Impact of mHealth chronic disease management on treatment adherence and patient outcomes: a systematic review

Impact of mobile health and telehealth technology on medication adherence of stroke patients: a systematic review and meta-analysis of randomized controlled trials

Background Stroke patients have low medication adherence after discharge, which leads to a high recurrence rate and poor disease control. Various strategies have been explored to enhance medication adherence in this patient population. Aim To evaluate the effects of mobile health (mHealth) and telehealth technology on medication adherence in stroke patients. Method All English studies that met the inclusion criteria published before September 2021 were obtained from PubMed, EMBASE, Web of Science, and Cochrane Library. Two researchers independently screened articles, extracted data, and evaluated the quality of the included studies. All articles were about randomized controlled trials. Medication adherence was used as the outcome index of this review. Random or fixed-effect models were used in statistical methods. I² statistics were used to evaluate heterogeneity. Results A total of ten studies met the inclusion criteria, covering 2151 stroke patients. Compared with the Usual Care group, the medication adherence scores of the mHealth technology group were better (standard mean deviation 0.67, 95% confidence interval, CI [0.49, 0.85], P < 0.001). The medication adherence ratio of the mHealth technology group was higher (odds ratio, OR, 2.81, 95% CI [1.35, 5.85], P = 0.006). Subgroup analysis showed that application and messaging interventions were more effective than the telephone call intervention (OR 4.05, 95% CI [2.10, 7.80], P < 0.001). The shorter the interval of the intervention, the better the medication adherence of patients (OR 4.24, 95% CI [2.30, 7.81], P < 0.001). Conclusion Compared with Usual Care, mHealth can effectively improve the medication adherence of stroke patients.

Health Education Through a Campaign and mHealth to Enhance Knowledge and Quality of Life Among Patients With Chronic Kidney Disease in Bangladesh: Protocol for a Randomized Controlled Trial

Background

Despite the growing burden of chronic kidney disease (CKD), disease knowledge and understanding are still lacking, especially in Bangladesh.

Objective

The aim of this study was to evaluate the outcome of a health education intervention in order to enhance knowledge, health-related quality of life (QOL), and motivation regarding healthy lifestyles among rural and periurban adults suffering from CKD.

Methods

A parallel-group (1:1) randomized controlled trial is ongoing in the Mirzapur subdistrict, Bangladesh, where two groups of patients with CKD are being compared. Patients aged 18 years and over with CKD (stages 1-3) were enrolled in November 2020. Patients were randomly allocated into either the intervention group (n=63) or the control group (n=63). The control group received usual treatment, while the intervention group received health education through a CKD campaign facilitated by a nephrologist and via mHealth (ie, periodic mobile phone calls) from community health workers. Both groups were followed up for a period of 6 months. The primary endpoint is patients’ increased knowledge measured using the Chronic Kidney Disease Knowledge Questionnaire. The secondary endpoints are improved QOL measured using the standardized EuroQol 5-Dimension 5-Level (EQ-5D-5L) questionnaire as well as improvements in the levels of blood pressure, BMI, serum creatinine, fasting blood sugar, hemoglobin, cholesterol, high-density lipoprotein cholesterol, triglyceride, serum uric acid, blood urea nitrogen, and albumin to creatinine ratio.

Results

Enrollment of participants began in November 2020; the intervention and follow-up were completed in May 2021. We enrolled 126 patients in the study. Patients’ mean ages were 57.97 (SD 15.03) years in the control group and 57.32 (SD 14.37) years in the intervention group. There were 45 out of 63 (71%) females in the control group and 38 out of 63 (60%) females in the intervention group. In addition, there were 38 out of 63 (60%) literate patients in the control group and 33 out of 63 (52%) literate patients in the intervention group.

Conclusions

It is expected that a combined approach, incorporating both a CKD campaign and mHealth, for health education may be an effective tool for increasing knowledge and improving QOL among patients with CKD.

Trial Registration

ClinicalTrials.gov NCT04094831; https://clinicaltrials.gov/ct2/show/NCT04094831

International Registered Report Identifier (IRRID)

DERR1-10.2196/30191

The effectiveness of a bespoke mobile application in improving adherence with removable orthodontic retention over 12 months: A randomized controlled trial

INTRODUCTION

The primary aim was to analyze the effect of providing a mobile application (My Retainers) on adherence with removable retention.

METHODS

Eighty-four participants planned for thermoplastic retainers were randomly allocated to 2 groups. The intervention group was given access to a bespoke mobile application, while the control group was not given access. Baseline data were obtained at the removal of orthodontic appliances with follow-up at 3 months, 6 months, 9 months, and 12 months. The primary outcome was objectively assessed retainer wear recorded using a TheraMon microelectronic sensor (MC Technology GmbH, Hargelsberg, Austria). Secondary outcomes were stability and periodontal implications.

RESULTS

The objectively assessed wear time at 12 months was low in both groups, being marginally higher in the intervention (median, 3.09 h/d; interquartile range, 8.1) than the control group (median, 1.44 h/d; interquartile range, 9.22) with no between-group statistical difference (P = 0.30, 95% confidence interval [CI], -3.91 to 1.19). No statistically significant difference was identified between the groups in terms of stability and periodontal outcomes. Improvement in plaque scores (P <0.0001; 95% CI, -0.20 to 0.15) and bleeding on probing (P <0.0001, 95% CI, -0.23 to -0.12) was noted over time with no periodontal attachment loss detected over the study period.

CONCLUSIONS

Provision of the mobile application did not lead to improved adherence with thermoplastic retainer wear. Similarly, no benefit in respect of either occlusal stability or periodontal health was observed over the 12-month study period. Further novel approaches to improve adherence with retainer wear and oral hygiene measures are required.

REGISTRATION

NCT03224481.

PROTOCOL

Not published.

FUNDING

This work was supported by funding from the European Orthodontic Society.

Antiretroviral Therapy and Retention in Care Experiences and Needs of Adolescents Living with HIV in Southern Ethiopia

Background

Adolescents with HIV are faced with challenges when taking care of their medication, which affects their treatment adherence. Therefore, this study aimed to explore the experiences and needs of adolescents living with HIV regarding their antiretroviral therapy adherence and retention in care in southern Ethiopia.

Methods

An inductive qualitative study design was applied to explore adolescents’ experiences and needs regarding antiretroviral treatment adherence and retention in care in southern Ethiopia. Eighteen adolescents were selected from five HIV care and treatment facilities by purposive sampling. The interviews followed an interview guide, translated into the participants’ national language. The interviews were transcribed verbatim and the first author developed a coding frame for the analysis by using NVivo software including meaning units and codes, which were discussed by all authors. Then, sub-themes and themes were identified and analyzed by qualitative content analysis.

Results

The results were described in two themes: barriers and facilitators for treatment adherence and retention in care. Barriers were described in seven subthemes and facilitators in three subthemes. Forgetting to take medication, hiding information, or non-disclosure of HIV status, being afraid to collect treatment drugs, being in an orphanage, and school activities were described as barriers while support from health care workers, families, personal motivation to cope with medication-related problems were described as facilitators for antiretroviral therapy adherence and retention in care.

Conclusion

Adherence is a major challenge among adolescents living with HIV in Ethiopia, with barriers that are unique to this age group and their living conditions. Therefore, interventions should be targeted to address privacy barriers, stigma, and lack of support.

[Mobile applications to improve drug adherence: Review and quality analysis]

OBJECTIVE

To review the mobile apps in the Spanish market to improve adherence to medications and evaluate their characteristics and quality to identify high-quality applications.

METHOD

A review was carried out following a stepwise procedure similar to a systematic review of the scientific literature. Apple Apps Store and Google Play Store mobile application digital distribution platforms. Applications aimed at supporting self-management of treatment, which generate reminders, in Spanish, updated in the last 2 years and free. We evaluate the applications according to a set of characteristics considered desirable and the quality with the Mobile App Rating Scale tool.

RESULTS

Out of 708 applications, 3 applications were selected. The Medisafe and Mytherapy applications had 89% and 78% of the desirable characteristics, respectively. Sergio Licea's application only had 56%. The highest global quality score was obtained by the MyTherapy application (3.79/5, IQR: 3-4), followed by Medisafe (3.72/5, (IQR: 3-4) and, finally, Sergio Licea (2.87/5, IQR: 2-4). The quality assessment coincides with the user assessment. There are many available applications, however, most did not meet the selection criteria.

CONCLUSIONS

A systematic stepwise process was able to identify the quality application to be tested in a future study that will provide evidence on the use of a multicomponent intervention to improve medication adherence.

Supportive Care Interventions for People With Cancer Assisted by Digital Technology: Systematic Review

BACKGROUND

Although relatively new, digital health interventions are demonstrating rapid growth because of their ability to facilitate access and overcome issues of location, time, health status, and most recently, the impact of a major pandemic. With the increased uptake of digital technologies, digital health has the potential to improve the provision of supportive cancer care.

OBJECTIVE

This systematic review aims to evaluate digital health interventions for supportive cancer care.

METHODS

Published literature between 2000 and 2020 was systematically searched in MEDLINE, PubMed, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, and Scopus. Eligible publications were randomized controlled trials of clinician-led digital health interventions to support adult cancer patients. The interventions included were determined by applying a digital health conceptual model. Studies were appraised for quality using the revised Cochrane risk of bias tool.

RESULTS

Twenty randomized controlled trials met the inclusion criteria for the analysis. Interventions varied by duration, frequency, degree of technology use, and applied outcome measures. Interventions targeting a single tumor stream, predominantly breast cancer, and studies involving the implementation of remote symptom monitoring have dominated the results. In most studies, digital intervention resulted in significant positive outcomes in patient-reported symptoms, levels of fatigue and pain, health-related quality of life, functional capacity, and depression levels compared with the control.

CONCLUSIONS

Digital health interventions are helpful and effective for supportive care of patients with cancer. There is a need for high-quality research. Future endeavors could focus on the use of valid, standardized outcome measures, maintenance of methodological rigor, and strategies to improve patient and health professional engagement in the design and delivery of supportive digital health interventions.

TRIAL REGISTRATION

PROSPERO CRD42020149730; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=149730.

Technology can`t replace people, but it is a helpful tool: A qualitative study on patients’ experiences of using a smartphone-application post-cardiac rehabilitation (Preprint)

Background

Exercise-based cardiac rehabilitation (CR) is a crucial part of the treatment of patients with cardiac diseases, and adherence to healthy behavior is a prerequisite to improve long-term prognosis. Unfortunately, adherence to healthy behavior adapted in CR is challenging for many cardiac patients in the long term. Recently, we demonstrated that follow-up conducted via an app for 1 year significantly improved adherence to healthy behavior after CR. To increase the knowledge and understanding of mobile Health (mHealth) interventions that can promote acceptance and adherence, qualitative research investigating patients’ experiences with these interventions is warranted.

Objective

The aim was to investigate patient experiences with individualized long-term follow-up conducted via an app for 1 year and their thoughts about what features promoted adherence to healthy behavior after CR. The purpose was to increase the understanding of significant findings previously reported and to guide future development of similar interventions in the field of adherence.

Methods

A qualitative study with individual interviews was conducted from November 2018 to May 2019. A thematic interview guide was used when conducting the semistructured in-depth interviews. The interviews were audio recorded and transcribed successively during the period in which the interviews were conducted. Texts were managed and systematized by NVivo. Interviews were analyzed by qualitative content analysis. Codes and themes were inductively developed.

Results

Ten patients who had participated in a randomized controlled trial evaluating the effect of follow-up conducted via an app on adherence to healthy behavior after CR were included. The median patient age was 65 years (range 46-72 years), and both genders were represented. The analysis resulted in the following 4 themes describing the patients’ experiences: (1) The person behind the app is crucial for motivation and adherence; (2) The app as a commitment; (3) The app as a path to independence; and (4) Suggestions for improvements. Features experienced as beneficial to promote adherence were individualized feedback and the use of goal setting. The significance of the person behind the app (the supervisor) who provided individualized feedback was a consistent finding. This person seemed to promote motivation in general and to enable other known behavioral change techniques.

Conclusions

The person behind the app (the supervisor) seems to be one of the most significant success factors in promoting adherence to healthy behavior after CR. This indicates that a health care provider must actively participate in a patient’s process of adherence to healthy behavior, even when using interventions, including an app. Future development of interventions in the field of adherence should strive to create tools that enable an ongoing collaborative relationship between the patient and the health care provider. The follow-up should be based on the patient’s own goals, and individualized feedback should be provided.

Relationship Between Efficiency, Effectiveness, and Learnability of Home Connected Medical Device in Ambulatory Surgery

Background: Currently, usability assessments of home connected medical devices do not systematically take into account learnability metrics. In case of the Smart Angel device-designed for monitoring ambulatory surgery patients-users are trained at the hospital and have to use the device at home to monitor their health remotely. Objective: The aim of this study was to better understand the relationships between two metrics of usability-efficiency and effectiveness-and learnability of the Smart Angel device. Materials and Methods: Twenty-eight participants were trained in a simulated hospital (SimUsanté), and then we filmed the participant using the device three times. Between each session, the participant had to complete questionnaires (sociodemographic and health literacy). Results: The results of a between-subject analysis [χ²(2) = 18.969, p < 0.001] and a within-subject analysis [F(2.28) = 13.34, p < 0.001, η² = 0.35] showed that efficiency (manipulation time) significantly improved with learnability (number of sessions). Conversely, effectiveness (number of manipulation errors) stagnated over the three sessions with a between-subject analysis [F(2.75) = 1.628, p = 0.203], while the within-subject analysis revealed that users seemed to significantly correct their errors with the number of sessions [F(2.28) = 6, p = 0.005, η² = 0.19]. By analyzing the errors, we observed that some errors could appear at any time (e.g., moving during the measurement) and others were systematic (e.g., the wrist blood pressure on the right arm). Conclusions: While the "first attempt" at using a home medical device is a major revealing step for the study of manipulation errors, learnability is an equally useful metric to include in usability studies, as well as in the very definition itself of usability.

Characteristics of mobile phone access and usage among caregivers in Pakistan - A mHealth survey of urban and rural population

INTRODUCTION

Globally mobile ownership and access is becoming very common, and breakthroughs in mobile technology have shaped digital communication, with 7 billion mobile phone users globally. Developing countries account for 80% of newly purchased mobile phone devices with majority of such countries having low Routine Immunization coverage and a high risk of vaccine preventable diseases. The use of mobile phones provides a tremendous potential for public health involvement.

OBJECTIVE

The aim of this study is to assess the acceptability and usability of mobile phones among infant caregivers in a LMIC setup and to explore the role of mHealth to improve immunization uptake and coverage.

METHODS

This is a cross-sectional survey exploring the regional differences in mobile phone ownership, usability and preferences, along with level of trust with others while sharing a mobile phone. The study was conducted with caregivers of infants in an urban and rural sites of Pakistan.

RESULTS

A total of 4472 households were approached, of which 3337 participants were eligible for the study (74.61 %). The reasons for not participating in the study (n = 1135) included (i) household locked or refusal to participate for 594 families (52%), (ii) child older than 14 days of life in 409 cases (36%), (iii) 80 (7%) families did not have access to a functional mobile phone, (iv) 36 (3%)families did not provide a mobile phone number, and (v) 14 (1%) could not stay within the HDSS for 6 months. Access to mobile phone with SMS features was considerably high at both sites: 99.1% in Matiari (rural site) and 96.7% in Karachi (urban). In Matiari 96.6% of the respondents reported having daily access to the phone, contrasting with only 51.4% in Karachi. In Karachi, the predominant spoken language was Urdu, whereas majority of the respondents in Matiari spoke Sindhi (34.6% vs. 70.9%).

CONCLUSION

Our study indicates high access to mobile phone in both urban and rural setup, However access to smart phone is still limited, urban and rural setup. Further, the acceptance of overall health- and barrier-based child immunization messages through mobile phone were quite high in both settings. Lastly automated calls were preferred over SMS due to literacy and local settings. This bears important implications for improving child immunization uptake through mobile phones in developing regions such as Pakistan.

An mHealth App to Support Fertility Patients Navigating the World of Infertility (Infotility): Development and Usability Study

Background

The experience of infertility and its treatment engenders considerable stress and is often described as an emotional rollercoaster. A mobile health (mHealth) app may be a novel solution to address the psychoeducational and psychosocial support needs of fertility patients because of its potential to reduce stress and increase patient empowerment. There are a few fertility-related apps that provide information and support to both men and women undergoing fertility treatment; however, none have documented their development and evaluation process.

Objective

This study aims to describe the development and evaluation process of a bilingual mHealth app, Infotility, designed to meet the psychoeducational and psychosocial support needs of men and women undergoing fertility treatment.

Methods

To develop the Infotility app, we adhered to the Medical Research Council guidelines for the development and evaluation of complex interventions. First, we conducted literature reviews and needs assessment surveys of fertility patients and health care providers who informed the content and design of the app. Second, we tested the intervention with a small group of end users who provided feedback on the design and appropriateness of the app’s content. Third, we evaluated the uptake and usability of the app using a pre-post study design. Finally, we updated the app’s content based on participants’ feedback and searched for partners to disseminate the app to the broader public.

Results

This study is the first to describe the development and evaluation process of an mHealth app for men and women undergoing fertility treatment. The app met its goal in providing fertility patients with a clinician-approved, portable resource for reliable information about medical and psychosocial aspects of infertility and its treatments and a confidential peer support forum monitored by trained peer supporters. Participants rated the engagement, functionality, information, and esthetics of the app positively, with an overall app quality mean score of 3.75 (SD 0.53) and a star rating of 3.43 (SD 0.75), with a total possible score and star rating of 5.00.

Conclusions

By documenting the systematic development and evaluation of the mHealth app for men and women undergoing fertility treatment, this paper can facilitate the replication of the study intervention and the development of similar mHealth apps.

Digital mHealth and Virtual Care Use in Pandemics: A Rapid Landscape Review of Interventions Used Internationally During COVID-19 in 4 Countries

BACKGROUND

As a result of the Coronavirus Disease-2019 (COVID-19) pandemic, providing health care while maintaining social distancing has resulted in the need to provide care remotely, support quarantined/isolated individuals, monitor infected individuals and their close contacts, as well as disseminate accurate information regarding COVID-19 to the public. This has led to an unprecedented rapid expansion of digital tools to provide digitized virtual care globally, especially mobile phone facilitated health interventions, called mHealth. To help keep abreast of different mHealth and virtual care technologies being used internationally to facilitate patient care and public health during the COVID-19 pandemic we did a rapid investigation of solutions being deployed and considered in 4 countries.

OBJECTIVE

To describe mHealth, and digital and contact tracing technologies being used in healthcare management of the COVID-19 pandemic among two high-income and two low-middle income countries.

METHODS

We compared virtual care interventions used for COVID-19 management among two high-income (HI) countries (the UK and Canada) and two low-middle (LMI) countries (Kenya and Rwanda). We focused on interventions used to facilitate patient care and public health. Information regarding specific virtual care technologies was procured from a variety of resources including grey literature, government & health organization website, and co-authors' personal experiences as implementers of COVID-19 virtual care strategies. Search engine queries were performed to find health information that would be easily accessible to the general public, with keywords including "COVID-19", "contact-tracing", "tool-kit", "telehealth", and "virtual care", in conjunction with corresponding national health authorities.

RESULTS

We identified a variety of technologies in Canada, the UK, Rwanda, and Kenya being used for patient care and public health. The aforementioned countries are using both video and text message-based platforms to facilitate communication with HCPs (ex. WelTel, Zoom). Nationally-developed contact-tracing apps are provided free to the public, with most of them using Bluetooth-based technology. We identified that often multiple complimentary technologies are being utilized for different aspects of patient care and public health with the common purpose to disseminate information safely. There was negligible difference among the types of technologies used in both HI and LMI countries, although LMI implemented virtual care interventions earlier during the pandemic's first wave which may account for their effective response.

CONCLUSIONS

Virtual care and mHealth technologies have evolved rapidly as a tool for health care support for both patient care and public health. It is evident that, on an international level, a variety of mHealth and virtual care interventions, often in combination, are required to be able to address patient care and public health concerns during the COVID-19 pandemic, independent of a country's economic standing.

CLINICALTRIAL

Effect of ICT-Based Self-Management System DialBeticsLite on Treating Abdominal Obesity in the Specific Health Guidance in Japan: Randomized Controlled Trial. (Preprint)

Background

Mobile health (mHealth) interventions, a more cost-effective approach compared with traditional methods of delivering lifestyle coaching in person, have been shown to improve physical parameters and lifestyle behavior among overweight populations. In Japan, the Specific Health Checkups and Specific Health Guidance (SHG) started in 2008 to treat obesity and abdominal obesity. However, the effectiveness of SHG is limited owing to its in-person counseling. The effect of mHealth on SHG has yet to be demonstrated.

Objective

This study aims to determine whether a mobile self-management app (DialBeticsLite) could make the SHG more beneficial among patients with abdominal obesity to achieve a reduction in visceral fat area (VFA).

Methods

This study was an open-label, 2-arm, parallel-design randomized controlled trial. We recruited 122 people in September 2017 and randomly assigned them into either the intervention or control group. All participants attended an educational group session that delivered information regarding diet and exercise. In addition, participants in the intervention group were asked to use DialBeticsLite for 3 months. DialBeticsLite facilitated the daily recording of several physical parameters and lifestyle behavior and provided feedback to encourage an improvement in behavior. The primary outcome was the change in VFA from baseline to the 3-month follow-up. Secondary outcomes included changes in both physical and metabolic parameters from baseline to the 3-month follow-up. The Welch 2-tailed t test was conducted to analyze the effects of DialBeticsLite on both the primary and secondary outcomes.

Results

Of the 122 participants recruited, 75 (61.5%) were analyzed because 47 (38.5%) were excluded: 37 (30.3%) because of ineligibility and 10 (8.2%) because of withdrawal of consent. The mean age was 49.3 (SD 6.1) years in the intervention group (41/75, 55%) and 48.5 (SD 5.3) years in the control group (34/75, 45%), and all participants were men, although unintentionally. The baseline characteristics did not differ significantly between the intervention and control groups, except for VFA. The average change of VFA was −23.5 (SD 20.6) cm² in the intervention group and +1.9 (SD 16.2) cm² in the control group (P<.001). Statistically significant differences were also found for the change of body weight, BMI, and waist circumference. These findings did not change after adjusting for VFA at the baseline. The intervention had no significant effect on any of the metabolic parameters. An exploratory analysis showed significant associations between the change in VFA and steps per day and between the change in VFA and calorie intake per day within the intervention group.

Conclusions

Our findings indicate that an mHealth intervention facilitating the daily monitoring of several physical parameters and lifestyle behavior can be highly effective in inducing visceral fat loss and weight loss among adults eligible for SHG.

Trial Registration

UMIN Clinical Trials Registry UMIN000042045; https://tinyurl.com/4vat3v53

Development features and study characteristics of mobile health apps in the management of chronic conditions: a systematic review of randomised trials

COVID-19 pandemic challenges have accelerated the reliance on digital health fuelling the expanded incorporation of mobile apps into healthcare services, particularly for the management of long-term conditions such as chronic diseases (CDs). However, the impact of health apps on outcomes for CD remains unclear, potentially owing to both the poor adoption of formal development standards in the design process and the methodological quality of studies. A systematic search of randomised trials was performed on Medline, ScienceDirect, the Cochrane Library and Scopus to provide a comprehensive outlook and review the impact of health apps on CD. We identified 69 studies on diabetes (n = 29), cardiovascular diseases (n = 13), chronic respiratory diseases (n = 13), cancer (n = 10) or their combinations (n = 4). The apps rarely adopted developmental factors in the design stage, with only around one-third of studies reporting user or healthcare professional engagement. Apps differed significantly in content, with a median of eight behaviour change techniques adopted, most frequently pertaining to the ‘Feedback and monitoring’ (91%) and ‘Shaping knowledge’ (72%) categories. As for the study methodologies, all studies adopted a traditional randomised control trial (RCT) design, with relatively short follow-ups and limited sample sizes. Findings were not significant for the majority of studies across all CD, with most RCTs revealing a high risk of bias. To support the adoption of apps for CD management, this review reinforces the need for more robust development and appropriate study characteristics to sustain evidence generation and elucidate whether study results reflect the true benefits of apps or a biased estimate due to unsuitable designs.

Post Discharge mHealth and Teach-Back Communication Effectiveness on Hospital Readmissions: A Systematic Review

Hospital readmissions pose a threat to the constrained health resources, especially in resource-poor low-and middle-income countries. In such scenarios, appropriate technologies to reduce avoidable readmissions in hospitals require innovative interventions. mHealth and teach-back communication are robust interventions, utilized for the reduction in preventable hospital readmissions. This review was conducted to highlight the effectiveness of mHealth and teach-back communication in hospital readmission reduction with a view to provide the best available evidence on such interventions. Two authors independently searched for appropriate MeSH terms in three databases (PubMed, Wiley, and Google Scholar). After screening the titles and abstracts, shortlisted manuscripts were subjected to quality assessment and analysis. Two authors checked the manuscripts for quality assessment and assigned scores utilizing the QualSyst tool. The average of the scores assigned by the reviewers was calculated to assign a summary quality score (SQS) to each study. Higher scores showed methodological vigor and robustness. Search strategies retrieved a total of 1932 articles after the removal of duplicates. After screening titles and abstracts, 54 articles were shortlisted. The complete reading resulted in the selection of 17 papers published between 2002 and 2019. Most of the studies were interventional and all the studies focused on hospital readmission reduction as the primary or secondary outcome. mHealth and teach-back communication were the two most common interventions that catered for the hospital readmissions. Among mHealth studies (11 out of 17), seven studies showed a significant reduction in hospital readmissions while four did not exhibit any significant reduction. Among the teach-back communication group (6 out of 17), the majority of the studies (5 out of 6) showed a significant reduction in hospital readmissions while one publication did not elicit a significant hospital readmission reduction. mHealth and teach-back communication methods showed positive effects on hospital readmission reduction. These interventions can be utilized in resource-constrained settings, especially low- and middle-income countries, to reduce preventable readmissions.

Patterns for Patient Engagement with the Hypertension Management and Effects of Electronic Health Care Provider Follow-up on These Patterns: Cluster Analysis

Background

Hypertension is a long-term medical condition. Electronic and mobile health care services can help patients to self-manage this condition. However, not all management is effective, possibly due to different levels of patient engagement (PE) with health care services. Health care provider follow-up is an intervention to promote PE and blood pressure (BP) control.

Objective

This study aimed to discover and characterize patterns of PE with a hypertension self-management app, investigate the effects of health care provider follow-up on PE, and identify the follow-up effects on BP in each PE pattern.

Methods

PE was represented as the number of days that a patient recorded self-measured BP per week. The study period was the first 4 weeks for a patient to engage in the hypertension management service. K-means algorithm was used to group patients by PE. There was compliance follow-up, regular follow-up, and abnormal follow-up in management. The follow-up effect was calculated by the change in PE (CPE) and the change in systolic blood pressure (CSBP, SBP) before and after each follow-up. Chi-square tests and z scores were used to ascertain the distribution of gender, age, education level, SBP, and the number of follow-ups in each cluster. The follow-up effect was identified by analysis of variances. Once a significant effect was detected, Bonferroni multiple comparisons were further conducted to identify the difference between 2 clusters.

Results

Patients were grouped into 4 clusters according to PE: (1) PE started low and dropped even lower (PELL), (2) PE started high and remained high (PEHH), (3) PE started high and dropped to low (PEHL), and (4) PE started low and rose to high (PELH). Significantly more patients over 60 years old were found in the PEHH cluster (P≤.05). Abnormal follow-up was significantly less frequent (P≤.05) in the PELL cluster. Compliance follow-up and regular follow-up can improve PE. In the clusters of PEHH and PELH, the improvement in PE in the first 3 weeks and the decrease in SBP in all 4 weeks were significant after follow-up. The SBP of the clusters of PELL and PELH decreased more (–6.1 mmHg and –8.4 mmHg) after follow-up in the first week.

Conclusions

Four distinct PE patterns were identified for patients engaging in the hypertension self-management app. Patients aged over 60 years had higher PE in terms of recording self-measured BP using the app. Once SBP reduced, patients with low PE tended to stop using the app, and a continued decline in PE occurred simultaneously with the increase in SBP. The duration and depth of the effect of health care provider follow-up were more significant in patients with high or increased engagement after follow-up.

Effectiveness of technology-assisted cardiac rehabilitation: A systematic review and meta-analysis

OBJECTIVES

The objectives of this review were to identify different technology-assisted interventions in cardiac rehabilitation, to explore and examine the effectiveness of technology-assisted cardiac rehabilitation.

DESIGN

A systematic review and meta-analysis.

METHODS

A systematic search was performed on six electronic databases: CINALH Complete, Cochrane Library, PubMed, MEDLINE via OvidSP, British Nursing Index and PsycINFO to identify randomised controlled trials from 2010 to 2020. Selection of studies was performed by screening the titles, abstracts and full texts, and two reviewers independently and critically appraised the included studies using the revised Cochrane risk of bias tool for randomized trials (RoB 2).

RESULTS

Nine randomised controlled trials met the inclusion criteria; five studies with some bias concerns related to allocation concealment (n = 2) and measurement of outcome (n = 4), and four studies were of low risk of bias. The pooled effect size showed comparable effectiveness between technology-assisted cardiac rehabilitation and conventional/centre-based cardiac rehabilitation on modifiable coronary risk factors (systolic and diastolic blood pressure, total cholesterol, p>0.05), psychological outcomes (anxiety: SMD 0.25, 95% CI -0.11 to 0.62, p = 0.17 and depression: SMD 0.09, 95% CI -0.16 to 0.35, p = 0.47). Narrative synthesis was performed for adherence to prescribed exercise sessions in cardiac rehabilitation. No significant adverse events occurred. The adverse events that did occur were self-reported, mostly unrelated to the interventions with technology and the number of events was comparable between both groups. Inconsistent results were found across the studies. This review revealed lack of self-efficacy and behaviour change theories/strategies, and educational emphasis among studies.

CONCLUSIONS

The results in the meta-analysis have indicated that technology-assisted cardiac rehabilitation demonstrated comparable results to conventional/centre-based cardiac rehabilitation. Technology-assisted cardiac rehabilitation is a potential alternative not only to remove cardiac rehabilitation barriers but also in the midst of current prolonged pandemic. Future studies on technology-assisted cardiac rehabilitation with the emphasis behavior change theories/strategies and education are required.

Using telemedicine to improve the quality of life of parents of infants with CHD surgery after discharge

OBJECTIVE

The purpose of this study was to investigate the effect of using telemedicine to improve the quality of life of parents of infants with congenital heart disease (CHD) surgery after discharge.

METHODS

A prospective randomized controlled study was conducted in a provincial hospital in China from November 2020 to April 2021 to compare the quality of life of parents of infants with CHD surgery after discharge between the WeChat follow-up group and the outpatient follow-up group. A total of 84 patients (42 in each group) and 168 parents (84 in each group) participated in this study.

RESULTS

One month after discharge, the Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) scores of parents in the intervention group were significantly lower than those in the control group (P < 0.05). Compared with the SAS and SDS scores at discharge, the scores of parents in the intervention group were significantly lower at 1 month after discharge (P < 0.05), while the scores of parents in the control group were similar at 1 month after discharge (P > 0.05). At discharge, in both the intervention group and the control group, the SAS and SDS scores of the mothers were higher than those of the fathers (P < 0.05). One month after discharge, in the control group, the SAS and SDS scores of the mothers were higher than those of the fathers (P < 0.05). One month after discharge, in the intervention group, the SAS and SDS scores of the mothers were similar to those of the fathers (P > 0.05). The comparison of the SAS and SDS scores of parents with different education levels showed that in both the intervention group and control group, the lower the parents' educational levels, the higher their SAS and SDS scores (P < 0.05). One month after discharge, in the control group, the lower the parents' education levels, the higher their SAS and SDS scores (P < 0.05). One month after discharge, in the intervention group, the SAS and SDS scores were similar among parents with different educational levels. The results of the World Health Organization Quality of Life Brief scale showed that the scores of the physiological, psychological, social and environmental fields at 1 month after discharge in the intervention group were significantly higher than those in the control group (P < 0.05).

CONCLUSION

Providing health education and medical support to the parents of infants with CHD surgery after discharge via telemedicine can effectively relieve parents' anxiety and depression and improve their quality of life.

Pharmacist-led intervention in treatment non-adherence and associated direct costs of management among ambulatory patients with type 2 diabetes in southwestern Nigeria

BACKGROUND

Non-adherence to recommended therapy remains a challenge to achieving optimal clinical outcome with resultant economic implications.

OBJECTIVE

To evaluate the effect of a pharmacist-led intervention on treatment non-adherence and direct costs of management among patients with type 2 diabetes (T2D).

METHOD

A quasi-experimental study among 201-patients with T2D recruited from two-tertiary healthcare facilities in southwestern Nigeria using semi-structured interview. Patients were assigned into control (HbA1c < 7%, n = 95) and intervention (HbA1c ≥ 7%, n = 106) groups. Baseline questionnaire comprised modified 4-item Medication Adherence Questions (MAQ), Perceived Dietary Adherence Questionnaire (PDAQ) and International Physical Activity Questionnaire, to assess participants' adherence to medications, diet and physical activity, respectively. Post-baseline, participants were followed-up for 6-month with patient-specific educational intervention provided to resolve adherence discrepancies in the intervention group only, while control group continued to receive usual care. Subsequently, direct costs of management for 6-month pre-baseline and 6-month post-baseline were estimated for both groups. Data were summarized using descriptive statistics. Chi-square, McNemar and paired t-test were used to evaluate categorical and continuous variables at p < 0.05.

RESULTS

Mean age was 62.9 ± 11.6 years, and 160(79.6%) were females. Glycated haemoglobin (HbA1c) was 6.1 ± 0.6% (baseline) and 6.1 ± 0.8% at 6-month post-baseline (p = 0.094) for control group, and 8.7 ± 1.5% (baseline) versus 7.8 ± 2.0% (6-month), p < 0.001, for the intervention. Post-baseline, response to MAQ items 1 (p = 0.017) and 2 (p < 0.001) improved significantly for the intervention. PDAQ score increased significantly from 51.8 ± 8.8 at baseline to 56.5 ± 3.9 at 6-month (p < 0.001) for intervention, and from 56.3 ± 4.0 to 56.5 ± 3.9 (p = 0.094) for the control group. Physical activity increased from 775.2 ± 700.5 Metabolic Equivalent Task (MET) to 829.3 ± 695.5MET(p < 0.001) and from 901.4 ± 743.5MET to 911.7 ± 752.6MET (p = 0.327) for intervention and control groups, respectively. Direct costs of management per patient increased from USD 327.3 ± 114.4 to USD 333.0 ± 118.4 (p = 0.449) for the intervention, while it decreased from USD 290.1 ± 116.97 to USD289.1 ± 120.0 (p = 0.89) for control group, at baseline and 6-month post-baseline, respectively.

CONCLUSION

Pharmacist-led intervention enhanced adherence to recommended medications, diet and physical activity among the intervention patients, with a corresponding significant improvement in glycaemic outcome and an insignificant increase in direct costs of management. There is a need for active engagement of pharmacists in management of patients with diabetes in clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04712916 . Retrospectively-registered.

Barriers and Facilitators Associated With App-Based Treatment for Female Urinary Incontinence: Mixed Methods Evaluation

BACKGROUND

App-based treatment for urinary incontinence is a proven effective and cost-effective alternative to care as usual, but successful implementation requires that we identify and address the barriers and facilitators associated with app use.

OBJECTIVE

The goal of the research was to explore the factors influencing app-based treatment for urinary incontinence and identify which barriers or facilitators are associated with treatment success or failure.

METHODS

We used a sequential explanatory mixed methods design to connect the results of a randomized controlled trial with data from semistructured interviews. This previous RCT had shown the noninferiority of app-based treatment compared with care as usual for urinary incontinence over 4 months. Participants who reported success or failure with app-based treatment, as measured by the change in International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form symptom score, were selected for telephone interview by purposive sampling (n=17). This study reports mainly on the qualitative component of our mixed methods study. Qualitative analyses were conducted in two ways. First, we analyzed the qualitative data of all interviewed participants and discussed the relationships between the main themes. Second, the experiences between the success (n=9) and failure group (n=8) were compared and contrasted to explore factors that were positively or negatively associated with the quantitative effect of app-based treatment. These factors were then interpreted as barriers to and facilitators of successful app-based treatment.

RESULTS

Four interrelated themes were identified as affecting the app based treatment effect: adherence, personal factors, app factors, and awareness. Qualitative analyses of the relationships between the themes showed that adherence-related factors directly influenced treatment effect in both a positive and negative matter. In turn, adherence was also positively and negatively influenced by the other 3 themes. Additionally, awareness was positively influenced by the treatment effect. Within these themes, several factors were identified that acted as barriers (eg, unrealistic expectation of time investment and interfering personal circumstances), facilitators (eg, strict integration of exercises and prior pelvic floor muscle therapy), or both (eg, personality traits and increased awareness of symptoms).

CONCLUSIONS

This study shows that the effect of app-based treatment for urinary incontinence is mainly influenced by adherence, which in turn is affected by personal factors, app-based factors, and awareness. The identified factors could function as both facilitators and barriers depending on the user and interaction with other themes. Insight into these facilitators and barriers could lead to improved implementation and increased treatment effectiveness by targeting women most likely to benefit and through further development of the app.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1002/nau.23507.

An investigation into the use of mHealth in musculoskeletal physiotherapy: Scoping Review (Preprint)

Background

Musculoskeletal physiotherapy provides conservative management for a range of conditions. Currently, there is a lack of engagement with exercise programs because of the lack of supervision and low self-efficacy. The use of mobile health (mHealth) interventions could be a possible solution to this problem, helping promote self-management at home. However, there is little evidence for musculoskeletal physiotherapy on the most effective forms of mHealth.

Objective

The aim of this review is to investigate the literature focusing on the use of mHealth in musculoskeletal physiotherapy and summarize the evidence.

Methods

A scoping review of 6 peer-reviewed databases was conducted in March 2021. No date limits were applied, and only articles written in the English language were selected. A reviewer screened all the articles, followed by 2 additional researchers screening a random sample before data extraction.

Results

Of the 1393 studies, 28 (2.01%) were identified. Intervention characteristics comprised stretching and strengthening exercises, primarily for degenerative joint pain and spinal conditions (5/28, 18%). The most reported use of mHealth included telephone and videoconferencing calls to provide a home exercise program or being used as an adjunct to physiotherapy musculoskeletal assessment (14/28, 50%). Although patient satisfaction with mHealth was reported to be high, reasons for disengagement included a lack of high-quality information and poor internet speeds. Barriers to clinical uptake included insufficient training with the intervention and a lack of time to become familiar.

Conclusions

mHealth has some benefits regarding treatment adherence and can potentially be as effective as normal physiotherapy care while being more cost-effective. The current use of mHealth is most effective when ongoing feedback from a health care professional is available.

Use of Patient-reported Outcome Measures and Patient-reported Experience Measures within Evaluation Studies of Telemedicine Applications: Systematic Review

Background

With the rise of digital health technologies and telemedicine, the need for evidence-based evaluation is growing. Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are recommended as an essential part of the evaluation of telemedicine. For the first time, a systematic review has been conducted to investigate the use of PROMs and PREMs in the evaluation studies of telemedicine covering all application types and medical purposes.

Objective

This study investigates the following research questions: in which scenarios are PROMs and PREMs collected for evaluation purposes, which PROM and PREM outcome domains have been covered and how often, which outcome measurement instruments have been used and how often, does the selection and quantity of PROMs and PREMs differ between study types and application types, and has the use of PROMs and PREMs changed over time.

Methods

We conducted a systematic literature search of the MEDLINE and Embase databases and included studies published from inception until April 2, 2020. We included studies evaluating telemedicine with patients as the main users; these studies reported PROMs and PREMs within randomized controlled trials, controlled trials, noncontrolled trials, and feasibility trials in English and German.

Results

Of the identified 2671 studies, 303 (11.34%) were included; of the 303 studies, 67 (22.1%) were feasibility studies, 70 (23.1%) were noncontrolled trials, 20 (6.6%) were controlled trials, and 146 (48.2%) were randomized controlled trials. Health-related quality of life (n=310; mean 1.02, SD 1.05), emotional function (n=244; mean 0.81, SD 1.18), and adherence (n=103; mean 0.34, SD 0.53) were the most frequently assessed outcome domains. Self-developed PROMs were used in 21.4% (65/303) of the studies, and self-developed PREMs were used in 22.3% (68/303). PROMs (n=884) were assessed more frequently than PREMs (n=234). As the evidence level of the studies increased, the number of PROMs also increased (τ=−0.45), and the number of PREMs decreased (τ=0.35). Since 2000, not only has the number of studies using PROMs and PREMs increased, but the level of evidence and the number of outcome measurement instruments used have also increased, with the number of PREMs permanently remaining at a lower level.

Conclusions

There have been increasingly more studies, particularly high-evidence studies, which use PROMs and PREMs to evaluate telemedicine. PROMs have been used more frequently than PREMs. With the increasing maturity stage of telemedicine applications and higher evidence level, the use of PROMs increased in line with the recommendations of evaluation guidelines. Health-related quality of life and emotional function were measured in almost all the studies. Simultaneously, health literacy as a precondition for using the application adequately, alongside proper training and guidance, has rarely been reported. Further efforts should be pursued to standardize PROM and PREM collection in evaluation studies of telemedicine.

Artificial Intelligence-Enabled ECG Algorithm Based on Improved Residual Network for Wearable ECG

Heart disease is the leading cause of death for men and women globally. The residual network (ResNet) evolution of electrocardiogram (ECG) technology has contributed to our understanding of cardiac physiology. We propose an artificial intelligence-enabled ECG algorithm based on an improved ResNet for a wearable ECG. The system hardware consists of a wearable ECG with conductive fabric electrodes, a wireless ECG acquisition module, a mobile terminal App, and a cloud diagnostic platform. The algorithm adopted in this study is based on an improved ResNet for the rapid classification of different types of arrhythmia. First, we visualize ECG data and convert one-dimensional ECG signals into two-dimensional images using Gramian angular fields. Then, we improve the ResNet-50 network model, add multistage shortcut branches to the network, and optimize the residual block. The ReLu activation function is replaced by a scaled exponential linear units (SELUs) activation function to improve the expression ability of the model. Finally, the images are input into the improved ResNet network for classification. The average recognition rate of this classification algorithm against seven types of arrhythmia signals (atrial fibrillation, atrial premature beat, ventricular premature beat, normal beat, ventricular tachycardia, atrial tachycardia, and sinus bradycardia) is 98.3%.

IntelligentPooling: Practical Thompson Sampling for mHealth

In mobile health (mHealth) smart devices deliver behavioral treatments repeatedly over time to a user with the goal of helping the user adopt and maintain healthy behaviors. Reinforcement learning appears ideal for learning how to optimally make these sequential treatment decisions. However, significant challenges must be overcome before reinforcement learning can be effectively deployed in a mobile healthcare setting. In this work we are concerned with the following challenges: 1) individuals who are in the same context can exhibit differential response to treatments 2) only a limited amount of data is available for learning on any one individual, and 3) non-stationary responses to treatment. To address these challenges we generalize Thompson-Sampling bandit algorithms to develop IntelligentPooling. IntelligentPooling learns personalized treatment policies thus addressing challenge one. To address the second challenge, IntelligentPooling updates each user's degree of personalization while making use of available data on other users to speed up learning. Lastly, IntelligentPooling allows responsivity to vary as a function of a user's time since beginning treatment, thus addressing challenge three.

Exercise Management Using a Mobile App in Patients With Parkinsonism: Prospective, Open-Label, Single-Arm Pilot Study

Background

Patients with parkinsonism have higher inactivity levels than the general population, and this results in increased comorbidities. Although exercise has benefits for motor function and quality of life (QOL) in patients with parkinsonism, these patients face many barriers to exercise participation, such as lack of motivation, fatigue, depression, and time constraints. Recently, the use of mobile apps has been highlighted as a remote exercise management strategy for patients with chronic diseases.

Objective

This study aimed to evaluate the effects of home-based exercise management with a customized mobile app on the exercise amount, physical activity, and QOL of patients with parkinsonism.

Methods

This was a prospective, open-label, single-arm pilot study. The therapist installed the app in the smartphones of the participants and educated them on how to use the app. The therapist developed an individualized multimodal exercise program that consisted of stretching, strengthening, aerobic, balance and coordination, and oral-motor and vocal exercises. Participants were encouraged to engage in an 8-week home-based exercise program delivered through a customized app. The alarm notifications of the app provided reminders to exercise regularly at home. The primary outcome was the exercise amount. The secondary outcomes were assessed using the International Physical Activity Questionnaire (IPAQ), Parkinson’s Disease Questionnaire-39 (PDQ-39), and Geriatric Depression Scale (GDS). The usability of the customized app was assessed using a self-report questionnaire.

Results

A total of 21 participants with parkinsonism completed the intervention and assessment between September and December 2020 (mean age: 72 years; women: 17/21, 81%; men: 4/21, 19%). The participants reported a significant increase in the total amount of exercise (baseline: mean 343.33, SD 206.70 min/week; 8-week follow-up: mean 693.10, SD 373.45 min/week; P<.001) and in the amount of each exercise component, including stretching, strengthening, balance and coordination, and oral-motor and vocal exercise after 8 weeks. Analysis of the secondary outcomes revealed significant improvements in the IPAQ (P=.006), PDQ-39 (P=.02), and GDS (P=.04) scores. The usability of the program with the mobile app was verified based on the positive responses such as “intention to use” and “role expectation for rehabilitation.”

Conclusions

Exercise management with a customized mobile app may be beneficial for improving exercise adherence, physical activity levels, depression management, and QOL in patients with parkinsonism. This remotely supervised technology-based, reinforcing, and multimodal exercise management strategy is recommended for use in patients with parkinsonism. In addition, this program proved useful as an alternative exercise management strategy during the COVID-19 pandemic when patients with Parkinson disease were less physically active than before and showed aggravation of symptoms. However, additional clinical trials are needed to evaluate the efficacy of this exercise program in a large population and to confirm its disease-modifying effects.

Mobile Health, Disease Knowledge, and Self-Care Behavior in Chronic Kidney Disease: A Prospective Cohort Study

Mobile health (mHealth) management is an emerging strategy of care for patients with chronic diseases. However, the effect of mHealth management on clinical outcomes of patients with chronic kidney disease (CKD) has not been well-studied. The aim of this study was to investigate the additional influence of mHealth on disease knowledge and self-care behavior in CKD patients who had received traditional education. We designed and developed a new healthcare mobile application, called iCKD, which has several major features, including home-based physiological signal monitoring, disease health education, nutrition analysis, medication reminder, and alarms and a warning system. Trained nurses interviewed patients with CKD using structured questionnaires of disease knowledge and self-care behavior. After propensity score matching, we analyzed 107 patients who used iCKD and traditional education, and 107 who received traditional education. The patients who used iCKD had higher disease knowledge scores than those who received traditional education. In multivariate analysis, iCKD was significantly and positively associated with disease knowledge scores. Patients with high education levels could have greater disease knowledge through using mHealth. There was no significant difference in total scores of self-care behavior between the two groups. In conclusion, mHealth can significantly increase disease knowledge in patients with CKD.

Bijou: Engaging Young MSM in HIV Care Using a Mobile Health Strategy

Young men who have sex with men (YMSM) living with HIV experience challenges with retention in care, which negatively affects viral suppression. To address this, researchers piloted Bijou, a program designed to provide health education through electronically delivered behavior and risk reduction modules. Participants were 29 YMSM aged 19-24 living with HIV from the southeastern US. Participants completed pre, post, and 3-month follow-up (3MFU) surveys assessing knowledge, intervention acceptability, satisfaction, self-efficacy, ehealth literacy, and usability. Findings revealed significant improvement in knowledge and e-health literacy from pre-test to post-test but lost significance at 3MFU. Self-efficacy scores did not show significant differences from pre-test to post-test or 3MFU. Participants who completed all modules considered Bijou usable and acceptable; however, many did not complete the program. Findings suggest a need for adaptations to promote knowledge retention, e-health literacy, engagement over time, and research with a larger, more representative sample.

Toward understanding the impact of mHealth features for people with HIV: a latent class analysis of PositiveLinks usage

PositiveLinks (PL) is a multi-feature smartphone-based platform to improve engagement-in-care and viral suppression (VS) among clinic patients living with HIV. Features include medication reminders, mood/stress check-ins, a community board, and secure provider messaging. Our goal was to examine how PL users interact with the app and determine whether usage patterns correlate with clinical outcomes. Patients (N = 83) at a university-based Ryan White clinic enrolled in PL from June 2016 to March 2017 and were followed for up to 12 months. A subset (N = 49) completed interviews after 3 weeks of enrollment to explore their experiences with and opinions of PL. We differentiated PL members based on 6-month usage of app features using latent class analysis. We explored characteristics associated with class membership, compared reported needs and preferences by class, and examined association between class and VS. The sample of 83 PL members fell into four classes. "Maximizers" used all app features frequently (27%); "Check-in Users" tended to interact only with daily queries (22%); "Moderate All-Feature Users" used all features occasionally (33%); and "As-Needed Communicators" interacted with the app minimally (19%). VS improved or remained high among all classes after 6 months. VS remained high at 12 months among Maximizers (baseline and 12-month VS: 100%, 94%), Check-in Users (82%, 100%), and Moderate All-Feature Users (73%, 94%) but not among As-Needed Communicators (69%, 60%). This mixed-methods study identified four classes based on PL usage patterns that were distinct in characteristics and clinical outcomes. Identifying and characterizing mHealth user classes offers opportunities to tailor interventions appropriately based on patient needs and preferences as well as to provide targeted alternative support to achieve clinical goals.

The impact of mobile applications on medication adherence: a systematic review

In 2008, Apple and Android launched their Application or "App" stores. Since then, there has been a growing interest in using mobile apps for improving medication adherence. However, research on the efficacy of apps, in terms of improved medication adherence and clinical outcome and/or patient-related outcome measures (PROMs) is scarce. The objective of this research was to systematically review the impact of apps on consumers' medication adherence and to determine the effect on clinical outcome and/or PROM(s). A systematic literature search was conducted to identify publications aimed at improving medication adherence published from January 2008 to April 2018. All studies were assessed for risk of bias using either the Risk Of Bias In Non-randomized Studies-of Interventions or the revised tool for Risk of Bias in randomized trials tool, depending on study design. Eleven randomized controlled trials (RCTs) and 10 non-RCTs were included. All 11 RCTs showed improvements in adherence; however, only seven reported statistically significant improvements in at least one adherence measure. Nine RCTs also demonstrated improvements in clinical outcome/PROM(s), of which five were statistically significant, whereas two RCTs did not report on clinical outcome/PROM(s). Only two studies using non-RCT study designs showed statistically significant improvements in all measures of adherence and clinical outcome/PROM(s). The risk of bias was moderate or serious for all included studies. Even though the use of an app may improve adherence, it is difficult to draw conclusions regarding the impact of apps on medication adherence due to the high degree of heterogeneity across studies, from the methodological design to the features of the app and the measure of adherence.

A Smart Diaper System Using Bluetooth and Smartphones to Automatically Detect Urination and Volume of Voiding: Prospective Observational Pilot Study in an Acute Care Hospital

Background

Caregivers of patients who wear conventional diapers are required to check for voiding every hour because prolonged wearing of wet diapers causes health problems including diaper dermatitis and urinary tract infections. However, frequent checking is labor intensive and disturbs patients’ and caregivers’ sleep. Furthermore, assessing patients’ urine output with diapers in an acute care setting is difficult. Recently, a smart diaper system with wetness detection technology was developed to solve these issues.

Objective

We aimed to evaluate the applicability of the smart diaper system for urinary detection, its accuracy in measuring voiding volume, and its effect on incontinence-associated dermatitis (IAD) occurrence in an acute care hospital.

Methods

This prospective, observational, single-arm pilot study was conducted at a single tertiary hospital. We recruited 35 participants aged ≥50 years who were wearing diapers due to incontinence between August and November 2020. When the smart diaper becomes wet, the smart diaper system notifies the caregiver to change the diaper and measures voiding volume automatically. Caregivers were instructed to record the weight of wet diapers on frequency volume charts (FVCs). We determined the voiding detection rate of the smart diaper system and compared the urine volume as automatically calculated by the smart diaper system with the volume recorded on FVCs. Agreement between the two measurements was estimated using a Bland-Altman plot. We also checked for the occurrence or aggravation of IAD and bed sores.

Results

A total of 30 participants completed the protocol and 390 episodes of urination were recorded. There were 108 records (27.7%) on both the FVCs and the smart diaper system, 258 (66.2%) on the FVCs alone, 18 (4.6%) on the smart diaper system alone, and 6 (1.5%) on the FVCs with sensing device lost. The detection rate of the smart diaper system was 32.8% (126/384). When analyzing records concurrently listed in both the FVCs and the smart diaper system, linear regression showed a strong correlation between the two measurements (R²=0.88, P<.001). The Bland-Altman assessment showed good agreement between the two measurements, with a mean difference of –4.2 mL and 95% limits of agreement of –96.7 mL and 88.3 mL. New occurrence and aggravation of IAD and bed sores were not observed. Bed sores improved in one participant.

Conclusions

The smart diaper system showed acceptable accuracy for measuring urine volume and it could replace conventional FVCs in acute setting hospitals. Furthermore, the smart diaper system has the potential advantage of preventing IAD development and bed sore worsening. However, the detection rate of the smart diaper system was lower than expected. Detection rate polarization among participants was observed, and improvements in the user interface and convenience are needed for older individuals who are unfamiliar with the smart diaper system.

Effectiveness of eHealth Interventions in Improving Medication Adherence for Patients With Chronic Obstructive Pulmonary Disease or Asthma: Systematic Review

Background

Poor treatment adherence in patients with chronic obstructive pulmonary disease (COPD) or asthma is a global public health concern with severe consequences in terms of patient health and societal costs. A potentially promising tool for addressing poor compliance is eHealth.

Objective

This review investigates the effects of eHealth interventions on medication adherence in patients with COPD or asthma.

Methods

A systematic literature search was conducted in the databases of Cochrane Library, PsycINFO, PubMed, and Embase for studies with publication dates between January 1, 2000, and October 29, 2020. We selected randomized controlled trials targeting adult patients with COPD or asthma, which evaluated the effectiveness of an eHealth intervention on medication adherence. The risk of bias in the included studies was examined using the Cochrane Collaboration’s risk of bias tool. The results were narratively reviewed.

Results

In total, six studies focusing on COPD and seven focusing on asthma were analyzed. Interventions were mostly internet-based or telephone-based, and could entail telemonitoring of symptoms and medication adherence, education, counseling, consultations, and self-support modules. Control groups mostly comprised usual care conditions, whereas a small number of studies used a face-to-face intervention or waiting list as the control condition. For COPD, the majority of eHealth interventions were investigated as an add-on to usual care (5/6 studies), whereas for asthma the majority of interventions were investigated as a standalone intervention (5/7 studies). Regarding eHealth interventions targeting medication adherence for COPD, two studies reported nonsignificant effects, one study found a significant effect in comparison to usual care, and three reported mixed results. Of the seven studies that investigated eHealth interventions targeting medication adherence in asthma, three studies found significant effects, two reported nonsignificant effects, and two reported mixed effects.

Conclusions

The mixed results on the effectiveness of eHealth interventions in improving treatment adherence for asthma and COPD are presumably related to the type, context, and intensity of the interventions, as well as to differences in the operationalization and measurement of adherence outcomes. Much remains to be learned about the potential of eHealth to optimize treatment adherence in COPD and asthma.

Effectiveness of mobile phone text message reminder interventions to improve adherence to antiretroviral therapy among adolescents living with HIV: A systematic review and meta-analysis

Background

Poor adherence to antiretroviral therapy in adolescents living with HIV is a global challenge. One of the key strategies to improve adherence is believed to be the use of digital adherence tools. However, evidence is limited in this area. Our objective was to investigate the effectiveness of mobile phone text message reminders in improving ART adherence for adolescents.

Methods

The preferred reporting item for systematic review and meta-analysis guideline was followed. A literature search was done in five databases (PubMed, Web of Science, Embase, Global Health and Cochrane) in August 2020. Additional searches for studies and grey literature were performed manually. We included studies with quantitative design exploring the effectiveness of text message reminders, targeting adolescents aged 10–19 years. Studies were excluded if the intervention involved phone calls, phone-based applications, or other complex tech services. Mean differences between intervention and standard of care were computed using a random effects model. Subgroup analyses were performed to identify sources of heterogeneity between one-way and two-way text messages.

Results

Of 2517 study titles screened, seven eligible studies were included in the systematic review. The total number of participants in the included studies was 987, and the study sample varied from 14 to 332. Five studies showed a positive impact of text messaging in improving adherence, while no significant difference was found between the intervention and the control (standard of care) group in the remaining two studies. The pooled mean difference between the intervention and the control group was 0.05 (95% CI: –0.08 to 0.17). There was considerable heterogeneity among the studies (I² = 78%).

Conclusion and recommendation

The meta-analysis of text message reminder interventions did not show a statistically significant difference in the improvement of ART adherence among adolescents living with HIV. The included studies were heterogeneous in the reported clinical outcomes, where the effectiveness of the intervention was identified in small studies which had a short follow-up period. Studies with bigger sample size and a longer follow-up period are needed.

Text Messaging in Cancer-Supportive Care: A Systematic Review

The global cancer disease burden is substantial, resulting in increased economic and clinical strain on our healthcare systems. A proposed solution is text-based communication, which can be used for cancer-supportive care. We conducted a systematic review to synthesize and describe the use of text-based communications for cancer-supportive care. Our population of interest included adult patients with cancer. A total of 18 studies were included in the review: 9 RCTs and 9 non-randomized interventional/observational studies. Patients were largely satisfied with text-based communication during their cancer care. Compared to controls, results for other outcomes including symptoms and quality of life were largely mixed; however, no harms were observed. Furthermore, positive outcomes were seen for specific interventions, such as text message medication reminders. These findings should be considered with caution due to the considerable heterogeneity observed between studies regarding their design and reported outcomes and the high risk of bias associated with 6/18 studies. Overall, this review suggests that text-based communication may be a complementary tool for cancer-supportive care; however, more research is needed to examine the feasibility of implementation and use.

Application of Smartphone Technologies in Disease Monitoring: A Systematic Review

Technologies play an essential role in monitoring, managing, and self-management of chronic diseases. Since chronic patients rely on life-long healthcare systems and the current COVID-19 pandemic has placed limits on hospital care, there is a need to explore disease monitoring and management technologies and examine their acceptance by chronic patients. We systematically examined the use of smartphone applications (apps) in chronic disease monitoring and management in databases, namely, Medline, Web of Science, Embase, and Proquest, published from 2010 to 2020. Results showed that app-based weight management programs had a significant effect on healthy eating and physical activity (p = 0.002), eating behaviours (p < 0.001) and dietary intake pattern (p < 0.001), decreased mean body weight (p = 0.008), mean Body Mass Index (BMI) (p = 0.002) and mean waist circumference (p < 0.001). App intervention assisted in decreasing the stress levels (paired t-test = 3.18; p < 0.05). Among cancer patients, we observed a high acceptance of technology (76%) and a moderately positive correlation between non-invasive electronic monitoring data and questionnaire (r = 0.6, p < 0.0001). We found a significant relationship between app use and standard clinical evaluation and high acceptance of the use of apps to monitor the disease. Our findings provide insights into critical issues, including technology acceptance along with regulatory guidelines to be considered when designing, developing, and deploying smartphone solutions targeted for chronic patients.

A Personalized Mobile Health Program for Type 2 Diabetes During the COVID-19 Pandemic: Single-Group Pre-Post Study

Background

With increasing type 2 diabetes prevalence, there is a need for effective programs that support diabetes management and improve type 2 diabetes outcomes. Mobile health (mHealth) interventions have shown promising results. With advances in wearable sensors and improved integration, mHealth programs could become more accessible and personalized.

Objective

The study aimed to evaluate the feasibility, acceptability, and effectiveness of a personalized mHealth-anchored intervention program in improving glycemic control and enhancing care experience in diabetes management. The program was coincidentally implemented during the national-level lockdown for COVID-19 in Singapore, allowing for a timely study of the use of mHealth for chronic disease management.

Methods

Patients with type 2 diabetes or prediabetes were enrolled from the Singapore Armed Forces and offered a 3-month intervention program in addition to the usual care they received. The program was standardized to include (1) in-person initial consultation with a clinical dietitian; (2) in-person review with a diabetes specialist doctor; (3) 1 continuous glucose monitoring device; (4) access to the mobile app for dietary intake and physical activity tracking, and communication via messaging with the dietitian and doctor; and (5) context-sensitive digital health coaching over the mobile app. Medical support was rendered to the patients on an as-needed basis when they required advice on adjustment of medications. Measurements of weight, height, and glycated hemoglobin A_1c (HbA_1c) were conducted at 2 in-person visits at the start and end of the program. At the end of the program, patients were asked to complete a short acceptability feedback survey to understand the motivation for joining the program, their satisfaction, and suggestions for improvement.

Results

Over a 4-week recruitment period, 130 individuals were screened, the enrollment target of 30 patients was met, and 21 patients completed the program and were included in the final analyses; 9 patients were lost to follow-up (full data were not available for the final analyses). There were no differences in the baseline characteristics between patients who were included and excluded from the final analyses (age category: P=.23; gender: P=.21; ethnicity: P>.99; diabetes status category: P=.52, medication adjustment category: P=.65; HbA_1c category: P=.69; BMI: P>.99). The 21 patients who completed the study rated a mean of 9.0 out of 10 on the Likert scale for both satisfaction questions. For the Yes-No question on benefit of the program, all of the patients selected “Yes.” Mean HbA_1c decreased from 7.6% to 7.0% (P=.004). There were no severe hypoglycemia events (glucose level <3.0 mmol/L) reported. Mean weight decreased from 76.8 kg to 73.9 kg (P<.001), a mean decrease of 3.5% from baseline weight. Mean BMI decreased from 27.8 kg/m² to 26.7 kg/m² (P<.001).

Conclusions

The personalized mHealth program was feasible, acceptable, and produced significant reductions in HbA_1c (P=.004) and body weight (P<.001) in individuals with type 2 diabetes. Such mHealth programs could overcome challenges posed to chronic disease management by COVID-19, including disruptions to in-person health care access.

A Health eLearning Ontology and Procedural Reasoning Approach for Developing Personalized Courses to Teach Patients about Their Medical Condition and Treatment

We propose a methodological framework to support the development of personalized courses that improve patients' understanding of their condition and prescribed treatment. Inspired by Intelligent Tutoring Systems (ITSs), the framework uses an eLearning ontology to express domain and learner models and to create a course. We combine the ontology with a procedural reasoning approach and precompiled plans to operationalize a design across disease conditions. The resulting courses generated by the framework are personalized across four patient axes-condition and treatment, comprehension level, learning style based on the VARK (Visual, Aural, Read/write, Kinesthetic) presentation model, and the level of understanding of specific course content according to Bloom's taxonomy. Customizing educational materials along these learning axes stimulates and sustains patients' attention when learning about their conditions or treatment options. Our proposed framework creates a personalized course that prepares patients for their meetings with specialists and educates them about their prescribed treatment. We posit that the improvement in patients' understanding of prescribed care will result in better outcomes and we validate that the constructs of our framework are appropriate for representing content and deriving personalized courses for two use cases: anticoagulation treatment of an atrial fibrillation patient and lower back pain management to treat a lumbar degenerative disc condition. We conduct a mostly qualitative study supported by a quantitative questionnaire to investigate the acceptability of the framework among the target patient population and medical practitioners.

Acceptability and Feasibility of a Mobile Health Application for Video Directly Observed Therapy of Buprenorphine for Opioid Use Disorders in an Office-based Setting

INTRODUCTION/BACKGROUND

Video directly observed therapy (video-DOT) through a mobile health platform may improve buprenorphine adherence and decrease diversion. This pilot study tested the acceptability and feasibility of using this technology among patients receiving buprenorphine in an office-based setting.

METHODS

Participants were instructed to record videos of themselves taking buprenorphine. Data were collected from weekly in-person visits over a 4-week period; assessments included self-report of medication adherence, substance use, satisfaction with treatment and use of the application, and also urine drug testing. Open-ended questions at the final visit solicited feedback on patients' experiences using the mobile health application.

RESULTS

The sample consisted of 14 patients; a majority were male (86%) and White (79%). All participants except 1 (93%) were able to use the application successfully to upload videos. Among those who successfully used the application, the percentage of daily videos uploaded per participant ranged from 18% to 96%; on average, daily videos were submitted by participants 72% of the time. Most participants (10/14; 71%) reported being "very satisfied" with the application; of the remaining 4 participants, 2 were "satisfied" and 2 were "neutral." Participants reported liking the accountability and structure of the application provided and its ease of use. Negative feedback included minor discomfort at viewing one's self during recording and the time required.

CONCLUSIONS

Based on these results, use of a mobile health application for video-DOT of buprenorphine appears feasible and acceptable for patients who are treated in an office-based setting. Further research is needed to test whether use of such an application can improve treatment delivery and health outcomes.

Effects of Mobile Health Technologies on Uptake of Routine Growth Monitoring among Caregivers of Children Aged 9 to 18 Months in Kenya

This study aimed at finding out the effects of mobile health (mhealth) technologies on uptake of Routine Growth Monitoring (RGM) among caregivers of children aged above 9 months in Kenya. This was a quasi-experimental study. The experiment groups received Short Text Message (STM) and Voice Call (VC). The analysis demonstrates that in month 1, caregivers who received STM were 6.875 times more likely to take their children for RGM compared to control (OR = 6.875; 95 CI: 3.591-13.164); caregivers who received VC were 6.750 times more likely to take their children for RGM compared to those in control arm (OR = 6.750; 95 CI: 3.522-12.938). Policy makers and implementers in the health will find these study findings useful in deciding whether or not to adopt STM or VC in improving uptake of RGM for children above 9 months.

A Comprehensive 6A Framework for Improving Patient Self-Management of Hypertension Using mHealth Services: Qualitative Thematic Analysis

Background

Hypertension affects over 15% of the world’s population and is a significant global public health and socioeconomic challenge. Mobile health (mHealth) services have been increasingly introduced to support hypertensive patients to improve their self-management behaviors, such as adherence to pharmacotherapy and lifestyle modifications.

Objective

This study aims to explore patients’ perceptions of mHealth services and the mechanisms by which the services support them to self-manage their hypertension.

Methods

A semistructured, in-depth interview study was conducted with 22 outpatients of the General Hospital of Ningxia Medical University from March to May 2019. In 2015, the hospital introduced an mHealth service to support community-dwelling outpatients with self-management of hypertension. Content analysis was conducted by following a grounded theory approach for inductive thematic extraction. Constant comparison and categorization classified the first-level codes with similar meanings into higher-level themes.

Results

The patient-perceived mechanisms by which the mHealth service supported their self-management of hypertension were summarized as 6A: access, assessment, assistance, awareness, ability, and activation. With the portability of mobile phones and digitization of information, the mHealth service provided outpatients with easy access to assess their vital signs and self-management behaviors. The assessment results gave the patients real-time awareness of their health conditions and self-management performance, which activated their self-management behaviors. The mHealth service also gave outpatients access to assistance, which included health education and self-management reminders. Both types of assistance could also be activated by abnormal assessment results, that is, uncontrolled or deteriorating blood pressure values, discomfort symptoms, or not using the service for a long period. With its scalable use to handle any possible information and services, the mHealth service provided outpatients with educational materials to learn at their own pace. This led to an improvement in self-management awareness and ability, again activating their self-management behaviors. The patients would like to see further improvements in the service to provide more useful, personalized information and reliable services.

Conclusions

The mHealth service extended the traditional hypertension care model beyond the hospital and clinician’s office. It provided outpatients with easy access to otherwise inaccessible hypertension management services. This led to process improvement for outpatients to access health assessment and health care assistance and improved their awareness and self-management ability, which activated their hypertension self-management behaviors. Future studies can apply the 6A framework to guide the design, implementation, and evaluation of mHealth services for outpatients to self-manage chronic conditions.

Efficacy of Mobile Health in Patients With Low Back Pain: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Low back pain is one of the most common health problems and a main cause of disability, which imposes a great burden on patients. Mobile health (mHealth) affects many aspects of people's lives, and it has progressed rapidly, showing promise as an effective intervention for patients with low back pain. However, the efficacy of mHealth interventions for patients with low back pain remains unclear; thus, further exploration is necessary.

OBJECTIVE

The purpose of this study was to evaluate the efficacy of mHealth interventions in patients with low back pain compared to usual care.

METHODS

This was a systematic review and meta-analysis of randomized controlled trials designed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) statement standard. We searched for studies published in English before October 2020 in the PubMed, EMBASE, Web of Science, and Cochrane Library databases. Two researchers independently scanned the literature, extracted data, and assessed the methodological quality of the included studies. Bias risks were assessed using the Cochrane Collaboration tool. We used RevMan 5.4 software to perform the meta-analysis.

RESULTS

A total of 9 studies with 792 participants met the inclusion criteria. The simultaneous use of mHealth and usual care showed a better reduction in pain intensity than usual care alone, as measured by the numeric rating scale (mean difference [MD] -0.85, 95% CI -1.29 to -0.40; P<.001), and larger efficacy in reducing disability, as measured by the Rolland-Morris Disability Questionnaire (MD -1.54, 95% CI -2.35 to -0.73; P<.001). Subgroup analyses showed that compared with usual care, mHealth using telephone calls significantly reduced pain intensity (MD -1.12, 95% CI -1.71 to -0.53; P<.001) and disability score (MD -1.68, 95% CI -2.74 to -0.63; P<.001). However, without the use of telephone calls, mHealth had no obvious advantage over usual care in improving pain intensity (MD -0.48, 95% CI -1.16 to 0.20; P=.16) and the disability score (MD -0.41, 95% CI -1.88 to 1.05; P=.58). The group that received a more sensitive feedback intervention showed a significantly reduced disability score (MD -4.30, 95% CI -6.95 to -1.69; P=.001).

CONCLUSIONS

The use of simultaneous mHealth and usual care interventions has better efficacy than usual care alone in reducing pain intensity and disability in patients with low back pain. Moreover, the results of subgroup analysis revealed that mHealth using telephone calls might play a positive role in improving pain intensity and disability in patients with low back pain.

mHealth Interventions for Treatment Adherence and Outcomes of Care for Cardiometabolic Disease Among Adults Living With HIV: Systematic Review

BACKGROUND

The success of antiretroviral therapy has led to an increase in life expectancy and an associated rise in the risk of cardiometabolic diseases (CMDs) among people living with HIV.

OBJECTIVE

Our aim was to conduct a systematic review to synthesize the existing literature on the patterns of use and effects of mobile health (mHealth) interventions for improving treatment adherence and outcomes of care for CMD among people living with HIV.

METHODS

A systematic search of multiple databases, including PubMed-MEDLINE, Embase, CINAHL, Scopus, Web of Science, African Journals online, ClinicalTrials.gov, and the World Health Organization Global Index Medicus of peer-reviewed articles, was conducted with no date or language restrictions. Unpublished reports on mHealth interventions for treatment adherence and outcomes of care for CMD among adults living with HIV were also included in this review. Studies were included if they had at least 1 component that used an mHealth intervention to address treatment adherence or 1 or more of the stated outcomes of care for CMD among people living with HIV.

RESULTS

Our search strategy yielded 1148 unique records. In total, 10 articles met the inclusion criteria and were included in this review. Of the 10 studies, only 4 had published results. The categories of mHealth interventions ranged from short messaging, telephone calls, and wearable devices to smartphone and desktop web-based mobile apps. Across the different categories of interventions, there were no clear patterns in terms of consistency in the use of a particular intervention, as most studies (9/10, 90%) assessed a combination of mHealth interventions. Short messaging and telephone calls were however the most common interventions. Half of the studies (5/10, 50%) reported on outcomes that were indirectly linked to CMD, and none of them provided reliable evidence for evaluating the effectiveness of mHealth interventions for treatment adherence and outcomes of care for CMD among people living with HIV.

CONCLUSIONS

Due to the limited number of studies and the heterogeneity of interventions and outcome measures in the studies, no definitive conclusions could be drawn on the patterns of use and effects of mHealth interventions for treatment adherence and outcomes of care for CMD among people living with HIV. We therefore recommend that future trials should focus on standardized outcomes for CMD. We also suggest that future studies should consider having a longer follow-up period in order to determine the long-term effects of mHealth interventions on CMD outcomes for people living with HIV.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42018086940; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018086940.

Questionnaire for the assessment of adherence barriers of intravitreal therapy: the ABQ-IVT

Objective

To develop and validate a questionnaire for the investigation of non-adherence (NA) barriers in patients receiving intravitreal injection (IVT).

Design

Questionnaire development and cross-sectional patient survey combined with a retrospective medical chart review.

Participants

German patients with neovascular age-related macular degeneration (nAMD) or diabetic macular edema (DME) receiving anti-vascular endothelial growth factor (anti-VEGF) treatment via IVT.

Methods

The previously validated (indications: atrial fibrillation, human immunodeficiency virus, chronic inflammatory lung disease) Adherence Barriers Questionnaire (ABQ) was revised according to specifications of IVT, within the framework of an expert panel. The ABQ-IVT, which initially consisted of 24 items formulated as statements (4-point-Likert-scale ranging from “strongly agree” to “strongly disagree”), was applied in a cross-sectional survey. Evaluation of the questionnaire included an assessment of internal consistency and factor analysis. The occurrence of potential barriers in the patient sample was evaluated using descriptive statistics. To identify patient subpopulations, hierarchical cluster analysis was performed using ABQ-IVT answers as predictors. Due to difficulties in capturing NA as an external criterion, the evaluation of the questionnaire was limited to its internal validity and reliability.

Main outcome measures

Patients’ answers to the ABQ-IVT questionnaire and interviews.

Results

Of 253 patients, 234 (92%) were able to complete the ABQ-IVT questionnaire. Within the reliability analysis, the ABQ-IVT was reduced to 17 items. The condensed questionnaire demonstrated good internal consistency (Cronbach’s alpha = 0.78), and factor analysis showed no evidence for subscales of the questionnaire. Nearly half of the patients (49%) reported being affected by at least three different barriers. On average, a patient was affected by 3.1 barriers. The most frequently reported barriers were “Challenge due to time commitment of physician visits” (45% of the patients), “Depression” (29%) and “Travel and opportunity costs” (27%). Cluster analysis identified six patient subpopulations, each affected by different sets of barriers and differed regarding their patient characteristics.

Conclusions

The ABQ-IVT is a practical and reliable instrument for identifying patient-specific barriers to IVT treatment adherence. In practice, the questionnaire may be useful in assessing whether individual patients are at higher risk of NA due to specific adherence barriers. Aside from better awareness, this allows earlier interventions, though these still need to be validated. Patient subpopulations face different barriers and may, therefore, need distinct preventative care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40942-021-00311-x.

Impact of a diabetes remote monitoring program on medication adherence

BACKGROUND: Medication nonadherence in diabetes is well documented to be associated with inadequate glycemic control. Through remote blood glucose (BG) monitoring, unlimited test strip and lancet supplies, personal coaching, and online access to clinical information and educational resources, diabetes remote monitoring (DRM) programs may provide a solution. OBJECTIVE: To examine the relationship between patient participation in a DRM solution and adherence to oral antidiabetic drugs (OAD). METHODS: A retrospective, propensity score-matched cohort study was conducted using deidentified administrative claims data from a large pharmacy benefit manager. Commercially insured patients aged 18 years or older and having 2 or more 30-day adjusted OAD claims comprised the target sample. Patients enrolled in insurance plans that implemented DRM, who had at least 1 BG check (ever engaged) between April 1, 2015, and March 31, 2018 (exposure) were matched to patients enrolled in insurance plans that did not implement DRM (nonexposure). After a 1:2 matching on baseline demographics, disease burden proxy, total pharmacy out-of-pocket costs, previous adherence and insulin use, nonexposure group participants were assigned the same first BG check date as their matched DRM participants. Medication adherence measured as proportion of days covered (PDC) in the 365 days following first BG check was examined as a continuous and binary outcome measure (PDC > 80% or adherent vs < 80% or nonadherent). Multivariable linear and logistic regression were conducted to examine differential magnitude in adherence and likelihood of being adherent, respectively. RESULTS: The final sample consisted of 6,002 exposure and 12,004 nonexposure group patients. DRM participants who were ever engaged had a 4.5% higher adherence rate (P < 0.001) and 42% higher odds of being adherent (P < 0.001) in the period after engagement compared with non-DRM participants. Sensitivity analyses showed that patients engaged continuously (> 1 BG check per week) for 3, 6, and 12 months had 5.1%, 5.2%, and 6.4% higher adherence rates, respectively (P < 0.001), and 52%, 64%, and 98% higher odds of being adherent, respectively (P < 0.001), compared with non-DRM participants. CONCLUSIONS: The study findings offer evidence that DRM engagement is associated with higher odds of medication adherence. DRM solutions that provide access to glucose test results, personalized coaching, educational resources, and lower testing supply cost can also influence adherence. Our findings have important implications for payers and patients related to improved health outcomes due to higher medication adherence. DISCLOSURES: Funding for this study was provided by Express Scripts. Munshi, Amelung, Carter, and Henderson are employed by Express Scripts. James and Shah are employed by Livongo, which provided the DRM solution.

A Clinician-Controlled Just-in-time Adaptive Intervention System (CBT+) Designed to Promote Acquisition and Utilization of Cognitive Behavioral Therapy Skills in Bulimia Nervosa: Development and Preliminary Evaluation Study

Background

Cognitive behavioral therapy (CBT) for bulimia nervosa (BN) is most effective when patients demonstrate adequate skill utilization (ie, the frequency with which a patient practices or uses therapeutic skills) and skill acquisition (ie, the ability to successfully perform a skill learned in treatment). However, rates of utilization and acquisition of key treatment skills (eg, regular eating, urge management skills, and mood management skills) by the end of the treatment are frequently low; as a result, outcomes from CBT for BN are affected. Just-in-time adaptive interventions (JITAIs) may improve skill acquisition and utilization by delivering real-time interventions during algorithm-identified opportunities for skill practice.

Objective

In this manuscript, we describe a newly developed JITAI system called CBT+ that is designed to facilitate the acquisition and utilization of CBT for BN treatment skills when used as a treatment augmentation. We also present feasibility, acceptability, and preliminary outcomes data from a small proof-of-concept pilot trial (n=5 patients and n=3 clinicians) designed to identify opportunities for iterative development of CBT+ ahead of a larger ongoing randomized controlled trial.

Methods

A total of 5 individuals with BN received 16 sessions of outpatient CBT for BN while using the CBT+ app. Data were collected from patients and clinicians to evaluate the feasibility (eg, app use and user adherence), acceptability (eg, qualitative patient and clinician feedback, including usefulness ratings of CBT+ on a 6-point Likert scale ranging from 1=extremely useless to 6=extremely useful), and preliminary outcomes (eg, improvements in skill utilization and acquisition and BN symptoms) of the CBT+ system.

Results

Patients reported that CBT+ was a relatively low burden (eg, quick and easy-to-use self-monitoring interface), and adherence to in-app self-monitoring was high (mean entries per day 3.13, SD 1.03). JITAIs were perceived as useful by both patients (median rating 5/6) and clinicians (median rating 5/6) for encouraging the use of CBT skills. Large improvements in CBT skills and clinically significant reductions in BN symptoms were observed post treatment. Although preliminary findings indicated that the CBT+ system was acceptable to most patients and clinicians, the overall study dropout was relatively high (ie, 2/5, 40% patients), which could indicate some moderate concerns regarding feasibility.

Conclusions

CBT+, the first-ever JITAI system designed to facilitate the acquisition and utilization of CBT for BN treatment skills when used as a treatment augmentation, was shown to be feasible and acceptable. The results indicate that the CBT+ system should be subjected to more rigorous evaluations with larger samples and should be considered for wider implementation if found effective. Areas for iterative improvement of the CBT+ system ahead of a randomized controlled trial are also discussed.

Mobile Apps to Improve Medication Adherence in Cardiovascular Disease: Systematic Review and Meta-analysis

Background

Adherence rates of preventative medication for cardiovascular disease (CVD) have been reported as 57%, and approximately 9% of all CVD events in Europe are attributable to poor medication adherence. Mobile health technologies, particularly mobile apps, have the potential to improve medication adherence and clinical outcomes.

Objective

The objective of this study is to assess the effects of mobile health care apps on medication adherence and health-related outcomes in patients with CVD. This study also evaluates apps’ functionality and usability and the involvement of health care professionals in their use.

Methods

Electronic databases (MEDLINE [Ovid], PubMed Central, Cochrane Library, CINAHL Plus, PsycINFO [Ovid], Embase [Ovid], and Google Scholar) were searched for randomized controlled trials (RCTs) to investigate app-based interventions aimed at improving medication adherence in patients with CVD. RCTs published in English from inception to January 2020 were reviewed. The Cochrane risk of bias tool was used to assess the included studies. Meta-analysis was performed for clinical outcomes and medication adherence, with meta-regression analysis used to evaluate the impact of app intervention duration on medication adherence.

Results

This study included 16 RCTs published within the last 6 years. In total, 12 RCTs reported medication adherence as the primary outcome, which is the most commonly self-reported adherence. The duration of the interventions ranged from 1 to 12 months, and sample sizes ranged from 24 to 412. Medication adherence rates showed statistically significant improvements in 9 RCTs when compared with the control, and meta-analysis of the 6 RCTs reporting continuous data showed a significant overall effect in favor of the app intervention (mean difference 0.90, 95% CI 0.03-1.78) with a high statistical heterogeneity (I²=93.32%). Moreover, 9 RCTs assessed clinical outcomes and reported an improvement in systolic blood pressure, diastolic blood pressure, total cholesterol, and low-density lipoprotein cholesterol levels in the intervention arm. Meta-analysis of these clinical outcomes from 6 RCTs favored app interventions, but none were significant. In the 7 trials evaluating app usability, all were found to be acceptable. There was a great variation in the app characteristics. A total of 10 RCTs involved health care professionals, mainly physicians and nurses, in the app-based interventions. The apps had mixed functionality: 2 used education, 7 delivered reminders, and 7 provided reminders in combination with educational support.

Conclusions

Apps tended to increase medication adherence, but interventions varied widely in design, content, and delivery. Apps have an acceptable degree of usability; yet the app characteristics conferring usability and effectiveness are ill-defined. Future large-scale studies should focus on identifying the essential active components of successful apps.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42019121385; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=121385

Atrial fibrillation self-management: a mobile telephone app scoping review and content analysis

Atrial fibrillation (AF) affects over 1.4 million people in the UK, resulting in a five-fold increased stroke risk and a three to four times greater risk of severe, disabling stroke. Atrial fibrillation, a chronic disease, requires monitoring, medication, and lifestyle measures. A self-management approach supported by mobile health (mHealth) may empower AF self-care. To assess the need to develop new mHealth self-management interventions for those with AF this review aimed to identify commercially available AF self-management apps, analyse, and synthesize (i) characteristics, (ii) functions, (iii) privacy/security, (iv) incorporated behaviour change techniques (BCTs), and (v) quality and usability. We searched app stores for 'atrial fibrillation' and 'anticoagulation', and included apps focused on AF self-management in the review. We examined app functions, privacy statements against best practice recommendations, the inclusion of BCTs using the App Behaviour Change Scale, and app quality/usability using the Mobile App Rating Scale. From an initial search of 555 apps, five apps were included in the review. Common functions were educational content, medication trackers, and communication with healthcare professionals. Apps contained limited BCTs, lacked intuitive functions and were difficult to use. Privacy policies were difficult to read. App quality rated from poor to acceptable and no app had been evaluated in a clinical trial. The review reports a lack of commercially available AF self-management apps of sufficient standard for use in healthcare settings. This highlights the need for clinically validated mHealth interventions incorporating evidence-based BCTs to support AF self-management.

Pathway-Driven Coordinated Telehealth System for Management of Patients With Single or Multiple Chronic Diseases in China: System Development and Retrospective Study

Background

Integrated care enhanced with information technology has emerged as a means to transform health services to meet the long-term care needs of patients with chronic diseases. However, the feasibility of applying integrated care to the emerging “three-manager” mode in China remains to be explored. Moreover, few studies have attempted to integrate multiple types of chronic diseases into a single system.

Objective

The aim of this study was to develop a coordinated telehealth system that addresses the existing challenges of the “three-manager” mode in China while supporting the management of single or multiple chronic diseases.

Methods

The system was designed based on a tailored integrated care model. The model was constructed at the individual scale, mainly focusing on specifying the involved roles and responsibilities through a universal care pathway. A custom ontology was developed to represent the knowledge contained in the model. The system consists of a service engine for data storage and decision support, as well as different forms of clients for care providers and patients. Currently, the system supports management of three single chronic diseases (hypertension, type 2 diabetes mellitus, and chronic obstructive pulmonary disease) and one type of multiple chronic conditions (hypertension with type 2 diabetes mellitus). A retrospective study was performed based on the long-term observational data extracted from the database to evaluate system usability, treatment effect, and quality of care.

Results

The retrospective analysis involved 6964 patients with chronic diseases and 249 care providers who have registered in our system since its deployment in 2015. A total of 519,598 self-monitoring records have been submitted by the patients. The engine could generate different types of records regularly based on the specific care pathway. Results of the comparison tests and causal inference showed that a part of patient outcomes improved after receiving management through the system, especially the systolic blood pressure of patients with hypertension (P<.001 in all comparison tests and an approximately 5 mmHg decrease after intervention via causal inference). A regional case study showed that the work efficiency of care providers differed among individuals.

Conclusions

Our system has potential to provide effective management support for single or multiple chronic conditions simultaneously. The tailored closed-loop care pathway was feasible and effective under the “three-manager” mode in China. One direction for future work is to introduce advanced artificial intelligence techniques to construct a more personalized care pathway.

The impact of common chronic conditions on health-related quality of life: a general population survey in Iran using EQ-5D-5L

Background

Diseases have undeniable effects on Health-Related Quality of Life (HRQoL). Chronic diseases, in particular, limit the productive potentials and HRQoL of individuals. EQ-5D is a very popular generic instrument, which can be used to estimate HRQoL scores in any diseases. The current study investigates mean HRQoL scores in certain chronic diseases and examines the relationship between utility scores and chronic diseases in Iran.

Method

This cross-sectional study was carried out among the general adult population of Tehran. 3060 individuals were chosen by a stratified probability sampling method. The EQ-5D-5L questionnaire was applied. The utility scores were estimated using the Iranian crosswalk-based value set. The effect of chronic diseases on the HRQoL scores was derived by the Ordinary Least Squares (OLS) method. Data was analyzed using Stata version 13 software.

Results

The mean ± standard deviation utility and EQ-VAS scores were 0.85 ± 0.14 and 76.73 ± 16.55 in the participants without any chronic conditions. The scores were 0.69 ± 0.17 and 61.14 ± 20.61 in the participants with chronic conditions. The highest and lowest mean utility scores were related to thyroid disease (0.70) and Stroke (0.54), respectively. Common chronic conditions had significant negative effects on the HRQoL scores. Stroke (0.204) and cancer (0.177) caused the most reduction in the EQ-5D-5L utility scores. Lumbar disc hernia, digestive diseases, osteoarthritis, breathing problems, and anxiety/nerves cause 0.133, 0.109, 0.108, 0.087, and 0.078 reductions, respectively, in the EQ-5D-5L utility scores.

Conclusion

This study provides insight into some common chronic conditions and their effects on the HRQoL. Policymakers and planners should pay attention to the effects of chronic conditions especially high prevalence one. They should adopt effective interventions to control this issue and increase health. The results of this study can also be beneficial in economic evaluation studies.

Feasibility of an Interactive Coaching App to Enhance Post-concussion Outpatient Care

Objectives: To determine the feasibility of patients to use a web-based health app for management of post-concussion (mTBI) symptoms in an out-patient setting. Participants: Seven (7) patients who were referred to an outpatient specialist clinic (physiatry) with persisting symptoms following a concussion. Participants had to be 18 years of age or older and more than 3 months post injury. Design: This was a prospective cohort study using a web-based platform for chronic disease management to guide patients in managing symptoms based on individual clinical recommendations. Each patient received weekly Symptom Management Plans created by a health coach and a physician specialist, designed to reinforce positive progress with clinical recommendations. Main Measures: Adherence to tracking daily recommendations and symptoms (data collected through the web-interface), The Rivermead Post-Concussion Questionnaire (self report) and a Satisfaction Questionnaire (self report). Results: Adherence to assigned clinical recommendations was close to 100%. Pre-post results on the patient reported outcome measure (Rivermead Post Concussion Tool) showed improvement for most patients in their experience of symptoms. The Satisfaction Questionnaire showed high rates of satisfaction with the App and the intervention in general. Conclusions: Use of a web-based health app with a health coach is feasible in this patient population from both the patient and clinician perspective based on high adherence. There is also some evidence of improvement of symptoms with this intervention over time. Further exploration of the use of this type of intervention with post-concussion patients could potentially impact long-term outcomes.

The Uptake and Use of Telemonitoring in Chronic Care Between 2014 and 2019: Nationwide Survey Among Patients and Health Care Professionals in the Netherlands

BACKGROUND

Telemonitoring could offer solutions to the mounting challenges for health care and could improve patient self-management. Studies have addressed the benefits and challenges of telemonitoring for certain patient groups.

OBJECTIVE

This paper will examine the nationwide uptake of telemonitoring in chronic care in the Netherlands from 2014 to 2019 by means of an annual representative survey among patients and health care professionals.

METHODS

Between 2014 and 2019, approximately 2900 patients with chronic diseases, 700 nurses, and 500 general practitioners (GPs) and medical specialists received a questionnaire. About 30 questions addressed topics about the use of eHealth and experiences with it, including data about telemonitoring.

RESULTS

Between 2014 and 2019, the use of telemonitoring remained stable for all groups except medical specialists. In medical specialist departments, the use of telemonitoring increased from 11.2% (18/161) in 2014 to 19.6% (36/184) in 2019 (χ24=12.3; P=.02). In 2019, telemonitoring was used by 5.8% (28/485) of people with chronic disease. This was 18.2% (41/225) in GP organizations and 40.4% (44/109), 38.0% (78/205), and 8.9% (29/325) in the organizations of nurses working in primary, secondary, and elderly care, respectively. Up to 10% of the targeted patient group such as diabetics were regarded by health care professionals as suitable for using telemonitoring. The main benefits mentioned by the patients were "comfort" (421/1043, 40.4%) and "living at home for longer/more comfortably" (334/1047, 31.9%). Health care professionals added "improvement of self-management" (63/176, 35.8% to 57/71, 80.3%), "better understanding of the patient's condition" (47/176, 26.7% to 42/71, 59.2%), "reduction of workload" (53/134, 39.6% of nurses in elderly care), "better tailoring of care plan to the patient's situation" (95/225, 42.2% of GPs), and "saves time for patients/caregivers" (61/176, 34.7% of medical specialists). Disadvantages mentioned by professionals were that "it takes time to monitor data" (13/130, 10% to 108/225, 48.0%), "it takes time to follow up alerts" (15/130, 11.5% to 117/225, 52.0%), and "it is difficult to estimate which patients can work with telemonitoring" (22/113, 19.5% to 94/225, 41.8%).

CONCLUSIONS

The uptake of telemonitoring in Dutch chronic care remained stable during 2014-2019 but increased among medical specialists. According to both patients and professionals, telemonitoring improves the quality of life and quality of care. Skills for suitably including eligible patients and for allocating the tasks of data monitoring and follow-up care within the team would help to further increase the use of telemonitoring.

eHealth and mHealth: Adherence to treatment in chronic diseases

Poor adherence to treatment is a common problem in patients with chronic diseases since, given their nature, they involve long-term therapeutic regimens, hence the importance of permanent follow-up. In general, it is known that adherence to treatment is necessary to achieve better health outcomes, improve quality of life, and reduce health care-related costs. The growth of eHealth, particularly telemedicine and mobile health (mHealth), has resulted in a real benefit of technological platforms in the therapeutic adherence of these patients. With this in mind, the aim of this reflection paper is to briefly describe the current state of eHealth strategies and the impact they may have on adherence to treatment in patients with chronic diseases.