When smartwatches contribute to health anxiety in patients with atrial fibrillation

"An excellent servant but a terrible master": Understanding the value of wearables for self-management in people with cystic fibrosis and their healthcare providers - A qualitative study

BACKGROUND

Wearables hold potential to improve chronic disease self-management in conditions like cystic fibrosis (CF) through remote monitoring, early detection of illness and motivation. Little is known about the acceptability and sustainability of integrating wearables into routine care from the perspectives of people with CF (pwCF) and their treating clinicians.

METHODS

A cross-sectional qualitative study involving semi-structured interviews with adult pwCF and focus groups comprising members of a CF multidisciplinary team (MDT) were conducted at a specialist CF centre in Australia. A phenomenological orientation underpinned the study. Inductive thematic analysis was performed using the Framework method. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

RESULTS

Nine pwCF and eight members of a CF MDT, representing six clinical disciplines, participated in the study. Eight themes were inductively generated from the data, of which four were identified from each group. PwCF valued wearables for providing real-time data to motivate healthy behaviours and support shared goal-setting with healthcare providers. Wearables did not influence adherence to CF-specific self-management practices and had some hardware limitations. Members of the CF MDT recognised potential benefits of remote monitoring and shared goal-setting, but advised caution regarding data accuracy, generating patient anxiety in certain personality traits, and lack of evidence supporting use in CF self-management.

CONCLUSIONS

Perspectives on integrating wearables into CF care were cautiously optimistic, with emerging risks related to patient anxiety and lack of evidence moderating acceptance.

A Digital Therapeutic Application (ePAL) to Manage Pain in Patients With Advanced Cancer: A Randomized Controlled Trial

BACKGROUND

Patients with advanced cancer often experience immense cancer pain that negatively impacts their quality of life. Interventions to address cancer-related pain are limited.

METHODS

We conducted a randomized trial of a digital therapeutic app (ePAL) for patients with advanced cancer receiving care in a specialty palliative care clinic at a tertiary care hospital. Patients were randomized to ePAL or usual care. ePAL included 1) active pain monitoring; 2) artificial intelligence algorithm to triage patient symptoms; and 3) patient education to address barriers to pain management. Participants were instructed to use ePAL over eight weeks. Patient-reported pain symptoms were assessed at baseline, Week-4, and Week-8 (primary endpoint) using the Brief Pain Inventory. Secondary outcomes include pain-related hospitalizations by Week-8.

RESULTS

We enrolled 112 patients who were randomly assigned to ePAL (N = 56) or usual care (N = 56). Patients utilized ePAL on average 2.1 times per week to report pain symptoms, and 47.6% reported their pain at least once per week over eight weeks. Patients randomized to ePAL reported lower pain scores at Week-4 (mean: 3.16 vs. 4.28, P = 0.010) and week-8 (mean:2.99 vs. 4.05, P = 0.017), compared to those receiving usual care. Participants randomized to ePAL were less likely to experience a pain-related hospitalization compared to those in the usual care group (7.1% vs. 23.2% P = 0.018) CONCLUSIONS: ePAL was associated with lower patient-reported pain and fewer pain-related hospitalizations compared to usual care in patients with advanced cancer. This study demonstrates the promise of digital therapeutics for improving patients' symptoms while reducing burdensome hospitalizations.

Wearable Devices, Health Care Use, and Psychological Well-Being in Patients With Atrial Fibrillation

BACKGROUND

Wearables are increasingly used by patients with atrial fibrillation (AF) for symptom monitoring and health management, but their impact on patient health care use and psychological well-being is not well understood.

METHODS AND RESULTS

In this retrospective, propensity-matched study of patients with AF, survey and electronic health record data were merged to compare AF-specific health care use (outpatient/inpatient visits, rhythm-related testing, and procedures) and informal health care use (telephone calls and patient portal messages) over a 9-month period between wearable users and nonusers. We also examined the effects of wearable cardiac monitoring features (eg, heart rate alerts, irregular rhythm notification, and ECG) on patient behavior and well-being. Of 172 patients with AF in this analysis (age, 72.6±9.0 years; 42% women), 83 used a wearable. Compared with nonusers, wearable users reported higher rates of symptom monitoring and preoccupation (P=0.03) and more AF treatment concerns (P=0.02). Moreover, 20% of wearable users experienced anxiety and always contacted their doctors in response to irregular rhythm notifications. After matching, AF-specific health care use was significantly greater among wearable users compared with nonusers (P=0.04), including significantly higher rates of ECGs, echocardiograms/transesophageal echocardiogram, and ablation. Wearable users were also significantly more likely to use informal health care resources compared with nonusers (P=0.05).

CONCLUSIONS

Wearables were associated with higher rates of symptom monitoring and preoccupation, AF treatment concerns, AF-specific health care use, and use of informal health care resources. Prospective, randomized studies are needed to understand the net effects of wearables and their alerts on patients, providers, and the health care system.

Feasibility characteristics of wrist-worn fitness trackers in health status monitoring for post-COVID patients in remote and rural areas

INTRODUCTION

Common, consumer-grade biosensors mounted on fitness trackers and smartwatches can measure an array of biometrics that have potential utility in post-discharge medical monitoring, especially in remote/rural communities. The feasibility characteristics for wrist-worn biosensors are poorly described for post-COVID conditions and rural populations.

METHODS

We prospectively recruited patients in rural communities who were enrolled in an at-home rehabilitation program for post-COVID conditions. They were asked to wear a FitBit Charge 2 device and biosensor parameters were analyzed [e.g. heart rate, sleep, and activity]. Electronic patient reported outcome measures [E-PROMS] for mental [bi-weekly] and physical [daily] symptoms were collected using SMS text or email [per patient preference]. Exit surveys and interviews evaluated the patient experience.

RESULTS

Ten patients were observed for an average of 58 days and half [N = 5] were monitored for 8 weeks or more. Five patients [50%] had been hospitalized with COVID [mean stay = 41 days] and 4 [36%] had required mechanical ventilation. As baseline, patients had moderate to severe levels of anxiety, depression, and stress; fatigue and shortness of breath were the most prevalent physical symptoms. Four patients [40%] already owned a smartwatch. In total, 575 patient days of patient monitoring occurred across 10 patients. Biosensor data was usable for 91.3% of study hours and surveys were completed 82.1% and 78.7% of the time for physical and mental symptoms, respectively. Positive correlations were observed between stress and resting heart rate [r = 0.360, p<0.01], stress and daily steps [r = 0.335, p<0.01], and anxiety and daily steps [r = 0.289, p<0.01]. There was a trend toward negative correlation between sleep time and physical symptom burden [r = -0.211, p = 0.05]. Patients reported an overall positive experience and identified the potential for wearable devices to improve medical safety and access to care. Concerns around data privacy/security were infrequent.

CONCLUSIONS

We report excellent feasibility characteristics for wrist-worn biosensors and e-PROMS as a possible substrate for multi-modal disease tracking in post-COVID conditions. Adapting consumer-grade wearables for medical use and scalable remote patient monitoring holds great potential.

Innovative health tracker that provides advanced functionalities to support and guide users in modifying their lifestyle: a Straussian ground theory approach

Objective

Health can be described as the state of homeostasis and optimal functioning across various bio-psycho-social dimensions and processes, allowing an individual to adapt and respond effectively to extrinsic and intrinsic challenges. Our thoughts, choices, behaviors, experiences, and feelings shape our existence. By transitioning from unconscious reactions to conscious responses, we can establish novel habits and behaviors, actively embracing positive shifts in our lifestyle.

Subjects and methods

The presented examination focuses on the smartwatch (SW), analyzing the incorporation of potentially progressive attributes that could enrich our lifestyle pursuits. The objective is not the health disorders themselves but the employment of wearable devices to create a strong sense of coherence in the Straussian grounded theory approach. The study had no subjects.

Results

The potential of the SW has been partially explored in lifestyle intervention, modification, research, and practice.

Conclusion

Based on our examination, creating an innovative SW capable of aiding individuals in better comprehending their behaviors and motivating them toward comprehensive changes in their lifestyle is a challenging yet attainable endeavor. Our ambition is to bring into existence SW capable of comprehensively measuring and evaluating interoception, circadian rhythm (CR), selected lifestyle pillars, and their associated components, and seamlessly integrating them into current SW features. It focuses on boosting motivation, maintenance, and amelioration regarding one's lifestyle. The novel approach strives to boost both immediate and underlying factors that actively contribute to improving one's metacognition.

Promises and Perils of Consumer Mobile Technologies in Cardiovascular Care: JACC Scientific Statement

Direct-to-consumer (D2C) wearables are becoming increasingly popular in cardiovascular health management because of their affordability and capability to capture diverse health data. Wearables may enable continuous health care provider-patient partnerships and reduce the volume of episodic clinic-based care (thereby reducing health care costs). However, challenges arise from the unregulated use of these devices, including questionable data reliability, potential misinterpretation of information, unintended psychological impacts, and an influx of clinically nonactionable data that may overburden the health care system. Further, these technologies could exacerbate, rather than mitigate, health disparities. Experience with wearables in atrial fibrillation underscores these challenges. The prevalent use of D2C wearables necessitates a collaborative approach among stakeholders to ensure effective integration into cardiovascular care. Wearables are heralding innovative disease screening, diagnosis, and management paradigms, expanding therapeutic avenues, and anchoring personalized medicine.

Educating the healthcare workforce of the future: lessons learned from the development and implementation of a 'Wearables in Healthcare' course

Digital health technologies will play an ever-increasing role in the future of healthcare. It is crucial that the people who will help make that transformation possible have the evidence-based and hands-on training necessary to address the many challenges ahead. To better prepare the future health workforce with the knowledge necessary to support the re-engineering of healthcare in an equitable, person-centric manner, we developed an experiential learning course-Wearables in Healthcare-for advanced undergraduate and graduate university students. Here we describe the components of that course and the lessons learned to help guide others interested in developing similar courses.

Use of Consumer Wearables in Health Research: Issues and Considerations

As wearable devices, which allow individuals to track and self-manage their health, become more ubiquitous, the opportunities are growing for researchers to use these sensors within interventions and for data collection. They offer access to data that are captured continuously, passively, and pragmatically with minimal user burden, providing huge advantages for health research. However, the growth in their use must be coupled with consideration of their potential limitations, in particular, digital inclusion, data availability, privacy, ethics of third-party involvement, data quality, and potential for adverse consequences. In this paper, we discuss these issues and strategies used to prevent or mitigate them and recommendations for researchers using wearables as part of interventions or for data collection.

Remote Technologies and Filial Obligations at a Distance: New Opportunities and Ethical Challenges

The coupled growth of population aging and international migration warrants attention on the methods and solutions available to adult children living overseas to provide distance caregiving for their aging parents. Despite living apart from their parents, the transnational informal care literature has indicated that first-generation immigrants remain committed to carry out their filial caregiving obligations in extensive and creative ways. With functions to remotely access health information enabled by emergency, wearable, motion, and video sensors, remote monitoring technologies (RMTs) may thus also allow these international migrants to be alerted in sudden changes and remain informed of their parent's state of health. As technological solutions for caregiving, RMTs could allow independent living for older persons while any unusual deviations from normal health patterns are detected and appropriately supported. With a vignette of a distance care arrangement, we engage with concepts such as filial piety, in-absentia caregiving distress, and the social exchange theory, as well as the upholding of shifting cultural ideals to illustrate the complex dynamic of the satisfaction and quality of the informal caregiving relationship. This paper extends the traditional ethical issues in technology-aided caregiving, such as autonomy, privacy, and justice, to be considered within the context of distance care. We also posit newer ethical considerations such as consent in power imbalances, harm to caregivers, and stigma. These known and new ethical issues aim to encourage further ethically conscious design and use of RMTs to support distance care for older persons.

Anxiety, patient activation, and quality of life among stroke survivors prescribed smartwatches for atrial fibrillation monitoring

Background

The detection of atrial fibrillation (AF) in stroke survivors is critical to decreasing the risk of recurrent stroke. Smartwatches have emerged as a convenient and accurate means of AF diagnosis; however, the impact on critical patient-reported outcomes, including anxiety, engagement, and quality of life, remains ill defined.

Objectives

To examine the association between smartwatch prescription for AF detection and the patient-reported outcomes of anxiety, patient activation, and self-reported health.

Methods

We used data from the Pulsewatch trial, a 2-phase randomized controlled trial that included participants aged 50 years or older with a history of ischemic stroke. Participants were randomized to use either a proprietary smartphone-smartwatch app for 30 days of AF monitoring or no cardiac rhythm monitoring. Validated surveys were deployed before and after the 30-day study period to assess anxiety, patient activation, and self-rated physical and mental health. Logistic regression and generalized estimation equations were used to examine the association between smartwatch prescription for AF monitoring and changes in the patient-reported outcomes.

Results

A total of 110 participants (mean age 64 years, 41% female, 91% non-Hispanic White) were studied. Seventy percent of intervention participants were novice smartwatch users, as opposed to 84% of controls, and there was no significant difference in baseline rates of anxiety, activation, or self-rated health between the 2 groups. The incidence of new AF among smartwatch users was 6%. Participants who were prescribed smartwatches did not have a statistically significant change in anxiety, activation, or self-reported health as compared to those who were not prescribed smartwatches. The results held even after removing participants who received an AF alert on the watch.

Conclusion

The prescription of smartwatches to stroke survivors for AF monitoring does not adversely affect key patient-reported outcomes. Further research is needed to better inform the successful deployment of smartwatches in clinical practice.

Cybersecurity Analysis of Wearable Devices: Smartwatches Passive Attack

Wearable devices are starting to gain popularity, which means that a large portion of the population is starting to acquire these products. This kind of technology comes with a lot of advantages, as it simplifies different tasks people do daily. However, as they recollect sensitive data, they are starting to be targets for cybercriminals. The number of attacks on wearable devices forces manufacturers to improve the security of these devices to protect them. Many vulnerabilities have appeared in communication protocols, specifically Bluetooth. We focus on understanding the Bluetooth protocol and what countermeasures have been applied during their updated versions to solve the most common security problems. We have performed a passive attack on six different smartwatches to discover their vulnerabilities during the pairing process. Furthermore, we have developed a proposal of requirements needed for maximum security of wearable devices, as well as the minimum requirements needed to have a secure pairing process between two devices via Bluetooth.

Clinical Targets and Attitudes Toward Implementing Digital Health Tools for Remote Measurement in Treatment for Depression: Focus Groups With Patients and Clinicians

BACKGROUND

Remote measurement technologies, such as smartphones and wearable devices, can improve treatment outcomes for depression through enhanced illness characterization and monitoring. However, little is known about digital outcomes that are clinically meaningful to patients and clinicians. Moreover, if these technologies are to be successfully implemented within treatment, stakeholders' views on the barriers to and facilitators of their implementation in treatment must be considered.

OBJECTIVE

This study aims to identify clinically meaningful targets for digital health research in depression and explore attitudes toward their implementation in psychological services.

METHODS

A grounded theory approach was used on qualitative data from 3 focus groups of patients with a current diagnosis of depression and clinicians with >6 months of experience with delivering psychotherapy (N=22).

RESULTS

Emerging themes on clinical targets fell into the following two main categories: promoters and markers of change. The former are behaviors that participants engage in to promote mental health, and the latter signal a change in mood. These themes were further subdivided into external changes (changes in behavior) or internal changes (changes in thoughts or feelings) and mapped with potential digital sensors. The following six implementation acceptability themes emerged: technology-related factors, information and data management, emotional support, cognitive support, increased self-awareness, and clinical utility.

CONCLUSIONS

The promoters versus markers of change differentiation have implications for a causal model of digital phenotyping in depression, which this paper presents. Internal versus external subdivisions are helpful in determining which factors are more susceptible to being measured by using active versus passive methods. The implications for implementation within psychotherapy are discussed with regard to treatment effectiveness, service provision, and patient and clinician experience.

Paroxysmal Atrial Fibrillation in Horses: Pathophysiology, Diagnostics and Clinical Aspects

Atrial fibrillation (AF) is the most common arrhythmia in horses causing poor performance. As in humans, the condition can be intermittent in nature, known as paroxysmal atrial fibrillation (pAF). This review covers the literature relating to pAF in horses and includes references to the human literature to compare pathophysiology, clinical presentation, diagnostic tools and treatment. The arrhythmia is diagnosed by auscultation and electrocardiography (ECG), and clinical signs can vary from sudden loss of racing performance to reduced fitness or no signs at all. If left untreated, pAF may promote electrical, functional and structural remodeling of the myocardium, thus creating a substrate that is able to maintain the arrhythmia, which over time may progress into permanent AF. Long-term ECG monitoring is essential for diagnosing the condition and fully understanding the duration and frequency of pAF episodes. The potential to adapt human cardiac monitoring systems and computational ECG analysis is therefore of interest and may benefit future diagnostic tools in equine medicine.

Heart Watch Study: protocol for a pragmatic randomised controlled trial

INTRODUCTION

Personal digital devices that provide health information, such as the Apple Watch, have developed an increasing array of cardiopulmonary tracking features which have received regulatory clearance and are directly marketed to consumers. Despite their widespread and increasing use, data about the impact of personal digital device use on patient-reported outcomes and healthcare utilisation are sparse. Among a population of patients with atrial fibrillation and/or atrial flutter undergoing cardioversion, our primary aim is to determine the impact of the heart rate measurement, irregular rhythm notification, and ECG features of the Apple Watch on quality of life and healthcare utilisation.

METHODS AND ANALYSIS

We are conducting a prospective, open-label multicentre pragmatic randomised clinical trial, leveraging a unique patient-centred health data sharing platform for enrolment and follow-up. A total of 150 patients undergoing cardioversion for atrial fibrillation or atrial flutter will be randomised 1:1 to receive the Apple Watch Series 6 or Withings Move at the time of cardioversion. The primary outcome is the difference in the Atrial Fibrillation Effect on QualiTy-of-life global score at 6 months postcardioversion. Secondary outcomes include inpatient and outpatient healthcare utilisation. Additional secondary outcomes include a comparison of the Apple Watch ECG and pulse oximeter features with gold-standard data obtained in routine clinical care settings.

ETHICS AND DISSEMINATION

The Institutional Review Boards at Yale University, Mayo Clinic, and Duke University Health System have approved the trial protocol. This trial will provide important data to policymakers, clinicians and patients about the impact of the heart rate, irregular rhythm notification, and ECG features of widely used personal digital devices on patient quality of life and healthcare utilisation. Findings will be disseminated to study participants, at professional society meetings and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04468321.