A 67-year-old male inmate at a state correctional facility presented to the cardiology clinic with a complaint of exertional angina. Prior to the onset of symptoms, he was very active and exercised regularly. His past medical history was notable for hypertension, smoking, and hyperlipidemia. His medical therapy consisted of 10 mg of amlodipine daily. His workup eventually led to cardiac catheterization and percutaneous intervention of a significant stenosis of his left anterior descending artery (LAD). Following his hospitalization, he was referred for cardiac rehabilitation (CR) based on the strong evidence supporting its positive effect on outcomes1. Unfortunately, the logistic requirements for CR (three times/week for 12 weeks) were prohibitive given his incarcerated status and limited prison resources for monitored transportation. As an alternative, he was enrolled into a virtual CR program (VCR) consisting of internet-based sessions of monitored exercise and risk factor modification. These sessions were live and one-on-one with exercise physiologists, nutritionists, and nursing staff. Exercise physiologists supervised exercise prescription and progression; registered nurses oversaw safety monitoring, symptom assessment, and escalation protocols; and nutritionists provided individualized nutrition education and cardiovascular risk-factor counseling. The exercise program focused on heart rate, strength, and endurance. Sample exercises included stepping in place, sit-to-stands, leg raises, and resistance band exercises. Following confirmation of adequate and reliable internet access, the patient completed the program using a laptop computer in a monitored activity room at the correctional facility. To assure patient safety, prison medical personnel trained in emergency cardiac care were readily available during all virtual sessions. During each functional assessment, an on-site correctional facility nurse monitored the patient in person, recording heart rate, blood pressure, and reviewed any reported symptoms before and after testing. Additionally, the patient was asked for rate of perceived exertion (RPE) using a reporting tool during testing and exercise. Virtual CR clinicians simultaneously supervised via video, observing appropriate exercise form, cadence, and safety. A safety protocol was established to halt activity for chest discomfort, undue dyspnea, blood pressure out of range (SBP < 90 or >180), or other staff concern. This layered monitoring approach was designed to approximate the safety oversight of center-based CR within the constraints of the correctional environment.

Measures of cardiovascular fitness were performed prior to entry into virtual CR and at program exit, administered virtually by VCR staff with on-site staff assisting with the performance of the fitness tests and assuring safety in the performance of fitness testing. These measures included a 2-min step test and a 30-s chair stand test2. Utilization of these tests for functional assessment allowed for performance of the tests virtually. Pre- and post-testing revealed objective improvements in functional capacity associated with the CR program, including a 21% improvement in the two-minute step test and an 88% improvement in the 30-s chair stand test (Table 1). The improvements in these tests were consistent with increased functional capacity based on prior literature in other rehabilitation scenarios3.

Table 1 Changes in fitness testing pre- and post-virtual cardiac rehabilitation
Full size table

While the right to health care is not specifically guaranteed in the United States Constitution, the constitutional right to health care among correctional inmates has been confirmed by the United States Supreme Court, beginning with the 1976 decision in Estelle v. Gamble4. Texas state prison inmate J.W. Gamble sued the Texas Department of Corrections alleging inadequate medical care and “deliberate indifference” regarding care for a back injury he suffered during work detail. The case reached the U.S. Supreme Court who held that such indifference to medical need violated the Eighth Amendment’s cruel and unusual punishment clause and that access to health care must be assured for prison inmates. More recently the right of incarcerated individuals to adequate health care was re-affirmed through the Federal Prison Oversight Act of 2024 (H.R. 3019/S.1401)5.

However, while these decisions mandate adequate access to health care among inmates, they do not lay out a pathway to achieve, nor attempt to define what represents adequate care. As such, access to health care resources among incarcerated individuals continues to constitute a challenge to the U.S. health care industry and inmates suffer from the long-term outcomes of inadequate primary prevention of disease, as well as limited application of evidence-based guidelines for management of acute illness6,7.

The effect of inadequate access to healthcare among incarcerated individuals has been well documented as it pertains to cardiovascular diseases8. Cardiovascular risk among incarcerated Americans is greater than that of the community population, and self-reported cardiovascular disease among prison and jail inmates has been as high as ten percent. The challenge of delivering adequate care to inmates with cardiovascular disease is complicated by the need for longitudinal care necessitating consistent access over a prolonged period. The mandates of the prison system classically include retribution, deterrence, rehabilitation, and incapacitiation9. The mandate of incapacitation, or protection of the public, requires that access for incarcerated persons follow carefully planned and resource intensive processes to protect the public well-being, resulting in further challenges to inmate access to medical care. The combination of high rates of uncontrolled cardiovascular risk factors and limited longitudinal cardiovascular care results in higher cardiovascular morbidity and mortality among inmates as well as greater burden on the medical system following release from carceral facilities8.

Telemedicine was first proposed three decades ago as a means of achieving adequate access and minimizing the complexities of longitudinal care of incarcerated individuals, initially as a means of delivering more cost-effective care to prison systems10. Telehealth involves the delivery of medical care at a distance involving an electronic modality, typically phone- and more recently internet-based. A notable development of novel telehealth services has been the use of telehealth and virtual platforms to deliver CR. Traditional “center-based” CR involves sessions of monitored exercise and risk factor modification, typically delivered as three sessions per week over a 12-week period. Center-based CR has been shown to have a robust impact on outcomes of eligible participants, including a significant reduction in mortality. As a result, CR continues to have a Class 1 recommendation in recent guidelines for management of patients with both chronic coronary disease11 and acute coronary syndromes12. However, despite organized national efforts to improve enrollment in CR in the United States, a recent report noted median risk-stratified enrollment of only 22% of CR-eligible Medicare beneficiaries13. Given the high rate of cardiac disease among incarcerated individuals and the access challenges of these individuals, it is likely that a large number of CR-eligible incarcerated individuals are not afforded access to a CR program. In support of this, there are no reports of CR completion among inmates in the medical literature. The financial burden of delivering longitudinal off-site care to incarcerated individuals is notable as it applies to CR: typically, transport of inmates for care outside of prison facilities requires at least 2 prison personnel even for low custody inmates14. Economic studies have estimated the median cost for just transport of inmates to these visits is over $1500 per trip; thus completion of a CR program would incur over $50,000 in transportation costs alone15. In addition to cost, attrition of prison staff and resultant challenges in commitment of personnel to chaperone inmates adds to the burden of longitudinal programs such as CR16.

Novel “virtual” CR programs delivered via an internet-based platform have recently been shown to be comparable in efficacy to traditional programs, making a virtual program a viable alternative which has the ability to expand access to underserved populations17. Given the limited access of CR for the population as a whole and the complexities of delivering longitudinal care to incarcerated individuals, virtual CR would theoretically be an optimal way to deliver CR to an incarcerated population. The aforementioned patient was able to complete the majority of the program and demonstrated functional improvements consistent with successful delivery of the robust evidence-based effect of CR. Admittedly, while our patient had an objectively good response to therapy, virtual delivery of CR to both a general eligible population as well as to incarcerated or other isolated individuals will require further trials before it can be considered a clear standard of care for CR delivery.

The application of CR via telemedicine can be considered an example of the effective use of a virtual care modality to deliver evidence-based care to an otherwise access-compromised and vulnerable population. Indeed, telemedicine and virtual care modalities should be the focus of future efforts at improving access to health care for incarcerated individuals across the clinical care spectrum, as part of ongoing efforts at fulfilling the judicial vision of the decision of the U.S. Supreme Court in Estelle vs. Gamble.