Mobile phone-based interventions for improving adherence to medication prescribed for the primary prevention of cardiovascular disease in adults

Efficacy of a Mobile Health App (eMOTIVA) Regarding Compliance With Cardiac Rehabilitation Guidelines in Patients With Coronary Artery Disease: Randomized Controlled Clinical Trial

BACKGROUND

Cardiac rehabilitation is fundamental among patients recovering from a coronary event, and mHealth technology may constitute a useful tool that provides guidelines based on scientific evidence in an entertaining, attractive, and user-friendly format.

OBJECTIVE

This study aimed to compare the efficacy of an mHealth intervention involving the eMOTIVA app and that of usual care regarding compliance with cardiac rehabilitation guidelines in terms of lifestyle, cardiovascular risk factors, and satisfaction among patients with acute coronary syndrome.

METHODS

A randomized controlled clinical trial with a parallel group design was conducted. It included 300 patients (mHealth group, 150; control group, 150) who underwent percutaneous coronary intervention for acute coronary syndrome. Both groups underwent evaluations initially (during hospitalization) and after 3 and 6 months (face-to-face consultations). The eMOTIVA app incorporates a virtual classroom providing audio and video information about a healthy lifestyle, a section for self-recording cardiovascular risk factors, and a section for feedback messages and gamification. The primary outcome variables were (1) adherence to the Mediterranean diet and the frequency of consumption of food; (2) physical activity level, sedentary time, and exercise capacity; (3) smoking cessation and nicotine dependence; (4) level of knowledge about cardiovascular risk factors; and (5) app satisfaction and usability.

RESULTS

The study analyzed 287 patients (mHealth group, 145; control group, 142). Most participants were male (207/300, 69.0%), and the mean age was 62.53 (SD 8.65) years. Significant improvements were observed in the mHealth group compared with the control group at 6 months in terms of (1) adherence to the Mediterranean diet (mean 11.92, SD 1.70 vs 8.92, SD 2.66 points; P<.001) and frequency of eating foods (red meat [≤1/week]: 141/143, 97.9% vs 96/141, 68.1%; industrial pastries [<2/week]: 129/143, 89.6% vs 80/141, 56.8%; oily fish [≥2/week]: 124/143, 86.1% vs 64/141, 41.4%; vegetables [≥2/day]: 130/143, 90.3% vs 78/141, 55.3%; fruit [≥2/day]: 128/143, 88.9% vs 85/141, 60.2%; all P<.001); (2) physical activity (mean 2112.66, SD 1196.67 vs 1372.60, SD 944.62 metabolic equivalents/week; P<.001) and sedentary time (mean 8.38, SD 1.88 vs 9.59, SD 2.09 hours; P<.001); (3) exercise capacity (distance: mean 473.49, SD 102.28 vs 447.25, SD 93.68 meters; P=.04); and (4) level of knowledge (mean 117.85, SD 3.83 vs 111.00, SD 7.11 points; P<.001). App satisfaction was high (mean 42.53, SD 6.38 points), and its usability was excellent (mean 95.60, SD 4.03 points).

CONCLUSIONS

With the eMOTIVA app, favorable results were obtained in the intervention group in terms of adherence to the Mediterranean diet, frequency of eating certain foods, physical activity, sedentary time, exercise capacity, knowledge level, systolic blood pressure, heart rate, and blood sugar level. Furthermore, participants reported high app satisfaction and rated its usability as excellent. Thus, this innovative tool is very promising.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05247606; https://clinicaltrials.gov/study/NCT05247606.

Influencing Factors to mHealth Uptake With Indigenous Populations: Qualitative Systematic Review

BACKGROUND

The advancements and abundance of mobile phones and portable health devices have created an opportunity to use mobile health (mHealth) for population health systems. There is increasing evidence for the feasibility and acceptance of mHealth with Indigenous populations. Providing a synthesis of qualitative findings of mHealth with Indigenous populations will gain insights into the strengths and challenges to mHealth use in Indigenous populations.

OBJECTIVE

This review aimed to identify and synthesize qualitative data pertaining to the experiences and perceptions of mHealth from the perspectives of end users (patients and service providers) living in the colonial settler democracies of Canada, Australia, New Zealand, the United States, the Pacific Islands, and the Sápmi region of northern Europe.

METHODS

In May 2021, systematic searches of peer-reviewed, scientific papers were conducted across the 5 databases of PubMed, CINAHL, Embase, PsycINFO, and Web of Science. Qualitative or mixed method studies were included where a mHealth intervention was the primary focus for responding to health challenges with Indigenous populations. Two authors independently screened papers for eligibility and assessed the risk of bias using a modified version of the Critical Appraisal Skills Programme. A meta-aggregative approach was used to analyze the findings of included studies.

RESULTS

Seventeen papers met the eligibility criteria, 8 studies with patients, 7 studies with service providers, and 2 studies that included both patients and service providers. Studies were conducted in Australia (n=10), Canada (n=2), New Zealand (n=2), Papua New Guinea (n=1), the United States (n=1), and Samoa (n=1). Our interpretation of these qualitative findings shows commonalities between Indigenous patients' and service providers' perceptions of mHealth. We summarize our findings in six themes: (1) mHealth literacy, (2) mHealth as a facilitator for connection and support, (3) mHealth content needed to be culturally relevant, (4) mHealth security and confidentiality, (5) mHealth supporting rather than replacing service providers, and (6) workplace and organizational capacity.

CONCLUSIONS

This research suggests that mHealth can meet the needs of both patients and service providers when the mHealth intervention is culturally relevant, accounts for digital and health literacy, incorporates interactive components, is supported by workplaces, fits into health provider workflows, and meets security and confidentiality standards. Future mHealth research with Indigenous populations should partner with key representatives (eg, patients, service providers, and executive leaders) in the mHealth design appropriate to the purpose, people, setting, and delivery.

Effectiveness of an eHealth intervention to improve subjective well-being and self-efficacy in cardiovascular disaease patients: A pilot non-randomized controlled trial

AIM

To evaluate the effectiveness of a multicomponent, eHealth-based self-efficacy intervention to promote subjective well-being and self-efficacy in patients with cardiovascular disease, exploring sex differences.

DESIGN

A pilot study of a two-arm non-randomized controlled trial.

METHODS

Forty-two cardiovascular patients (31% women) participated in the study. The experimental group received a personalized psychoeducational session and a 14-days eHealth intervention. Subjective well-being (positive and negative affect) and self-efficacy (chronic and cardiac) were assessed at baseline, post-psychoeducational session, post-eHealth intervention and at two follow-ups.

RESULTS

The levels of the experimental group in positive affect, at post-eHealth and follow-up 1, and self-efficacy, at post-eHealth, and both follow-ups, were statistically significantly higher compared to the control group (all ps < .05). When considering sex, the intervention was effective only for men. The results highlight the potential of eHealth interventions for cardiac patients and underline the importance of considering a gender perspective in their treatment.

Coverage and Acceptability of Mobile Phone Messages for Cancer Prevention: a Population-Based Study in a Latin American Country

Mobile health (m-health) has shown positive effects on disease prevention; however, several factors might influence its effectiveness, particularly in low- and middle-income countries. Randomized trials provide data with high internal validity but no major information on population impact. We conducted a pilot population-based study to assess the feasibility of cancer prevention through m-health in a Latin American population. A sample of affiliates to a health insurance company in Colombia was randomly selected and assigned to receive a short message service (SMS) or voice messages (VMS) during 4 weeks; weekly frequencies 2 and 7. Baseline and post-intervention surveys were conducted. Overall, 797 affiliates were contacted (SMS 393, VMS 404) but only 15.3% and 24.8% enrolled, respectively. Over 80% acceptability was observed among participants for all items evaluated (usefulness, understandability, timing, and frequency); however, 2-VMS per week was the only frequency consistent with the declared number of messages received and listened. Other frequencies resulted in high reception recall but low willingness to read/listen the messages. The willingness to be part of future programs was 20.0%. The gap between declared acceptability and practice, low participation rates, and low willingness to read/listen messages indicate m-health should be part of multicomponent interventions and should not be conceived as the sole intervention.

Information and communication technology-based interventions for chronic diseases consultation: Scoping review

BACKGROUND

Medical consultations are often critical meetings between patients and health personnel to provide treatment, health-management advice, and exchange of information, especially for people living with chronic diseases. The adoption of patient-operated Information and Communication Technologies (ICTs) allows the patients to actively participate in their consultation and treatment. The consultation can be divided into three different phases: before, during, and after the meeting. The difference is identified by the activities in preparation (before), the meeting, conducted either physically or in other forms of non-face-to-face interaction (during), and the follow-up activities after the meeting (after). Consultations can be supported by various ICT-based interventions, often referred to as eHealth, mHealth, telehealth, or telemedicine. Nevertheless, the use of ICTs in healthcare settings is often accompanied by security and privacy challenges due to the sensitive nature of health information and the regulatory requirements associated with storing and processing sensitive information.

OBJECTIVE

This scoping review aims to map the existing knowledge and identify gaps in research about ICT-based interventions for chronic diseases consultations. The review objective is guided by three research questions: (1) which ICTs are used by people with chronic diseases, health personnel, and others before, during, and after consultations; (2) which type of information is managed by these ICTs; and (3) how are security and privacy issues addressed?

METHODS

We performed a literature search in ACM, IEEE, PubMed, Scopus, and Web of Science and included primary studies published between January 2015 and June 2020 that used ICT before, during, and/or after a consultation for chronic diseases. This review presents and discusses the findings from the included publications structured around the three research questions.

RESULTS

Twenty-four studies met the inclusion criteria. Only five studies reported the use of ICTs in all three phases: before, during, and after consultations. The main ICTs identified were smartphone applications, web-based portals, cloud-based infrastructures, and electronic health record systems. Different devices like sensors and wearable devices were used in 23 studies to gather diverse information. Regarding the type of information managed by these ICTs, we identified nine categories: physiological data, treatment information, medical history, consultation media like images or videos, laboratory results, reminders, lifestyle parameters, symptoms, and patient identification. Security issues were addressed in 20 studies, while only eight of the included studies addressed privacy issues.

CONCLUSIONS

This scoping review highlights the potential for a new model of consultation for patients with chronic diseases. Furthermore, it emphasizes the possibilities for consultations besides physical and remote meetings. The scoping review also revealed a narrow focus on security and privacy. Security issues were more likely to be mentioned in the included publications, although with limited details. Future research should focus more on security and privacy due to the increasing amount of sensitive information gathered and used for consultations.

Monitoring of Cardiovascular Diseases: An Analysis of the Mobile Applications Available in the Google Play Store

Cardiovascular diseases have always been here, but there has been an increase in their numbers over time. Even though there are in the digital world a few applications to help with this kind of problem, there are not enough to fulfill the needs of the patients. This study reviews mobile applications that allow patients to monitor and report cardiovascular diseases. It presents a review of 14 mobile applications that were free to download in Portugal and classified and compared according to their characteristics. The selection criteria combined the following keywords: “patient”, “cardiac/or heart”, “report”, and (“tracking” or “monitoring”). Based on the analysis, we point out the errors of the applications and present some solutions. To finish, we investigated how mobile applications can help patients track and self-report cardiovascular diseases.

Improving Blood Pressure Control Using Digital Communication Methods in Serbia

Background: The purpose of this study was to compare home and office BP in the adjustment of antihypertensive treatment. Methods: This study was an open, prospective, noninterventional, multicenter clinical trial that occurred between July 2019 and February 2020, in 34 cities in the territory of the Republic of Serbia, which monitored 1581 participants for 6 months. Depending on the used blood pressure monitoring method used, all patients were divided into control (office BP monitoring) and experimental (home BP telemonitoring) groups. We collected anamnestic data and data about systolic blood pressure (SP), in mmHg, diastolic blood pressure (DP), in mmHg, and heart rate (HR), in beats/minute, from all patients. Results: SP values were significantly different at baseline, and at the second, third, and fourth visits between the two tested groups. Home and office BP decreased significantly (p < 0.000) during the 6-month follow-up. We observed a statistically significant influence of the presence of diabetes mellitus and dyslipidemia on the dynamics of differences between SP monitoring values. Conclusions: Our study suggests that novel technologies in BP monitoring can be excellent alternatives for BP assessment in hypertensive patients with other cardiovascular risk factors such as diabetes and dyslipidemia.

Validity and Reliability of the Korean Version of the Health Information Technology Usability Evaluation Scale: Psychometric Evaluation

Background

Rigorous development of mobile technologies requires the use of validated instruments to evaluate the usability of these tools, which has become more relevant with the expansion of these technologies. Although various usability evaluation tools have been developed, there are relatively few simple evaluation instruments that have been validated across diseases and languages in mobile health (mHealth) information technology for use in multiple diseases.

Objective

The purpose of this study is to validate the Korean version of the Health Information Technology Usability Evaluation Scale (Korean Health-ITUES) and assess its applicability for different health conditions.

Methods

To develop the Korean Health-ITUES, we used a validation process involving the following 3 steps: (1) customization of the Health-ITUES for menstrual symptoms, (2) translation of the Health-ITUES from English into Korean, and (3) examination of the reliability and validity of the instrument. The translation process adhered to the World Health Organization (WHO) guidelines for translation and back-translation, expert review, and reconciliation.

Results

The Korean Health-ITUES showed reliable internal consistency with Cronbach α=.951; meanwhile, factor loadings of the 20 items in the 4 subscales ranged from 0.416 to 0.892.

Conclusions

The Health-ITUES demonstrated reliability and validity for its use in assessing mHealth apps’ usability in young Korean women with menstrual discomfort. Given the strong psychometric properties of this tool in Korean and English and across 2 different health conditions, the Health-ITUES is a valid and reliable instrument for assessing the usability of mHealth apps. The Health-ITUES is also a valid instrument for evaluating mHealth technologies, which are widely used by patients to self-manage their health and by providers to improve health care delivery.

Interventions for Adherence Improvement in the Primary Prevention of Cardiovascular Diseases: Expert Consensus Statement

Over the last 2 decades, the management of chronic disease in Korea has been improved, but it has gradually stagnated. In order to improve care and reduce cardiovascular morbidity and mortality, it is crucial to improve primary prevention of cardiovascular diseases. In recent international guidelines for hypertension, diabetes, hyperlipidemia, obesity, and other conditions, adherence issues have become more frequently addressed. However, in terms of implementation in practice, separate approaches by dozens of related academic specialties need to be integrated into a systematic approach including clinician’s perspectives such as the science behind adherence, clinical skills, and interaction within team approach.

In primary prevention for cardiovascular diseases, there are significant barriers to adherence including freedom from symptoms, long latency for therapeutic benefits, life-long duration of treatment, and need for combined lifestyle changes. However, to implement more systematic approaches, the focus on adherence improvement needs to be shifted away from patient factors to the effects of the treatment team and healthcare system. In addition to conventional educational approaches, more patient-oriented approaches such as patient-centered clinical communication skills, counseling using motivational strategies, decision-making by patient empowerment, and a multi-disciplinary team approach should be developed and implemented. Patients should be involved in a program of self-monitoring, self-management, and active counseling. Because most effective interventions on adherence improvement demand greater resources, the health care system and educational or training system of physicians and healthcare staff need to be supported for systematic improvement.

The Effects of a Digital Mental Health Intervention in Adults With Cardiovascular Disease Risk Factors: Analysis of Real-World User Data

Background

The American Heart Association has identified poor mental health as a key barrier to healthy behavior change for those with cardiovascular disease (CVD) risk factors such as high blood pressure, high cholesterol, and diabetes. Digital mental health interventions, like those delivered via the internet to computers or smartphones, may provide a scalable solution to improving the mental and physical health of this population. Happify is one such intervention and has demonstrated evidence of efficacy for improving aspects of mental health in both the general population and in users with chronic conditions.

Objective

The objectives of this analysis of real-world data from Happify users with self-reported CVD risk factors, including high blood pressure and cholesterol, diabetes, and heart disease, were to examine whether these users would report improvements in subjective well-being and anxiety over time (H1) and use of Happify as recommended would be associated with significantly greater improvement in subjective well-being and anxiety over time compared to less-than-recommended usage (H2).

Methods

Data were obtained from existing Happify users who reported the aforementioned CVD risk factors. The sample included 1803 users receiving at least 6 weeks’ exposure to Happify (ranging from 42 days to 182 days) who completed at least one activity and two assessments within the app during that time. Subjective well-being was assessed with the Happify Scale, a 9-item measure of positive emotionality and life satisfaction, and anxiety was assessed with the Generalized Anxiety Disorder 2 (GAD-2). To evaluate H1, changes over time in both outcomes were assessed using mixed effects linear regression models, controlling for demographics and usage. For H2, an interaction term was added to the models to assess whether usage as recommended was associated with greater improvement over time.

Results

Both hypotheses were supported. For both the Happify scale and GAD-2, the initial multivariable model without an interaction demonstrated an effect for time from baseline, and the addition of the interaction term between time and recommended use was significant as well.

Conclusions

This analysis of real-world data provides preliminary evidence that Happify users with self-reported CVD risk factors including high blood pressure or cholesterol, diabetes, and heart disease experienced improved well-being and anxiety over time and that those who used Happify as recommended experienced greater improvements in these aspects of mental health than those who completed fewer activities. These findings extend previous research, which demonstrated that engagement with Happify as recommended was associated with improved well-being among physically healthy users and in those with chronic conditions, to a new population for whom mental health is especially critical: those at risk of developing CVD.

Systematic Review of RCTs Assessing the Effectiveness of mHealth Interventions to Improve Statin Medication Adherence: Using the Behaviour-Change Technique Taxonomy to Identify the Techniques That Improve Adherence

Statin non-adherence is a common problem in the management of cardiovascular disease (CVD), increasing patient morbidity and mortality. Mobile health (mHealth) interventions may be a scalable way to improve medication adherence. The objectives of this review were to assess the literature testing mHealth interventions for statin adherence and to identify the Behaviour-Change Techniques (BCTs) employed by effective and ineffective interventions. A systematic search was conducted of randomised controlled trials (RCTs) measuring the effectiveness of mHealth interventions to improve statin adherence against standard of care in those who had been prescribed statins for the primary or secondary prevention of CVD, published in English (1 January 2000-17 July 2020). For included studies, relevant data were extracted, the BCTs used in the trial arms were coded, and a quality assessment made using the Risk of Bias 2 (RoB2) questionnaire. The search identified 17 relevant studies. Twelve studies demonstrated a significant improvement in adherence in the mHealth intervention trial arm, and five reported no impact on adherence. Automated phone messages were the mHealth delivery method most frequently used in effective interventions. Studies including more BCTs were more effective. The BCTs most frequently associated with effective interventions were "Goal setting (behaviour)", "Instruction on how to perform a behaviour", and "Credible source". Other effective techniques were "Information about health consequences", "Feedback on behaviour", and "Social support (unspecified)". This review found moderate, positive evidence of the effect of mHealth interventions on statin adherence. There are four primary recommendations for practitioners using mHealth interventions to improve statin adherence: use multifaceted interventions using multiple BCTs, consider automated messages as a digital delivery method from a credible source, provide instructions on taking statins, and set adherence goals with patients. Further research should assess the optimal frequency of intervention delivery and investigate the generalisability of these interventions across settings and demographics.

Effectiveness of Text Messaging as an Incentive to Maintain Physical Activity after Cardiac Rehabilitation: A Randomized Controlled Pilot Study

Although the efficacy of cardiac rehabilitation (CR) is proven, the need to improve patients’ adherence has emerged. There are only a few studies that have investigated the effect of sending text messages after a CR period to stimulate subjects’ ongoing engagement in regular physical activity (PA). A randomized controlled pilot trial was conducted after CR, sending a daily PA text message reminder to an intervention group (IG), which was compared with a usual care control group (CG) during three months of follow-up. Thirty-two subjects were assessed pre- and post-study intervention with GPAQ, submaximal iso-watt exercise testing, a 30 s sit-to-stand test, a bilateral arm curl test, and a final survey on a seven-point Likert scale. A statistically significant difference in the increase of moderate PA time (Δ 244.7 (95% CI 189.1, 300.4) minutes, p < 0.001) and in the reduction of sedentary behavior time (Δ −77.5 (95% CI 104.9, −50.1) minutes, p = 0.004) was shown when the IG was compared with the CG. This was associated with an improvement in heart rate, blood pressure, and patients’ Borg rating on the category ratio scale 10 (CR10) in iso-watt exercise testing (all p < 0.05). Furthermore, only the IG did not show a worsening of the strength parameters in the follow-up leading to a change of the 30 s sit-to-stand test with a difference of +2.2 (95% CI 1.23, 3.17) repetitions compared to CG (p = 0.03). The telemedical intervention has been appreciated by the IG, whose willingness to continue with regular PA emerged to be superior compared to the CG. Text messages are an effective and inexpensive adjuvant after phase 2 CR that improves adherence to regular PA. Further studies are needed to confirm these results in a larger patient population and in the long term.

Patients and Professionals as Partners in Hypertension Care: Qualitative Substudy of a Randomized Controlled Trial Using an Interactive Web-Based System Via Mobile Phone

BACKGROUND

The use of technology has the potential to support the patient´s active participation regarding treatment of hypertension. This might lead to changes in the roles of the patient and health care professional and affect the partnership between them.

OBJECTIVE

The aim of this qualitative study was to explore the partnership between patients and health care professionals and the roles of patients and professionals in hypertension management when using an interactive web-based system for self-management of hypertension via the patient's own mobile phone.

METHODS

Focus group interviews were conducted with 22 patients and 15 professionals participating in a randomized controlled trial in Sweden aimed at lowering blood pressure (BP) using an interactive web-based system via mobile phones. The interviews were audiorecorded and transcribed and analyzed using thematic analysis.

RESULTS

Three themes were identified: the technology, the patient, and the professional. The technology enabled documentation of BP treatment, mainly for sharing knowledge between the patient and the professional. The patients gained increased knowledge of BP values and their relation to daily activities and treatment. They were able to narrate about their BP treatment and take a greater responsibility, inspired by new insights and motivation for lifestyle changes. Based on the patient's understanding of hypertension, professionals could use the system as an educational tool and some found new ways of communicating BP treatment with patients. Some reservations were raised about using the system, that it might be too time-consuming to function in clinical practice and that too much measuring could result in stress for the patient and an increased workload for the professionals. In addition, not all professionals and patients had adopted the instructions regarding the use of the system, resulting in less realization of its potential.

CONCLUSIONS

The use of the system led to the patients taking on a more active role in their BP treatment, becoming more of an expert of their BP. When using the system as intended, the professionals experienced it as a useful resource for communication regarding BP and lifestyle. Patients and professionals described a consultation on more equal grounds. The use of technology in hypertension management can promote a constructive and person-centered partnership between patient and professional. However, implementation of a new way of working should bring benefits and not be considered a burden for the professionals. To establish a successful partnership, both the patient and the professional need to be motivated toward a new way of working.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03554382; https://clinicaltrials.gov/ct2/show/NCT03554382.

Digital therapeutics in neurology

Digital therapeutics (DTx) is a section of digital health defined by the DTx Alliance as “delivering evidence-based therapeutic interventions to patients that are driven by software to prevent, manage, or treat a medical disorder or disease. They are used independently or in concert with medications, devices, or other therapies to optimize patient care and health outcomes”. Chronic disabling diseases could greatly benefit from DTx. In this narrative review, we provide an overview of DTx in the care of patients with neurological dysfunctions.

Mobile phone-based interventions for improving adherence to medication prescribed for the primary prevention of cardiovascular disease in adults

BACKGROUND

Cardiovascular disease (CVD) is a major cause of disability and mortality globally. Premature fatal and non-fatal CVD is considered to be largely preventable through the control of risk factors by lifestyle modifications and preventive medication. Lipid-lowering and antihypertensive drug therapies for primary prevention are cost-effective in reducing CVD morbidity and mortality among high-risk people and are recommended by international guidelines. However, adherence to medication prescribed for the prevention of CVD can be poor. Approximately 9% of CVD cases in the EU are attributed to poor adherence to vascular medications. Low-cost, scalable interventions to improve adherence to medications for the primary prevention of CVD have potential to reduce morbidity, mortality and healthcare costs associated with CVD.

OBJECTIVES

To establish the effectiveness of interventions delivered by mobile phone to improve adherence to medication prescribed for the primary prevention of CVD in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two other databases on 7 January 2020. We also searched two clinical trials registers on 5 February 2020. We searched reference lists of relevant papers. We applied no language or date restrictions.

SELECTION CRITERIA

We included randomised controlled trials investigating interventions delivered wholly or partly by mobile phones to improve adherence to cardiovascular medications prescribed for the primary prevention of CVD. We only included trials with a minimum of one-year follow-up in order that the outcome measures related to longer-term, sustained medication adherence behaviours and outcomes. Eligible comparators were usual care or control groups receiving no mobile phone-delivered component of the intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. The main outcomes of interest were objective measures of medication adherence (blood pressure (BP) and cholesterol), CVD events, and adverse events. We contacted study authors for further information when this was not reported.

MAIN RESULTS

We included 14 trials with 25,633 randomised participants. Participants were recruited from community-based primary and tertiary care or outpatient clinics. The interventions varied widely from those delivered solely through short messaging service (SMS) to those involving a combination of modes of delivery, such as SMS in addition to healthcare worker training, face-to-face counselling, electronic pillboxes, written materials, and home blood pressure monitors. Some interventions only targeted medication adherence, while others additionally targeted lifestyle changes such as diet and exercise. Due to heterogeneity in the nature and delivery of the interventions and study populations, we reported most results narratively, with the exception of two trials which were similar enough to meaningfully pool in meta-analyses. The body of evidence for the effect of mobile phone-based interventions on objective outcomes of adherence (BP and cholesterol) was of low certainty, due to most trials being at high risk of bias, and inconsistency in outcome effects. Two trials were at low risk of bias. Among five trials (total study enrolment: 5441 participants) recording low-density lipoprotein cholesterol (LDL-C), two studies found evidence for a small beneficial intervention effect on reducing LDL-C (-5.30 mg/dL, 95% confidence interval (CI) -8.30 to -2.30; and -9.20 mg/dL, 95% CI -17.70 to -0.70). The other three studies found results varying from a small reduction (-7.7 mg/dL) to a small increase in LDL-C (0.77 mg/dL). All of which had wide confidence intervals that included no effect. Across 13 studies (25,166 participants) measuring systolic blood pressure, effect estimates ranged from a large reduction (MD -12.45 mmHg, 95% CI -15.02 to -9.88) to a small increase (MD 2.80 mmHg, 95% CI 0.30 to 5.30). We found a similar range of effect estimates for diastolic BP, ranging from -12.23 mmHg (95% CI 14.03 to -10.43) to 1.64 mmHg (95% CI -0.55 to 3.83) (11 trials, 19,716 participants). Four trials showed intervention benefits for systolic and diastolic BP with confidence intervals excluding no effect, and among these were all three of the trials evaluating self-monitoring of blood pressure with mobile phone-based telemedicine. The fourth trial included SMS and provider support (with additional varied features). Seven studies (19,185 participants) reported 'controlled' BP as an outcome, and intervention effect estimates varied from negligible effects (odds ratio (OR) 1.01, 95% CI 0.76 to 1.34) to large improvements in BP control (OR 2.41, 95% CI: 1.57 to 3.68). The three trials of clinician training or decision support combined with SMS (with additional varied features) had confidence intervals encompassing benefits and harms, with point estimates close to zero. Pooled analyses of the two trials of interventions solely delivered through SMS were indicative of little or no beneficial intervention effect on systolic BP (MD -1.55 mmHg, 95% CI -3.36 to 0.25; I2 = 0%) and small increases in controlled BP (OR 1.32, 95% CI 1.06 to 1.65; I2 = 0%). Based on four studies (12,439 participants), there was very low-certainty evidence (downgraded twice for imprecision and once for risk of bias) relating to the intervention effect on combined (fatal and non-fatal) CVD events. Two studies (2535 participants) provided low-certainty evidence for the effect of the intervention on cognitive outcomes, with little or no difference between trial arms for perceived quality of care and satisfaction with treatment. There was moderate-certainty evidence (downgraded due to risk of bias) that the interventions did not cause harm, based on six studies (8285 participants). Three studies reported no adverse events attributable to the intervention. One study reported no difference between groups in experience of adverse effects of statins, and that no participants reported intervention-related adverse events. One study stated that potential side effects were similar between groups. One study reported a similar number of deaths in each arm, but did not provide further information relating to potential adverse events.

AUTHORS' CONCLUSIONS

There is low-certainty evidence on the effects of mobile phone-delivered interventions to increase adherence to medication prescribed for the primary prevention of CVD. Trials of BP self-monitoring with mobile-phone telemedicine support reported modest benefits. One trial at low risk of bias reported modest reductions in LDL cholesterol but no benefits for BP. There is moderate-certainty evidence that these interventions do not result in harm. Further trials of these interventions are warranted.

Effects of Message Framing and Time Discounting on Health Communication for Optimum Cardiovascular Disease and Stroke Prevention (EMT-OCSP): a protocol for a pragmatic, multicentre, observer-blinded, 12-month randomised controlled study

INTRODUCTION

Primary prevention of cardiovascular disease (CVD) and stroke often fails due to poor adherence among patients to evidence-based prevention recommendations. The proper formatting of messages portraying CVD and stroke risks and interventional benefits may promote individuals' perception and motivation, adherence to healthy plans and eventual success in achieving risk control. The main objective of this study is to determine whether risk and intervention communication strategies (gain-framed vs loss-framed and long-term vs short-term contexts) and potential interaction thereof have different effects on the optimisation of adherence to clinical preventive management for the endpoint of CVD risk reduction among subjects with at least one CVD risk factor.

METHODS AND ANALYSIS

This trial is designed as a 2×2 factorial, observer-blinded multicentre randomised controlled study with four parallel groups. Trial participants are aged 45-80 years and have at least one CVD risk factor. Based on sample size calculations for primary outcome, we plan to enrol 15 000 participants. Data collection will occur at baseline, 6 months and 1 year after randomisation. The primary outcomes are changes in the estimated 10-year CVD risk, estimated lifetime CVD risk and estimated CVD-free life expectancy from baseline to the 1-year follow-up.

ETHICS AND DISSEMINATION

This study received approval from the Ethical Committee of West China Hospital, Sichuan University and will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04450888.

Digital Technology Interventions for Risk Factor Modification in Patients With Cardiovascular Disease: Systematic Review and Meta-analysis

BACKGROUND

Approximately 50% of cardiovascular disease (CVD) cases are attributable to lifestyle risk factors. Despite widespread education, personal knowledge, and efficacy, many individuals fail to adequately modify these risk factors, even after a cardiovascular event. Digital technology interventions have been suggested as a viable equivalent and potential alternative to conventional cardiac rehabilitation care centers. However, little is known about the clinical effectiveness of these technologies in bringing about behavioral changes in patients with CVD at an individual level.

OBJECTIVE

The aim of this study is to identify and measure the effectiveness of digital technology (eg, mobile phones, the internet, software applications, wearables, etc) interventions in randomized controlled trials (RCTs) and determine which behavior change constructs are effective at achieving risk factor modification in patients with CVD.

METHODS

This study is a systematic review and meta-analysis of RCTs designed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) statement standard. Mixed data from studies extracted from selected research databases and filtered for RCTs only were analyzed using quantitative methods. Outcome hypothesis testing was set at 95% CI and P=.05 for statistical significance.

RESULTS

Digital interventions were delivered using devices such as cell phones, smartphones, personal computers, and wearables coupled with technologies such as the internet, SMS, software applications, and mobile sensors. Behavioral change constructs such as cognition, follow-up, goal setting, record keeping, perceived benefit, persuasion, socialization, personalization, rewards and incentives, support, and self-management were used. The meta-analyzed effect estimates (mean difference [MD]; standard mean difference [SMD]; and risk ratio [RR]) calculated for outcomes showed benefits in total cholesterol SMD at -0.29 [-0.44, -0.15], P<.001; high-density lipoprotein SMD at -0.09 [-0.19, 0.00], P=.05; low-density lipoprotein SMD at -0.18 [-0.33, -0.04], P=.01; physical activity (PA) SMD at 0.23 [0.11, 0.36], P<.001; physical inactivity (sedentary) RR at 0.54 [0.39, 0.75], P<.001; and diet (food intake) RR at 0.79 [0.66, 0.94], P=.007. Initial effect estimates showed no significant benefit in body mass index (BMI) MD at -0.37 [-1.20, 0.46], P=.38; diastolic blood pressure (BP) SMD at -0.06 [-0.20, 0.08], P=.43; systolic BP SMD at -0.03 [-0.18, 0.13], P=.74; Hemoglobin A1C blood sugar (HbA1c) RR at 1.04 [0.40, 2.70], P=.94; alcohol intake SMD at -0.16 [-1.43, 1.10], P=.80; smoking RR at 0.87 [0.67, 1.13], P=.30; and medication adherence RR at 1.10 [1.00, 1.22], P=.06.

CONCLUSIONS

Digital interventions may improve healthy behavioral factors (PA, healthy diet, and medication adherence) and are even more potent when used to treat multiple behavioral outcomes (eg, medication adherence plus). However, they did not appear to reduce unhealthy behavioral factors (smoking, alcohol intake, and unhealthy diet) and clinical outcomes (BMI, triglycerides, diastolic and systolic BP, and HbA1c).

Mobile health applications for disease screening and treatment support in low-and middle-income countries: A narrative review

The advances in mobile technologies and applications are driving the transformation in health services delivery globally. Mobile phone penetration is increasing exponentially in low-and middle-income countries, hence using mobile phones for healthcare services could reach more people in resource-limited settings than the traditional forms of healthcare provision. The review presents recent literature on facilitators and barriers of implementing mHealth for disease screening and treatment support in low-and middle-income countries. We searched for relevant literature from the following electronic databases: MEDLINE; CINAHL with full text via EBSCOhost; Science Direct; PubMed; Google Scholar and Web of Science using the keywords for relevant studies. We searched for published studies from 2015 to August 2020 with no language limitations. A total of 721 articles identified, 125 articles met the inclusion criteria and were included in the qualitative synthesis. The review demonstrates relevant facilitators for the implementation of mHealth, which includes knowledge, attitudes, and perceptions of stakeholders on the use of mHealth and the performance of mHealth for disease diagnosis in low and-middle-income countries. Barriers and challenges hindering the implementation of mHealth applications were also identified. We proposed a framework for improving the implementation of mHealth for disease screening and treatment support in low-and middle-income countries.

Factors Affecting Health-Promoting Behaviors in Patients with Cardiovascular Disease

Cardiovascular disease is the leading cause of death globally and the second most common cause of death in South Korea. Health-promoting behaviors recommended for patients with cardiovascular disease include control of diet, physical activity, cessation of smoking, medication adherence, and adherence to medical recommendations. This study aimed to determine the relationship between depression, anxiety, perception of health status, and health-promoting behavior in patients from South Korea who have suffered from cardiovascular disease. The study population comprised 161 patients at the cardiovascular center at H Hospital who were diagnosed with cardiovascular disease. Descriptive statistics and stepwise multiple regression were employed to analyze the data. Negative correlations existed between depression, perception of health status, and health-promoting behavior. By contrast, a positive correlation existed between the perception of health status and health-promoting behavior. The main factors affecting health-promoting behaviors were alcohol consumption, duration of diagnosis, perception of health status, and depression. These variables explained 15.8% of the variance. To prevent adverse cardiac events, patients who suffer from cardiovascular disease should be assessed as soon as possible to identify psychiatric symptoms, thereby developing a potential intervention aimed at decreasing negative illness consequences.

Tailored Interventions to Improve Medication Adherence for Cardiovascular Diseases

Over the past half-century, medical research on cardiovascular disease (CVD) has achieved a great deal; however, medication adherence is unsatisfactory. Nearly 50% of patients do not follow prescriptions when taking medications, which limits the ability to maximize their therapeutic effects and results in adverse clinical outcomes and high healthcare costs. Furthermore, the effects of medication adherence interventions are disappointing, and tailored interventions have been proposed as an appropriate way to improve medication adherence. To rethink and reconstruct methods of improving medication adherence for CVD, the literature on tailored interventions for medication adherence focusing on CVD within the last 5 years is retrieved and reviewed. Focusing on identifying nonadherent patients, detecting barriers to medication adherence, delivering clinical interventions, and constructing theories, this article reviews the present state of tailored interventions for medication adherence in CVD and also rethinks the present difficulties and suggests avenues for future development.

Awareness about barriers to medication adherence in cardiovascular patients and strategies used in clinical practice by Portuguese clinicians: a nationwide study

BACKGROUND

Although much is known about cardiovascular patients' medication adherence, the extent to which clinicians perceive non-adherence as a barrier in clinical practice is little explored. Objective To evaluate knowledge and awareness about potential barriers to medication adherence, and to evaluate strategies used in clinical practice by Portuguese clinicians on how to foster medication adherence of patients undergoing secondary cardiovascular prevention. Setting Nominal Group Technique (NGT) at the University of Lisbon; online survey addressed to physicians working in primary and secondary care in Portugal. Method A narrative literature review was conducted in Pubmed to identify studies describing interventions targeted at physicians to manage medication adherence. The NGT included 12 allied healthcare professionals with recognized expertise in medication adherence and was organised in four phases, resulting in survey development. The survey was used in a cross-sectional national study where clinicians reported their knowledge and perceptions about patients' medication adherence and their daily practice. Main outcome measures Knowledge and awareness about barriers to medication adherence; and practice patterns. Results A total of 296 papers were identified, 26 of which were included. Four main topics were selected to be used in the NGT: adherence determinants, detecting non-adherence, fostering adherence, and educating physicians. NGT resulted in a survey, reaching 451 physicians, mostly practicing in primary care. Most had specific education on medication adherence and considered patient interviews and prescription records the most useful assessment methods. Nonetheless, many recognised often using clinical judgement to evaluate adherence in practice. Barriers to medication adherence were perceived to occur often during implementation. Most perceived reasons for uncontrolled hypertension were non-adherence to lifestyle recommendations and to medication. Less than half the physicians asked their patients if medication was taken. More useful enabling strategies included reducing daily doses, reviewing therapeutic options and motivational interventions. Conclusions Clinicians seem well informed about the importance of medication adherence and aware of problems encountered in practice. Limited time during medical appointment may be a barrier for better patient support.

[Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Cardiovascular Prevention Guidelines.]

We present the adaptation for Spain of the updated European Cardiovascular Prevention Guidelines. In this update, greater stress is laid on the population approach, and especially on the promotion of physical activity and healthy diet through dietary, leisure and active transport policies in Spain. To estimate vascular risk, note should be made of the importance of recalibrating the tables used, by adapting them to population shifts in the prevalence of risk factors and incidence of vascular diseases, with particular attention to the role of chronic kidney disease. At an individual level, the key element is personalised support for changes in behaviour, adherence to medication in high-risk individuals and patients with vascular disease, the fostering of physical activity, and cessation of smoking habit. Furthermore, recent clinical trials with PCSK9 inhibitors are reviewed, along with the need to simplify pharmacological treatment of arterial hypertension to improve control and adherence to treatment. In the case of patients with type 2 diabetes mellitus and vascular disease or high vascular disease risk, when lifestyle changes and metformin are inadequate, the use of drugs with proven vascular benefit should be prioritised. Lastly, guidelines on peripheral arterial disease and other specific diseases are included, as is a recommendation against prescribing antiaggregants in primary prevention.

Integration of Mobile Health Into Sickle Cell Disease Care to Increase Hydroxyurea Utilization: Protocol for an Efficacy and Implementation Study

BACKGROUND

Hydroxyurea prevents disease complications among patients with sickle cell disease (SCD). Although its efficacy has been endorsed by the National Health Lung and Blood Institute evidence-based guidelines, its adoption is low, both by patients with SCD and providers. Mobile health (mHealth) apps provide benefits in improving medication adherence and self-efficacy among patients with chronic diseases and have facilitated prescription among medical providers. However, mHealth has not been systematically tested as a tool to increase hydroxyurea adherence nor has the combination of mHealth been assessed at both patient and provider levels to increase hydroxyurea utilization.

OBJECTIVE

This study aims to increase hydroxyurea utilization through a combined two-level mHealth intervention for both patients with SCD and their providers with the goals of increasing adherence to hydroxyurea among patients and improve hydroxyurea prescribing behavior among providers.

METHODS

We will test the efficacy of 2 mHealth interventions to increase both patient and provider utilization and knowledge of hydroxyurea in 8 clinical sites of the NHLBI-funded Sickle Cell Disease Implementation Consortium (SCDIC). The patient mHealth intervention, InCharge Health, includes multiple components that address memory, motivation, and knowledge barriers to hydroxyurea use. The provider mHealth intervention, Hydroxyurea Toolbox (HU Toolbox), addresses the clinical knowledge barriers in prescribing and monitoring hydroxyurea. The primary hypothesis is that among adolescents and adults with SCD, adherence to hydroxyurea, as measured by the proportion of days covered (the ratio of the number of days the patient is covered by the medication to the number of days in the treatment period), will increase by at least 20% after 24 weeks of receiving the InCharge Health app, compared with their adherence at baseline. As secondary objectives, we will (1) examine the change in health-related quality of life, acute disease complications, perceived health literacy, and perceived self-efficacy in taking hydroxyurea among patients who use InCharge Health and (2) examine potential increases in the awareness of hydroxyurea benefits and risks, appropriate prescribing, and perceived self-efficacy to correctly administer hydroxyurea therapy among SCD providers between baseline and 9 months of using the HU Toolbox app. We will measure the reach, adoption, implementation, and maintenance of both the InCharge Health and the HU Toolbox apps using the reach, effectiveness, adoption, implementation, and maintenance framework and qualitatively evaluate the implementation of both mHealth interventions.

RESULTS

The study is currently enrolling study participants. Recruitment is anticipated to be completed by mid-2021.

CONCLUSIONS

If this two-level intervention, that is, the combined use of InCharge Health and HU Toolbox apps, demonstrates efficacy in increasing adherence to hydroxyurea and prescribing behavior in patients with SCD and their providers, respectively, both apps will be offered to other institutions outside the SCDIC through a future large-scale implementation-effectiveness study.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04080167; https://clinicaltrials.gov/ct2/show/NCT04080167.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/16319.

Updates in heart failure 30-day readmission prevention

Heart failure (HF) and HF 30-day readmission rates have been a major focus of efforts to reduce health care cost in the recent era. Since the implementation of the Affordable Care Act (ACA) in 2012 and the Hospital Readmission Reduction Program (HRRP), concerted efforts have focused on reduction of 30-day HF readmissions and other admission diagnoses targeted by the HRRP. Hospitals and organizations have instituted wide-ranging programs to reduce short-term readmissions, but the data supporting these programs is often mixed. In this review, we will discuss the challenges associated with reducing HF readmissions and summarize the rationale and effect of specific programs on HF 30-day readmission rates, ranging from medical therapy and adherence to remote hemodynamic monitoring. Finally, we will review the effect that the focus on reducing 30-day HF readmissions has had on the care of the HF patient.

A Cyber-Physical System for Near Real-Time Monitoring of At-Home Orthopedic Rehabilitation and Mobile-Based Provider-Patient Communications to Improve Adherence: Development and Formative Evaluation

BACKGROUND

Knee extensor muscle performance is reduced after lower extremity trauma and orthopedic surgical interventions. At-home use of neuromuscular electrical stimulation (NMES) may improve functional recovery, but adherence to at-home interventions is low. Greater benefits from NMES may be realized with closer monitoring of adherence to at-home prescriptions and more frequent patient-provider interactions.

OBJECTIVE

This study aimed to develop a cyber-physical system to monitor at-home adherence to NMES prescription and facilitate patient-provider communications to improve adherence in near real time.

METHODS

The RehabTracker cyber-physical system was developed to accomplish this goal and comprises four components: (1) hardware modifications to a commercially available NMES therapy device to monitor device use and provide Bluetooth functionality; (2) an iPhone Operating System-based mobile health (mHealth) app that enables patient-provider communications in near real time; (3) a clinician portal to allow oversight of patient adherence with device use; and (4) a back-end server to store data, enable adherence analysis, and send automated push notifications to the patient. These four elements were designed to be fully compliant with the Health Insurance Portability and Accountability Act. The system underwent formative testing in a cohort of patients following anterior cruciate ligament rupture (n=7) to begin to assess face validity.

RESULTS

Compared with the NMES device software-tracked device use, the RehabTracker system recorded 83% (40/48) of the rehabilitation sessions, with 100% (32/32) of all sessions logged by the system in 4 out of 7 patients. In patients for whom tracking of automated push notifications was enabled, 100% (29/29) of the push notifications sent by the back-end server were received by the patient. Process, hardware, and software issues contributing to these inaccuracies are detailed.

CONCLUSIONS

RehabTracker represents a promising mHealth app for tracking and improving adherence with at-home NMES rehabilitation programs and warrants further refinement and testing.

Barriers and facilitators to the implementation of a community-based hypertension improvement project in Ghana: a qualitative study of ComHIP

BACKGROUND

Globally, hypertension is a leading cause of cardiovascular disease and mortality, with the majority of deaths occurring in low- and middle-income countries. Because the burden of hypertension is increasing in low resource settings with restricted infrastructure, it is imperative that new models for hypertension care are realised. One such model is the Community-based Hypertension Improvement Project (ComHIP) which employs a community-based method of task-shifting for managing hypertension. This study is a qualitative analysis of the barriers and facilitators of the main components of ComHIP.

METHODS

We purposively selected 55 informants for semi-structured interviews or focus group discussions, which were carried out bythree trained local researchers in Krobo, Twi or English. Informants included patients enrolled in ComHIP, health care providers and Licensed Chemical Sellers trained by ComHIP, and Ghana Health Service employees. Data were analysed using a multi-step thematic analysis.

RESULTS

While results of the effectiveness of the intervention are pending, overall, patients and nurses reported positive experiences within ComHIP, and found that it helped enable them to manage their hypertension. Healthcare providers appreciated the additional training, but had some gaps in their knowledge. Ghana Health Service employees were cautiously optimistic about the programme, but expressed some worries about the sustainability of the programme. Many informants expressed concerns over the inability of community nurses and workers to dispense anti-hypertensives, due to legal restrictions.

CONCLUSIONS

The WHO recommends task-sharing as a technique for managing chronic conditions such as hypertension in resource constrained settings. ComHIP presents an example of a task-sharing programme with a high level of acceptability to all participants. Going forward, we recommend greater levels of communication and dialogue to allow community-based health workers to be allowed to dispense anti-hypertensives.

Telemonitoring and remote counseling in hypertensive patients. Looking for new ways to do old jobs

XXI century emphasized humanity to embrace the digital era after a reality of Third and Fourth Industrial Revolutions, nowadays dictating new terms of social networking. It is expected that information and communication technologies integrated with value-based medicine will significantly impact healthcare delivery to tremendous number of patients with socially important noncommunicable diseases. Cardiovascular illnesses comprise the greatest part of such pathologies. Hypertension (HTN) being the most prevalent cardiovascular disease is also the key modifiable cardiovascular risk factor yet seems to be an attractive target for both value-based concept and telehealth interventions. Present review addresses up-to-date science on telehealth, sets out the main well-known, but yet unsolved challenges in management of HTN along with the new approaches involving telemedicine programs, digital health outlooks. The main barriers of telehealth implementation are also considered along with the possible solutions.

New warfarin anticoagulation management model after heart valve surgery: rationale and design of a prospective, multicentre, randomised trial to compare an internet-based warfarin anticoagulation management model with the traditional warfarin management model

INTRODUCTION

Warfarin is an effective anticoagulant and the only oral anticoagulant available for patients with mechanical heart valves. The prothrombin time and the associated international normalised ratio (INR) are routinely tested to monitor the response to anticoagulation therapy in patients. Patients who undergo mechanical heart valve replacement need lifelong anticoagulation therapy, and their INR is regularly measured to adjust the anticoagulation strength and the dose of anticoagulation drugs. Appropriate warfarin anticoagulation management can reduce patient complications, such as bleeding and thrombosis, and improve the long-term survival rate. We propose modern internet technology as a platform to build a warfarin anticoagulation follow-up system after valve replacement surgery. This system will provide doctors and patients with more standardised and safer follow-up methods as well as a method to further reduce the risk of warfarin anticoagulation-related complications and improve its therapeutic effects.

METHODS AND ANALYSIS

A prospective, multicentre, randomised, controlled trial will be conducted. A total of 700 patients who require long-term warfarin anticoagulation monitoring after heart valve replacement will be enrolled and randomly divided at a 1:1 ratio into a traditional outpatient anticoagulation management group and a group undergoing a new method of management based on the internet technology with follow-up for 1 year. Differences in the percentage of time in the therapeutic range (TTR), drug dose adjustments, bleeding/thrombosis and other related complications will be observed. The primary endpoint is the difference in the TTR between the two groups. The purpose of this study is to explore a safer and more effective mode of doctor-patient interaction and communication in the internet era. As of 13 July 2019, 534 patients had been enrolled.

ETHICS AND DISSEMINATION

This study protocol was approved by the Ethics Committee of Beijing Anzhen Hospital, Capital Medical University. The results will be published in a peer-reviewed medical journal.

TRIAL REGISTRATION NUMBER

ChiCTR1800016204.

[Antihypertensive Effect of Switching to a Fixed Perindopril/Amlodipine Combination in Patients Ineffectively Treated by Free Sartan-Containing Combinations. Results of the AVANGARD Study]

Finding the best options for combined antihypertensive therapy is one of the main tasks to be solved for achieving target blood pressure (BP) and, accordingly, reduction of the risk of complications in patients with arterial hypertension (AH).Purpose of this study was to evaluate the effectiveness of the perindopril arginine/amlodipine fixed combination in patients with 1-2 degree hypertension not achieving BP control on previous therapy with sartan-containing free combinations.

MATERIALS AND METHODS

In the multicenter open uncontrolled observational program AVANGARD 203 doctors in 53 cities of the Russian Federation included 658 patients who had not achieved target BP on therapy with two drugs, one of which was sartan (sartan with diuretic, calcium antagonist, β-blocker, or moxonidine in 49%, 33%, 17%, and 1% of cases, respectively). This therapy was replaced with a fixed combination of perindopril arginine/amlodipine. Duration of observation was 3 months.

RESULTS

On therapy with perindopril arginine/amlodipine, BP decreased 159.9±8.5/92.1±7.4 to 125.8±7.1/77.4±5.5 mm Hg. Target BP &lt;140/90 mm Hg was achieved in 93.5% of patients (office measurement); target BP &lt;135/85 mm Hg - in 83.5% of patients (home measurement). Mean 24-hour BP variability decreased from 4.4±2.9/3.0±2.0 to 3.0±2.2/2.2±1.7 mm Hg (p&lt;0.01). Number of patients complaining of headache decreased by 2.9 times, dizziness - by 2.8 times, fatigue - by 2.3 times, irritability - by 3.0 times, sleep disturbances - by 2.3 times, dyspnea - by 3.8 times, palpitations - by 2.7 times, angina pectoris attacks - by 4.6 times. Dose of perindopril arginine/amlodipine was 10/5 mg in 36.6%, and 10/10 mg in 28.3% of cases, respectively. Number ofparticipants who dropped out ofthe study prematurely was 11 (1.6%) (1 because of adverse event). Adverse events were observed in 4 more patients (2 [0.14%] - edema of lower extremities, and 2 [0.14%] -cough), but they did not require the withdrawal of therapy.

CONCLUSION

In case of ineffective combination therapy containing sartans, transfer of patients to a fixed combination of perindopril and amlodipine should be considered.

Using mHealth for the management of hypertension in UK primary care: an embedded qualitative study of the TASMINH4 randomised controlled trial

BACKGROUND

Self-monitoring of blood pressure is common but how telemonitoring with a mobile healthcare (mHealth) solution in the management of hypertension can be implemented by patients and healthcare professionals (HCPs) is currently unclear.

AIM

Evaluation of facilitators and barriers to self- and telemonitoring interventions for hypertension within the Telemonitoring and Self-monitoring in Hypertension (TASMINH4) trial.

DESIGN AND SETTING

An embedded process evaluation of the TASMINH4 randomised controlled trial (RCT), in the West Midlands, in UK primary care, conducted between March 2015 and September 2016.

METHOD

A total of 40 participants comprising 23 patients were randomised to one of two arms: mHealth (self-monitoring by free text/short message service [SMS]) and self-monitoring without mHealth (self-monitoring using paper diaries). There were also15 healthcare professionals (HCPs) and two patient caregivers.

RESULTS

Four key implementation priority areas concerned: acceptability of self- and telemonitoring to patients and HCPs; managing data; communication; and integrating self-monitoring into hypertension management (structured care). Structured home monitoring engaged and empowered patients to self-monitor regardless of the use of mHealth, whereas telemonitoring potentially facilitated more rapid communication between HCPs and patients. Paper-based recording integrated better into current workflows but required additional staff input.

CONCLUSION

Although telemonitoring by mHealth facilitates easier communication and convenience, the realities of current UK general practice meant that a paper-based approach to self-monitoring could be integrated into existing workflows with greater ease. Self-monitoring should be offered to all patients with hypertension. Telemonitoring appears to give additional benefits to practices over and above self-monitoring but both need to be offered to ensure generalisability.

Persuasive design features within a consumer-focused eHealth intervention integrated with the electronic health record: A mixed methods study of effectiveness and acceptability

INTRODUCTION

eHealth strategies targeting health-related behaviour often incorporate persuasive software design. To further engage patients with their overall health management, consumer-facing web portals may be integrated with data from one or more care providers. This study aimed to explore effectiveness for healthier behaviour of persuasive design characteristics within a web application integrated with the primary health care electronic record; also patient and general practitioner (GP) preferences for future integrated records.

METHODS

Mixed methods study within the Consumer Navigation of Electronic Cardiovascular Tools randomised controlled trial. Participants were patients with moderate-high risk of cardiovascular disease, and their GPs. Survey and web analytic data were analysed with descriptive statistics. Interview and focus group transcripts were recorded, transcribed, coded and analysed for themes.

RESULTS

Surveys (n = 397) received from patients indicated improved medication adherence (31.8%); improved mental health and well-being (40%); higher physical activity (47%); and healthier eating (61%). Users of the interactive features reported benefiting from personalised cardiovascular disease risk score (73%); goal tracking (69%); risk factor self-monitoring (52%) and receipt of motivational health tips (54%). Focus group and interview participants (n = 55) described customisations that would increase portal appeal and relevance, including more provider interaction. Of the GP survey respondents (n = 38), 74% reported increased patient attendance and engagement with their care. For future integrated portals, 94% of GPs were in favour and key themes among interviewees (n = 17) related to design optimisation, impact on workflow and data security.

CONCLUSION

Intervention features reflecting the persuasive design categories of Primary Task support, Dialogue support and System Credibility support facilitated healthier lifestyle behaviour. Patients valued customisable functions and greater patient-provider interactivity. GPs identified system challenges but saw advantages for patients and the health care relationship. Future studies could further elucidate the persuasive design principles that are at play and which may promote adoption of EHR-integrated consumer portals.

An Intervention for Changing Sedentary Behavior Among African Americans With Multiple Sclerosis: Protocol

BACKGROUND

Sedentary behavior is a major concern among patients with multiple sclerosis (MS), as it may accelerate disease progression and exacerbate physical disability. This is especially concerning among African Americans, a segment of the MS population who present with greater neurological disability and higher odds of physical comorbidities than their Caucasian counterparts.

OBJECTIVE

To date, researchers have not proposed interventions that focus on changing sedentary behavior in African Americans with MS.

METHODS

This paper describes a pilot study that examines the feasibility and efficacy of using text messaging along with theory-driven newsletters and behavioral coaching for changing sedentary behavior in African Americans with MS. We herein present the methods, procedures, and outcomes for our ongoing study.

RESULTS

Enrollment began in February 2018 and is expected to conclude in April 2019. Study results will be reported in the fall of 2019.

CONCLUSIONS

After completion of this pilot intervention, we will summarize our study results in manuscripts for publication in peer-reviewed journals that will provide critical information on the feasibility and efficacy of our strategy. These results will inform future studies and, potentially, larger interventions for remotely reducing sedentary behavior in African Americans with MS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03671499; https://clinicaltrials.gov/ct2/show/NCT03671499 (Archived by WebCite at http://www.webcitation.org/77MZnxyNy).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12973.

Establishment of a New Platform for the Management of Patients After Cardiac Surgery: Descriptive Study

BACKGROUND

Medical care for the Chinese population has been focused on first-line treatment, but with little follow-up on treated patients. As an important part of clinical work, follow-up evaluations are of great significance for the long-term survival of patients and for clinical and scientific research. However, the overall follow-up rate of discharged patients after surgery has been low for many years because of the limitations of certain follow-up methods and the presence of objective, practical problems.

OBJECTIVE

This study aimed to construct a new two-way interactive telemedicine follow-up platform to improve the collection of clinical data after cardiac surgery and provide reliable and high-quality follow-up services.

METHODS

Computer and network technologies were employed in the context of "Internet +" to develop follow-up databases and software compatible with a mobile network. Postoperative follow-up quality data including the follow-up rate and important postoperative indices were used as standards to evaluate the new follow-up management model after cardiac surgery.

RESULTS

This system has been officially operated for more than 5 years. A total of 5347 patients undergoing cardiac surgery have been enrolled, and the total follow-up rate was 90.22%. In addition, 6349 echocardiographic images, 4717 electrocardiographic images, and 3504 chest radiographic images have been uploaded during follow-up assessments. The international standardized ratio was 20,696 person-times.

CONCLUSIONS

This new management follow-up platform can be used to effectively collect clinical data, provide technical support for academic research, extend medical services, and provide more help to patients. It is of great significance for managing patients after cardiac surgery.

Mobile Phone Ownership, Health Apps, and Tablet Use in US Adults With a Self-Reported History of Hypertension: Cross-Sectional Study

Background

Mobile phone and tablet ownership have increased in the United States over the last decade, contributing to the growing use of mobile health (mHealth) interventions to help patients manage chronic health conditions like diabetes. However, few studies have characterized mobile device ownership and the presence of health-related apps on mobile devices in people with a self-reported history of hypertension.

Objective

This study aimed to describe the prevalence of smartphone, tablet, and basic mobile phone ownership and the presence of health apps by sociodemographic factors and self-reported hypertension status (ie, history) in a nationally representative sample of US adults, and to describe whether mobile devices are associated with health goal achievement, medical decision making, and patient-provider communication.

Methods

Data from 3285 respondents from the 2017 Health Information National Trends Survey were analyzed. Participants were asked if they owned a smartphone, tablet, or basic mobile phone and if they had health apps on a smartphone or tablet. Participants were also asked if their smartphones or tablets helped them achieve a health-related goal like losing weight, make a decision about how to treat an illness, or talk with their health care providers. Chi-square analyses were conducted to test for differences in mobile device ownership, health app presence, and app helpfulness by patient characteristics.

Results

Approximately 1460 (37.6% weighted prevalence) participants reported a history of hypertension. Tablet and smartphone ownership were lower in participants with a history of hypertension than in those without a history of hypertension (55% vs 66%, P=.001, and 86% vs 68%, P<.001, respectively). Participants with a history of hypertension were more likely to own a basic mobile phone only as compared to those without a history of hypertension (16% vs 9%, P<.001). Among those with a history of hypertension exclusively, basic mobile phone, smartphone, and tablet ownership were associated with age and education, but not race or sex. Older adults were more likely to report having a basic mobile phone only, whereas those with higher education were more likely to report owning a tablet or smartphone. Compared to those without a history of hypertension, participants with a history of hypertension were less likely to have health-related apps on their smartphones or tablets (45% vs 30%, P<.001) and report that mobile devices helped them achieve a health-related goal (72% vs 63%, P=.01).

Conclusions

Despite the increasing use of smartphones, tablets, and health-related apps, these tools are used less among people with a self-reported history of hypertension. To reach the widest cross-section of patients, a mix of novel mHealth interventions and traditional health communication strategies (eg, print, web based, and in person) are needed to support the diverse needs of people with a history of hypertension.

Mobile phone-based interventions for improving adherence to medication prescribed for the primary prevention of cardiovascular disease in adults

BACKGROUND

Cardiovascular disease (CVD) is a major cause of disability and mortality globally. Premature fatal and non-fatal CVD is considered to be largely preventable through the control of risk factors via lifestyle modifications and preventive medication. Lipid-lowering and antihypertensive drug therapies for primary prevention are cost-effective in reducing CVD morbidity and mortality among high-risk people and are recommended by international guidelines. However, adherence to medication prescribed for the prevention of CVD can be poor. Approximately 9% of CVD cases in the EU are attributed to poor adherence to vascular medications. Low-cost, scalable interventions to improve adherence to medications for the primary prevention of CVD have potential to reduce morbidity, mortality and healthcare costs associated with CVD.

OBJECTIVES

To establish the effectiveness of interventions delivered by mobile phone to improve adherence to medication prescribed for the primary prevention of CVD in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two other databases on 21 June 2017 and two clinical trial registries on 14 July 2017. We searched reference lists of relevant papers. We applied no language or date restrictions.

SELECTION CRITERIA

We included randomised controlled trials investigating interventions delivered wholly or partly by mobile phones to improve adherence to cardiovascular medications prescribed for the primary prevention of CVD. We only included trials with a minimum of one-year follow-up in order that the outcome measures related to longer-term, sustained medication adherence behaviours and outcomes. Eligible comparators were usual care or control groups receiving no mobile phone-delivered component of the intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. We contacted study authors for disaggregated data when trials included a subset of eligible participants.

MAIN RESULTS

We included four trials with 2429 randomised participants. Participants were recruited from community-based primary care or outpatient clinics in high-income (Canada, Spain) and upper- to middle-income countries (South Africa, China). The interventions received varied widely; one trial evaluated an intervention focused on blood pressure medication adherence delivered solely through short messaging service (SMS), and one intervention involved blood pressure monitoring combined with feedback delivered via smartphone. Two trials involved interventions which targeted a combination of lifestyle modifications, alongside CVD medication adherence, one of which was delivered through text messages, written information pamphlets and self-completion cards for participants, and the other through a multi-component intervention comprising of text messages, a computerised CVD risk evaluation and face-to-face counselling. Due to heterogeneity in the nature and delivery of the interventions, we did not conduct a meta-analysis, and therefore reported results narratively.We judged the body of evidence for the effect of mobile phone-based interventions on objective outcomes (blood pressure and cholesterol) of low quality due to all included trials being at high risk of bias, and inconsistency in outcome effects. Of two trials targeting medication adherence alongside other lifestyle modifications, one reported a small beneficial intervention effect in reducing low-density lipoprotein cholesterol (mean difference (MD) -9.2 mg/dL, 95% confidence interval (CI) -17.70 to -0.70; 304 participants), and the other found no benefit (MD 0.77 mg/dL, 95% CI -4.64 to 6.18; 589 participants). One trial (1372 participants) of a text messaging-based intervention targeting adherence showed a small reduction in systolic blood pressure (SBP) for the intervention arm which delivered information-only text messages (MD -2.2 mmHg, 95% CI -4.4 to -0.04), but uncertain evidence of benefit for the second intervention arm that provided additional interactivity (MD -1.6 mmHg, 95% CI -3.7 to 0.5). One study examined the effect of blood pressure monitoring combined with smartphone messaging, and reported moderate intervention benefits on SBP and diastolic blood pressure (DBP) (SBP: MD -7.10 mmHg, 95% CI -11.61 to -2.59; DBP: -3.90 mmHg, 95% CI -6.45 to -1.35; 105 participants). There was mixed evidence from trials targeting medication adherence alongside lifestyle advice using multi-component interventions. One trial found large benefits for SBP and DBP (SBP: MD -12.45 mmHg, 95% CI -15.02 to -9.88; DBP: MD -12.23 mmHg, 95% CI -14.03 to -10.43; 589 participants), whereas the other trial demonstrated no beneficial effects on SBP or DBP (SBP: MD 0.83 mmHg, 95% CI -2.67 to 4.33; DBP: MD 1.64 mmHg, 95% CI -0.55 to 3.83; 304 participants).Two trials reported on adverse events and provided low-quality evidence that the interventions did not cause harm. One study provided low-quality evidence that there was no intervention effect on reported satisfaction with treatment.Two trials were conducted in high-income countries, and two in upper- to middle-income countries. The interventions evaluated employed between three and 16 behaviour change techniques according to coding using Michie's taxonomic method. Two trials evaluated interventions that involved potential users in their development.

AUTHORS' CONCLUSIONS

There is low-quality evidence relating to the effects of mobile phone-delivered interventions to increase adherence to medication prescribed for the primary prevention of CVD; some trials reported small benefits while others found no effect. There is low-quality evidence that these interventions do not result in harm. On the basis of this review, there is currently uncertainty around the effectiveness of these interventions. We identified six ongoing trials being conducted in a range of contexts including low-income settings with potential to generate more precise estimates of the effect of primary prevention medication adherence interventions delivered by mobile phone.