The role of mHealth for improving medication adherence in patients with cardiovascular disease: a systematic review

Incentives and individualized coaching improve completion rates of supervised exercise therapy for claudication

OBJECTIVE

Supervised exercise therapy (SET) provides clinical benefit for patients suffering from intermittent claudication and has been widely recommended as first-line therapy before endovascular or surgical intervention. However, published rates of SET program completion range from 5% to 55%, with historic completion of 54% at our own institution. As such, we sought to identify if targeted patient-supportive interventions improve SET completion rates while still maintaining efficacious SET programming.

METHODS

Patients who were diagnosed with intermittent claudication, as defined by ankle-brachial index (ABI) <0.9 without rest pain, were offered enrollment in a prospective quality improvement protocol for our 12-week SET for peripheral artery disease program. Program completion was defined as ≥24 of 36 offered sessions over 12 weeks. A three-pronged approach was utilized to improve completion during the study, including financial incentives up to $180, scheduled coaching with our advanced practitioner staff, and informational materials on the importance of SET programming and lifestyle modification. Patient-reported improvements in walking symptoms were tracked via regularly administered questionnaires. Functional measures of SET programming including total walking duration and distance, metabolic equivalent of task, and ABIs; vascular intervention within 12-months after enrollment was also collected and compared using univariate paired analysis.

RESULTS

In total, seventy-three patients were enrolled in SET for peripheral artery disease programming over the study period. Utilizing our three-pronged coaching approach, 56 patients completed SET programming, increasing our SET completion rate to 76.7% over a 2-year study period. Compared with pre-SET baseline, patients who completed SET noted less pain, aching, cramps in calves when walking (P = .004), and less difficulty walking 1 block (P = .038). Additionally, patients significantly increased their metabolic equivalent of task (3.1 vs 2.6; P < .001), total walking duration (30 mins vs 13.5 mins; P < .001), and total walking distance (0.7 vs 0.3 miles; P < .001) from their pre-SET baseline. There were no changes in participant ABIs from enrollment to completion in participants. Patients who completed SET programming also delayed vascular intervention compared with those who did not complete SET or declined participation (213.5 vs 122.5 days from enrollment; P = .041).

CONCLUSIONS

Targeted incentives, including cost-coverage vouchers and personalized coaching with instructional materials, successfully improved patient completion of a prescribed SET program. Patients who completed SET programming reported subjective improvement in walking symptoms and objective walking benefits. In addition, these patients had delayed time to vascular intervention, supporting current vascular guidelines advocating for effective SET therapy prior to offering vascular intervention for intermittent claudication.

Interventions for increasing medication adherence in heart failure patients: A narrative review

Heart failure is one of the critical and most costly medical challenges of the 21st century. It is a chronic debilitating condition and adherence to medication, a precondition for successful treatment is often poor. There are various interventions for improving the adherence. Depending on the goal of the intervention, these are roughly patient centric, healthcare provider centric and system centric. We provide an overview of these interventions with a focus on effectiveness and appropriateness in different clinical situations. Their use can lead to improved patient outcomes and reduced economic burden of the disease.

A meta-analysis of effectiveness of mobile health interventions on health-related outcomes in patients with heart failure

AIMS

To systematically evaluate the effectiveness of mobile health (mHealth) interventions on medication adherence in patients with heart failure.

METHODS

The literature search was conducted in PubMed, Web of Science, the Cochrane Library databases, Embase, China National Knowledge Infrastructure (CNKI), Wanfang Database and China Scientific Journal Database (VIP). The retrieval period was from the establishment of the database to May 2023. The included studies were trials to explore the effectiveness of mHealth interventions on medication adherence in patients with heart failure. Cochrane collaboration's tool was used for assessing risk of bias in randomized controlled trials. Stata 17.0 software was used to conduct data analysis. Continuous data were expressed as standard mean differences, and dichotomous data were expressed as relative risks with 95% confidence intervals (CIs).

RESULTS

A total of 13 studies and 2534 participants were included. One study was rated as Grade A, and the other 12 studies were Grade B. The results of meta-analysis indicate that mHealth interventions are effective in improving medication adherence [relative risk (RR) = 1.26, 95% CI 1.10-1.44, P < 0.05 and standard mean difference = 0.80, 95% CI 0.44-1.15, P < 0.05], and reducing readmission rates (RR = 0.63, 95% CI 0.53-0.76, P < 0.05) and mortality (RR = 0.63, 95% CI 0.43-0.94, P < 0.05) of patients with heart failure.

CONCLUSION

mHealth interventions are beneficial to improve medication adherence in patients with heart failure, and could effectively reduce the readmission rates and mortality of patients in the studies. There is a need to continuously improve the professional abilities of intervention personnel, carry out teamwork, and extend intervention and follow-up time. Convenient, fast and low-cost mobile medical devices should be adopted to reduce the cost of medical treatment. Scientific and reasonable intervention content will be formulated according to evidence-based guidelines and theoretical basis to enhance patients' ability at self-management and understanding of heart failure knowledge.

Effectiveness of eHealth Interventions in Improving Medication Adherence Among Patients With Cardiovascular Disease: Systematic Review and Meta-Analysis

BACKGROUND

Nonadherence to medication among patients with cardiovascular diseases undermines the desired therapeutic outcomes. eHealth interventions emerge as promising strategies to effectively tackle this issue.

OBJECTIVE

The aim of this study was to conduct a network meta-analysis (NMA) to compare and rank the efficacy of various eHealth interventions in improving medication adherence among patients with cardiovascular diseases (CVDs).

METHODS

A systematic search strategy was conducted in PubMed, Embase, Web of Science, Cochrane, China National Knowledge Infrastructure Library (CNKI), China Science and Technology Journal Database (Weipu), and WanFang databases to search for randomized controlled trials (RCTs) published from their inception on January 15, 2024. We carried out a frequentist NMA to compare the efficacy of various eHealth interventions. The quality of the literature was assessed using the risk of bias tool from the Cochrane Handbook (version 2.0), and extracted data were analyzed using Stata16.0 (StataCorp LLC) and RevMan5.4 software (Cochrane Collaboration). The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.

RESULTS

A total of 21 RCTs involving 3904 patients were enrolled. The NMA revealed that combined interventions (standardized mean difference [SMD] 0.89, 95% CI 0.22-1.57), telephone support (SMD 0.68, 95% CI 0.02-1.33), telemonitoring interventions (SMD 0.70, 95% CI 0.02-1.39), and mobile phone app interventions (SMD 0.65, 95% CI 0.01-1.30) were statistically superior to usual care. However, SMS compared to usual care showed no statistical difference. Notably, the combined intervention, with a surface under the cumulative ranking curve of 79.3%, appeared to be the most effective option for patients with CVDs. Regarding systolic blood pressure and diastolic blood pressure outcomes, the combined intervention also had the highest probability of being the best intervention.

CONCLUSIONS

The research indicates that the combined intervention (SMS text messaging and telephone support) has the greatest likelihood of being the most effective eHealth intervention to improve medication adherence in patients with CVDs, followed by telemonitoring, telephone support, and app interventions. The results of these network meta-analyses can provide crucial evidence-based support for health care providers to enhance patients' medication adherence. Given the differences in the design and implementation of eHealth interventions, further large-scale, well-designed multicenter trials are needed.

TRIAL REGISTRATION

INPLASY 2023120063; https://inplasy.com/inplasy-2023-12-0063/.

Implementation of risk-based lipid-lowering therapies in older (age ≥ 65 years) and very-old adults (age ≥ 75 years) with ischemic heart disease in the greater Salzburg region

Introduction: European guidelines recommend the implementation of lipid-lowering therapies (LLTs) in adults (≥ 65 years) with established atherosclerotic cardiovascular disease (ASCVD) and for risk-based primary prevention in older adults (≤ 75 years), yet their use in very-old adults (> 75 years) is controversial, discretionary, and oriented on the presence of risk factors. The aim of this retrospective study is to assess guideline-directed LLT implementation and low-density lipoprotein cholesterol (LDL-C) target achievement in high-/very-high-risk older/very-old adults (65-74 and ≥ 75 years) at presentation for ST-segment elevation myocardial infarction (STEMI) and also to assess evidence-based care delivery to older adults in our region. Methods: All STEMI patients with available LDL-C and total cholesterol presenting for treatment at a large tertiary center in Salzburg, Austria, 2018-2020, were screened (n = 910). High-risk/very-high-risk patients (n = 369) were classified according to European guidelines criteria and divided into cohorts by age: < 65 years (n = 152), 65-74 years (n = 104), and ≥ 75 years (n = 113). Results: Despite being at high-/very-high-risk, prior LLT use was < 40% in the total cohort, with no significant difference by age. Statin monotherapy predominated; 20%-23% of older/very-old adults in the entire cohort were using low-/moderate-intensity stains, 11%-13% were using high-intensity statins, 4% were on ezetimibe therapy, and none were taking proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. In the secondary prevention cohort, 53% of older/very-old patients used prior LLTs. Significantly higher percentages of older/oldest ASCVD patients (43% and 49%) met LDL-C targets < 70 mg/dL compared to patients < 65 years (29%; p = 0.033), although just 22% and 30% of these older groups attained stricter LDL-C targets of < 55 mg/dL. Low LLT uptake (16%) among older adults aged 64-74 years for primary prevention resulted in 17% and 10% attainment of risk-based LDL-C targets < 70 mg/dL and < 55 mg/dL, respectively. Oldest adults (≥ 75 years) in both primary and secondary prevention groups more often met risk-based targets than older and younger adults, despite predominantly receiving low-/moderate-intensity statin monotherapy. Conclusion: Secondary prevention was sub-optimal in our region. Less than half of older/very-old adults with established ASCVD met LDL-C targets at the time of STEMI, suggesting severe care-delivery deficits in LLT implementation. Shortcomings in initiation of risk-based LLTs were also observed among high-/very-high-risk primary prevention patients < 75 years, with the achievement of risk-based LDL-C targets in 10%-48% of these patients.

Improving medication adherence in cardiovascular disease

Non-adherence to medication is a global health problem with far-reaching individual-level and population-level consequences but remains unappreciated and under-addressed in the clinical setting. With increasing comorbidity and polypharmacy as well as an ageing population, cardiovascular disease and medication non-adherence are likely to become increasingly prevalent. Multiple methods for detecting non-adherence exist but are imperfect, and, despite emerging technology, a gold standard remains elusive. Non-adherence to medication is dynamic and often has multiple causes, particularly in the context of cardiovascular disease, which tends to require lifelong medication to control symptoms and risk factors in order to prevent disease progression. In this Review, we identify the causes of medication non-adherence and summarize interventions that have been proven in randomized clinical trials to be effective in improving adherence. Practical solutions and areas for future research are also proposed.

Adherence to Antihypertensive Therapy and Its Determinants: A Systematic Review

Hypertension is a globally prevalent condition, and low adherence to antihypertensive therapy is considered one of the main causes of poor blood pressure (BP) control. Non-adherence to antihypertensive treatment is a complex issue that can arise from various factors; however, gaining an understanding of this provides key targets for intervention strategies. This study aimed to provide an overview of the current status and recent developments regarding our understanding of the determinants of patients' adherence to antihypertensives. A systematic review was performed using the electronic databases MEDLINE/PubMed, Web of Science, Scientific Electronic Library Online (SciELO), and "Índex das Revistas Médicas Portuguesas", which included studies published between 2017 and 2021 following the PICOS model: (P) Adult patients with the diagnosis of primary hypertension, using at least one antihypertensive agent; (I) all interventions on both pharmacological and non-pharmacological level; (C) patient's adherence against their non-adherence; (O) changes in adherence to the therapeutic plan; and (S) any study design (except review articles) written in English, French, Spanish or Portuguese. Articles were reviewed by two researchers and their quality was assessed. Subsequently, determinants were classified according to their consistent or inconsistent association with adherence or non-adherence. Only 45 of the 635 reports identified met the inclusion criteria. Adherence was consistently associated with patient satisfaction with communication, patient-provider relationship, their treatment, and use of eHealth and mHealth strategies; a patient's mental and physical health, including depression, cognitive impairment, frailty, and disability, previous hospitalization, occurrence of vital events; drug treatment type and appearance; and unwillingness due to health literacy, self-efficacy, and both implicit and explicit attitudes towards treatment. There were discrepancies regarding the association of other factors to adherence, but these inconsistent factors should also be taken into account. In conclusion, the barriers to adherence are varied and often interconnected between socioeconomic, patient, therapy, condition, and healthcare system levels. Healthcare teams should invest in studying patients' non-adherence motives and tailoring interventions to individual levels, by using a multifaceted approach to assess adherence. Further research is needed to analyze the impact of implicit attitudes, the use of new technological approaches, and the influence of factors that are inconsistently associated with non-adherence, to understand their potential in implementing adherence strategies.

Use of aspirin in cardiovascular disease prevention-the role of online information search

OBJECTIVES

This study intends to examine influences of online information search on the use of aspirin in cardiovascular diseases (CVDs) prevention among the applicable adult population in the United States.

METHODS

We used data of 2018 National Health Interview Survey (NHIS). Our study sample is limited to adults age 40 or older to be consistent with the American Heart Association/American College of Cardiology Foundation (AHA/ACCF) guidelines for aspirin use. Linear probability models were used to test the association between patient's aspirin use behaviors and the variables of interest in four separate models.

RESULTS

Our results show that the use of aspirin for CVD prevention was associated with online health information seeking in different ways. When patients received doctors' advice to use aspirin, online information seeking has a negative influence, depending on whether the individual has CVD risk factors. However, for patients without recommendations from providers, the effects of online information seeking on self-initiated aspirin use depend on the different types of preventions (primary vs. secondary) and CVD risk factors.

CONCLUSION

Overall, online health information might lead to both overuse and underuse of aspirin in CVD preventions. Findings in this study may lead to decision-making that is not consistent with advice from healthcare professionals and/or established clinical guidelines.

Mobile phone text messaging for medication adherence in secondary prevention of cardiovascular disease

BACKGROUND

Cardiovascular diseases (CVDs) are the leading cause of death globally, accounting for almost 18 million deaths annually. People with CVDs have a five times greater chance of suffering a recurrent cardiovascular event than people without known CVDs. Although drug interventions have been shown to be cost-effective in reducing the risk of recurrent cardiovascular events, adherence to medication remains suboptimal. As a scalable and cost-effective approach, mobile phone text messaging presents an opportunity to convey health information, deliver electronic reminders, and encourage behaviour change. However, it is uncertain whether text messaging can improve medication adherence and clinical outcomes. This is an update of a Cochrane review published in 2017.

OBJECTIVES

To evaluate the benefits and harms of mobile phone text messaging for improving medication adherence in people with CVDs compared to usual care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases, and two trial registers. We also checked the reference lists of all primary included studies and relevant systematic reviews and meta-analyses. The date of the latest search was 30 August 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with participants with established arterial occlusive events. We included trials investigating interventions using short message service (SMS) or multimedia messaging service (MMS) with the aim of improving adherence to medication for the secondary prevention of cardiovascular events. The comparator was usual care. We excluded cluster-RCTs and quasi-RCTs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were medication adherence, fatal cardiovascular events, non-fatal cardiovascular events, and combined CVD event. Secondary outcomes were low-density lipoprotein cholesterol for the effect of statins, blood pressure for antihypertensive drugs, heart rate for the effect of beta-blockers, urinary 11-dehydrothromboxane B2 for the antiplatelet effects of aspirin, adverse effects, and patient-reported experience. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 18 RCTs involving a total of 8136 participants with CVDs. We identified 11 new studies in the review update and seven studies in the previous version of the review. Participants had various CVDs including acute coronary syndrome, coronary heart disease, stroke, myocardial infarction, and angina. All studies were conducted in middle- and high-income countries, with no studies conducted in low-income countries. The mean age of participants was 53 to 64 years. Participants were recruited from hospitals or cardiac rehabilitation facilities. Follow-up ranged from one to 12 months. There was variation in the characteristics of text messages amongst studies (e.g. delivery method, frequency, theoretical grounding, content used, personalisation, and directionality). The content of text messages varied across studies, but generally included medication reminders and healthy lifestyle information such as diet, physical activity, and weight loss. Text messages offered advice, motivation, social support, and health education to promote behaviour changes and regular medication-taking. We assessed risk of bias for all studies as high, as all studies had at least one domain at unclear or high risk of bias. Medication adherence Due to different evaluation score systems and inconsistent definitions applied for the measurement of medication adherence, we did not conduct meta-analysis for medication adherence. Ten out of 18 studies showed a beneficial effect of mobile phone text messaging for medication adherence compared to usual care, whereas the other eight studies showed either a reduction or no difference in medication adherence with text messaging compared to usual care. Overall, the evidence is very uncertain about the effects of mobile phone text messaging for medication adherence when compared to usual care. Fatal cardiovascular events Text messaging may have little to no effect on fatal cardiovascular events compared to usual care (odds ratio 0.83, 95% confidence interval (CI) 0.47 to 1.45; 4 studies, 1654 participants; low-certainty evidence). Non-fatal cardiovascular events We found very low-certainty evidence that text messaging may have little to no effect on non-fatal cardiovascular events. Two studies reported non-fatal cardiovascular events, neither of which found evidence of a difference between groups. Combined CVD events We found very low-certainty evidence that text messaging may have little to no effect on combined CVD events. Only one study reported combined CVD events, and did not find evidence of a difference between groups. Low-density lipoprotein cholesterol Text messaging may have little to no effect on low-density lipoprotein cholesterol compared to usual care (mean difference (MD) -1.79 mg/dL, 95% CI -4.71 to 1.12; 8 studies, 4983 participants; very low-certainty evidence). Blood pressure Text messaging may have little to no effect on systolic blood pressure (MD -0.93 mmHg, 95% CI -3.55 to 1.69; 8 studies, 5173 participants; very low-certainty evidence) and diastolic blood pressure (MD -1.00 mmHg, 95% CI -2.49 to 0.50; 5 studies, 3137 participants; very low-certainty evidence) when compared to usual care. Heart rate Text messaging may have little to no effect on heart rate compared to usual care (MD -0.46 beats per minute, 95% CI -1.74 to 0.82; 4 studies, 2946 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Due to limited evidence, we are uncertain if text messaging reduces medication adherence, fatal and non-fatal cardiovascular events, and combined cardiovascular events in people with cardiovascular diseases when compared to usual care. Furthermore, text messaging may result in little or no effect on low-density lipoprotein cholesterol, blood pressure, and heart rate compared to usual care. The included studies were of low methodological quality, and no studies assessed the effects of text messaging in low-income countries or beyond the 12-month follow-up. Long-term and high-quality randomised trials are needed, particularly in low-income countries.

Mobile Health Application for Seizure Management: A Human-Systems Integration Approach

OBJECTIVE

The study aims to develop a mHealth application for seizure management based on the human system integration (HSI) approach.

BACKGROUND

Unmet healthcare needs among people with epilepsy continue to exist despite the advancement in healthcare technology. Current seizure management methods are found to be ineffective. Therefore, a more efficient strategy such as mHealth technology is necessary to aid seizure management.

METHOD

The needs identification phase involved identifying the user requirements by interviewing 10 stakeholders and conducting thematic analysis and needs interpretation technique. In the solution identification phase, the system requirements were derived using various human-centered design and systems engineering approaches and were evaluated through quality function deployment to determine design targets. For the design and evaluation phase, the design targets were reflected in the app through the iterative prototyping process, and the interface and functional design were evaluated by seven human factors and ergonomics experts and four stakeholders, respectively.

RESULTS

Three primary needs and ten user requirements were derived from the needs identification phase. Ten out of fifteen system requirements were selected as design targets to be included in the final prototype. Results of the evaluation showed that the interface design of the proposed app showed superior usability compared to a competitor app and that the app functions were beneficial for the stakeholders.

CONCLUSION

The mHealth app designed through the HSI framework showed good potential in addressing the main issues in seizure management.

APPLICATION

The mHealth app design methodology based on the HSI approach can be applied to the design of small-scale systems in various domains.

Effectiveness of digital health interventions on blood pressure control, lifestyle behaviours and adherence to medication in patients with hypertension in low-income and middle-income countries: a systematic review and meta-analysis of randomised controlled trials

Background

Digital health interventions can be effective for blood pressure (BP) control, but a comparison of the effectiveness and application of these types of interventions has not yet been systematically evaluated in low- and middle-income countries (LMICs). This study aimed to compare the effectiveness of digital health interventions according to the World Health Organisation (WHO) classifications of patients in terms of BP control, lifestyle behaviour changes, and adherence to medication in patients with hypertension in LMICs.

Methods

In this systematic review and meta-analysis, we searched the PubMed, Scopus, Web of Science, Embase, CINAHL, and Cochrane Library databases for randomised controlled trials (RCTs) published in English, comprised of adults (≥18 years old) with hypertension and the intervention consisted of digital health interventions according to WHO's classifications for patients in LMICs between January 1, 2009, and July 17, 2023. We excluded RCTs that considered patients with hypertension comorbidities such as diabetes and hypertension-mediated target organ damage (HMTOD). The references were downloaded into Mendeley Desktop and imported into the Rayyan web tool for deduplication and screening. The risk of bias was assessed using Cochrane Risk of Bias 2. Data extraction was done according to Cochrane's guidelines. The main outcome measures were mean systolic blood pressure (SBP) and BP control which were assessed using the random-effect DerSimonian-Laird and Mantel-Haenszel models. We presented the BP outcomes, lifestyle behaviour changes and medication adherence in forest plots as well as summarized them in tables. This study is registered with PROSPERO, CRD42023424227.

Findings

We identified 9322 articles, of which 22 RCTs from 12 countries (n = 12,892 respondents) were included in the systematic review. The quality of the 22 studies was graded as high risk (n = 7), had some concerns (n = 3) and low risk of bias (n = 12). A total of 19 RCTs (n = 12,418 respondents) were included in the meta-analysis. Overall, digital health intervention had significant reductions in SBP [mean difference (MD) = -4.43 mmHg (95% CI -6.19 to -2.67), I2 = 92%] and BP control [odds ratio (OR) = 2.20 (95% CI 1.64-2.94), I2 = 78%], respectively, compared with usual care. A subgroup analysis revealed that short message service (SMS) interventions had the greatest statistically significant reduction of SBP [MD = -5.75 mm Hg (95% Cl -7.77 to -3.73), I2 = 86%] compared to mobile phone calls [MD = 3.08 mm Hg (-6.16 to 12.32), I2 = 87%] or smartphone apps interventions [MD = -4.06 mm Hg (-6.56 to -1.55), I2 = 79%], but the difference between groups was not statistically significant (p = 0.14). The meta-analysis showed that the interventions had a significant effect in supporting changes in lifestyle behaviours related to a low salt diet [standardised mean difference (SMD) = 1.25; (95% CI 0.64-1.87), I2 = 89%], physical activity [SMD = 1.30; (95% CI 0.23-2.37), I2 = 94%] and smoking reduction [risk difference (RR) = 0.03; (95% CI 0.01-0.05), I2 = 0%] compared to the control group. In addition, improvement in medication adherence was statistically significant and higher in the intervention group than in the control group [SMD = 1.59; (95% CI 0.51-2.67), I2 = 97%].

Interpretation

Our findings suggest that digital health interventions may be effective for BP control, changes in lifestyle behaviours, and improvements in medication adherence in LMICs. However, we observed high heterogeneity between included studies, and only two studies from Africa were included. The combination of digital health interventions with clinical management is crucial to achieving optimal clinical effectiveness in BP control, changes in lifestyle behaviours and improvements in medication adherence.

Funding

None.

Do digital health interventions hold promise for stroke prevention and care in Black and Latinx populations in the United States? A scoping review

BACKGROUND

Black and Latinx populations are disproportionately affected by stroke and are likely to experience gaps in health care. Within fragmented care systems, remote digital solutions hold promise in reversing this pattern. However, there is a digital divide that follows historical disparities in health. Without deliberate attempts to address this digital divide, rapid advances in digital health will only perpetuate systemic biases. This study aimed to characterize the range of digital health interventions for stroke care, summarize their efficacy, and examine the inclusion of Black and Latinx populations in the evidence base.

METHODS

We searched PubMed, the Web of Science, and EMBASE for publications between 2015 and 2021. Inclusion criteria include peer-reviewed systematic reviews or meta-analyses of experimental studies focusing on the impact of digital health interventions on stroke risk factors and outcomes in adults. Detailed information was extracted on intervention modality and functionality, clinical/behavioral outcome, study location, sample demographics, and intervention results.

RESULTS

Thirty-eight systematic reviews met inclusion criteria and yielded 519 individual studies. We identified six functional categories and eight digital health modalities. Case management (63%) and health monitoring (50%) were the most common intervention functionalities. Mobile apps and web-based interventions were the two most commonly studied modalities. Evidence of efficacy was strongest for web-based, text-messaging, and phone-based approaches. Although mobile applications have been widely studied, the evidence on efficacy is mixed. Blood pressure and medication adherence were the most commonly studied outcomes. However, evidence on the efficacy of the various intervention modalities on these outcomes was variable. Among all individual studies, only 38.0% were conducted in the United States (n = 197). Of these U.S. studies, 54.8% adequately reported racial or ethnic group distribution. On average, samples were 27.0% Black, 17.1% Latinx, and 63.4% White.

CONCLUSION

While evidence of the efficacy of selected digital health interventions, particularly those designed to improve blood pressure management and medication adherence, show promise, evidence of how these interventions can be generalized to historically underrepresented groups is insufficient. Including these underrepresented populations in both digital health experimental and feasibility studies is critical to advancing digital health science and achieving health equity.

mHealth application for improving treatment outcomes for patients with multidrug-resistant tuberculosis in Vietnam: an economic evaluation protocol for the V-SMART trial

INTRODUCTION

The Strengthen the Management of Multidrug-Resistant Tuberculosis in Vietnam (V-SMART) trial is a randomised controlled trial of using mobile health (mHealth) technologies to improve adherence to medications and management of adverse events (AEs) in people with multidrug-resistant tuberculosis (MDR-TB) undergoing treatment in Vietnam. This economic evaluation seeks to quantify the cost-effectiveness of this mHealth intervention from a healthcare provider and societal perspective.

METHODS AND ANALYSIS

The V-SMART trial will recruit 902 patients treated for MDR-TB across seven participating provinces in Vietnam. Participants in both intervention and control groups will receive standard community-based therapy for MDR-TB. Participants in the intervention group will also have a purpose-designed App installed on their smartphones to report AEs to health workers and to facilitate timely management of AEs. This economic evaluation will compare the costs and health outcomes between the intervention group (mHealth) and the control group (standard of care). Costs associated with delivering the intervention and health service utilisation will be recorded, as well as patient out-of-pocket costs. The health-related quality of life (HRQoL) of study participants will be captured using the 36-Item Short Form Survey (SF-36) questionnaire and used to calculate quality-adjusted life-years (QALYs). Incremental cost-effectiveness ratios (ICERs) will be based on the primary outcome (proportion of patients with treatment success after 24 months) and QALYs gained. Sensitivity analysis will be conducted to test the robustness of the ICERs. A budget impact analysis will be conducted from a payer perspective to provide an estimate of the total budget required to scale-up delivery of the intervention.

ETHICS AND DISSEMINATION

Ethical approval for the study was granted by the University of Sydney Human Research Ethics Committee (2019/676), the Scientific Committee of the Ministry of Science and Technology, Vietnam (08/QD-HDQL-NAFOSTED) and the Institutional Review Board of the National Lung Hospital, Vietnam (13/19/CT-HDDD). Study findings will be published in peer-reviewed journals and conference proceedings.

TRIAL REGISTRATION NUMBER

ACTRN12620000681954.

NPS MedicineWise application in supporting medication adherence in chronic heart failure: an acceptability and feasibility pilot study

Introduction

Heart failure (HF) is an increasing global concern. Despite evidence-based pharmacotherapy, associated morbidity and mortality remain high. This study aimed to assess the acceptability, feasibility, and value of the NPS MedicineWise dose reminder app in a tiered, pharmacist-led intervention to address medication non-adherence in patients with HF.

Methods

This prospective, single-blinded, randomised controlled trial recruited 55 patients with HF between September 2019 and October 2020. Participants were randomly assigned to either the intervention or control arms. Intervention participants used the app which prompted medication administration at each dosing interval. Control participants received standard care and remained blinded to the app throughout the study. Treatment non-adherence prompted a tiered, pharmacist-led intervention. Comparison of the Self-Efficacy for Appropriate Medication Use Scale (SEAMS) at baseline and 6-months measured the app's value in supporting medication adherence. Secondary outcome measures included self-reported medication knowledge, health-related quality of life, psychological wellbeing, and signs and symptoms of HF. Data were analysed using standard statistical tests with significance set at α 0.05.

Results

Approximately half of respondents reported managing HF and medications better by using the MedicineWise app (Tier 1). Most respondents expressed satisfaction with the in-app messages (Tier 2) and pharmacists' phone calls (Tier 3). The intervention participants demonstrated a significant improvement in the SEAMS between baseline and 6-months follow-up.

Discussion

It is feasible and potentially of value to use the MedicineWise app with a tiered, pharmacist-led intervention to support medication adherence in patients with HF. Our findings provide clinicians with "real-world" information on the practicality and potential value of using mobile health to support treatment adherence in patients with HF.

Trial registration number

Australian New Zealand Clinical Trials Registry Clinical trial registration number: ACTRN12619000289112p (http://www.ANZCTR.org.au/ACTRN12619000289112p.aspx).

Exploring the Need and Benefits of Digital Therapeutics (DTx) for the Management of Heart Failure in India

Indian heart failure (HF) registries consistently indicate high hospital readmissions and increased mortality rates after HF diagnosis. The challenges of Indian cardiologists in HF management include limited longitudinal data, frequent readmissions, low medication adherence, inadequate monitoring and follow-up, insufficient patient education, and lack of standard guidelines on cardiac rehabilitation. This article outlines the adoption of digital therapeutics (DTx) in HF management as a potential solution to address these challenges. DTx services offer improved medication adherence, early symptom identification, remote vital monitoring, timely intervention, patient education on symptoms, self-awareness, and lifestyle. Overall, DTx for HF comprises a dedicated team of cardiologists, health coaches, care managers, and globally certified connected devices to provide comprehensive and proactive monitoring, personalized coaching and support, behavioral engagement to improve adherence, emergency response system, delivery of medications and diagnostic tests at home, and a dedicated application for caregivers. DTx has the potential to enhance HF management in India.

Varenicline Combined With Oral Nicotine Replacement Therapy and Smartphone-Based Medication Reminders for Smoking Cessation: Feasibility Randomized Controlled Trial

BACKGROUND

Varenicline and oral nicotine replacement therapy (NRT) have each been shown to increase the likelihood of smoking cessation, but their combination has not been studied. In addition, smoking cessation medication adherence is often poor, thus, challenging the ability to evaluate medication efficacy.

OBJECTIVE

This study examined the effects of combined varenicline and oral NRT and smartphone medication reminders on pharmacotherapy adherence and smoking abstinence among adults enrolled in smoking cessation treatment.

METHODS

A 2×2 factorial design was used. Participants (N=34) were randomized to (1) varenicline + oral NRT (VAR+NRT) or varenicline alone (VAR) and (2) smartphone medication reminder messages (REM) or no reminder messages (NREM) over 13 weeks. Participants assigned to VAR+REM received varenicline reminder prompts, and those assigned to VAR+NRT+REM also received reminders to use oral NRT. The other 2 groups (VAR+NREM and VAR+NRT+NREM) did not receive medication reminders. Participants were not blinded to intervention groups. All participants received tobacco cessation counseling. Smartphone assessments of smoking as well as varenicline and NRT use (if applicable) were prompted daily through the first 12 weeks after a scheduled quit date. Descriptive statistics were generated to characterize the relations between medication and reminder group assignments with daily smoking, daily varenicline adherence, and daily quantity of oral NRT used. Participants completed follow-up assessments for 26 weeks after the quit date.

RESULTS

Participants were predominantly White (71%), and half were female (50%). On average, participants were 54.2 (SD 9.4) years of age, they smoked an average of 19.0 (SD 9.0) cigarettes per day and had smoked for 34.6 (SD 12.7) years. Descriptively, participants assigned to VAR+NRT reported more days of smoking abstinence compared to VAR (29.3 vs 26.3 days). Participants assigned to REM reported more days of smoking abstinence than those assigned to NREM (40.5 vs 21.8 days). Participants assigned to REM were adherent to varenicline on more days compared to those assigned to NREM (58.6 vs 40.5 days), and participants assigned to VAR were adherent to varenicline on more days than those assigned to VAR + NRT (50.7 vs 43.3 days). In the subsample of participants assigned to VAR+NRT, participants assigned to REM reported more days where ≥5 pieces of NRT were used than NREM (14.0 vs 7.4 days). Average overall medication adherence (assessed via the Medication Adherence Questionnaire) showed the same pattern as the daily smartphone-based adherence assessments.

CONCLUSIONS

Preliminary findings indicated that smoking cessation interventions may benefit from incorporating medication reminders and combining varenicline with oral NRT, though combining medications may be associated with poorer adherence. Further study is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03722966; https://classic.clinicaltrials.gov/ct2/show/NCT03722966.

The effect of telephone counseling based on Orem's model on adherence to treatment and resilience of patients with coronary angioplasty: a randomized clinical trial

BACKGROUND

This study aimed to determine the effect of telephone counseling based on Orem's Self-Care Model on adherence to treatment and resilience of patients with coronary angioplasty.

METHODS

This randomized clinical trial was performed on 80 patients in the Cardiac Intensive Care Unit of Shiraz University of Medical Sciences. Patients were randomly divided into two groups of 40 (intervention and control). Questionnaires on adherence to treatment of chronic patients and resilience for patients with cardiovascular and respiratory diseases were filled out before and 8 weeks after the intervention. In the intervention group, the telephone call schedule consisted of three calls per week for 8 weeks.

RESULTS

Before the intervention, no significant difference was found between the groups about adherence to treatment and resilience. However, after the intervention, a significant difference was found between the groups as to adherence to treatment and resilience (P < 0.001).

CONCLUSION

Nursing consultation using telephone calls based on Orem's model increases the adherence to treatment and resilience of patients undergoing coronary angioplasty. Telephone counseling can help the patients adhere to their treatment plans and develop resilience skills.

Telemedicine: an Effective and Low-Cost Lesson From the COVID-19 Pandemic for the Management of Heart Failure Patients

PURPOSE

The purpose of this review is to explore the benefits and controversies that telemedicine (TM), applied to patients with heart failure (HF), can provide in terms of diagnosis, therapeutic management, and prognosis improvement. During the coronavirus disease 19 (COVID-19) outbreak, TM emerged as the most effective and feasible method available to ensure continuous care for chronic diseases. Among these, HF, characterized by high mortality, morbidity, and the need for frequent visits, may benefit of the TM role. HF patients are affected by frequent exacerbations undergoing a progressive prognosis impoverishment, strongly depending on the disease's management. A precise clinical handling is always required, with a constant optimization of the therapy, a continuous control of risk factors, and a sensitive attention to any change in symptoms, clinical signs, and laboratory tests. In this context, TM has shown to improve therapy adherence and HF: patients' self-care, impacting the prognosis even if specific results are controversial. Major evidence shows that TM may allow an adequate primary prevention, reducing the impact of the main cardiovascular risk factors. TM can also be useful for the secondary prevention, early detecting a likely HF exacerbation before it becomes clinically manifest, thereby lowering the need for hospitalization. Moreover, an optimal up-titration of the therapy and an increase in treatment adherence are feasible by using TM. However, some studies did not show unambiguous results, and uncertainties still remain.

The Promise and Risks of mHealth in Heart Failure Care

Mobile health (mHealth) is an emerging approach to health care. It involves wearable, connected technologies that facilitate patient-symptom or physiological monitoring, support clinical feedback to patients and physicians, and promote patients' education and self-care. Evolving algorithms may involve artificial intelligence and can assist in data aggregation and health care teams' interpretations. Ultimately, the goal is not merely to collect data; rather, it is to increase actionability. mHealth technology holds particular promise for patients with heart failure, especially those with frequently changing clinical status. mHealth, ideally, can identify care opportunities, anticipate clinical courses and augment providers' capacity to implement, titrate and monitor interventions safely, including evidence-based therapies. Although there have been marked advancements in the past decade, uncertainties remain for mHealth, including questions regarding optimal indications and acceptable payment models. In regard to mHealth capability, a better understanding is needed of the incremental benefit of mHealth data over usual care, the accuracy of specific mHealth data points in making clinical care decisions, and the efficiency and precision of algorithms used to dictate actions. Importantly, emerging regulations in the wake of COVID-19, and now the end of the federal public health emergency, offer both opportunity and risks to the broader adoption of mHealth-enabled services. In this review, we explore the current state of mHealth in heart failure, with particular attention to the opportunities and challenges this technology creates for patients, health care providers and other stakeholders.

Investigation of Factors Affecting Adherence to Adjuvant Hormone Therapy in Early-Stage Breast Cancer Patients: A Comprehensive Systematic Review

PURPOSE

Adherence and persistence to adjuvant hormone therapy (AHT) are seldom maintained among early-stage hormone receptor-positive breast cancer (BC) survivors, despite the significant clinical benefits of long-term AHT. As the factors influencing adherence to AHT remain unclear, this study aimed to comprehensively identify such factors and classify them into specific dimensions.

METHODS

PubMed, Cochrane Library, Embase, PsycINFO, and CINAHL were searched for qualified articles. The search mainly focused on three components: early-stage (0-III) BC, oral AHT administration, and adherence to AHT, with keywords derived from MeSH and entry terms. The factors identified were then classified into six categories based on a modified WHO multidimensional model.

RESULTS

Overall, 146 studies were included; the median sample size was 651 (range, 31-40,009), and the mean age of the population was 61.5 years (standard deviation, 8.3 years). Patient- and therapy-related factors were the most frequently investigated factors. Necessity/concern beliefs and self-efficacy among patient-related factors were consistently related to better adherence than depression. Although drug side effects and medication use cannot be modified easily, a refined prescription strategy for the initiation and switching of AHT is likely to increase adherence levels.

CONCLUSION

An effective psychological program that encourages positive views and beliefs about medication and management strategies for each therapy may be necessary to improve adherence to AHT. Social support and a sense of belonging can be enhanced through community participation and social media for better adherence to AHT. Patient-centered communication and appropriate recommendations by physicians may be attributable to better adherence outcomes. Findings from systematically organized factors that influence adherence to AHT may contribute to the establishment of intervention strategies to benefit patients with early-stage BC to achieve optimal health.

Telehealth Use to Address Cardiovascular Disease and Hypertension in the United States: A Systematic Review and Meta-Analysis, 2011-2021

Background

The use of telehealth for the management and treatment of hypertension and cardiovascular disease (CVD) has increased across the United States (U.S.), especially during the COVID-19 pandemic. Telehealth has the potential to reduce barriers to accessing health care and improve clinical outcomes. However, implementation, outcomes, and health equity implications related to these strategies are not well understood. The purpose of this review was to identify how telehealth is being used by U.S. health care professionals and health systems to manage hypertension and CVD and to describe the impact these telehealth strategies have on hypertension and CVD outcomes, with a special focus on social determinants of health and health disparities.

Methods

This study comprised a narrative review of the literature and meta-analyses. The meta-analyses included articles with intervention and control groups to examine the impact of telehealth interventions on changes to select patient outcomes, including systolic and diastolic blood pressure. A total of 38 U.S.-based interventions were included in the narrative review, with 14 yielding data eligible for the meta-analyses.

Results

The telehealth interventions reviewed were used to treat patients with hypertension, heart failure, and stroke, with most interventions employing a team-based care approach. These interventions utilized the expertise of physicians, nurses, pharmacists, and other health care professionals to collaborate on patient decisions and provide direct care. Among the 38 interventions reviewed, 26 interventions utilized remote patient monitoring (RPM) devices mostly for blood pressure monitoring. Half the interventions used a combination of strategies (e.g., videoconferencing and RPM). Patients using telehealth saw significant improvements in clinical outcomes such as blood pressure control, which were comparable to patients receiving in-person care. In contrast, the outcomes related to hospitalizations were mixed. There were also significant decreases in all-cause mortality when compared to usual care. No study explicitly focused on addressing social determinants of health or health disparities through telehealth for hypertension or CVD.

Conclusions

Telehealth appears to be comparable to traditional in-person care for managing blood pressure and CVD and may be seen as a complement to existing care options for some patients. Telehealth can also support team-based care delivery and may benefit patients and health care professionals by increasing opportunities for communication, engagement, and monitoring outside a clinical setting.

Optimal management of patients after acute coronary syndrome

Patients with clinically established atherosclerotic cardiovascular disease are at a very high risk of recurrent cardiovascular events. An adequate management of risk factors and the implementation of healthy behaviours significantly decrease the risk of unfavourable clinical outcomes and future cardiovascular events, including death. Patients discharged after an acute coronary syndrome should be managed according to their individual risk level in order to ensure the appropriate treatment. Nevertheless, care pathways should also take into consideration the available resources and the logistical/structural aspects. In this setting, cardiac rehabilitation is prosed as a multidisciplinary approach to improving daily function and reducing cardiovascular risk factors. The organization of a network with the involvement of different medical and non-medical figures is essential to ensure successful outcomes and expected cost-effectiveness.

Effectiveness of mHealth Interventions in Medication Adherence among Patients with Cardiovascular Diseases: A Systematic Review

mHealth interventions have been reported to improve adherence to long-term therapies in chronic conditions. Therefore, this study aimed at determining the effectiveness of mHealth interventions in medication adherence among patients with cardiovascular diseases (CVDs), a leading cause of mortality globally. Relying on our inclusion criteria and the PRISMA recommendations, a literature search was carried out in the PubMed, Medline, and ProQuest databases for primary studies that investigated the impact of mHealth on medication adherence for cardiovascular disease (CVD) between 2000–2021. A total of 23 randomized controlled trials with 34,915 participants matched the selection criteria. The mHealth interventions used included text messages, mobile phone applications, and voice calls, which were used either as a single intervention or combined. Additionally, studies on enhancing drug adherence had contradictory findings: most of the studies elaborated positive results; however, six studies were unable to reveal any significant effect. Finally, a risk bias analysis revealed varying outcomes across all studies. This review, as a whole, supported the notion that mHealth interventions can be effective in improving adherence to CVD medication even though they could not improve adherence to all CVD medications when compared with controls. Further trials with more refined designs integrated with comprehensive interventions are needed to produce better health outcomes.

Effect of visual presentation of atherosclerotic carotid plaque on adherence to secondary preventive therapy using mHealth technologies (PreventiPlaque app): Study protocol for a randomized controlled trial

Background

Cardiovascular disease is the major cause of death worldwide. Although knowledge regarding diagnosing and treating cardiovascular disease has increased dramatically, secondary prevention remains insufficiently implemented due to failure among affected individuals to adhere to guideline recommendations. This has continued to lead to high morbidity and mortality rates. Involving patients in their healthcare and facilitating their active roles in their chronic disease management is an opportunity to meet the needs of the increasing number of cardiovascular patients. However, simple recall of advice regarding a more preventive lifestyle does not affect sustainable behavioral lifestyle changes. We investigate the effect of plaque visualization combined with low-threshold daily lifestyle tasks using the smartphone app PreventiPlaque to evaluate change in cardiovascular risk profile.

Methods

and study design: This randomized, controlled clinical trial includes 240 participants with ultrasound evidence of atherosclerotic plaque in one or both carotid arteries, defined as focal thickening of the vessel wall measuring 50% more than the regular vessel wall. A criterion for participation is access to a smartphone suitable for app usage. The participants are randomly assigned to an intervention or a control group. While both groups receive the standard of care, the intervention group has additional access to the PreventiPlaque app during the 12-month follow-up. The app includes daily tasks that promote a healthier lifestyle in the areas of smoking cessation, medication adherence, physical activity, and diet. The impact of plaque visualization and app use on the change in cardiovascular risk profile is assessed by SCORE2. Feasibility and effectiveness of the PreventiPlaque app are evaluated using standardized and validated measures for patient feedback.

Ethics and dissemination

This clinical trial is approved by the ethics committee of the University of Duisburg-Essen (Germany). Study results will be disseminated at conferences and in peer-reviewed journals. Information regarding the PreventiPlaque app is available via print media, social media channels, and on the authors' websites.

The Influence of Mobile Device Type on Camera-Based Monitoring of Neck Movements for Cervical Rehabilitation

We developed a mobile application for cervical rehabilitation that uses a non-invasive camera-based head-tracker sensor for monitoring neck movements. The intended user population should be able to use the mobile application in their own mobile device, but mobile devices have different camera sensors and screen dimensions that could affect the user performance and neck movement monitoring. In this work, we studied the influence of mobile devices type on camera-based monitoring of neck movements for rehabilitation purposes. We conducted an experiment to test whether the characteristics of a mobile device affect neck movements when using the mobile application with the head-tracker. The experiment consisted of the use of our application, containing an exergame, in three mobile devices. We used wireless inertial sensors to measure the real-time neck movements performed while using the different devices. The results showed that the effect of device type on neck movements was not statistically significant. We included the sex factor in the analysis, but there was no statistically significant interaction between sex and device variables. Our mobile application proved to be device-agnostic. This will allow intended users to use the mHealth application regardless of the type of device. Thus, future work can continue with the clinical evaluation of the developed application to analyse the hypothesis that the use of the exergame will improve therapeutic adherence in cervical rehabilitation.

Optimizing digital health technologies to improve therapeutic skill use and acquisition alongside enhanced cognitive-behavior therapy for binge-spectrum eating disorders: Protocol for a randomized controlled trial

OBJECTIVE

Adjunctive mobile health (mHealth) technologies offer promise for improving treatment response to enhanced cognitive-behavior therapy (CBT-E) among individuals with binge-spectrum eating disorders, but research on the key "active" components of these technologies has been very limited. The present study will use a full factorial design to (1) evaluate the optimal combination of complexity of two commonly used mHealth components (i.e., self-monitoring and microinterventions) alongside CBT-E and (2) test whether the optimal complexity level of these interventions is moderated by baseline self-regulation. Secondary aims of the present study include evaluating target engagement associated with each level of these intervention components and quantifying the component interaction effects (i.e., partially additive, fully additive, or synergistic effects).

METHOD

Two hundred and sixty-four participants with binge-spectrum eating disorders will be randomized to six treatment conditions determined by the combination of self-monitoring condition (i.e., standard self-monitoring or skills monitoring) and microinterventions condition (i.e., no microinterventions, automated microinterventions, or just-in-time adaptive interventions) as an augmentation to 16 sessions of CBT-E. Treatment outcomes will be measured using the Eating Disorder Examination and compared by treatment condition using multilevel models.

RESULTS

Results will clarify the "active" components in mHealth interventions for binge eating.

DISCUSSION

The present study will provide critical insight into the efficacy of commonly used digital intervention components (i.e., skills monitoring and microinterventions) alongside CBT-E. Furthermore, results of this study may inform personalization of digital intervention intensity based on patient profiles of self-regulation.

PUBLIC SIGNIFICANCE

This study will examine the relative effectiveness of commonly used components of application-based interventions as an augmentation to cognitive-behavioral therapy for binge eating. Findings from this study will inform the development of an optimized digital intervention for individuals with binge eating.

How to optimize the adherence to a guideline-directed medical therapy in the secondary prevention of cardiovascular diseases: a clinical consensus statement from the European Association of Preventive Cardiology

A key factor to successful secondary prevention of cardiovascular disease (CVD) is optimal patient adherence to treatment. However, unsatisfactory rates of adherence to treatment for CVD risk factors and CVD have been observed consistently over the last few decades. Hence, achieving optimal adherence to lifestyle measures and guideline-directed medical therapy in secondary prevention and rehabilitation is a great challenge to many healthcare professionals. Therefore, in this European Association of Preventive Cardiology clinical consensus document, a modern reappraisal of the adherence to optimal treatment is provided, together with simple, practical, and feasible suggestions to achieve this goal in the clinical setting, focusing on evidence-based concepts.

Resident Willingness to Participate in Digital Contact Tracing in a COVID-19 Hotspot: Findings From a Detroit Panel Study

BACKGROUND

Digital surveillance tools and health informatics show promise in counteracting diseases but have limited uptake. A notable illustration of the limits of such tools is the general failure of digital contact tracing in the United States in response to COVID-19.

OBJECTIVE

We investigated the associations between individual characteristics and the willingness to use app-based contact tracing in Detroit, a majority-minority city that experienced multiple waves of COVID-19 outbreaks and deaths since the start of the pandemic. The aim of this study was to examine variations among residents in the willingness to download a contact tracing app on their phones to provide public health officials with information about close COVID-19 contact during summer 2020.

METHODS

To examine residents' willingness to participate in digital contact tracing, we analyzed data from 2 waves of the Detroit Metro Area Communities Study, a population-based survey of Detroit, Michigan residents. The data captured 1873 responses from 991 Detroit residents collected in June and July 2020. We estimated a series of multilevel logit models to gain insights into differences in the willingness to participate in digital contact tracing across a variety of individual attributes, including race/ethnicity, degree of trust in the government, and level of education, as well as interactions among these variables.

RESULTS

Our results reflected widespread reluctance to participate in digital contact tracing in response to COVID-19, as less than half (826/1873, 44.1%) of the respondents said they would be willing to participate in app-based contact tracing. Compared to White respondents, Black (odds ratio [OR] 0.45, 95% CI 0.23-0.86) and Latino (OR 0.32, 95% CI 0.11-0.99) respondents were significantly less willing to participate in digital contact tracing. Trust in the government was positively associated with the willingness to participate in digital contact tracing (OR 1.17, 95% CI 1.07-1.27), but this effect was the strongest for White residents (OR 2.14, 95% CI 1.55-2.93). We found similarly divergent patterns of the effects of education by race. While there were no significant differences among noncollege-educated residents, White college-educated residents showed greater willingness to use app-based contact tracing (OR 6.12, 95% CI 1.86-20.15) and Black college-educated residents showed less willingness (OR 0.46, 95% CI 0.26-0.81).

CONCLUSIONS

Trust in the government and education contribute to Detroit residents' wariness of digital contact tracing, reflecting concerns about surveillance that cut across race but likely arise from different sources. These findings point to the importance of a culturally informed understanding of health hesitancy for future efforts hoping to leverage digital contact tracing. Though contact tracing technologies have the potential to advance public health, unequal uptake may exacerbate disparate impacts of health crises.

SPUR: A Patient-Reported Medication Adherence Model as a Predictor of Admission and Early Readmission in Patients Living with Type 2 Diabetes

PURPOSE

Poor medication adherence (MA) is linked to an increased likelihood of hospital admission. Early interventions to address MA may reduce this risk and associated health-care costs. This study aimed to evaluate a holistic Patient Reported Outcome Measure (PROM) of MA, known as SPUR, as a predictor of general admission and early readmission in patients living with Type 2 Diabetes.

PATIENTS AND METHODS

An observational study design was used to assess data collected over a 12-month period including 6-month retrospective and 6-month prospective monitoring of the number of admissions and early readmissions (admissions occurring within 30 days of discharge) across the cohort. Patients (n = 200) were recruited from a large South London NHS Trust. Covariates of interest included: age, ethnicity, gender, level of education, income, the number of medicines and medical conditions, and a Covid-19 diagnosis. A Poisson or negative binomial model was employed for count outcomes, with the exponentiated coefficient indicating incident ratios (IR) [95% CI]. For binary outcomes (Coefficient, [95% CI]), a logistic regression model was developed.

RESULTS

Higher SPUR scores (increased adherence) were significantly associated with a lower number of admissions (IR = 0.98, [0.96, 1.00]). The number of medical conditions (IR = 1.07, [1.01, 1.13]), age ≥80 years (IR = 5.18, [1.01, 26.55]), a positive Covid-19 diagnosis during follow-up (IR = 1.83, [1.11, 3.02]) and GCSE education (IR = 2.11, [1.15,3.87]) were factors associated with a greater risk of admission. When modelled as a binary variable, only the SPUR score (-0.051, [-0.094, -0.007]) was significantly predictive of an early readmission, with patients reporting higher SPUR scores being less likely to experience an early readmission.

CONCLUSION

Higher levels of MA, as determined by SPUR, were significantly associated with a lower risk of general admissions and early readmissions among patients living with Type 2 Diabetes.

Functions of mHealth Diabetes Apps That Enable the Provision of Pharmaceutical Care: Criteria Development and Evaluation of Popular Apps

Personal digital health apps for managing diabetes should include functions that enable the provision of pharmaceutical care services and allow within-app communication with pharmacists and other healthcare providers, thereby improving patient outcomes. The primary aim of this study was to assess the functions of diabetes apps that were relevant to providing pharmaceutical care services (i.e., medication management, adherence, non-pharmacological management, interoperability, and communication). Sixteen criteria related to pharmaceutical care were developed and then used to assess ten popular diabetes apps. The highest numbers of pharmaceutical care criteria were met by the apps Diabetes:M and mySugr (11 criteria); Contour™Diabetes, Dario Health, and OneTouch Reveal^® (ten); and DiabetesConnect and ESYSTA (nine); followed by Glucose Buddy (eight), meala (seven), and lumind (three). The most prevalent functions were related to promoting adherence and non-pharmacological management, but most criteria relevant to medication management were lacking. Five apps allowed within-app communication between patients and healthcare professionals (HCPs); however, no app included communication with pharmacists. High-quality diabetes apps are powerful tools to support pharmaceutical care and remotely monitor diabetes patients. Improvements are needed as they often lack many medication management functions, including within-app communication with HCPs (especially pharmacists). To maximize diabetes app use and improve outcomes, app developers should consider including pharmacists alongside other healthcare providers when customizing app designs.

Effectiveness of cardiac rehabilitation programs in improving medication adherence in patients with cardiovascular disease: a systematic review protocol

OBJECTIVE

The objective of this review is to measure the effectiveness of cardiac rehabilitation programs versus standard care on medication adherence in patients with cardiovascular disease.

INTRODUCTION

Poor adherence to long-term medications increases the risk of morbidity and mortality, and decreases quality of life in patients with cardiovascular diseases. Several strategies have been trialed to improve medication adherence, one of which is cardiac rehabilitation programs. Although evidence has indicated that such programs increase medication adherence, the extent of their effectiveness and translation into clinical practice is not well documented. Our systematic review will collect and analyze the available evidence for clinical practice implementation.

INCLUSION CRITERIA

The search will aim to locate randomized controlled trials. Where randomized controlled trials are not available, quasi-experimental studies, case-control studies, observational studies, and other study designs will be included. Studies that measure effectiveness of cardiac rehabilitation programs compared with standard care on medication adherence in cardiovascular disease patients will be included.

METHODS

Databases, including MEDLINE (Ovid), Emcare (Ovid), Embase (Ovid), Cochrane CENTRAL, Scopus, CINAHL (EBSCO), and unpublished sources will be searched. Articles in English and non-English-language articles with an English abstract, published from database inception to the present, will be included. Articles will be screened and reviewed by 2 independent reviewers for inclusion. Critical appraisal tools will be applied to the included studies. Data will be extracted using the appropriate extraction tools and synthesized for the objectives of the study.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021284705.

How Digital Therapeutics Are Urging the Need for a Paradigm Shift: From Evidence-Based Health Care to Evidence-Based Well-being

A scientific paradigm consists of a set of shared rules, beliefs, values, methods, and instruments for addressing scientific problems. Currently, health care embraces the paradigm of evidence-based health care (EBH). This paradigm prompts health care institutions to base decisions on the best available evidence, which is commonly generated in large-scale randomized controlled trials. We illustrate the application of EBH via the evaluation of drugs. We show how EBH is challenged when it is applied to the evaluation of digital therapeutics, which refers to technology and data to prevent, manage, or treat a medical disorder or disease. We conclude that amid the growing application of digital therapeutics, the paradigm of EBH is challenged in four domains: population, intervention, comparison, outcome. In the second part of this viewpoint, we argue for a paradigm shift in health care so we can optimally evaluate and implement digital therapeutics, and we sketch out the contours of this novel paradigm. We address the need for considering design in health care and evaluation processes, studying user values so that health care can move from a focus on health to well-being, focusing on individual experiences rather than the average, addressing the need for evaluation in authentic use contexts, and stressing the need for continuous evaluation of the dynamic relations between users, context, and digital therapeutics. We conclude that the transition from EBH toward evidence-based well-being would improve the successful implementation of digital technologies in health care.

Impact of the COVID-19 Pandemic on the Implementation of Mobile Health to Improve the Uptake of Hydroxyurea in Patients With Sickle Cell Disease: Mixed Methods Study

BACKGROUND

Hydroxyurea therapy is effective for reducing complications related to sickle cell disease (SCD) and is recommended by National Health Lung and Blood Institute care guidelines. However, hydroxyurea is underutilized, and adherence is suboptimal. We wanted to test a multilevel mobile health (mHealth) intervention to increase hydroxyurea adherence among patients and improve prescribing among providers in a multicenter clinical trial. In the first 2 study sites, participants were exposed to the early phases of the COVID-19 pandemic, which included disruption to their regular SCD care.

OBJECTIVE

We aimed to describe the impact of the COVID-19 pandemic on the implementation of an mHealth behavioral intervention for improving hydroxyurea adherence among patients with SCD.

METHODS

The first 2 sites initiated enrollment 3 months prior to the start of the pandemic (November 2019 to March 2020). During implementation, site A clinics shut down for 2 months and site B clinics shut down for 9 months. We used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to evaluate the implementation and effectiveness of the intervention. mHealth implementation was assessed based on patients' daily app use. Adherence to hydroxyurea was calculated as the proportion of days covered (PDC) from prescription records over the first 12 and 24 weeks after implementation. A linear model examined the relationship between app usage and PDC change, adjusting for baseline PDC, lockdown duration, and site. We conducted semistructured interviews with patients, health care providers, administrators, and research staff to identify factors associated with mHealth implementation and effectiveness. We used a mixed methods approach to investigate the convergence of qualitative and quantitative findings.

RESULTS

The percentage of patients accessing the app decreased after March 15, 2020 from 86% (n=55) to 70% (n=45). The overall mean PDC increase from baseline to week 12 was 4.5% (P=.32) and to week 24 was 1.5% (P=.70). The mean PDC change was greater at site A (12 weeks: 20.9%; P=.003; 24 weeks: 16.7%; P=.01) than site B (12 weeks: -8.2%; P=.14; 24 weeks: -10.3%; P=.02). After adjustment, PDC change was 13.8% greater in those with increased app use after March 15, 2020. Interview findings indicated that site B's closure during COVID-19 had a greater impact, but almost all patients reported that the InCharge Health app helped support more consistent medication use.

CONCLUSIONS

We found significant impacts of the early clinic lockdowns, which reduced implementation of the mHealth intervention and led to reduced patient adherence to hydroxyurea. However, disruptions were lower among participants who experienced shorter clinic lockdowns and were associated with higher hydroxyurea adherence. Investigation of added strategies to mitigate the effects of care interruptions during major emergencies (eg, patient coaching and health navigation) may "insulate" the implementation of interventions to increase medication adherence.

TRIAL REGISTRATION

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/16319.

mHealth Apps Using Behavior Change Techniques to Self-report Data: Systematic Review

Background

The popularization of mobile health (mHealth) apps for public health or medical care purposes has transformed human life substantially, improving lifestyle behaviors and chronic condition management.

Objective

This review aimed to identify behavior change techniques (BCTs) commonly used in mHealth, assess their effectiveness based on the evidence reported in interventions and reviews to highlight the most appropriate techniques to design an optimal strategy to improve adherence to data reporting, and provide recommendations for future interventions and research.

Methods

We performed a systematic review of studies published between 2010 and 2021 in relevant scientific databases to identify and analyze mHealth interventions using BCTs that evaluated their effectiveness in terms of user adherence. Search terms included a mix of general (eg, data, information, and adherence), computer science (eg, mHealth and BCTs), and medicine (eg, personalized medicine) terms.

Results

This systematic review included 24 studies and revealed that the most frequently used BCTs in the studies were feedback and monitoring (n=20), goals and planning (n=14), associations (n=14), shaping knowledge (n=12), and personalization (n=7). However, we found mixed effectiveness of the techniques in mHealth outcomes, having more effective than ineffective outcomes in the evaluation of apps implementing techniques from the feedback and monitoring, goals and planning, associations, and personalization categories, but we could not infer causality with the results and suggest that there is still a need to improve the use of these and many common BCTs for better outcomes.

Conclusions

Personalization, associations, and goals and planning techniques were the most used BCTs in effective trials regarding adherence to mHealth apps. However, they are not necessarily the most effective since there are studies that use these techniques and do not report significant results in the proposed objectives; there is a notable overlap of BCTs within implemented app components, suggesting a need to better understand best practices for applying (a combination of) such techniques and to obtain details on the specific BCTs used in mHealth interventions. Future research should focus on studies with longer follow-up periods to determine the effectiveness of mHealth interventions on behavior change to overcome the limited evidence in the current literature, which has mostly small-sized and single-arm experiments with a short follow-up period.

A Systematic Review of Personalized Health Applications through Human–Computer Interactions (HCI) on Cardiovascular Health Optimization

Introduction: Currently, the deployment of human–computer interactive technologies to provide personalized care has grown and immensely taken shape in most healthcare settings. With the increasing growth of the internet and technology, personalized health interventions including smartphones, associated apps, and other interventions demonstrate prowess in various health fields, including cardiovascular management. This systematic review thus examines the effectiveness of various human–computer interactions technologies through telehealth (mainly eHealth) towards optimizing the outcomes in cardiovascular treatment. Methods: A comprehensive search of MEDLINE, EMBASE, and CINAHL databases using key terms was conducted from 2000 to November 2021 to identify suitable studies that explored the use of human–computer interaction technologies to provide a personalized care approach to facilitate bolstered outcomes for cardiovascular patients, including the elderly. The included studies were assessed for quality and risk of bias, and the authors undertook a data extraction task. Results: Ten studies describing the use of a mix of personalized health app (mHealth) interventions were identified and included in the study. Among the included studies, nine of them were randomized trials. All of the studies demonstrated the effectiveness of various personalized health interventions in maximizing the benefits of cardiovascular disease treatment. Conclusions: Personalized health application interventions through precision medicine has great potential to boost cardiovascular disease management outcomes, including rehabilitation. Fundamentally, since each intervention’s focus might differ based on the disease and outcome preference, it is recommended that more research be done to tailor the interventions to specific disease and patient outcome expectations.

Teleconsultation as an advanced practice nursing during the COVID-19 pandemic based on Roy and Chick-Meleis

Teleconsultation can be classified as an advanced practice nursing that requires nurses' clinical reasoning based on a consistent theoretical framework to use in the nursing process. Our study conducted a theoretical-reflective analysis, based on Callista Roy's Adaptation Model of Nursing and Chick-Meleis' Transition Theory, about the contribution of teleconsultation as an advanced practice nursing in the care of older adults with chronic diseases during the COVID-19 pandemic. We reflect on this in two moments: "nursing theories and dealing with COVID-19" and "ways of adapting to new care models and advanced practice nursing," based on communication and information technologies. The worsening of the pandemic in Brazil changed life cycles, health/disease and organizational processes, demanding the development of an adaptive-transactional state by users and health care providers. Thus, information and communication technologies combined with advanced practice nursing can relieve social distancing and its repercussions on health care.

Mobile Health Applications and Medication Adherence of Patients With Hypertension: A Systematic Review and Meta-Analysis

INTRODUCTION

Current evidence has revealed the beneficial effects of mobile health applications on systolic and diastolic blood pressure. However, there is still no solid evidence of the underlying factors for these outcomes, and hypertension treatment is performed mainly by medication intake. This study aims to analyze the impacts of health applications on medication adherence of patients with hypertension and understand the underlying factors.

METHODS

A systematic review and meta-analysis were conducted considering controlled clinical trials published, without year filter, through July 2020. The searches were performed in the electronic databases of Scopus, MEDLINE, and BVSalud. Study characteristics were extracted for qualitative synthesis. The meta-analysis examined medication-taking behavior outcomes using the generic inverse-variance method to combine multiple variables.

RESULTS

A total of 1,199 records were identified, of which 10 studies met the inclusion criteria for qualitative synthesis, and 9 met the criteria for meta-analysis with 1,495 participants. The analysis of mean changes revealed significant improvements in medication adherence (standardized mean difference=0.41, 95% CI=0.02, 0.79, I²=82%, p=0.04) as well as the analysis of the values measured after follow-up (standardized mean difference=0.60, 95% CI=0.30, 0.90, I²=77%, p<0.0001). Ancillary improvements were also identified, such as patients' perceived confidence, treatment self-efficacy and self-monitoring, acceptance of technology, and knowledge about the condition and how to deal with health issues.

DISCUSSION

There is evidence that mobile health applications can improve medication adherence in patients with hypertension, with broad heterogeneity between studies on the topic. The use of mobile health applications conceivably leads to ancillary improvements inherent to better medication adherence.

Technology-Based Interventions to Promote the HIV Preexposure Prophylaxis (PrEP) Care Continuum: Protocol for a Systematic Review

BACKGROUND

Preexposure prophylaxis (PrEP) is a promising biomedical intervention for HIV prevention. Researchers have proposed the PrEP care continuum to guide and evaluate PrEP implementation programs. Technology-based interventions (TBIs) have been widely used in HIV prevention and treatment programs, including for the promotion of the PrEP care continuum. The rapid development of new interventions using technology and electronic health methods emphasizes the need for a review of the effectiveness of these TBIs.

OBJECTIVE

The aim of this systematic review is to summarize the effectiveness and acceptability of TBIs used to promote the HIV PrEP care continuum.

METHODS

We will conduct a systematic literature search in PubMed, Embase, MEDLINE, PsycINFO, Web of Science, CINAHL, and the Cochrane Central Register of Controlled Trials following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Only intervention studies (ie, studies meeting the criteria of randomized controlled trials or quasi-experimental studies) evaluating the effectiveness of TBIs will be included. We will search the National Institutes of Health Research Portfolio Online Reporting Tools (NIH RePORT) for interventions involving PrEP. At least 2 reviewers will independently screen and select the studies, extract the data, and evaluate the quality of the studies, and discrepancies will be resolved by a senior author. We will provide a narrative synthesis of the included studies and present details about the study populations, interventions, and PrEP-related outcomes of significance.

RESULTS

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42021249562). As of August 2021, we have completed the initial search and identified 1213 records. Study screening and data extracting are in progress. We expect the results to be ready by summer 2022.

CONCLUSIONS

The findings of this review will summarize successful experiences and lessons learned from the existing literature and therefore inform the design and implementation of intervention studies for PrEP care promotion.

TRIAL REGISTRATION

PROSPERO CRD42021249562; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=249562.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/33045.

A Psycholgical Intervention Delivered by Automated Mobile Phone Messaging Stabilized Hip and Knee Function During the COVID-19 Pandemic: A Randomized Controlled Trial

BACKGROUND

We conducted a randomized controlled trial to evaluate the effectiveness of acceptance and commitment therapy (ACT) delivered via a mobile phone messaging robot to patients who had their total hip arthroplasty or total knee arthroplasty procedures postponed due to the COVID-19 pandemic.

METHODS

Ninety patients scheduled for total hip arthroplasty or total knee arthroplasty who experienced surgical delay due to the COVID-19 pandemic were randomized to the ACT group, receiving 14 days of twice daily automated mobile phone messages, or the control group, who received no messages. Minimal clinically important differences (MCIDs) in preintervention and postintervention patient-reported outcome measures were utilized to evaluate the intervention.

RESULTS

Thirty-eight percent of ACT group participants improved and achieved MCID on the Patient-Reported Outcome Measure Information System Physical Health compared to 17.5% in the control group (P = .038; number needed to treat [NNT] 5). For the joint-specific Hip Disability and Osteoarthritis Outcome Score Joint Replacement and Knee Disability and Osteoarthritis Outcome Score Joint Replacement (KOOS JR), 24% of the ACT group achieved MCID compared to 2.5% in the control group (P = .004; NNT 5). An improvement in the KOOS JR was found in 29% of the ACT group compared to 4.2% in the control group (P = .028; NNT 5). Fourteen percent of the ACT group participants experienced a clinical important decline in the KOOS JR compared to 41.7% in the control group (P = .027; NNT 4).

CONCLUSION

A psychological intervention delivered via a text messaging robot improved physical function and prevented decline in patient-reported outcome measures in patients who experienced an unexpected surgical delay during the COVID-19 pandemic.

LEVEL OF EVIDENCE

1.

Use of digital technology tools to characterize adherence to prescription-grade omega-3 polyunsaturated fatty acid therapy in post-myocardial or hypertriglyceridemic patients: Primary results of the DIAPAsOn prospective observational study (Preprint)

Background

Maintaining sustained adherence to medication for optimal management of chronic noninfectious diseases, such as atherosclerotic vascular disease, is a well-documented therapeutic challenge.

Objective

The DIAPAsOn study was a 6-month, multicenter prospective observational study in the Russian Federation that examined adherence to a preparation of highly purified omega-3 polyunsaturated fatty acids (Omacor) in 2167 adult patients with a history of recent myocardial infarction or endogenous hypertriglyceridemia.

Methods

A feature of DIAPAsOn was the use of a bespoke electronic patient engagement and data collection system to monitor adherence. Adherence was also monitored by enquiry at clinic visits. A full description of the study’s aims and methods has appeared in JMIR Research Protocols.

Results

The net average reduction from baseline in both total and low-density lipoprotein cholesterol was approximately 1 mmol/L and the net average increase in high-density lipoprotein cholesterol was 0.2 (SD 0.53) mmol/L (P<.001 for all outcomes vs baseline). The mean triglyceride level was 3.0 (SD 1.3) mmol/L at visit 1, 2.0 (SD 0.9) mmol/L at visit 2, and 1.7 (SD 0.7) mmol/L at visit 3 (P<.001 for later visits vs visit 1). The percentage of patients with a triglyceride level <1.7 mmol/L rose from 13.1% (282/2151) at baseline to 54% (1028/1905) at the end of the study. Digital reporting of adherence was registered by 8.3% (180/2167) of patients; average scores indicted poor adherence. However, a clinic-based enquiry suggested high levels of adherence. Data on health-related quality of life accrued from digitally engaged patients identified improvements among patients reporting high adherence to study treatment, but patient numbers were small.

Conclusions

The lipid and lipoprotein findings indicate that Omacor had nominally favorable effects on the blood lipid profile. Less than 10% of patients enrolled in DIAPAsOn used the bespoke digital platform piloted in the study, and the level of self-reported adherence to medication by these patients was also low. Reasons for this low uptake and adherence are unclear. Better adherence was recorded in clinical reports.

Trial Registration

ClinicalTrials.gov NCT03415152; https://clinicaltrials.gov/ct2/show/NCT03415152

Acceptability and feasibility of the NPS MedicineWise mobile phone application in supporting medication adherence in patients with chronic heart failure: Protocol for a pilot study

INTRODUCTION

Heart failure (HF) is an increasing global concern. Despite evidence-based pharmacotherapy, morbidity and mortality remain high in HF. Medication non-adherence is a crucial factor in optimising clinical outcomes. A growing number of smartphone applications (apps) assist management. While evidence support their use to promote treatment adherence, apps alone may not be the solution. The objective of this pilot study is to assess the acceptability and feasibility of a tiered intervention added to the NPS MedicineWise dose reminder app (MedicineWise app) in supporting medication adherence in HF.

METHODS AND ANALYSIS

This prospective, single-blinded, randomised controlled trial will recruit 55 Australian patients with HF to be randomly assigned to either intervention (MedicineWise app + usual care) or control (usual care alone) arm. Control participants will remain unaware of the intervention throughout the study. At baseline, intervention participants will be instructed in the MedicineWise app. A reminder will then prompt medication administration at each dosing interval. If non-adherence is suggested from 24 hourly reports (critical medications) or 72 hours (non-critical medications), the individual/s will be escalated through a tiered, pharmacist-led intervention. The primary outcome will be the acceptability and feasibility of this approach in supporting adherence. Between-group comparison of the Self-Efficacy for Appropriate Medication Use Scale (SEAMS) at baseline, 3 and 6 months will be used to measure the app's value in supporting adherence. Secondary outcome measures include self-reported medication adherence and knowledge, health-related quality of life, psychological wellbeing, signs and symptoms of HF, and medication and HF knowledge.

ETHICS AND DISSEMINATION

The protocol received ethics approval from Central Adelaide Clinical Human Research Ethics Committee (Protocol number R20190302) and University of South Australia Human Research Ethics Committee (Protocol number 202450). Findings will be disseminated through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry Clinical trial number: ACTRN12619000289112p (http://www.ANZCTR.org.au/ACTRN12619000289112p.aspx).

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

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

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

Teleconsulta como prática avançada de enfermagem na pandemia de COVID-19 à luz de Roy e Chick-Meleis

RESUMO A teleconsulta pode ser definida como uma prática avançada de enfermagem que requer do enfermeiro raciocínio clínico fundamentado em um arcabouço teórico consistente para aplicação no processo de enfermagem. No presente estudo, realizou-se uma análise teórico-reflexiva, fundamentada no Modelo de Adaptação de Callista Roy e na Teoria de Transição de Chick-Meleis, sobre a contribuição da teleconsulta como prática avançada de enfermagem no atendimento a pacientes idosos e com doenças crônicas no contexto da pandemia de covid-19. A reflexão é apresentada em dois momentos: “teorias de enfermagem e o enfrentamento da covid-19” e “formas de adaptação a novos modelos de assistência e as práticas avançadas em enfermagem”, norteados pelas tecnologias de comunicação e informação. O agravamento da pandemia no Brasil trouxe mudanças relacionadas aos ciclos de vida, aos processos saúde/doença e organizacionais, demandando o desenvolvimento de um estado adaptativo-transacional por parte dos usuários e profissionais de saúde. Neste contexto, as tecnologias da informação e comunicação aliadas à prática avançada de enfermagem representam papel fundamental para atenuar o distanciamento social e suas repercussões na assistência à saúde.

Demand for Mobile Health in Developing Countries During COVID-19: Vietnamese's Perspectives from Different Age Groups and Health Conditions

BACKGROUND

Vietnam's economy and intellectual standards have witnessed significant development, improving conditions for residents to acquire novel mHealth applications. Additionally, the outbreak of the COVID-19 pandemic has influenced Vietnamese awareness of healthcare; however, previous studies have only been clinician-centered rather than customer-centered.

METHODS

This study addresses this literature gap by interviewing 50 Vietnamese participants grouped by age, namely Generation X, Generation Y, and Generation Z, and health conditions, namely whether participants or family members have chronic illness. The study utilized semi-structured and in-depth interviews to collect the data and used thematic analysis to analyze the data under the unified theory of acceptance and use of technology framework.

RESULTS

Most participants were willing to adopt this technology and demanded a convenient and user-friendly one-stop-shop solution, endorsements from credible and authoritative sources, and professional customer services. However, each group also had distinctive demands and behaviors.

CONCLUSION

This study contributes theoretically by providing context-rich demand for Vietnamese customers across three generations and healthcare conditions during the COVID-19 pandemic and comparing their behavior with pre-COVID literature. While this research provides helpful information for potential app developers, this study also suggests that mHealth developers and policymakers should pay more attention to the differences in the demand of age groups and health conditions.

Effectiveness and usability of mobile health applications for medication adherence in patients with heart failure: a systematic review protocol

OBJECTIVE

This review will assess the effectiveness and usability of mobile health applications to improve medication adherence in patients with heart failure.

INTRODUCTION

Poor medication adherence by heart failure patients is a major cause of negative clinical outcomes, high rates of hospital readmissions, and death, thereby increasing costs for patients and the health care system. Several studies have shown that the use of mobile health applications improves self-care by heart failure patients, including medication adherence. Therefore, gathering evidence on these studies will help researchers and clinicians understand the impact of such interventions on patient care.

INCLUSION CRITERIA

Eligible studies will evaluate medication adherence in participants aged ≥18 years diagnosed with heart failure who are using app-based (software) interventions. Experimental and observational studies will be included. We will exclude studies with interventions that used mobile applications without functionality to assist the user in organizing and taking their medications.

METHODS

Articles published from database inception to the present day, without language restrictions, will be selected from Embase, MEDLINE, LILACS, Scopus, Web of Science, CINAHL, and the Cochrane Library. Two independent reviewers will screen articles, assess methodological quality, and extract data using JBI assessment and extraction instruments. Discrepancies will be solved by consensus and a third reviewer will be consulted if necessary. A narrative synthesis of findings will be presented, and statistical analysis will be used when appropriate.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020147816.