An internet-based interactive telemonitoring system for improving childhood asthma outcomes in Taiwan

Telemonitoring of pediatric asthma in outpatient settings: A systematic review

Telemonitoring technologies are rapidly evolving, offering a promising solution for remote monitoring and timely management of asthma acute episodes. We aimed to describe current pediatric asthma telemonitoring technologies. A systematic review was conducted until September 2023 on Medline, Scopus, and Web of Science. We included studies of children (0-18 years) with asthma or recurrent wheezing whose respiratory condition was telemonitored outside the healthcare setting. A narrative synthesis was performed. We identified 40 telemonitoring technologies described in 40 studies. The more frequently used technologies for telemonitoring were mobile applications (n = 21) and web-based systems (n = 14). Telemonitoring duration varied between 2 weeks and 32 months. Data collection included asthma symptoms (n = 30), patient-reported outcome measures (PROMs) (n = 11), spirometry/peak flow readings (n = 20), medication adherence (n = 17), inhaler technique (n = 3), air quality (n = 2), and respiratory sounds (n = 2). Both parents and children were the technology target users in most studies (n = 23). Technology training was reported in 23 studies of which 3 provided ongoing support. Automatic feedback was found in 30 studies, mostly related with asthma control. HCP were involved in data management in 27 studies. Technologies were tested in samples from 4 to 327 children, with most studies including school-aged children and/or adolescents (n = 38) and eight including preschool children. This review provides an overview of existing technologies for the outpatient telemonitoring of pediatric asthma. Specific technologies for preschool children represent a gap in the literature that needs to be specifically addressed in future research.

Telemedicine with special focus on allergic diseases and asthma-Status 2022: An EAACI position paper

Efficacious, effective and efficient communication between healthcare professionals (HCP) and patients is essential to achieve a successful therapeutic alliance. Telemedicine (TM) has been used for decades but during the COVID-19 pandemic its use has become widespread. This position paper aims to describe the terminology and most important forms of TM among HCP and patients and review the existing studies on the uses of TM for asthma and allergy. Besides, the advantages and risks of TM are discussed, concluding that TM application reduces costs and time for both, HCP and patients, but cannot completely replace face-to-face visits for physical examinations and certain tests that are critical in asthma and allergy. From an ethical point of view, it is important to identify those involved in the TM process, ensure confidentiality and use communication channels that fully guarantee the security of the information. Unmet needs and directions for the future regarding implementation, data protection, privacy regulations, methodology and efficacy are described.

The Management of Pediatric Asthma Using Telehealth: An Integrative Review

Introduction: Asthma is one of the most chronic noncommunicable diseases of childhood, affecting 1 in 12 children in the United States. The use of telemedicine for the management of pediatric asthma has shown improved health outcomes; however, it is important to understand what can impact its acceptance. The purpose of this review was to identify the facilitators and barriers to pediatric asthma management, as viewed by stakeholders. Methods: An electronic literature search was performed using PubMed, Scopus, and Cumulative Index to Nursing and Allied Health Literature Complete. Articles included in the review contained perceptions of the use of telemedicine for the management of pediatric asthma, as viewed by stakeholders. The socioecological model was used as the theoretical framework to extract data based on its five levels. Results: After reviewing full texts of 143 articles, 118 were excluded, leaving 25 articles included in this review. A majority of included articles focused on mobile health (m-Health) studies for the management of pediatric asthma, with the remaining articles studying synchronous telemedicine or a combination of modalities. Common themes were identified; however, most were focused on the use of m-Health and few studies contained the viewpoints of the caregiver, children, or providers regarding synchronous telemedicine. Discussion: This integrative review identified a number of facilitators and barriers for the management of asthma using telemedicine. However, more qualitative studies are needed to evaluate the perceptions of caregivers, patients, and primary providers regarding synchronous telehealth. It was also recognized that telemedicine may increase instead of reduce health care disparities.

Effectiveness of eAsthmaCare on Symptoms, Childhood Asthma Control Test, and Lung Function among Asthmatic Children

A web-based self-health management system-eAsthmaCare, was developed as an intervention for asthmatic children. A randomized controlled trial was performed. Consent was obtained for 98 children with asthma to participate in the study and the pre- and post-test data collection process. The experimental group was given access to eAsthmaCare online management, the control group was subjected to general asthma management. The experimental and control groups' asthma symptoms, Childhood Asthma Control Test (C-ACT) scores, and lung function were evaluated, and their pre- and 3-month post-test results were compared. The following records were maintained: (1) medication record (2) daily asthma symptoms log (3) monthly C-ACT and lung function records. The C-ACT results indicated a p-value of < .01 for: overall improvements to childhood asthma symptoms, time effect, group and time interaction effects, and group and time interaction effects in relation to sleeping condition on the previous day; cough symptom time effect, and group and time interaction effects; the two groups' time effect in relation to cough symptoms; the two groups' time effect in relation to monthly activity restrictions (number of days); and the two groups' time effect in relation to nasal symptoms; the two groups' time effect; and group and time interaction effects (p < .01). In terms of the predictive values for lung function (FVC, FEV1, PEFR), the improvements in both groups were not statistically significant. The implementation of the eAsthmaCare intervention might have a positive impact on pediatric patients, making it an effective management tool for monitoring asthmatic children's physical function and discomfort.

A study in patient satisfaction regarding telemedicine consultations in radiation oncology

INTRODUCTION

Telemedicine consultations can be a cost-effective and convenient method of communication, particularly with patients living in remote areas. Given the dearth of patient-reported satisfaction data with this form of consultation in Radiation Oncology, we surveyed patients to assess this in our department.

METHODS

The study recruited patients who had experienced both a Telemedicine consultation and an in-person consultation with the same radiation oncologist at our tertiary centre in South Australia. Eligible patients were identified from the Royal Adelaide Hospital oncology information system. The patient satisfaction questionnaire was sent via registered post with a reply-paid envelope. The questionnaire consisted of 38 questions divided into four major categories, focusing on communication, medical care, privacy/confidentiality and convenience. Results of the survey were tabulated in an excel spreadsheet.

RESULTS

Between 1 January 2018 and 1 January 2019, 130 eligible patients were identified. One hundred and nine patients were alive and contactable of whom 37 responded (34%). Two surveys were returned incomplete resulting in 35 patient responses available for analysis. The median age was 70 years (range 35-87); 74% were male. There was no statistically significant difference between the satisfaction scores for Telemedicine and in-person consultations with regards to communication, privacy/confidentiality or overall satisfaction. The respondent felt it was more important to be examined when the consultation was conducted in-person and found Telemedicine consultations more convenient in terms of cost and time.

CONCLUSION

Telemedicine used in Radiation Oncology is an effective form of consultation that is convenient, provides a similar level of patient satisfaction and maintains patient confidentiality. Telemedicine consultations should therefore be considered for all rural and remote cancer patients where feasible.

Digital interventions to improve adherence to maintenance medication in asthma

BACKGROUND

Asthma is the most common chronic lung condition worldwide, affecting 334 million adults and children globally. Despite the availability of effective treatment, such as inhaled corticosteroids (ICS), adherence to maintenance medication remains suboptimal. Poor ICS adherence leads to increased asthma symptoms, exacerbations, hospitalisations, and healthcare utilisation. Importantly, suboptimal use of asthma medication is a key contributor to asthma deaths. The impact of digital interventions on adherence and asthma outcomes is unknown.

OBJECTIVES

To determine the effectiveness of digital interventions for improving adherence to maintenance treatments in asthma.

SEARCH METHODS

We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted the most recent searches on 1 June 2020, with no restrictions on language of publication. A further search was run in October 2021, but studies were not fully incorporated.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) including cluster- and quasi-randomised trials of any duration in any setting, comparing a digital adherence intervention with a non-digital adherence intervention or usual care. We included adults and children with a clinical diagnosis of asthma, receiving maintenance treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures for data collection. We used GRADE to assess quantitative outcomes where data were available.

MAIN RESULTS

We included 40 parallel randomised controlled trials (RCTs) involving adults and children with asthma (n = 15,207), of which eight are ongoing studies. Of the included studies, 30 contributed data to at least one meta-analysis. The total number of participants ranged from 18 to 8517 (median 339). Intervention length ranged from two to 104 weeks. Most studies (n = 29) reported adherence to maintenance medication as their primary outcome; other outcomes such as asthma control and quality of life were also commonly reported. Studies had low or unclear risk of selection bias but high risk of performance and detection biases due to inability to blind the participants, personnel, or outcome assessors. A quarter of the studies had high risk of attrition bias and selective outcome reporting. We examined the effect of digital interventions using meta-analysis for the following outcomes: adherence (16 studies); asthma control (16 studies); asthma exacerbations (six studies); unscheduled healthcare utilisation (four studies); lung function (seven studies); and quality of life (10 studies). Pooled results showed that patients receiving digital interventions may have increased adherence (mean difference of 14.66 percentage points, 95% confidence interval (CI) 7.74 to 21.57; low-certainty evidence); this is likely to be clinically significant in those with poor baseline medication adherence. Subgroup analysis by type of intervention was significant (P = 0.001), with better adherence shown with electronic monitoring devices (EMDs) (23 percentage points over control, 95% CI 10.84 to 34.16; seven studies), and with short message services (SMS) (12 percentage points over control, 95% CI 6.22 to 18.03; four studies). No significant subgroup differences were seen for interventions having an in-person component versus fully digital interventions, adherence feedback, one or multiple digital components to the intervention, or participant age. Digital interventions were likely to improve asthma control (standardised mean difference (SMD) 0.31 higher, 95% CI 0.17 to 0.44; moderate-certainty evidence) - a small but likely clinically significant effect. They may reduce asthma exacerbations (risk ratio 0.53, 95% CI 0.32 to 0.91; low-certainty evidence). Digital interventions may result in a slight change in unscheduled healthcare utilisation, although some studies reported no or a worsened effect. School or work absence data could not be included for meta-analysis due to the heterogeneity in reporting and the low number of studies. They may result in little or no difference in lung function (forced expiratory volume in one second (FEV1)): there was an improvement of 3.58% predicted FEV1, 95% CI 1.00% to 6.17%; moderate-certainty evidence); however, this is unlikely to be clinically significant as the FEV1 change is below 12%. Digital interventions likely increase quality of life (SMD 0.26 higher, 95% CI 0.07 to 0.45; moderate-certainty evidence); however, this is a small effect that may not be clinically significant. Acceptability data showed positive attitudes towards digital interventions. There were no data on cost-effectiveness or adverse events. Our confidence in the evidence was reduced by risk of bias and inconsistency.

AUTHORS' CONCLUSIONS

Overall, digital interventions may result in a large increase in adherence (low-certainty evidence). There is moderate-certainty evidence that digital adherence interventions likely improve asthma control to a degree that is clinically significant, and likely increase quality of life, but there is little or no improvement in lung function. The review found low-certainty evidence that digital interventions may reduce asthma exacerbations. Subgroup analyses show that EMDs may improve adherence by 23% and SMS interventions by 12%, and interventions with an in-person element and adherence feedback may have greater benefits for asthma control and adherence, respectively. Future studies should include percentage adherence as a routine outcome measure to enable comparison between studies and meta-analysis, and use validated questionnaires to assess adherence and outcomes.

Effectiveness of technological interventions to improve healthcare communication with children with long-term conditions: A systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the effectiveness of technological interventions used to improve communication between healthcare professionals (HCPs) and children with long-term conditions (LTCs).

METHODS

PROSPERO: CRD42020221977. Five electronic databases were searched from inception to May 2021 for randomised controlled trials. Study characteristics were described and random-effects meta-analysis was conducted.

RESULTS

Nineteen studies were included, involving 1995 participants. Technological interventions were found to significantly improve participants' knowledge of their condition (standardised mean difference [SMD] 0.39; 95% CI 0.07-0.71; p = 0.02) and lead to a more internal health locus of control (SMD 0.50; 95% CI 0.25-0.76; p < 0.0001). There was no statistically significant improvement in physiological measures or emergency healthcare use.

CONCLUSION

This systematic review showed some benefits of using technology to improve communication between HCPs and children with LTCs. Future primary research should use rigorous methods for subsequent reviews to draw conclusions with greater confidence in the evidence. Establishing a core outcome set within this field of study would enable consistent measurement of outcomes.

PRACTICE IMPLICATIONS

Our findings indicate value in integrating communication technologies in the child health setting, aiming to establish greater continuity of care and maintain patient-clinician relationships between healthcare visits.

Features of successful interventions to improve adherence to inhaled corticosteroids in children with asthma: A narrative systematic review

INTRODUCTION

Nonadherence to inhaled corticosteroids (ICSs) in children with asthma leads to significant morbidity and mortality. Few adherence interventions have been effective and little is known about what contributes to intervention effectiveness. This systematic review summarizes the efficacy and the characteristics of effective interventions.

METHODS

Six databases were systematically searched on October 3, 2020 for randomized control trials measuring adherence to ICS in children with asthma. A narrative synthesis was conducted focusing on intervention efficacy and study reliability. Intervention content was coded based on the National Institute for Health and Care Excellence guidelines for medicines adherence (the Perceptions and Practicalities Approach, PAPA) and behavior change techniques (BCTs), to determine the effective aspects of the intervention.

RESULTS

Of 240 studies identified, 25 were eligible for inclusion. Thirteen of the 25 studies were categorized as being highly reliable. Nine of the 13 interventions were effective at increasing adherence and 6 of those met the criteria for a PAPA intervention. Techniques targeting perceptions and practicalities in successful interventions included rewards, reminders, feedback and monitoring of adherence, pharmacological support, instruction on how to take their ICS/adhere, and information about triggers for symptoms and nonadherence.

CONCLUSION

Adherence interventions in children with asthma have mixed effectiveness. Effective intervention studies were more frequently of higher quality, were tailored to individuals' perceptual and practical adherence barriers, and used multiple BCTs. However, due to the small number of included studies and varying study design quality, conclusions drawn here are preliminary. Future research is needed to test a PAPA-based intervention with a rigorous study design.

Lung Function Tests, Quality of Life and Telemedicine: Three Windows on the Multifaceted World of Asthma in Adolescents

Asthma is a heterogeneous disease usually characterized by chronic airway inflammation and recognized as the most prevalent chronic illness among children. Despite this, the knowledge as to how asthma affects adolescents is still scarce. One of the main management problems of asthmatic adolescents is the poor adherence to pharmacological and non-pharmacological treatments. The assessment of respiratory function and the impact on quality of life are still two crucial challenges in the management of asthmatic adolescents. Additionally, the COVID-19 pandemic has prompted physicians to explore complementary management strategies including telemedicine technologies. This review aims to provide an update on the contribution of respiratory functional tests, how asthma affects quality of life of adolescents and, finally, how telemedicine contributes to the management of adolescent asthmatics during the COVID-19 pandemic.

The Impact of Adherence and Health Literacy on Difficult-to-Control Asthma

Medication nonadherence and health literacy are key factors that influence the management of difficult-to-control asthma. Adherence, or the extent to which a patient follows a treatment plan, extends beyond asthma medication use and includes an appropriate inhaler technique. Assessment of adherence is critical before making a diagnosis of severe asthma and stepping up asthma therapy but is challenging in the clinical context. Health literacy, or the degree to which individuals can obtain, process, and understand health information and services needed to make health care decisions, is additionally important for asthma management and has been shown to impact medication adherence. Initiatives aiming to improve difficult-to-control asthma should address medication adherence and health literacy. Universal health literacy precautions are recommended while communicating with patients, in addition to the creation of low health literacy asthma action plans. To improve adherence, a comprehensive assessment of adherence should be conducted. Additional evidence-based interventions aiming to improve adherence focus on appropriate inhaler use, improved access to medications, the use of digital platforms, school-based asthma interventions, and the implementation of culturally tailored interventions. Data are limited regarding the use of these initiatives in patients with severe or difficult-to-control asthma.

Asthma Management Using the Mobile Asthma Evaluation and Management System in China

PURPOSE

As stated in the Global Initiative for Asthma, there are still some asthmatic patients who have not achieved asthma control. Mobile is a useful tool for asthma management. We aimed to compare the advantages of mobile management with traditional management in improving adherence and control of asthma.

METHODS

In this prospective, multicentre, randomized, controlled and parallel-group study, we enrolled patients with poor adherence and uncontrolled asthma at 32 hospitals in 28 provinces in China. Patients were randomly assigned to the mobile management or traditional management groups for 12 months. The primary endpoint was the proportion of patients with good adherence (Medication Adherence Report Scale for Asthma [MARS-A] score ≥ 45) for 6 months. This study is registered at ClinicalTrials.gov (NCT02917174).

RESULTS

Between April 2017 and April 2018, 923 patients were eligible for randomization (mobile group, n = 461; traditional group, n = 462). Dropout was 84 (18.2%) in the mobile management group and 113 (24.4%) patients in the traditional management group. The proportion of patients with good adherence was significantly higher in the mobile management group than in the traditional management group (66.0% vs. 58.99%, P = 0.048). The mobile management group showed higher mean MARS-A score (at 1, 6, 9, and 12 months) and asthma control test scores (at 6 and 9 months), and lower total lost rate to follow-up within 12 months than the traditional management group.

CONCLUSIONS

Mobile asthma management can improve adherence and asthma control compared to traditional management.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02917174.

Meta-Analysis of Adherence Promotion Interventions in Pediatric Asthma

BACKGROUND

Youth with asthma commonly have suboptimal adherence to inhaled corticosteroids (ICS). It is critical to systematically evaluate the effectiveness of ICS adherence promotion interventions and discern which techniques are most effective.

OBJECTIVE

This study aims to (1) quantify the extent to which interventions improve ICS adherence in pediatric asthma, (2) explore differences in effect size estimates based on intervention and study characteristics, and (3) characterize the risk of bias across interventions.

METHODS

We conducted literature searches across five databases. Included studies quantitatively measured ICS adherence as an intervention outcome among youth (<18 years old) diagnosed with asthma and were published after 1997. We analyzed aggregate effect sizes and moderator variables using random-effects models and characterized risk of bias using the Cochrane Collaboration tool.

RESULTS

Thirty-three unique studies met inclusion criteria. At post-intervention, the aggregate effect size for pediatric ICS adherence promotion interventions was small but significant (n = 33, g = 0.39, 95% confidence interval [CI] = 0.24-0.54); however, the aggregate effect size at follow-up was not statistically significant (n = 6, g = 0.38, 95% CI = -0.08 to 0.83). Method of adherence measurement and intervention format were significant moderators. Most interventions had a high risk of performance bias and an unclear risk of bias in one or more domains.

CONCLUSIONS

ICS adherence promotion interventions are effective among youth with asthma. Additional longitudinal research is needed to quantify a more precise measure of intervention effectiveness over time, and moderators of intervention effectiveness should be reassessed as the literature base expands.

Efficacy of digital health interventions in youth with chronic medical conditions: A meta-analysis

BACKGROUND

Digital health interventions might extend service provisions for youth with chronic medical conditions (CC) and comorbid mental health symptoms. We aimed to comprehensively evaluate the efficacy of Internet- and mobile-based interventions (IMIs) for different psychological and disease-related outcomes in children and adolescents with CC.

METHOD

Studies were identified by systematic searches in CENTRAL, Embase, MEDLINE/PubMed and PsycINFO, complemented by searches in reference lists of eligible studies and other reviews. We included studies, when they were randomized controlled trials (RCTs) comparing the efficacy of an IMI to control conditions in improving psychological and disease-related outcomes in youth (mean age ≤ 18 years) with CC. Study selection, data extraction and risk of bias assessment were conducted independently by two reviewers. Meta-analyses were performed within a random-effects model, and Hedges' g (with 95% confidence intervals) was calculated as effect size measure. Primary outcomes were comorbid mental health symptoms (i.e., depression, anxiety and stress), as well as quality of life and self-efficacy.

RESULTS

A total of 19 randomized controlled trials (2410 patients) were included in this meta-analysis. IMIs were associated with improvements in self-efficacy (g = 0.38; 95% CI, 0.15 to 0.61; I 2 = 0) and combined disease-related outcomes (g = -0.13; 95% CI, -0.25 to -0.01; I 2 = 21). Meta-analyses on other outcomes were non-significant, and some pre-planned analyses were not feasible because of a shortage of studies.

CONCLUSION

The available evidence on IMIs for improving mental and health-related outcomes in youth with CC is limited. Our findings point to a rather small benefit and limited efficacy. Future research is needed, to comprehensively assess the potential of IMIs to extend collaborative care, and to identify factors contributing to improved user-centered interventions with better treatment outcomes.

CARE: an observational study of adherence to home nebulizer therapy among children with asthma

Background:

The prevalence of pediatric asthma in China is approximately 3%, and asthma remains poorly controlled in many of these patients. This study assessed the rate of adherence to home nebulizer treatment in paediatric patients in China.

Methods:

The CARE study was a 12-week, multicentre, prospective, observational study across 12 tertiary hospitals in China. Patients were aged 0–14 years, clinically diagnosed with asthma and prescribed home nebulizer inhaled corticosteroid (ICS) therapy for ⩾3 months. The primary endpoint was electronically monitored treatment adherence. Patients attended onsite visits at 0, 4, 8 and 12 weeks to assess asthma control, severity and treatment adherence (recorded by electronic monitoring devices and caregivers).

Results:

The full analysis set included 510 patients. Median treatment adherence reported by electronic monitoring devices was 69.9%, and median caregiver-reported adherence was 77.9%. The proportion of patients with well-controlled asthma increased from 12.0% at baseline to 77.5% at visit 4. Increased time between asthma diagnosis and study enrolment was a significant predictor for better adherence [coefficient: 0.01, p = 0.0138; 95% confidence interval (CI): 0.00, 0.01] and asthma control (odds ratio = 1.001, p = 0.0498; 95% CI: 1.000, 1.002). Negative attitude to treatment by the caregiver was associated with poorer asthma control.

Conclusions:

Adherence to home nebulization, a widely used treatment for asthma, was high among Chinese pediatric patients. Asthma control improved with increasing treatment duration. These results suggest that home nebulization of ICS is an effective and recommendable long-term treatment for paediatric patients with asthma.

Trial registration

ClinicalTrials.gov identifier: NCT03156998

The reviews of this paper are available via the supplemental material section.

A Systematic Review and Meta-Analysis of Change in Health-Related Quality of Life for Interactive Telehealth Interventions for Patients With Asthma

OBJECTIVES

Asthma is one of the most common major noncommunicable diseases in the world and affects individuals of all ages. Medication is used to achieve and maintain quality of life (QOL) for people with asthma. Telehealth interventions offer optimized and personalized symptom monitoring with timely treatment adjustment and the potential to increase medication adherence for individuals with asthma. This study examines and synthesizes the available data on the change in the QOL for patients with asthma who use interactive telehealth interventions, and identifies the most effective telehealth modalities used for intervention in this area.

METHODS

Literature searches were conducted in 5 databases in November 2018 for studies measuring a change in QOL for patients with asthma. Study QOL outcomes, where possible, were pooled in a meta-analysis.

RESULTS

Seventeen publications (describing 16 studies) comprising 2015 patients were included. Based on a meta-analysis, interactive telehealth interventions can improve QOL outcomes for people living with asthma, although the improved effects may be small: web portals (0.51, 95% confidence interval [CI] -0.00 to 1.03), interactive smartphone apps (0.30, 95% CI -0.16 to 0.76) and remote monitoring (standardized mean difference 0.20, 95% CI -0.11 to 0.52). Intervention delivery modalities identified include interactive web portals, smartphone apps, and remote monitoring programs.

CONCLUSIONS

The findings provide a comprehensive overview of the available literature on interactive telehealth interventions, including interactive web portals, smartphone apps, and remote monitoring programs. These findings demonstrated that a positive change in QOL can be attributed to these interventions and provide evidence for the implementation of telehealth interventions for individuals with asthma.

Evaluation of Daily Lives of Children and Adolescents with Celiac Disease and Nursing Approaches

The incidence of celiac disease has been increasing in recent years. Celiac disease is an autoimmune enteropathy that emerges mostly in the childhood period. This disorder is a chronic condition of the small intestine due to gluten intake in individuals with genetic predisposition. In the treatment of celiac disease, gluten-free diet therapy is applied. However, the adaptation process to the diet may create difficulties for patients. Compliance with diet is much more difficult among patients with celiac disease in childhood and adolescence than in adult patients. Children and adolescents face distinct difficulties in their homes, at school, and in their social lives. Besides following dietary treatment, children and adolescents living with celiac disease need peer support to manage their daily routines. In this article, we aimed to discuss the problems experienced by children and adolescents living with celiac disease and nursing approaches to these problems.

Biomedical REAl-Time Health Evaluation (BREATHE): toward an mHealth informatics platform

OBJECTIVE

To describe a configurable mobile health (mHealth) framework for integration of physiologic and environmental sensors to be used in studies focusing on the domain of pediatric asthma.

MATERIALS AND METHODS

The Biomedical REAl-Time Health Evaluation (BREATHE) platform connects different sensors and data streams, contextualizing an individual's symptoms and daily activities over time to understand pediatric asthma's presentation and its management. A smartwatch/smartphone combination serves as a hub for personal/wearable sensing devices collecting data on health (eg, heart rate, spirometry, medications), motion, and personal exposures (eg, particulate matter, ozone); securely transmitting information to BREATHE's servers; and interacting with the user (eg, ecological momentary assessments). Server-side integration of electronic health record data and spatiotemporally correlated information (eg, weather, traffic) elaborates on these observations. An initial panel study involving pediatric asthma patients was conducted to assess BREATHE.

RESULTS

Twenty subjects were enrolled, during which BREATHE accrued seven consecutive days of continuous data per individual. The data were used to confirm knowledge about asthma (use of controller inhalers, time-activity behaviors, personal air pollution exposure), and additional analyses provided insights into within-day associations of environmental triggers and asthma exacerbations. Exit surveys focusing on mHealth usability, while positive, noted several translational challenges.

DISCUSSION

Based on these promising results, a longitudinal panel study to evaluate individual microenvironments and exposures is ongoing. Lessons learned thus far reflect the need to address various usability aspects, including convenience and ongoing engagement.

CONCLUSION

BREATHE enables multi-sensor mHealth studies, capturing new types of information alongside an evolving understanding of personal exposomes.

An Internet-Based Asthma Self-Management Program Increases Knowledge About Asthma

BACKGROUND

Asthma education (AE) is associated with reduced hospitalization and disability. We compared the effectiveness of an electronic AE program (eAEP) with a conventional face-to-face AE program (presence-based AEP; pAEP) for asthma knowledge (AK) with regard to self-management.

METHODS

A randomized controlled pilot study was conducted in a pulmonary reha- bilitation clinic. AK was determined by means of the Asthma Knowledge Test (AKT). The change in AKT score within each group was calculated with a paired t-test. Group differences were estimated with adjusted linear regression models.

RESULTS

In the intervention group (n = 41), the AKT score increased from 41.57 (standard deviation 5.63) at baseline to 45.82 (3.84) after completion of the eAEP (p < 0.001), and again to 47.20 (3.78) after completion of the pAEP (p = 0.046). In the control group (n = 41), the score increased from 41.73 (4.74) at baseline to 45.72 (3.65) after completion of the pAEP (p < 0.001). There was no relevant differ- ence in knowledge gain between the eAEP and the pAEP group after completion of the corresponding educational sessions (p = 0.881). The AKT score was higher in the eAEP group after obligatory participation in pAEP than in the group that only completed the pAEP (p = 0.020).

CONCLUSION

An internet-based AEP could help to reduce the knowledge deficits of a large proportion of patients with asthma.

Systematic Review of Digital Interventions for Pediatric Asthma Management

BACKGROUND

Pediatric patients with asthma take only approximately half of their prescribed medication. Digital interventions to improve adherence for youth with asthma exist and have the potential to improve accessibility, cost-effectiveness, and customizability.

OBJECTIVE

To systematically review published research examining digital interventions to promote adherence to the treatment of pediatric asthma.

METHODS

A systematic search of the PubMed, Scopus, CINAHL, PsycINFO, and reference review databases was conducted. Articles were included if adherence was an outcome in a randomized controlled trial of a digital intervention for children with asthma. We compared samples, intervention characteristics, adherence measurement and outcomes, as well as additional health outcomes across studies.

RESULTS

Of the 264 articles reviewed, 15 studies met inclusion criteria and were included in the review. Overall, 87% of the digital interventions demonstrated improved adherence and 53% demonstrated improved health outcomes. All the promising interventions included a behavioral component and most were 3 to 6 months in length, delivered through a digital stand-alone medium (eg, automated personalized texts, mobile health apps, and website), and assessed adherence to controller medication.

CONCLUSIONS

Overall, digital interventions aimed at improving adherence are promising and also improve health outcomes in addition to medication adherence. Although future studies using evidence-based adherence assessment and multifactorial design should be conducted, the current literature suggests that both digital stand-alone interventions and interventions combining digital technology with support from a health care team member result in improved adherence and asthma outcomes. Recommendations for digital interventions for pediatric patients with asthma with adherence concerns are provided.

Enhancing Asthma Patients' Self-Management through Smartphone-Based Application: Design, Usability Evaluation, and Educational Intervention

OBJECTIVE

The aim of this study was to design and evaluate a smartphone-based application for improving self-management in patients with asthma and evaluate its effects on their knowledge.

METHODS

In this applied research, based on the Clinical Practice Guideline and a systematic review, a questionnaire was designed to determine the application information content and functionality requirements by 15 pediatric and adult asthma and allergy specialist. Then the application was designed and developed using Adobe Air software on the Android operating system. Usability evaluation of the mobile application was performed using the standard questionnaire for user interaction satisfaction (QUIS), which completed by 30 patients with asthma, 8 information technology (IT) specialists, and 2 asthma and allergy specialists. Self-management knowledge of 30 asthma patients was measured using a researcher-made questionnaire before and after using the application.

RESULTS

The number of specialists in the both Delphi rounds was 15 and the mean work experiences were 17.6 years. The most important elements for asthma self-management were avoiding exposure to allergen and triggers (96%), drug treatment (94.6%), and how to use the therapeutic tools (92.4%), and the most important functionalities were alerting the patients when they did not control asthma (92%), setting reminders for timely drug use (85.4%) and therapeutic tools (82.6%), recording prescription drugs (82.6%), and peak flow meter values (82%). Usability evaluation showed that 30 patients with asthma, 8 IT specialists, and 2 physicians evaluated the application at a "good" level. The mean score of the patients' knowledge before intervention was 2.43 ± 0.95 which after intervention was significantly increased to 4.3 ± 0.56 (p < 0.001).

CONCLUSION

Considering the desirable outcomes of application evaluation and a positive impact of this educational intervention on asthma patients' knowledge, it is possible to use mobile-based self-management programs to help these patients to manage illness and gain knowledge and self-management skills.

Electronic Health Interventions for Preventing and Treating Negative Psychological Sequelae Resulting From Pediatric Medical Conditions: Systematic Review

BACKGROUND

Pediatric medical conditions have the potential to result in challenging psychological symptoms (eg, anxiety, depression, and posttraumatic stress symptoms [PTSS]) and impaired health-related quality of life in youth. Thus, effective and accessible interventions are needed to prevent and treat psychological sequelae associated with pediatric medical conditions. Electronic health (eHealth) interventions may help to meet this need, with the capacity to reach more children and families than in-person interventions. Many of these interventions are in their infancy, and we do not yet know what key components contribute to successful eHealth interventions.

OBJECTIVE

The primary objective of this study was to conduct a systematic review to summarize current evidence on the efficacy of eHealth interventions designed to prevent or treat psychological sequelae in youth with medical conditions.

METHODS

MEDLINE (PubMed) and PsycINFO databases were searched for studies published between January 1, 1998, and March 1, 2019, using predefined search terms. A total of 2 authors independently reviewed titles and abstracts of search results to determine which studies were eligible for full-text review. Reference lists of studies meeting eligibility criteria were reviewed. If the title of a reference suggested that it might be relevant for this review, the full manuscript was reviewed for inclusion. Inclusion criteria required that eligible studies (1) had conducted empirical research on the efficacy of a Web-based intervention for youth with a medical condition, (2) had included a randomized trial as part of the study method, (3) had assessed the outcomes of psychological sequelae (ie, PTSS, anxiety, depression, internalizing symptoms, or quality of life) in youth (aged 0-18 years), their caregivers, or both, (4) had included assessments at 2 or more time points, and (5) were available in English language.

RESULTS

A total of 1512 studies were reviewed for inclusion based on their title and abstracts; 39 articles qualified for full-text review. Moreover, 22 studies met inclusion criteria for the systematic review. Of the 22 included studies, 13 reported results indicating that eHealth interventions significantly improved at least one component of psychological sequelae in participants. Common characteristics among interventions that showed an effect included content on problem solving, education, communication, and behavior management. Studies most commonly reported on child and caregiver depression, followed by child PTSS and caregiver anxiety.

CONCLUSIONS

Previous research is mixed but suggests that eHealth interventions may be helpful in alleviating or preventing problematic psychological sequelae in youth with medical conditions and their caregivers. Additional research is needed to advance understanding of the most powerful intervention components and to determine when and how to best disseminate eHealth interventions, with the goal of extending the current reach of psychological interventions.

Effects of parent-based social media and moderate exercise on the adherence and pulmonary functions among asthmatic children

Our previous study showed Tai-Chi-Chuan (TCC) training, a moderate exercise, at school improved pulmonary function and inflammation profiles in children with mild asthma. However, habitual practice is hard to maintain with the lack of continuous family and peer support. We investigated whether parental intervention with social media could enhance children's adherence to exercise at home and improve asthmatic outcome measures. Parents were opted to attend a 12-week TCC classroom training, supervise home practice, and report to a four-step web-based social media platform to stay updated and motivated through logging activity and tracking competition. Fractional exhaled nitric oxide (FeNO), FEV1/FVC and peak expiratory flow (PEF) were measured before and after 12 weeks of training. Fifty-three asthmatic children were allocated into non-TCC (control, n = 12), TCC groups with moderate-to-severe (TCC-S, n = 26) and mild-to-moderate (TCC-M, n = 15) asthma. We found both TCC groups exhibited better pulmonary function than the non-TCC control. TCC increased FVC in mild-to-moderate asthma children while more pronounced improvement in FEV1, FEV1/FVC, PEF and FeNO was noticed in moderate-to-severe asthmatic children. All TCC subjects retained greater participation and better interaction online except for low-ranking families who dramatically dropped their practice 9 weeks later. For asthmatic children, moderate exercise improves pulmonary functions in a severity-dependent fashion. Parent-based Learn-Practice-Persuade-Award wheel is a useful platform to motivate children engagement in physical activity. Classical social persuasive skills could enhance general parent-child relationship but tend to decrease in persuasiveness over time in low-ranking families.

Development and Testing of a Mobile App for Pain Management Among Cancer Patients Discharged From Hospital Treatment: Randomized Controlled Trial

Background

The incidence of cancer pain increases in discharged patients because of discontinued standard treatments and reductions in medication adherence. Motivated by the need for better pain management in discharged patients, we developed a mobile phone app (Pain Guard) to provide continuous treatment information and feedback to discharged cancer patients suffering from pain.

Objective

The aim was to design, construct, and test the Pain Guard app in patients managing cancer pain, evaluate the total remission rate of pain and the improvement in quality of life (QoL) to improve pain management for cancer pain patients, and assess patient acceptance of the app.

Methods

This randomized controlled double-arm study involved 58 patients with cancer pain symptoms. Participants were randomly assigned to a group receiving care through the Pain Guard app (n=31) or to a control group (n=27) who received only traditional pharmaceutical care. In a pretest, participants were rated using a baseline cancer pain assessment and QoL evaluation. During treatment, the consumption levels of analgesic drugs were recorded every week. After a 4-week study period, another round of cancer pain assessment and QoL evaluation was conducted. The system’s usability, feasibility, app compliance, and satisfaction were also assessed. Our primary outcome was remission rate of pain, and secondary outcomes were medication adherence, improvements in QoL, frequency of breakthrough cancer pain (BTcP), incidence of adverse reactions, and satisfaction of patients.

Results

All participants (N=58) successfully completed the study. There were no significant differences in baseline pain scores or baseline QoL scores between groups. At the end of the study, the rate of pain remission in the trial group was significantly higher than that in the control group (P<.001). The frequency of BTcP in the app group was considerably lower than that in the control group (P<.001). The rate of medication adherence in the trial group was considerably higher than that in the control group (P<.001). Improvements in global QoL scores in the trial group were also significantly higher than those in the control group (P<.001). The incidence of adverse reactions in the trial group (7/31) was lower than that in the control group (12/27), especially constipation, with significant differences (P=.01). The 31 participants in the trial group completed a satisfaction survey regarding Pain Guard: 23 (74%) indicated that they were satisfied with receiving pharmaceutical care by Pain Guard, 5 (16%) indicated that they were somewhat satisfied, 2 (6%) indicated neutral feelings, and 1 (3%) indicated that they were somewhat dissatisfied; no participants indicated that they were very dissatisfied.

Conclusions

Pain Guard was effective for the management of pain in discharged patients with cancer pain, and its operability was effective and easily accepted by patients.

Trial Registration

Chinese Clinical Trials Registry ChiCTR1800016066; http://www.chictr.org.cn/showproj.aspx?proj=27153

Pilot Testing the Feasibility of a Game Intervention Aimed at Improving Help Seeking and Coping Among Sexual and Gender Minority Youth: Protocol for a Randomized Controlled Trial

Background

Sexual and gender minority youth (SGMY; eg, lesbian, gay, bisexual, and transgender youth) experience myriad substance use and mental health disparities compared with their cisgender (nontransgender) heterosexual peers. Despite much research showing these disparities are driven by experiences of bullying and cyberbullying victimization, few interventions have aimed to improve the health of bullied SGMY. One possible way to improve the health of bullied SGMY is via a Web-accessible game intervention. Nevertheless, little research has examined the feasibility of using a Web-accessible game intervention with SGMY.

Objective

This study aimed to describe the protocol for a randomized controlled trial (RCT) pilot, testing the feasibility and limited efficacy of a game-based intervention for increasing help-seeking–related knowledge, intentions, self-efficacy, behaviors, productive coping skills use, and coping flexibility and reducing health risk factors and behaviors among SGMY.

Methods

We enrolled 240 SGMY aged 14 to 18 years residing in the United States into a 2-arm prospective RCT. The intervention is a theory-based, community-informed, computer-based, role playing game with 3 primary components: encouraging help-seeking behaviors, encouraging use of productive coping, and raising awareness of Web-based resources. SGMY randomized to both the intervention and control conditions will receive a list of SGMY-inclusive resources, covering a variety of health-related topics. Control condition participants received only the list of resources. Notably, all study procedures are conducted via the internet. We conveniently sampled SGMY using Web-based advertisements. Study assessments occur at enrollment, 1 month after enrollment, and 2 months after enrollment. The primary outcomes of this feasibility study include implementation procedures, game demand, and game acceptability. Secondary outcomes include help-seeking intentions, self-efficacy, and behaviors; productive coping strategies and coping flexibility; and knowledge and use of Web-based resources. Tertiary outcomes include bullying and cyberbullying victimization, loneliness, mental health issues, substance use, and internalized sexual and gender minority stigma.

Results

From April to July 2018, 240 participants were enrolled and randomized. Half of the enrolled participants (n=120) were randomized into the intervention condition and half (n=120) into the control condition. At baseline, 52.1% (125/240) of the participants identified as gay or lesbian, 26.7% (64/240) as bisexual, 24.2% (58/240) as queer, and 11.7% (28/240) as another nonheterosexual identity. Nearly half (113/240) of participants were a gender minority: 36.7% (88/240) were cisgender boys, and 16.3% (39/240) were cisgender girls. There were no differences in demographic characteristics between intervention and control condition participants.

Conclusions

Web-accessible game interventions overcome common impediments of face-to-face interventions and present a unique opportunity to reach SGMY and improve their health. This trial will provide data on feasibility and limited efficacy that can inform future Web-based studies and a larger RCT aimed at improving health equity for SGMY.

Trial Registration

ClinicalTrials.gov NCT03501264; https://clinicaltrials.gov/ct2/show/NCT03501264 (Archived by WebCite at http://www.webcitation.org/72HpafarW)

International Registered Report Identifier (IRRID)

DERR1-10.2196/12164

[Effectiveness of Telemonitoring Intervention in Children and Adolescents with Asthma: A Systematic Review and Meta-Analysis]

PURPOSE

This review aimed to evaluate the effectiveness of telemonitoring (TM) in the management of children and adolescents with asthma.

METHODS

We searched Ovid-MEDLINE, Ovid-EMBASE, CENTRAL (Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health Literature), and 5 domestic databases to identify randomized controlled trials (RCTs) published through December 2017. Two reviewers independently selected relevant studies, assessed methodological quality and extracted data. We performed a meta-analysis of TM versus usual care and summarized the intervention characteristics of included studies.

RESULTS

Of the 3,095 articles identified, 8 RCTs (9 articles) were included in this review. The type of TM intervention of included studies was varying across studies (transmitted data, transmission frequency, data review, etc.). The pooled asthma control score was not significantly different between TM and usual care (standardized mean difference 0.04, 95% confidence interval (CI) -0.20~0.28). Another pooled analysis demonstrated no statistically significant difference in asthma exacerbation between TM and usual care (odds ratio 0.95, 95% CI 0.43~2.09). Overall, the pooled results from these studies revealed that TM did not lead to clinically significant improvements in health outcomes, but some studies in our analysis suggested that TM increased patient medication adherence and intervention adherence.

CONCLUSION

The current evidence base does not demonstrate any differences between TM intervention and usual care, but TM intervention might be considered a promising strategy for the delivery of self-management support for children and adolescents with asthma. Further well-designed studies are needed to assess the effects on clinical outcomes.

Effect of a mobile health, sensor-driven asthma management platform on asthma control

BACKGROUND

Asthma inflicts a significant health and economic burden in the United States. Self-management approaches to monitoring and treatment can be burdensome for patients.

OBJECTIVE

To assess the effect of a digital health management program on asthma outcomes.

METHODS

Residents of Louisville, Kentucky, with asthma were enrolled in a single-arm pilot study. Participants received electronic inhaler sensors that tracked the time, frequency, and location of short-acting β-agonist (SABA) use. After a 30-day baseline period during which reference medication use was recorded by the sensors, participants received access to a digital health intervention designed to enhance self-management. Changes in outcomes, including mean daily SABA use, symptom-free days, and asthma control status, were compared among the initial 30-day baseline period and all subsequent months of the intervention using mixed-model logistic regressions and χ² tests.

RESULTS

The mean number of SABA events per participant per day was 0.44 during the control period and 0.27 after the first month of the intervention, a 39% reduction. The percentage of symptom-free days was 77% during the baseline period and 86% after the first month, a 12% improvement. Improvement was observed throughout the study; each intervention month demonstrated significantly lower SABA use and higher symptom-free days than the baseline month (P < .001). Sixty-nine percent had well-controlled asthma during the baseline period, 67% during the first month of the intervention. Each intervention month demonstrated significantly higher percentages than the baseline month (P < .001), except for month 1 (P = .80).

CONCLUSION

A digital health asthma management intervention demonstrated significant reductions in SABA use, increased number of symptom-free days, and improvements in asthma control.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02162576.

A virtual asthma clinic for children: fewer routine outpatient visits, same asthma control

eHealth is an appealing medium to improve healthcare and its value (in addition to standard care) has been assessed in previous studies. We aimed to assess whether an eHealth intervention could improve asthma control while reducing 50% of routine outpatient visits.In a multicentre, randomised controlled trial with a 16-month follow-up, asthmatic children (6-16 years) treated in eight Dutch hospitals were randomised to usual care (4-monthly outpatient visits) and online care using a virtual asthma clinic (VAC) (8-monthly outpatient visits with monthly web-based monitoring). Outcome measures were the number of symptom-free days in the last 4 weeks of the study, asthma control, forced expiratory volume in 1 s, exhaled nitric oxide fraction, asthma exacerbations, unscheduled outpatient visits, hospital admissions, daily dose of inhaled corticosteroids and courses of systemic corticosteroids.We included 210 children. After follow-up, symptom-free days differed statistically between the usual care and VAC groups (difference of 1.23 days, 95% CI 0.42-2.04; p=0.003) in favour of the VAC. In terms of asthma control, the Childhood Asthma Control Test improved more in the VAC group (difference of 1.17 points, 95% CI 0.09-2.25; p=0.03). No differences were found for other outcome measures.Routine outpatient visits can partly be replaced by monitoring asthmatic children via eHealth.

Early detection of pulmonary exacerbations in children with Cystic Fibrosis by electronic home monitoring of symptoms and lung function

Pulmonary exacerbations (PEx) in Cystic Fibrosis (CF) are associated with an increased morbidity and even mortality. We investigated whether early detection of PEx in children with CF is possible by electronic home monitoring of symptoms and lung function. During this one-year prospective multi-centre study, 49 children with CF were asked to use a home monitor three times a week. Measurements consisted of a respiratory symptom questionnaire and assessment of Forced Expiratory Volume in one second (FEV1). Linear mixed-effects and multiple logistic regression analyses were used. In the 2 weeks before a PEx, the Respiratory Symptom Score (RSS) of the home monitor increased (p = 0.051). The FEV1 as percentage of predicted (FEV1%pred) did not deteriorate in the 4 weeks before a PEx. Nevertheless, the FEV1%pred at the start of exacerbation was significantly lower than the FEV1%pred in the non-exacerbation group (mean difference 16.3%, p = 0.012). The combination of FEV1%pred and RSS had a sensitivity to predict an exacerbation of 92.9% (CI 75.0-98.8%) and a specificity of 88.9% (CI 50.7-99.4%). The combination of home monitor FEV1%pred and RSS can be helpful to predict a PEx in children with CF at an early stage.

Telemedicine is as effective as in-person visits for patients with asthma

BACKGROUND

Access to asthma specialists is a problem, particularly in rural areas, thus presenting an opportunity for management using telemedicine.

OBJECTIVE

To compare asthma outcomes during 6 months in children managed by telemedicine vs in-person visits.

METHODS

Children with asthma residing in 2 remote locations were offered the choice of an in-person visit or a telemedicine session at a local clinic. The telemedicine process involved real-time use of a Remote Presence Solution (RPS) equipped with a digital stethoscope, otoscope, and high-resolution camera. A telefacilitator operated the RPS and performed diagnostic and educational procedures, such as spirometry and asthma education. Children in both groups were assessed initially, after 30 days, and at 6 months. Asthma outcome measures included asthma control using validated tools (Asthma Control Test, Childhood Asthma Control Test, and Test for Respiratory and Asthma Control in Kids) and patient satisfaction (telemedicine group only). Noninferiority analysis of asthma control was performed using the minimally important difference of an adjusted asthma control test that combined the 3 age groups.

RESULTS

Of 169 children, 100 were seen in-person and 69 via telemedicine. A total of 34 in-person and 40 telemedicine patients completed all 3 visits. All had a small, although statistically insignificant, improvement in asthma control over time. Telemedicine was noninferior to in-person visits. Most of the telemedicine group subjects were satisfied with their experience.

CONCLUSION

Children with asthma seen by telemedicine or in-person visits can achieve comparable degrees of asthma control. Telemedicine can be a viable alternative to traditional in-person physician-based care for the treatment and management of asthma.

Development and Testing of an Intelligent Pain Management System (IPMS) on Mobile Phones Through a Randomized Trial Among Chinese Cancer Patients: A New Approach in Cancer Pain Management

Background

Cancer has become increasingly prevalent in China over the past few decades. Among the factors that determine the quality of life of cancer patients, pain has commonly been recognized as a most critical one; it could also lead to the ineffective treatment of the cancer. Driven by the need for better pain management for cancer patients, our research team developed a mobile-based Intelligent Pain Management System (IPMS).

Objective

Our objective was to design, develop, and test the IPMS to facilitate real-time pain recording and timely intervention among cancer patients with pain. The system’s usability, feasibility, compliance, and satisfaction were also assessed.

Methods

A sample of 46 patients with cancer pain symptoms were recruited at the Oncology Center of Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Chongming Branch (hereinafter referred to as “the Oncology Center”). In a pretest, participants completed a pain management knowledge questionnaire and were evaluated using the baseline cancer pain assessment and Karnofsky Performance Status (KPS) evaluation. The participants were then randomly assigned into two groups (the trial group and the control group). After a 14-day trial period, another round of cancer pain assessment, KPS evaluation and pain management knowledge assessment were repeated. In the trial group, the data were fully automatically collected by the IPMS. In the control group, the data were collected using conventional methods, such as phone interviews or door-to-door visits by physicians. The participants were also asked to complete a satisfaction questionnaire on the use of the IPMS.

Results

All participants successfully completed the trial. First, the feasibility of IPMS by observing the number of daily pain assessments recorded among patients was assessed. Second, the users’ satisfaction, effectiveness of pain management, and changes in the quality of their lives were evaluated. All the participants gave high satisfaction score after they used IMPS. Both groups reported similar pain scores and KPS scores at the baseline. At the end of the trial, the mean pain score of the trial group was significantly lower than of the control group (P<.001). The ending KPS score of the trial group was significantly higher than of the control group (P<.001). The improvement of pain management knowledge score in the trial group was more pronounced than that in the control group (P<.001).

Conclusions

This study provided preliminary data to support the potentials of using IPMS in cancer pain communication between patients and doctors and to provide real-time supportive intervention on a convenient basis at a low cost. Overall, the IPMS can serve as a reliable and effective approach to control cancer pain and improve quality of life for patients with cancer pain.

Trial Registration

Clinicaltrials.gov NCT02765269; http://clinicaltrials.gov/ct2/show/NCT02765269 (Archived by WebCite at http://www.webcitation.org/6rnwsgDgv)

Developing a ubiquitous health management system with healthy diet control for metabolic syndrome healthcare in Taiwan

BACKGROUND AND OBJECTIVE

Self-management in healthcare can allow patients managing their health data anytime and everywhere for prevention of chronic diseases. This study established a prototype of ubiquitous health management system (UHMS) with healthy diet control (HDC) for people who need services of metabolic syndrome healthcare in Taiwan.

METHODS

System infrastructure comprises of three portals and a database tier with mutually supportive components to achieve functionality of diet diaries, nutrition guides, and health risk assessments for self-health management. With the diet, nutrition, and personal health database, the design enables the analytical diagrams on the interactive interface to support a mobile application for diet diary, a Web-based platform for health management, and the modules of research and development for medical care. For database integrity, dietary data can be stored at offline mode prior to transformation between mobile device and server site at online mode.

RESULTS

The UHMS-HDC was developed by open source technology for ubiquitous health management with personalized dietary criteria. The system integrates mobile, internet, and electronic healthcare services with the diet diary functions to manage healthy diet behaviors of users. The virtual patients were involved to simulate the self-health management procedure. The assessment functions were approved by capturing the screen snapshots in the procedure. The proposed system development was capable for practical intervention.

CONCLUSION

This approach details the expandable framework with collaborative components regarding the self-developed UHMS-HDC. The multi-disciplinary applications for self-health management can support the healthcare professionals to reduce medical resources and improve healthcare effects for the patient who requires monitoring personal health condition with diet control. The proposed system can be practiced for intervention in the hospital.

PELICAN: Content evaluation of patient-centered care for children with asthma based on an online tool

BACKGROUND

We assessed the content of an intervention which integrates individual goals in outpatient clinic asthma management (based on self management principles) of children 6-12 years of age.

METHODS

This is a content evaluation study and was part of a randomized controlled multicenter trial with 9 months follow-up in five Dutch outpatient asthma clinics among children with asthma aged 6-12 years. Information on children's individual problems and their level of impairment (as indicated by the Pelican instrument), asthma management goals, and actions (as indicated by written action plans) was collected. Satisfaction of parents, children, and nurses were assessed with questionnaires and analyzed with descriptive statistics.

RESULTS

Most frequently identified problems by children (n = 42) were "cough," "cigarette smoke," and "shortness of breath." Eighty-two percent of items that were selected by children showed room for improvement. About 2-7 actions were formulated and children had an active role in more than 76% of the actions. "Using rescue medication prior to activities/triggers," and "talk to others about your asthma" were most frequently recommended. Children thought the Pelican instrument was easy (95%) and fun (65%) and both parents and nurses were positive about the incorporation of the program in asthma management. Following barriers were found: (1) only 25% of goals was formulated according to SMART principles; (2) traditional management aspects (such as medication use) are often treated instead of individual problems of children.

CONCLUSION

Implementation of patient-centered care based on the Pelican instrument is recommended in specialized care, although more extensive training of nurses in PCC will improve the successful execution of the evaluated treatment. Pediatr Pulmonol. 2016;51:993-1003. © 2016 Wiley Periodicals, Inc.

Home telemonitoring and remote feedback between clinic visits for asthma

BACKGROUND

Asthma is a chronic disease that causes reversible narrowing of the airways due to bronchoconstriction, inflammation and mucus production. Asthma continues to be associated with significant avoidable morbidity and mortality. Self management facilitated by a healthcare professional is important to keep symptoms controlled and to prevent exacerbations.Telephone and Internet technologies can now be used by patients to measure lung function and asthma symptoms at home. Patients can then share this information electronically with their healthcare provider, who can provide feedback between clinic visits. Technology can be used in this manner to improve health outcomes and prevent the need for emergency treatment for people with asthma and other long-term health conditions.

OBJECTIVES

To assess the efficacy and safety of home telemonitoring with healthcare professional feedback between clinic visits, compared with usual care.

SEARCH METHODS

We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to May 2016. We also searched www.clinicaltrials.gov, the World Health Organization (WHO) trials portal and reference lists of other reviews, and we contacted trial authors to ask for additional information.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs) of adults or children with asthma in which any form of technology was used to measure and share asthma monitoring data with a healthcare provider between clinic visits, compared with other monitoring or usual care. We excluded trials in which technologies were used for monitoring with no input from a doctor or nurse. We included studies reported as full-text articles, those published as abstracts only and unpublished data.

DATA COLLECTION AND ANALYSIS

Two review authors screened the search and independently extracted risk of bias and numerical data, resolving disagreements by consensus.We analysed dichotomous data as odds ratios (ORs) while using study participants as the unit of analysis, and continuous data as mean differences (MDs) while using random-effects models. We rated evidence for all outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) approach.

MAIN RESULTS

We found 18 studies including 2268 participants: 12 in adults, 5 in children and one in individuals from both age groups. Studies generally recruited people with mild to moderate persistent asthma and followed them for between three and 12 months. People in the intervention group were given one of a variety of technologies to record and share their symptoms (text messaging, Web systems or phone calls), compared with a group of people who received usual care or a control intervention.Evidence from these studies did not show clearly whether asthma telemonitoring with feedback from a healthcare professional increases or decreases the odds of exacerbations that require a course of oral steroids (OR 0.93, 95% confidence Interval (CI) 0.60 to 1.44; 466 participants; four studies), a visit to the emergency department (OR 0.75, 95% CI 0.36 to 1.58; 1018 participants; eight studies) or a stay in hospital (OR 0.56, 95% CI 0.21 to 1.49; 1042 participants; 10 studies) compared with usual care. Our confidence was limited by imprecision in all three primary outcomes. Evidence quality ratings ranged from moderate to very low. None of the studies recorded serious or non-serious adverse events separately from asthma exacerbations.Evidence for measures of asthma control was imprecise and inconsistent, revealing possible benefit over usual care for quality of life (MD 0.23, 95% CI 0.01 to 0.45; 796 participants; six studies; I(2) = 54%), but the effect was small and study results varied. Telemonitoring interventions may provide additional benefit for two measures of lung function.

AUTHORS' CONCLUSIONS

Current evidence does not support the widespread implementation of telemonitoring with healthcare provider feedback between asthma clinic visits. Studies have not yet proven that additional telemonitoring strategies lead to better symptom control or reduced need for oral steroids over usual asthma care, nor have they ruled out unintended harms. Investigators noted small benefits for quality of life, but these are subject to risk of bias, as the studies were unblinded. Similarly, some benefits for lung function are uncertain owing to possible attrition bias.Larger pragmatic studies in children and adults could better determine the real-world benefits of these interventions for preventing exacerbations and avoiding harms; it is difficult to generalise results from this review because benefits may be explained at least in part by the increased attention participants receive by taking part in clinical trials. Qualitative studies could inform future research by focusing on patient and provider preferences, or by identifying subgroups of patients who are more likely to attain benefit from closer monitoring, such as those who have frequent asthma attacks.

Exploring effectiveness and effective components of self-management interventions for young people with chronic physical conditions: A systematic review

OBJECTIVE

To systematically explore the effectiveness and effective components of self-management interventions.

METHODS

Study selection criteria were: Original articles in English published between 2003 and 2015; focusing on youth with chronic conditions; describing self-management interventions; with clear outcome measures; using RCT design. The random effects analysis was applied in which standardized mean differences per study were calculated.

RESULTS

42 RCTs were included. Interventions focused on medical management, provided individually in clinical settings or at home by mono-disciplinary teams showed a trend in improving adherence. Interventions delivered individually at home by mono-disciplinary teams showed a trend in improving dealing with a chronic condition.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Adherence could be improved through interventions focused on medical management, provided individually in a clinical or home setting by a mono-disciplinary team. Interventions focused on dealing with a chronic condition might be provided individually, through telemedicine programs facilitating peer-support. These intervention elements seemed effective irrespective of diagnosis, and may therefore act as good starting points for further research into and for improvement of self-management support for youth with chronic conditions in pediatric care. Results underlined the need to systematically develop and evaluate self-management interventions, since this may provide more evidence for effectiveness and effective intervention components.

Remote Patient Monitoring via Non-Invasive Digital Technologies: A Systematic Review

BACKGROUND

We conducted a systematic literature review to identify key trends associated with remote patient monitoring (RPM) via noninvasive digital technologies over the last decade.

MATERIALS AND METHODS

A search was conducted in EMBASE and Ovid MEDLINE. Citations were screened for relevance against predefined selection criteria based on the PICOTS (Population, Intervention, Comparator, Outcomes, Timeframe, and Study Design) format. We included studies published between January 1, 2005 and September 15, 2015 that used RPM via noninvasive digital technology (smartphones/personal digital assistants [PDAs], wearables, biosensors, computerized systems, or multiple components of the formerly mentioned) in evaluating health outcomes compared to standard of care or another technology. Studies were quality appraised according to Critical Appraisal Skills Programme.

RESULTS

Of 347 articles identified, 62 met the selection criteria. Most studies were randomized control trials with older adult populations, small sample sizes, and limited follow-up. There was a trend toward multicomponent interventions (n = 26), followed by smartphones/PDAs (n = 12), wearables (n = 11), biosensor devices (n = 7), and computerized systems (n = 6). Another key trend was the monitoring of chronic conditions, including respiratory (23%), weight management (17%), metabolic (18%), and cardiovascular diseases (16%). Although substantial diversity in health-related outcomes was noted, studies predominantly reported positive findings.

CONCLUSIONS

This review will help decision makers develop a better understanding of the current landscape of peer-reviewed literature, demonstrating the utility of noninvasive RPM in various patient populations. Future research is needed to determine the effectiveness of RPM via noninvasive digital technologies in delivering patient healthcare benefits and the feasibility of large-scale implementation.

Remote versus face-to-face check-ups for asthma

BACKGROUND

Asthma remains a significant cause of avoidable morbidity and mortality. Regular check-ups with a healthcare professional are essential to monitor symptoms and adjust medication.Health services worldwide are considering telephone and internet technologies as a way to manage the rising number of people with asthma and other long-term health conditions. This may serve to improve health and reduce the burden on emergency and inpatient services. Remote check-ups may represent an unobtrusive and efficient way of maintaining contact with patients, but it is uncertain whether conducting check-ups in this way is effective or whether it may have unexpected negative consequences.

OBJECTIVES

To assess the safety and efficacy of conducting asthma check-ups remotely versus usual face-to-face consultations.

SEARCH METHODS

We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to 24 November 2015. We also searched www.clinicaltrials.gov, the World Health Organization (WHO) trials portal, reference lists of other reviews and contacted trial authors for additional information.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs) of adults or children with asthma that compared remote check-ups conducted using any form of technology versus standard face-to-face consultations. We excluded studies that used automated telehealth interventions that did not include personalised contact with a health professional. We included studies reported as full-text articles, as abstracts only and unpublished data.

DATA COLLECTION AND ANALYSIS

Two review authors screened the literature search results and independently extracted risk of bias and numerical data. We resolved any disagreements by consensus, and we contacted study authors for missing information.We analysed dichotomous data as odds ratios (ORs) using study participants as the unit of analysis, and continuous data as mean differences using the random-effects models. We rated all outcomes using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Six studies including a total of 2100 participants met the inclusion criteria: we pooled four studies including 792 people in the main efficacy analyses, and presented the results of a cluster implementation study (n = 1213) and an oral steroid tapering study (n = 95) separately. Baseline characteristics relating to asthma severity were variable, but studies generally recruited people with asthma taking regular medications and excluded those with COPD or severe asthma. One study compared the two types of check-up for oral steroid tapering in severe refractory asthma and we assessed it as a separate question. The studies could not be blinded and dropout was high in four of the six studies, which may have biased the results.We could not say whether more people who had a remote check-up needed oral corticosteroids for an asthma exacerbation than those who were seen face-to-face because the confidence intervals (CIs) were very wide (OR 1.74, 95% CI 0.41 to 7.44; 278 participants; one study; low quality evidence). In the face-to-face check-up groups, 21 participants out of 1000 had exacerbations that required oral steroids over three months, compared to 36 (95% CI nine to 139) out of 1000 for the remote check-up group. Exacerbations that needed treatment in the Emergency Department (ED), hospital admission or an unscheduled healthcare visit all happened too infrequently to detect whether remote check-ups are a safe alternative to face-to-face consultations. Serious adverse events were not reported separately from the exacerbation outcomes.There was no difference in asthma control measured by the Asthma Control Questionnaire (ACQ) or in quality of life measured on the Asthma Quality of Life Questionnaire (AQLQ) between remote and face-to-face check-ups. We could rule out significant harm of remote check-ups for these outcomes but we were less confident because these outcomes are more prone to bias from lack of blinding.The larger implementation study that compared two general practice populations demonstrated that offering telephone check-ups and proactively phoning participants increased the number of people with asthma who received a review. However, we do not know whether the additional participants who had a telephone check-up subsequently benefited in asthma outcomes.

AUTHORS' CONCLUSIONS

Current randomised evidence does not demonstrate any important differences between face-to-face and remote asthma check-ups in terms of exacerbations, asthma control or quality of life. There is insufficient information to rule out differences in efficacy, or to say whether or not remote asthma check-ups are a safe alternative to being seen face-to-face.

Development of an integrated e-health tool for people with, or at high risk of, cardiovascular disease: The Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) web application

BACKGROUND

Cardiovascular disease is the leading killer globally and secondary prevention substantially reduces risk. Uptake of, and adherence to, face-to-face preventive programs is often low. Alternative models of care are exploiting the prominence of technology in daily life to facilitate lifestyle behavior change.

OBJECTIVE

To inform the development of a web-based application integrated with the primary care electronic health record, we undertook a collaborative user-centered design process to develop a consumer-focused e-health tool for cardiovascular disease risk reduction.

METHODS

A four-phase iterative process involved ten multidisciplinary clinicians and academics (primary care physician, nurses and allied health professionals), two design consultants, one graphic designer, three software developers and fourteen proposed end-users. This 18-month process involved, (1) defining the target audience and needs, (2) pilot testing and refinement, (3) software development including validation and testing the algorithm, (4) user acceptance testing and beta testing. From this process, researchers were able to better understand end-user needs and preferences, thereby improving and enriching the increasingly detailed system designs and prototypes for a mobile responsive web application.

RESULTS

We reviewed 14 relevant applications/websites and sixteen observational and interventional studies to derive a set of core components and ideal features for the system. These included the need for interactivity, visual appeal, credible health information, virtual rewards, and emotional and physical support. The features identified as essential were: (i) both mobile and web-enabled 'apps', (ii) an emphasis on medication management, (iii) a strong psychosocial support component. Subsequent workshops (n=6; 2×1.5h) informed the development of functionality and lo-fidelity sketches of application interfaces. These ideas were next tested in consumer focus groups (n=9; 3×1.5h). Specifications for the application were refined from this feedback and a graphic designer iteratively developed the interface. Concurrently, the electronic health record was linked to the consumer portal. A written description of the final algorithms for all decisions and outputs was provided to software programmers. These algorithmic outputs to the app were first validated against those obtained from an independently programmed version in STATA 11. User acceptance testing (n=5, 2×1.0h) and beta testing revealed technical bugs and interface concerns across commonly-used web browsers and smartphones. These were resolved and re-tested until functionality was optimized.

CONCLUSION

End-users of a cardiovascular disease prevention program have complex needs. A user-centered design approach aided the integration of these needs into the concept, specifications, development and refinement of a responsive web application for risk factor reduction and disease prevention.

The WEB-based Asthma Control: an intriguing connection or a dangerous hazard?

Globally, an estimated 300 million people have asthma, presenting a considerable and increasing burden of disease for healthcare systems, families, and patients themselves. Despite two decades of guidelines, asthma seems to remain not optimally controlled in a substantial proportion of people. The achievement of asthma control is the result of the interaction among different variables concerning the disease pattern and patients’ and physicians’ knowledge and behavior. It is well known that adherence to treatment increases in parallel to patient education. There is now a growing interest in the use of digital information technologies to promote asthma control and improve outcomes. Mobile health, or mHealth, refers to mobile devices, medical sensors, and communication technologies that can enhance chronic disease care and monitoring. Aim of this review was to evaluate the web resources nowadays available and to analyze the published studies about the web-based instruments used to improve asthma knowledge, control asthma outcomes. In general, studies revealed that the technology is well accepted. Interactive asthma technology may be, in addition, of help in reaching populations difficult to reach, such as inner city populations. The number of tools and apps available continues to increase, and agencies such as the FDA, become involved in their regulation, thus the mHealth landscape will continue to evolve. Although asthma tools and apps have great potential to improve care for asthma, the proof of data reproducibility, the demonstration of effectiveness, and the privacy issues still represent the major technical problems.

The impact of effective paediatric adherence promotion interventions: systematic review and meta-analysis

BACKGROUND

Understanding the impact of effective paediatric adherence promotion interventions on patients, families and the healthcare system is necessary to inform efforts to improve healthcare quality and control costs. Building on previous research suggesting that improving adherence may have far-reaching benefits, the objective of this study was to quantify the impact of effective adherence promotion interventions for children and adolescents with a chronic medical condition on patients, families and the healthcare system.

METHODS

Authors systematically reviewed articles indexed in PubMed, PsycINFO and CINAHL to identify randomized controlled trials of paediatric adherence promotion interventions. Interventions that improved paediatric adherence and examined patient-level, family-level or healthcare system-level outcomes in children and adolescents (M age ≤ 18 years) with a chronic medical condition were included. Two authors independently extracted and classified outcome variables as patient-level (quality of life and disease-related activity restrictions), micro-level (family functioning, family conflict, caregiver quality of life, caregiver sleep interruption, caregiver days away from work and patient missed school days) or macro-level variables (emergency department visits, hospitalizations, outpatient visits and urgent care visits). Outcome variables detailed in previously published reviews (i.e. disease severity) were excluded.

RESULTS

Twenty studies representing 19 unique samples met inclusion criteria. An additional eight articles representing trials that did not significantly improve adherence were included in post hoc analyses. Compared with control interventions, effective paediatric adherence promotion interventions improved patient quality of life and family-level outcomes and decreased healthcare utilization among children and adolescents with a chronic medical condition.

CONCLUSIONS

Interdisciplinary efforts to improve healthcare quality and reduce spending among children and adolescents with a chronic medical condition may be enhanced by incorporating effective paediatric adherence promotion interventions. As relatively few chronic medical conditions were represented in included studies, future research should examine the impact of paediatric adherence promotion interventions in other populations.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Study protocol for a randomised controlled trial evaluating the efficacy of a telehealth program--management of asthma with supportive telehealth of respiratory function in pregnancy (MASTERY©)

Background

Telehealth has the potential to improve asthma management through regular monitoring of lung function and/or asthma symptoms by health professionals in conjunction with feedback to patients. Although the benefits of telehealth for improving asthma management have been extensively studied, the feasibility of telehealth for supporting asthma management in pregnant women has not been investigated. This study aims to evaluate the use of telehealth for remotely monitoring lung function and optimising asthma control during pregnancy.

Methods

A randomised controlled trial comparing usual care with a telehealth program (MASTERY^©) has been conducted. The intervention comprised a mobile application – Breathe-easy^© supported by a Bluetooth-enabled handheld device (COPD-6®), which was used for self-monitoring of lung function (FEV₁, FEV₆) twice daily, and recording asthma symptoms and medication usage weekly; and a written asthma action plan (WAAP). The primary outcome measure is change in asthma control measured using the Asthma Control Questionnaire (ACQ). Secondary outcomes include changes in mini-Asthma Quality of Life Questionnaire (mAQLQ) score, lung function, asthma-related health visits, days off work/study, and oral corticosteroid use. Outcome data were collected at baseline, 3 months and 6 months by a research assistant masked to group allocation. Maternal and neonatal outcomes were also collected post-partum.

Discussion

This is the first study to evaluate the application of telehealth to optimize asthma management in pregnant women. If effective, this telehealth program could improve asthma self-management by pregnant women which may reduce the maternal and fetal risks of poorly controlled asthma during pregnancy.

Trial registration

Australian New Zealand Clinical Trials Registry (ACTRN 12613000800729) 17 July 2013

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-015-0082-3) contains supplementary material, which is available to authorized users.

Telehealth application on the rehabilitation of children and adolescents

OBJECTIVE

To systematically review the literature on the telehealth initiatives in telerehabilitation practices in children and adolescents from zero to 18 years old.

DATA SOURCES

Randomized and controlled clinical trials published in the past ten years (January 2002 to February 2012) in Medline/PubMed, Medline/BVS, PEDro and Cochrane Library databases. The descriptors "telemedicine", "rehabilitation" and "telehealth" were used in three different languages (English, Portuguese and Spanish).

DATA SYNTHESIS

From the 20 studies found in the literature, nine were included in this review. Most of the studies showed that telerehabilitation is able to produce better results in the treatment when compared to the traditional methods, providing less frequency of symptoms, better disease control, better quality of life and greater adherence to treatment.

CONCLUSIONS

Telerehabilitation is a viable and effective strategy in the treatment of common diseases in children and adolescents. However, there are few studies on the subject in this age group. Although telehealth is already consolidated worldwide, there are no studies in Brazil that used the telerehabilitation in children and adolescents, which reinforces the need for more research and investments.

Self-management interventions for young people with chronic conditions: A systematic overview

OBJECTIVE

To provide a systematic overview of self-management interventions (SMI) for young people with chronic conditions with respect to content, formats, theories, and evaluated outcomes.

METHODS

Embase, Medline, PsycINFO, Web-of-Science, CINAHL, and Cochrane were searched. Reviews' reference lists were scrutinized. Selected studies were: Original research articles in English published between 2003 and March 2014; about the evaluation of SMI for 7 to 25-year-olds with somatic chronic conditions/physical disabilities; with clear outcomes and intervention descriptions. The classification of medical, role and emotion management served to review content. Formats, theories, and evaluated outcomes were summarized.

RESULTS

86 studies were reviewed. Most aimed at medical management and were unclear about theoretical bases. Although a variety of outcomes was evaluated and the distribution over self-management domains was quite unpredictable, outcomes conceptually related to specific content. A content-based framework for the evaluation of self-management interventions is presented.

CONCLUSIONS AND PRACTICE IMPLICATIONS

SMI relate to self-management tasks and skill-building. Yet, conceptualizations of self-management support often remained unclear and content focuses predominantly on the medical domain, neglecting psycho-social challenges for chronically ill young people. Future evaluations should match outcomes/themes to content and characteristics. Our framework and overview of SMI characteristics and outcomes may assist clinicians in providing self-management support.

Rede social e virtual de apoio ao adolescente que convive com doenças crônicas: uma revisão integrativa

Objetivo: identificar o papel do enfermeiro na rede social e virtual de apoio aos adolescentes que convivem com o diagnóstico de doença crônica. Metodologia: trata-se de uma revisão integrativa, realizada na base de dados: MEDLINE, LILACS e BDENF, no período de junho a novembro de 2013, com artigos indexados a partir de 2008 até 2013 e os descritores: “enfermagem”, “apoio social”, “adolescentes”, “doenças crônicas” e “rede social”. Resultados: os artigos descrevem que o apoio social de forma direta aos portadores de doenças crônicas ou por meio do apoio que os pais recebem, afetará positivamente no estado de saúde do portador. Conclusão: o enfermeiro deve estar preparado para fornecer o apoio necessário às famílias e ao portador de doença crônica com o objetivo de melhorar a saúde do paciente. Esse apoio por meio das redes sociais virtuais é um novo método que vem conquistando espaço e trazendo grandes benefícios para esses pacientes e seus familiares.

The use of behavior change theory in Internet-based asthma self-management interventions: a systematic review

Background

The high prevalence rate of asthma represents a major societal burden. Advancements in information technology continue to affect the delivery of patient care in all areas of medicine. Internet-based solutions, social media, and mobile technology could address some of the problems associated with increasing asthma prevalence.

Objective

This review evaluates Internet-based asthma interventions that were published between 2004 and October 2014 with respect to the use of behavioral change theoretical frameworks, applied clinical guidelines, and assessment tools.

Methods

The search term (Asthma AND [Online or Internet or Mobile or Application or eHealth or App]) was applied to six bibliographic databases (Ovid MEDLINE, PubMed, BioMed Central, ProQuest Computing, Web of Knowledge, and ACM Digital Library) including only English-language articles published between 2004 and October 2014. In total, 3932 articles matched the priori search terms and were reviewed by the primary reviewer based on their titles, index terms, and abstracts. The matching articles were then screened by the primary reviewer for inclusion or exclusion based on their abstract, study type, and intervention objectives with respect to the full set of priori inclusion and exclusion criteria; 331 duplicates were identified and removed. A total of 85 articles were included for in-depth review and the remaining 3516 articles were excluded. The primary and secondary reviewer independently reviewed the complete content of the 85 included articles to identify the applied behavioral change theories, clinical guidelines, and assessment tools. Findings and any disagreement between reviewers were resolved by in-depth discussion and through a consolidation process for each of the included articles.

Results

The reviewers identified 17 out of 85 interventions (20%) where at least one model, framework, and/or construct of a behavioral change theory were applied. The review identified six clinical guidelines that were applied across 30 of the 85 interventions (35%) as well as a total of 21 assessment tools that were applied across 32 of the 85 interventions (38%).

Conclusions

The findings of this literature review indicate that the majority of published Internet-based interventions do not use any documented behavioral change theory, clinical guidelines, and/or assessment tools to inform their design. Further, it was found that the application of clinical guidelines and assessment tools were more salient across the reviewed interventions. A consequence, as such, is that many Internet-based asthma interventions are designed in an ad hoc manner, without the use of any notable evidence-based theoretical frameworks, clinical guidelines, and/or assessment tools.

Parent-reported outcomes of a shared decision-making portal in asthma: a practice-based RCT

BACKGROUND

Electronic health record (EHR)-linked patient portals are a promising approach to facilitate shared decision-making between families of children with chronic conditions and pediatricians. This study evaluated the feasibility, acceptability, and impact of MyAsthma, an EHR-linked patient portal supporting shared decision-making for pediatric asthma.

METHODS

We conducted a 6-month randomized controlled trial of MyAsthma at 3 primary care practices. Families were randomized to MyAsthma, which tracks families' asthma treatment concerns and goals, children's asthma symptoms, medication side effects and adherence, and provides decision support, or to standard care. Outcomes included the feasibility and acceptability of MyAsthma for families, child health care utilization and asthma control, and the number of days of missed school (child) and work (parent). Descriptive statistics and longitudinal regression models assessed differences in outcomes between study arms.

RESULTS

We enrolled 60 families, 30 in each study arm (mean age 8.3 years); 57% of parents in the intervention group used MyAsthma during at least 5 of the 6 study months. Parents of children with moderate to severe persistent asthma used the portal more than others; 92% were satisfied with MyAsthma. Parents reported that use improved their communication with the office, ability to manage asthma, and awareness of the importance of ongoing attention to treatment. Parents in the intervention group reported that children had a lower frequency of asthma flares and intervention parents missed fewer days of work due to asthma.

CONCLUSIONS

Use of an EHR-linked asthma portal was feasible and acceptable to families and improved clinically meaningful outcomes.

Monitoring strategies in children with asthma: a randomised controlled trial

BACKGROUND

Asthma guidelines recommend monitoring of asthma control. However, in a substantial proportion of children, asthma is poorly controlled and the best monitoring strategy is not known.

OBJECTIVES

We studied two monitoring strategies for their ability to improve asthma outcomes in comparison with standard care (SC): web-based monthly monitoring with the (Childhood) Asthma Control Test (ACT or C-ACT) and 4-monthly monitoring of FENO.

METHODS

In this randomised controlled, partly blinded, parallel group multicentre trial with a 1-year follow-up, children aged 4-18 with a doctor's diagnosis of asthma treated in seven hospitals were randomised to one of the three groups. In the web group, treatment was adapted according to ACT obtained via a website at 1-month intervals; in the FENO group according to ACT and FENO, and in the SC group according to the ACT at 4-monthly visits. The primary endpoint was the change from baseline in the proportion of symptom-free days (SFD).

RESULTS

Two-hundred and eighty children (mean age 10.4 years, 66% boys) were included; 268 completed the study. Mean changes from baseline in SFD were similar between the groups: -2.1% (web group, n=90), +8.9% (FENO group, n=91) versus 0.15% (SC, n=87), p=0.15 and p=0.78. Daily dose of inhaled corticosteroids (ICS) decreased more in the web-based group compared with both other groups (-200 μg/day, p<0.01), while ACT and SFD remained similar.

CONCLUSIONS

The change from baseline in SFD did not differ between monitoring strategies. With web-based ACT monitoring, ICS could be reduced substantially while control was maintained.

TRIAL REGISTRATION NUMBER

NTR 1995.