 2010; Italy; RCT NR 78.2, SD 7.3 57.9% male NR NR NR NR NR NR NR NR NR NR NR Aggie H. Balka, Wim Davidse, Paula van Dommelen, Ellen Klaassen, Kadir Caliskan, Pieter van der Burgh, Christina M. Leenders; 2008; Netherlands; RCT Total: 33-87 Total: 66 Total: 30% female NR NR NR Patients were required to be able to use the tele-guidance system, implying baseline digital skills, but no details reported NR Total: 32% hypertension, 31% diabetes mellitus, 23% COPD Control: 30% hypertension, 31% diabetes mellitus, 20% COPD Intervention: 35% hypertension, 30% diabetes mellitus, 27% COPD NR NR NR NR NR Control: 42-87 Control: 65 Control: 25% female Intervention: 33-85 Intervention: 68 Intervention: 36% female Palmira Bernocchi, Michele Vitacca, Maria Teresa La Rovere, Maurizio Volterrani, Tiziana Galli, Doriana Baratti, Mara Paneroni, Giuseppe Campolongo, Barbara Sposato, Simonetta Scalvini; 2005, UK, Germany, Netherlands; RCT NR Control: 70 (SD 9.5) Control: 75% male NR NR NR NR NR NR NR NR NR NR NR Intervention: 71 (SD 9) Intervention: 88% male Andreas Blomqvist, Maria Bäck, Leonie Klompstra, Anna Strömberg, Tiny Jaarsma; 2025; Sweden; RCT NR Total 78 (SD 7) Total 40% female; NR NR NR Mixed, some participant needed support NR Diabetes 25%, COPD 25%, hypertension 50%, atrial fibrillation 40%, kidney disease 25% NR NR NR NR NR Control 77 (SD 5) Control: 40% female Intervention: 78 (SD 9) Intervention: 40% female Giuseppe Boriani, Antoine Da Costa, Aurelio Quesada, Renato Pietro Ricci, Stefano Favale, Gabriele Boscolo, Nicolas Clementy, Valentina Amori, Lorenza Mangoni di S. Stefano, Haran Burri; 2017; Europe & Israel; RCT NR Control 67 Control 73.1% male NR NR NR NR NR Control: 45.3% ischemic cardiomyopathy, 40.7% MI, 24.5% atrial arrhythmia, 14.7% atrial fibrillation, 37% diabetes, 40.8% hypertension, 6.2% previous TIA or stroke, 15.6% COPD NR NR NR NR NR Intervention 66 Intervention 78.8% male Intervention: 42.8% ischemic cardiomyopathy, 38.5% MI, 29.2% atrial arrhythmia, 20.7% atrial fibrillation, 31.3% diabetes, 46.2% hypertension, 8.7% previous TIA or stroke, 14.2% COPD Josiane J.J. Boyne, Hubertus J.M. Vrijhoef, Harry J.G.M. Crijns, Gerjan De Weerd, Johannes Kragten, Anton P.M. Gorgels; 2012; Netherlands; RCT Control: 37-93 Total: 71 Total: 59% male, 41% female NR Control: 66% married/partner Control: 34% primary school, 41% second school/low vocational training, 13% medium vocational training, 11% high vocational/university NR (participants received training to use devices) NR NR NR NR NR NR NR Intervention: 32-91 Control: 71.9 Control: 60% male, 40% female Intervention: 62% married/partner Intervention: 33% primary school, 48% second school/low vocational training, 10% medium vocational training, 9% high vocational/university Intervention: 71.0 Intervention: 58% male, 42% female Darshan H. Brahmbhatt, Heather J. Ross, Mary O’Sullivan, Veronica Artanian, Brigitte Mueller, Kyle Runeckles, Chun-Po Steve Fan, Valeria E. Rac, Emily Seto; 2024; Canada; RCT NR NR Control: 27% female NR NR NR NR NR Control: previous MI 21%, previous PCI 13%, previous CABG 13%, hypertension 29%, diabetes 21%, stroke/TIA 8%, asthma/COPD 8%, dyslipidemia 10% NR NR NR NR NR Median age control: 54, intervention: 56 Intervention: 34% female Intervention: previous MI 14%, previous PCI 7%, previous CABG 7%, hypertension 34%, diabetes 16%, atrial fibrillation 30%, stroke/TIA 30%, asthma/COPD 5%, dyslipidemia 32% Carly M. Goldstein, Emily C. Gathright, Mary A. Dolansky, John Gunstad, Anthony Sterns, Joseph D. Redle, Richard Josephson, Joel W. Hughes; 2014; USA; RCT NR 69 NR 83% Caucasian NR NR NR English-speaking only NR Average MMSE score 28.7 Urban NR NR NR Leanne L. Lefler, Sarah J. Rhoads, Melodee Harris, Ashley E. Funderburg, Sandra A. Lubin, Isis D. Martel, Jennifer L. Faulkner, Janet L. Rooker, Deborah K. Bell, Heather Marshall, Claudia J. Beverly; 2018; USA; Mixed-methods study NR NR 43% female, 57% male 18% Black non-Hispanic, 79% White non-Hispanic, 4% American-Indian/Alakan 11% single/never married, 46% married, 43% separated/divorced/widowed 39% some high school/high school graduate/GED; 43% some college/associate’s degree, 18% Bachelor’s degree Had working telephone English require to be primary language 32% diabetes, 11% asthma, 43% lung disease, 68% hypertension, 54% arthritis or other rheumatic disease, 29% cancer Patients with dementia, diagnosed via St. Louis University Mental Status score <30, excluded Rural NR NR NR 55-59: 18% 60-64: 21% 65-69: 25% Above 70: 36% Daniel Sahlin, Babak Rezanezad, Marie-Louise Edvinsson, Erasums Bachus, Olle Melander, Sofia Gerward; 2022; Sweden; RCT NR Total 79 Total: 39% Control: 47% female NR NR NR Many required support Swedish-speaking patients only 39% diabetes mellitus, 19% COPD, 51% hypertension, 22% kidney disease, 61% atrial fibrillation NR NR NR NR NR Control: 77 Intervention: 33% female Intervention: 80 Marcia J. Wade, Akshay S. Desai, Claire M. Spettell, Aaron D. Snyder, Virginia McGowan-Stackewicz, Paula J. Kummer, Maureen C. Maccoy, Randall S. Krakauer; 2011; USA; RCT NR 78.1 NR Control 20.4% black/African American NR NR NR NR Median ≥5 comorbid conditions per person, no significant differences between groups NR NR NR NR NR Intervention: 24.4% Black/African American Open in a new tab Table 3. Intervention characteristics. Authors, year, country, study design Digital intervention type Technology/Platform used Targeted functions Mode of delivery Duration Involvement of healthcare providers Co-designwith older adults (Y/N) Efficacy (Statistically significant outcomes) Diana M. Achury-Saldaña, Rafael A. Gonzalez, Angel Garcia, Alejandro Mariño, Wilson R. Bohorquez; 2024; Colombia; Randomized clinical trial Mobile health (mHealth) app + Remote monitoring system. ControlVit (custom-developed app and web platform; mobile app built with Ionic framework; web app built with MySQL, NodeJS, AngularJS). Symptom monitoring (weight, BP, HR, symptom questionnaire) Mobile app (patient side) + web-based platform (clinician side) 6 months Regular clinician monitoring and feedback — nurses reviewed daily data, verified alerts by phone, and intervened per protocol. NR reduced HF readmissions (p = 0.0081) and deaths (p = 0.024) in intervention group vs control. ControlVit smartphone app for daily symptom tracking, biometric entry (weight, BP, HR), and self-care education, paired with clinician-facing web platform for real-time monitoring and alerts. Medication/self-care education (informational capsules) Real-time clinical monitoring and alerts to clinicians Communication (nurse follow-up phone calls for alerts) Tariq Ahmed, Nihar R Desai, Yu Yamamoto, Aditya Biswas, Lama Ghazi, Melissa Martin, Michael Simonov, Ravi Dhar, Allen Hsiao, Nitu Kashyap, Larry Allen, Eric J Velazquez, F Perry Wilson; 2022; United States; RCT Clinicians were presented with patients’ 1-year mortality risk, calculated using a validated algorithm derived from historical EHR data, during order-entry interactions to inform clinical decision-making. The alert was developed in accordance with best practices for clinical decision support and refined through consultations with clinicians and behavioral economics experts. Risk categories, ranging from very low to very high, were color-coded, and clinicians were given the opportunity to provide feedback on the accuracy of the assessment. Mortality estimates were unavailable for patients outside the EHR. Shared EHR (Epic Systems) Provide prognostic information to guide decisions regarding initiation and intensity of treatment, and/or more appropriate end-of-life care Shared EHR (Epic Systems) 1 year Clinician-led N No statistically significant outcomes Marie A Bakitas, J Nicholas Dionne-Odom, Deborah B Ejem, Rachel Wells, Andres Azuero, Macy L Stockdill, Konda Keebler, Elizabeth Sockwell, Sheri Tims, Sally Engler, Karen Steinhauser, Elizabeth Kvale, Raegan W Durant, Rodney O Tucker, Kathryn L Burgio, Jose Tallaj, Keith M Swetz, Salpy V Pamboukian; 2020; United States; RCT ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare for Patients and Caregivers) intervention: in-person palliative care consultation and 6 weekly nurse-coach telephone sessions lasting 20-40 minutes and monthly follow up for 48 weeks Telephone Teaching patients and caregivers skills to co0pe with their illness Telephone 48 weeks Initial palliative care consultation, 6 weekly nurse-coach telephone sessions, and monthly clinician follow up NR No significant improvement in QOL or mood. Clinically significant improvement in pain intensity (t-score -2.8) and interference (t-score -2.3) Roberto Antonicelli, Ilaria Mazzanti, Angela M. Abbatecola, Gianfranco Parati; 2010; Italy; RCT In the TM group, patients or their relatives were contacted via telephone at least once a week by the CHF team to gather information regarding their symptoms, treatment adherence, blood pressure, heart rate, weight, and 24-hour urine output, as well as a weekly ECG transmission. Telephone Regular visits with clinician Telephone 12 months In control group, contacted monthly via telephone and seen every 4 months in clinic. In TM group, contacted via telephone at least once a week as well as clinic visits arranged as needed NR Statistically significant increase in usage of beta-blockers, statins, and aldosterone receptor antagonists. Statistically significant decrease in nitrate administration at 12 months compared to baseline. Significantly lower combined mortality and hospital readmission for CHF in treatment group (p<0.01). Aggie H. Balka, Wim Davidse, Paula van Dommelen, Ellen Klaassen, Kadir Caliskan, Pieter van der Burgh, Christina M. Leenders; 2008; Netherlands; RCT Web-based platform/portal — patients accessed online tools for education and regular communication with nurses MOTIVA system Provided disease education, supported self-care, and enabled weekly communication with healthcare providers Web portal Mean follow-up 288 days Heart failure nurses reviewed patient responses and interacted weekly through the platform N Yes — improved patient knowledge of heart failure (p<0.001); no significant change in self-care, quality of life, or depression Palmira Bernocchi, Michele Vitacca, Maria Teresa La Rovere, Maurizio Volterrani, Tiziana Galli, Doriana Baratti, Mara Paneroni, Giuseppe Campolongo, Barbara Sposato, Simonetta Scalvini; 2005, UK, Germany, Netherlands; RCT Remote monitoring system — home-based devices transmitting physiological data (weight, blood pressure, ECG, heart rate) to providers for review Weekly structured call with nurse tutor. Patients were provided with a pulse oximeter and a portable one-lead ECG for real-time telemonitoring of vital signs. Patients could call in case of urgent need at any time. The physiotherapist tutor designed a personalized exercise program for each participant, and each participant was provided with a mini-ergometer, pedometer, and diary Symptom and biometric monitoring, real-time transmission of health data, early detection of deterioration Home-based electronic devices linked to telephone lines 4 months and 6 months Clinicians reviewed transmitted data and responded when abnormalities were detected; nurses provided structured support in the comparison group N Yes — both telemonitoring and nurse support improved 6 minute walk test scores, reduced dyspnea, improved QoL, and reduced hospital admissions compared with usual care. Andreas Blomqvist, Maria Bäck, Leonie Klompstra, Anna Strömberg, Tiny Jaarsma; 2025; Sweden; RCT Mobile health (mHealth) app — smartphone application designed to reduce sedentary behavior and increase physical activity in older adults with heart failure Activity Coach app, adapted from Optilogg (existing Swedish mHealth tool) Symptom and activity monitoring, prompts to reduce sedentary time, motivational feedback, education for self-care Smartphone app + accelerometer 12 weeks Minimal – mostly self-led app use with researchers providing setup and support N Feasibility study, so efficacy outcomes cannot be assessed Giuseppe Boriani, Antoine Da Costa, Aurelio Quesada, Renato Pietro Ricci, Stefano Favale, Gabriele Boscolo, Nicolas Clementy, Valentina Amori, Lorenza Mangoni di S. Stefano, Haran Burri; 2017; Europe & Israel; RCT Remote monitoring system — home-based device transmitting physiological and device diagnostics to clinicians for ongoing follow-up Medtronic CareLink system with automatic alerts (OptiVol® thoracic impedance, AF/atrial tachyarrhythmia, device integrity) Monitoring device function, arrhythmias, fluid status; supporting clinician decision-making; reducing need for in-office visits Home monitor connected to CRT-D device (remote transmission to clinicians) 2 years Regular clinician monitoring of remote transmissions; follow-up alternated between remote and in-office visits N No significant improvement in primary composite endpoint, significant reduction in healthcare utilization. Josiane J.J. Boyne, Hubertus J.M. Vrijhoef, Harry J.G.M. Crijns, Gerjan De Weerd, Johannes Kragten, Anton P.M. Gorgels; 2012; Netherlands; RCT Remote monitoring system — daily symptom and biometric monitoring transmitted to nurses for review Philips Motiva telemonitoring system Monitoring symptoms, weight, BP, HR; supporting self-care; individualized nurse feedback Home-based monitoring device connected to TV/telephone line 1 year Nurses monitored transmitted data and provided tailored feedback and education N No statistically significant improvements in primary outcome of time to first heart failure hospitalization Darshan H. Brahmbhatt, Heather J. Ross, Mary O’Sullivan, Veronica Artanian, Brigitte Mueller, Kyle Runeckles, Chun-Po Steve Fan, Valeria E. Rac, Emily Seto; 2024; Canada; RCT Mobile app – Medly platform (standard of care) is a smartphone app in which patients inputted weight, blood pressure, heart rate, and any reported symptoms. Smartphone app, Medly platform Monitor weight, blood pressure, heart rate, and symptoms, and algorithmically advise patients immediately whether to continue regular medications, take additional diuretic, and/or to seek medical assistance Smartphone app 6 months Minimal involvement N Statistically significant improvement in time to GDMT titration and fewer in-person and There was no significant difference in the number of urgent clinic/emergency department visits. Carly M. Goldstein, Emily C. Gathright, Mary A. Dolansky, John Gunstad, Anthony Sterns, Joseph D. Redle, Richard Josephson, Joel W. Hughes; 2014; USA; RCT Electronic pillbox provided medication reminder alarms, as well as a second medication reminder via smartphone medication adherence app Medsignals electronic pillbox iRx Reminder medication adherence app Provide reminders to take medication, as well as allow for logging of medication adherence. The app also provided information regarding timings of medications and any special instructions. App, pillbox 28 days Minimal N No statistically significant outcomes Leanne L. Lefler, Sarah J. Rhoads, Melodee Harris, Ashley E. Funderburg, Sandra A. Lubin, Isis D. Martel, Jennifer L. Faulkner, Janet L. Rooker, Deborah K. Bell, Heather Marshall, Claudia J. Beverly; 2018; USA; Mixed-methods study Remote monitoring system — home-based devices transmitting physiological data to nurses for follow-up Cloud DX Connected Health Kit (containing Android Health Tablet, Bluetooth-paired body weight scale, and Pulswave Universal Serial Bus BP wrist monitor) Daily biometric monitoring, symptom detection, nurse alerts and follow-up, patient education Home telemonitoring device linked to telephone line 12 weeks Nurses reviewed transmitted data daily and contacted patients if abnormalities were detected N Overall found mHealth equipment to be feasible and with potential to improve patient outcomes Daniel Sahlin, Babak Rezanezad, Marie-Louise Edvinsson, Erasums Bachus, Olle Melander, Sofia Gerward; 2022; Sweden; RCT Remote monitoring system — home-based devices transmitting biometric data (weight, BP, HR, SpO 2 ) to nurses OPTILOGG tool Daily biometric monitoring, medication optimization, nurse follow-up, early detection of deterioration Home monitoring devices with automated data upload 240 days Moderate – physicians create parameters upon prescription of tool. Afterwards, no monitoring is done and rather trends are shared at appointments N Significantly improved self-care behaviors in the intervention group (21.5% vs 26%, p=0.014), fewer in-hospital days, and unplanned hospital visits. Marcia J. Wade, Akshay S. Desai, Claire M. Spettell, Aaron D. Snyder, Virginia McGowan-Stackewicz, Paula J. Kummer, Maureen C. Maccoy, Randall S. Krakauer; 2011; USA; RCT Remote monitoring system – unit in patient’s home. Wired blood pressure monitor and wireless weight scale transmitted information. Intel HGS system – touch screen, remote patient management unit in member’s home, and case manager user interface Monitoring symptoms (health status, activities, medication adherence), transmitting information from blood pressure monitor and weighing scale, and facilitating telemedicine appointments Home-based monitoring device 6 months Information transmitted to case managers, frequently reviewed by physicians. N No statistically significant improvement in primary composite outcome. Open in a new tab The majority of studies (n=11, 79%) 35 – 42 , 44 – 46 did not report participants’ age range. Of the studies that did, the age range was wide, from 33 48 to 92. 47 Despite this diversity in range, the mean age (among studies that reported it) was clustered in the higher range, ranging from 63 to 80. 36 – 45 , 47 , 48 Age did not appear to be a contributing factor to adherence or engagement across the sample. Multiple studies noted that, despite participants being older adults, they were capable of using the technology associated with the interventions 35 , 40 , 45 , 48 and even reported high satisfaction with it. 40 , 45 , 48 Only five studies (36%) reported participants’ socioeconomic indicators. 35 , 38 , 39 , 43 , 47 Two studies 38 , 39 reported on the employment status. The two studies used broad categories as “employees, freelancers, pensioners, homemakers, and others”. 38 , 39 Four (28.5%) studies included information on the marital status of participants. 35 , 38 , 39 , 43 Furthermore, in those studies, 46-66% of participants were married and/or living with a partner. Boyne et al. (2012) noted that participants in their study who cohabited with a partner derived greater benefits from the telemonitoring intervention. 43 Educational attainment was another socioeconomic indicator covered by four of the studies (28.5%). 35 , 38 , 39 , 43 One study conducted in the United States explicitly noted that its findings on educational achievement were lower than the national average. 35 This did not appear to have an impact on adherence or engagement with the intervention. 35 Where reported, participants’ education ranged from less than high school to university or graduate degrees, with most samples skewed toward individuals with secondary or post-secondary education. 35 , 38 , 39 In studies that reported both intervention and control groups, distributions were generally similar between groups. 43 The majority of studies (n=9, 64%) in this review did not report the racial or ethnic identity of their participants. 36 , 38 , 42 – 48 In the studies that did report it, 2 , 4 , 11 , 12 , 14 there were differences in the identities present, as well as the level of detail reported. Thirteen studies reported a majority of White participants and one reported a majority of African Americans. 39 Theme 3. Equity-relevant exclusion and underreported domains Several equity-relevant domains were poorly reported across studies. Sexual orientation and health literacy were not reported in any included study, and disability status was rarely measured. Cognitive impairment was frequently used as an exclusion criterion. Over half of the studies (n=9, 64%) included in this review did not report participants’ cognitive status. The three studies that included cognitive status 35 , 39 , 40 used different criteria, including the Callahan Cognitive Scale, the Mini-Mental State Examination (MMSE), and the St. Louis University Mental Status Score (SLUMS). Additionally, participants with cognitive impairment were excluded from the sample. One study, which examined medication adherence using an electronic pillbox, explained that the exclusion was due to the fact that those with severe cognitive impairment would not reasonably be expected to manage their medication. 40 Language requirements were rarely reported across the included studies. Of the 14 studies, 4 (29%) explicitly described participants’ language: two required participants to be English-speaking only, 39 , 40 one required English as the primary language, 35 and one included only Swedish-speaking patients. 44 The remaining 10 studies (71%) did not report any information on participants’ language. Only five (36%) of the fourteen included studies provided details on the geographic location of the periods. Of those studies, three involved participants exclusively in urban areas and one had a high proportion of urban participants, ranging from 72.1% to 75.8% across groups. 4 One study focused on participants from rural settings. 12 None of the 14 included studies reported participants’ sexual orientation or health literacy. This represents a significant gap in understanding how these factors may influence engagement, access, and outcomes in virtual rehabilitation interventions for older adults. Of the 14 included studies, 7 (50%) provided some information about participants’ digital literacy or access, though details were often minimal or implicit. 36 , 38 , 39 , 48 To capture participants’ digital literacy, we extracted descriptions of participants’ ability to access or use technology (e.g., device ownership like a phone, 35 training, 43 or inclusion criteria related to digital skills 38 , 39 ). When reported, we noted whether participants were required to have digital skills at baseline, received training or support, 43 or demonstrated mixed ability. In one study, participants demonstrated mixed levels of digital health access, with several requiring technical support to engage with the intervention. 36 Reporting of participants’ disability status was very limited. Of the 14 studies, only 1 (7%) provided data, reporting that approximately 47-49% of participants in intervention and control groups had a disability. 39 Theme 4. Clinical and comorbidity characteristics Comorbidity burden was commonly reported using standardized indices, with participants generally presenting with multiple chronic conditions. 11 of 14 studies (79%) provided data on participants’ comorbid conditions. Comorbidities were commonly reported, though with varying detail across studies. The most frequently reported conditions among participants included hypertension, 35 , 38 , 42 , 44 , 46 , 48 diabetes mellitus, 35 , 44 , 46 , 48 COPD/asthma/lung disease, 35 , 44 , 46 , 48 atrial fibrillation, 37 , 42 , 44 chronic kidney disease, cardiovascular disease, and stroke. 42 , 46 Other reported comorbidities included dyslipidemia, 46 hypothyroidism, 38 obstructive sleep apnea, 38 arthritis/rheumatic disease, 35 and cancer. 35 Several studies reported overall comorbidity burden using the Charlson Comorbidity Index or median number of conditions per participant, 39 with mean indices ranging from 3.2 to 3.4 and a median of ≥5 comorbid conditions per person. 41 Reporting often included separate percentages for intervention and control groups. Recommendations from included studies for equity Few studies explicitly reported recommendations (n=5, 36%), but where provided, common themes emphasized the need to test interventions in broader, more diverse populations, including participants with lower digital literacy, cognitive challenges, or greater clinical vulnerability. Other recommendations highlighted the importance of longer follow-up periods to assess the sustainability of outcomes, culturally sensitive approaches (particularly in palliative care contexts), and strategies to enhance recruitment and inclusivity. See Table 4 . Table 4. Equity considerations. Authors, year, country, study design Designed for specific subgroups Strategies for digital inclusion Subgroup outcome reporting Equity-related limitations discussed Equity-related future recommendations Diana M. Achury-Saldaña, Rafael A. Gonzalez, Angel Garcia, Alejandro Mariño, Wilson R. Bohorquez; 2024; Colombia; Randomized clinical trial No Provided training (2 hours, online) for app and devices NR NR NR Provided calibrated scale and digital BP monitor to all participants App designed to function offline and sync when internet is available Inclusion criteria required ability to handle mobile devices Tariq Ahmed, Nihar R Desai, Yu Yamamoto, Aditya Biswas, Lama Ghazi, Melissa Martin, Michael Simonov, Ravi Dhar, Allen Hsiao, Nitu Kashyap, Larry Allen, Eric J Velazquez, F Perry Wilson; 2022; United States; RCT No NR NR NR NR Marie A Bakitas, J Nicholas Dionne-Odom, Deborah B Ejem, Rachel Wells, Andres Azuero, Macy L Stockdill, Konda Keebler, Elizabeth Sockwell, Sheri Tims, Sally Engler, Karen Steinhauser, Elizabeth Kvale, Raegan W Durant, Rodney O Tucker, Kathryn L Burgio, Jose Tallaj, Keith M Swetz, Salpy V Pamboukian; 2020; United States; RCT Not intentionally designed for any subgroups, however study represented largest proportion of HF palliative care trial participants who were African American, likely attributed to mostly African American recruiters NR NR NR NR Roberto Antonicelli, Ilaria Mazzanti, Angela M. Abbatecola, Gianfranco Parati; 2010; Italy; RCT No NR NR NR NR Aggie H. Balka, Wim Davidse, Paula van Dommelen, Ellen Klaassen, Kadir Caliskan, Pieter van der Burgh, Christina M. Leenders; 2008; Netherlands; RCT No NR NR NR Recommended future research in broader and less digitally skilled populations with longer follow up Palmira Bernocchi, Michele Vitacca, Maria Teresa La Rovere, Maurizio Volterrani, Tiziana Galli, Doriana Baratti, Mara Paneroni, Giuseppe Campolongo, Barbara Sposato, Simonetta Scalvini; 2005, UK, Germany, Netherlands; RCT No NR Training provided for participants in the telemonitoring arm to use devices NR NR Andreas Blomqvist, Maria Bäck, Leonie Klompstra, Anna Strömberg, Tiny Jaarsma; 2025; Sweden; RCT No Provided training and technical support for app use NR Recruitment challenges likely excluded less digitally literate individuals Larger trials should include strategies to recruit broader populations, particularly those with low digital literacy Giuseppe Boriani, Antoine Da Costa, Aurelio Quesada, Renato Pietro Ricci, Stefano Favale, Gabriele Boscolo, Nicolas Clementy, Valentina Amori, Lorenza Mangoni di S. Stefano, Haran Burri; 2017; Europe & Israel; RCT No NR NR Predominantly Italian cohort may have limited generalizability of cost effectiveness findings NR Josiane J.J. Boyne, Hubertus J.M. Vrijhoef, Harry J.G.M. Crijns, Gerjan De Weerd, Johannes Kragten, Anton P.M. Gorgels; 2012; Netherlands; RCT No Training provided to participants to use device NR Relatively young and stable HF population limits applicability to older or more severe patients Suggested testing telemonitoring in more vulnerable or higher-risk HF populations Darshan H. Brahmbhatt, Heather J. Ross, Mary O’Sullivan, Veronica Artanian, Brigitte Mueller, Kyle Runeckles, Chun-Po Steve Fan, Valeria E. Rac, Emily Seto; 2024; Canada; RCT No NR NR NR NR Carly M. Goldstein, Emily C. Gathright, Mary A. Dolansky, John Gunstad, Anthony Sterns, Joseph D. Redle, Richard Josephson, Joel W. Hughes; 2014; USA; RCT No All participants were provided training via study personnel visiting their home and explaining the smartphone’s features. A skill-based test was then conducted to confirm learning. NR Lack of diverse sample may limit applicability across cultural or socioeconomic groups Authors recommended broader recruitment and culturally sensitive approaches to palliative care in heart failure Leanne L. Lefler, Sarah J. Rhoads, Melodee Harris, Ashley E. Funderburg, Sandra A. Lubin, Isis D. Martel, Jennifer L. Faulkner, Janet L. Rooker, Deborah K. Bell, Heather Marshall, Claudia J. Beverly; 2018; USA; Mixed-methods study Yes – underserved, rural, and largely African American population Provided telemonitoring devices and nurse support to overcome access barriers NR Small, localized sample may not generalize; barriers to those with very low digital skills or limited home infrastructure not fully addressed Recommend testing in larger and more diverse sample, and to further work on supporting patients with limited digital literacy Daniel Sahlin, Babak Rezanezad, Marie-Louise Edvinsson, Erasums Bachus, Olle Melander, Sofia Gerward; 2022; Sweden; RCT No NR NR Acknowledged exclusion of those with severe cognitive impairment may have limited inclusivity Larger trials needed, including strategies to reach patients with lower digital literacy or cognitive challenges Marcia J. Wade, Akshay S. Desai, Claire M. Spettell, Aaron D. Snyder, Virginia McGowan-Stackewicz, Paula J. Kummer, Maureen C. Maccoy, Randall S. Krakauer; 2011; USA; RCT No NR NR NR NR Open in a new tab Discussion This scoping review examined how older adults are represented in research on digital health interventions for heart failure and how participant characteristics and intervention design influence engagement. We conducted a systematic search of four databases following the Joanna Briggs Institute methodology and used the PROGRESS-Plus framework to assess equity-related reporting across 14 randomized controlled trials. We focused on identifying who was included in these studies and how factors such as age, cognitive function, socioeconomic status, sex or gender, racial or ethnic identity, and geographic location were considered. Most studies underreported or inconsistently described these characteristics, particularly cognitive status, race or ethnicity, and socioeconomic background, which limited assessment of equity and generalizability. Despite this, older adults demonstrated good engagement and satisfaction with technology across interventions. However, the evidence base remains skewed toward urban, White, and male participants, underscoring the need for more inclusive research designs and standardized equity reporting in digital health trials for heart failure. This review found that age did not appear to limit adherence or engagement, which challenges assumptions that older adults are less able or willing to adopt digital health interventions. This finding has been echoed in previous research, which also found that older adults are willing to adopt digital health interventions, particularly when they perceive them as useful, easy to use, and beneficial for their health. 49 Overall, our findings demonstrate persistent underrepresentation and inconsistent reporting of cognitive status, socioeconomic background, racial/ethnic identity, geographic location, digital literacy, and language across trials of digital health interventions for older adults with heart failure. Participants with cognitive impairment were frequently excluded from randomized trials, despite the high prevalence of cognitive decline in this population. For example, while only a few studies reported on cognitive status, those studies measured cognitive impairment to exclude individuals from randomized controlled trials, despite the high prevalence of cognitive decline among those living with heart failure. 50 Similarly, individuals from lower socioeconomic backgrounds, racial and ethnic minority groups, rural or remote regions, and those with limited education, digital literacy, or non-English language proficiency were rarely represented. These gaps have important implications for the generalizability and real-world applicability of digital health interventions, particularly in the context of heart failure self-management, which requires sustained monitoring, medication adherence, and timely symptom recognition. Language and literacy barriers may further limit comprehension of automated alerts, instructional content, and health data displays when interventions are developed primarily in English or at higher literacy levels. This omission has important implications for heart failure care, as patients with lower educational attainment or limited digital skills may struggle to navigate app-based platforms or interpret complex health data, leading to lower engagement and adherence. 51 Without intentional design adaptations, digital health technologies risk widening existing inequities by privileging populations with greater technological familiarity and resource access. Future digital heart failure programs should prioritize user-centered development, including multilingual and plain-language interfaces, caregiver-inclusive features, and iterative testing with diverse older adults. These recommendations are consistent with national and international calls for inclusive digital innovation articulated Canada’s Pan-Canadian Health Data Strategy 52 and the WHO’s Global Strategy on Digital Health (2020–2025), 53 both of which emphasize equitable access, accessibility, and population-level benefit in digital health implementation. These policies explicitly call for digital health solutions adaptable to varying levels of literacy, language, and access, recognizing that, without intentional inclusion, technology can exacerbate rather than reduce disparities in care. The systematic exclusion of participants with cognitive impairment in several trials is particularly concerning in the context of heart failure care. Cognitive decline is highly prevalent among older adults living with heart failure and is associated with challenges in symptom recognition, medication adherence, and complex self-management behaviors. Excluding individuals with cognitive impairment may therefore limit the external validity of trial findings and restrict understanding of how digital health interventions perform in populations who may benefit most from supportive monitoring technologies. This pattern reflects a broader tendency in digital health research to prioritize participants perceived as technologically capable rather than those with greatest clinical vulnerability. Similarly, socioeconomic variables such as education level and marital status were reported inconsistently and often treated as descriptive characteristics rather than analytic factors linked to intervention accessibility or outcomes. Limited reporting of socioeconomic indicators constrains assessment of structural barriers that influence digital health adoption, including resource availability, caregiving support, and technology familiarity. From a health equity perspective, these gaps hinder evaluation of whether digital interventions align with goals of inclusive care for older adults with heart failure, where social and economic context plays a critical role in intervention feasibility and benefit distribution. Future trials should actively recruit participants who have been historically underrepresented, including individuals with cognitive impairment, lower socioeconomic status, racial and ethnic minorities, rural residents, and those with limited digital literacy or non-English language proficiency. Standardized reporting of these characteristics is necessary to assess generalizability, identify disparities in engagement or outcomes, and ensure interventions are accessible and effective across diverse populations. Without tailoring interventions to accommodate varying literacy and language needs, digital health tools risk widening existing disparities in outcomes, leaving those most vulnerable to hospitalization and a poor prognosis least able to benefit from available innovations. Digital heart failure programs integrating digital health tools should prioritize user testing with diverse older adults, offer multilingual and plain-language interfaces, and include training or caregiver support to bridge digital literacy gaps. Our review found that some interventions still produced beneficial outcomes despite minimal direct engagement with healthcare providers, while others with regular provider interaction had mixed results. This suggests that the design and features of the digital intervention itself, such as modality, frequency, and personalization, may have a stronger influence on engagement and effectiveness than the degree of provider involvement. The implications of this finding are that well-designed digital interventions for heart failure can reduce reliance on intensive provider contact without compromising patient engagement or outcomes, potentially helping address workforce constraints and improving the scalability of care. For example, research on remote monitoring and app-based interventions has shown that features such as automated feedback, personalized alerts, and interactive symptom tracking can sustain adherence and self-management even when direct provider interaction is limited. 54 , 55 Theoretically, this means health systems could deploy scalable digital programs that maintain patient engagement and optimize outcomes, while freeing provider time for patients who need more intensive support. On the other hand, some existing self-management interventions have failed to achieve expected outcomes when the technology was overly complex, poorly integrated with daily routines, or insufficiently tailored to users’ health literacy or cognitive capacity. 56 Thus, clinically, the implication is that digital heart failure programs must prioritize careful co-design and usability testing, balancing automation with targeted provider support, to optimize both engagement and health outcomes. It also suggests that health systems should evaluate interventions not just on provider involvement but also on how the digital tool’s features align with patient needs, promoting scalable and effective models of care. Limitations This scoping review has several limitations that should be considered when interpreting the findings. First, the review was restricted to studies published in English and conducted in high-income countries. This may have excluded relevant research from low- and middle-income contexts, where digital health interventions face different infrastructural, cultural, and resource challenges. Consequently, the generalizability of findings is limited to settings with comparable healthcare systems and technological capacity. Second, only randomized controlled trials were included. While this decision strengthened the methodological rigor of the included evidence, it excluded qualitative and mixed-method studies that could have provided valuable insights into participant experiences, usability, and contextual barriers to engagement. Third, publication bias may also be present, as studies demonstrating positive or significant findings are more likely to be published than those reporting null or negative results. Similarly, as many included studies were conducted over a decade ago, the technologies used may not reflect current digital health capabilities, potentially underestimating the usability and accessibility of more recent innovations. Finally, as is typical of scoping reviews, this study did not include a formal assessment of methodological quality or risk of bias, nor did it attempt to evaluate intervention efficacy. The purpose was to map and describe the existing evidence base rather than to assess causal relationships. Future systematic reviews could build on these findings by incorporating quality appraisal, subgroup analyses, and meta-analytic approaches to evaluate how intervention design and participant characteristics influence outcomes in digital health for heart failure. In addition, the review was limited to studies published in English and conducted in high-income country contexts, which may introduce selection bias and restrict the generalizability of equity-related findings, particularly for populations in low- and middle-income settings where digital health access and reporting practices may differ. Conclusion This scoping review highlights both the potential and the current limitations of digital health interventions for older adults with heart failure. Overall, older adults demonstrated strong engagement and satisfaction with these technologies, challenging assumptions that age is a barrier to adoption. However, the evidence base is limited by underrepresentation of key subgroups, including individuals with cognitive impairment, lower socioeconomic status, racial and ethnic minorities, rural residents, and those with limited digital literacy or non-English language proficiency. Intervention design features, such as modality, frequency, personalization, and usability, appear to have a greater influence on engagement and outcomes than the degree of direct healthcare provider involvement, suggesting that well-designed digital programs can achieve meaningful impacts even with minimal provider contact. These findings underscore the importance of inclusive, user-centered design, multilingual and plain-language interfaces, and supportive strategies such as caregiver involvement or training to bridge digital literacy gaps. Clinically, adopting these principles can improve the scalability, accessibility, and effectiveness of digital heart failure programs, helping to reduce disparities in care and optimize self-management across diverse older adult populations. Future research should prioritize equity-focused recruitment, standardized reporting of participant characteristics, and rigorous evaluation of intervention features to ensure that digital health innovations benefit all older adults living with heart failure. Supplemental material Supplemental material - Digital health interventions for older adults with heart failure: A scoping review of participant representation, engagement, and equity considerations sj-pdf-1-dhj-10.1177_20552076261438677.pdf (164.8KB, pdf) Supplemental material for Digital health interventions for older adults with heart failure: A scoping review of participant representation, engagement, and equity considerations by Kristina M. Kokorelias, Peter M Hoang, Maira Khan, and Maurita T. Harris in Digital Health. Supplemental material - Digital health interventions for older adults with heart failure: A scoping review of participant representation, engagement, and equity considerations sj-pdf-2-dhj-10.1177_20552076261438677.pdf (454.6KB, pdf) Supplemental material for Digital health interventions for older adults with heart failure: A scoping review of participant representation, engagement, and equity considerations by Kristina M. Kokorelias, Peter M Hoang, Maira Khan, and Maurita T. Harris in Digital Health. Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a TRANSFORM HF Collaboration Starter Grant. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Supplemental material: Supplemental material for this article is available online. ORCID iD Kristina M. 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Supplementary Materials Supplemental material - Digital health interventions for older adults with heart failure: A scoping review of participant representation, engagement, and equity considerations sj-pdf-1-dhj-10.1177_20552076261438677.pdf (164.8KB, pdf) Supplemental material for Digital health interventions for older adults with heart failure: A scoping review of participant representation, engagement, and equity considerations by Kristina M. Kokorelias, Peter M Hoang, Maira Khan, and Maurita T. Harris in Digital Health. Supplemental material - Digital health interventions for older adults with heart failure: A scoping review of participant representation, engagement, and equity considerations sj-pdf-2-dhj-10.1177_20552076261438677.pdf (454.6KB, pdf) Supplemental material for Digital health interventions for older adults with heart failure: A scoping review of participant representation, engagement, and equity considerations by Kristina M. Kokorelias, Peter M Hoang, Maira Khan, and Maurita T. Harris in Digital Health. Articles from Digital Health are provided here courtesy of SAGE Publications ACTIONS View on publisher site PDF (3.1 MB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top