Designing and Testing Telehealth Interventions to Improve Outcomes for Cardiovascular Patients:

Effects of an internet support system to assist cancer patients in reducing symptom distress: a randomized controlled trial

BACKGROUND

Cancer patients experience many physical and psychosocial problems for which they need support. WebChoice is an Internet-based, interactive health communication application that allows cancer patients to monitor their symptoms and problems, provides individually tailored information and self-management support, e-communication with expert cancer nurses, and an e-forum for group discussion with other patients.

OBJECTIVE

The objective of this study was to examine the effects of WebChoice on symptom distress (primary outcome), depression, self-efficacy, health-related quality of life, and social support (secondary outcomes).

METHODS

In this 1-year repeated-measures randomized controlled trial, 325 breast and prostate cancer patients were randomized into 1 experimental group with access to WebChoice and 1 control group who received URLs of publicly available cancer Web sites.

RESULTS

Group differences on symptom distress were significant only for the global symptom distress index on the Memorial Symptom Assessment Scale (slope estimate, -0.052 [95% confidence interval, -0.101 to -0.004]; t = 4.42; P = .037). There were no significant group differences on secondary outcomes. Additional analyses showed significant within-group improvements in depression in the experimental group only. In the control group, self-efficacy and health-related quality of life deteriorated significantly over time.

CONCLUSION

This randomized controlled trial is one of the first to evaluate effects of an interactive health communication application to support cancer patients in illness management on symptoms. Although only 1 hypothesis was partially supported, the combined results show a clear trend toward better scores in the intervention group on most outcome measures.

IMPLICATIONS FOR PRACTICE

If findings can be supported with additional research, WebChoice may become an important tool to support nursing care that can equip cancer patients to better manage their illness.

Alternative models of cardiac rehabilitation: a systematic review

The traditional hospital-based model of cardiac rehabilitation faces substantial challenges, such as cost and accessibility. These challenges have led to the development of alternative models of cardiac rehabilitation in recent years. The aim of this study was to identify and critique evidence for the effectiveness of these alternative models. A total of 22 databases were searched to identify quantitative studies or systematic reviews of quantitative studies regarding the effectiveness of alternative models of cardiac rehabilitation. Included studies were appraised using a Critical Appraisal Skills Programme tool and the National Health and Medical Research Council's designations for Level of Evidence. The 83 included articles described interventions in the following broad categories of alternative models of care: multifactorial individualized telehealth, internet based, telehealth focused on exercise, telehealth focused on recovery, community- or home-based, and complementary therapies. Multifactorial individualized telehealth and community- or home-based cardiac rehabilitation are effective alternative models of cardiac rehabilitation, as they have produced similar reductions in cardiovascular disease risk factors compared with hospital-based programmes. While further research is required to address the paucity of data available regarding the effectiveness of alternative models of cardiac rehabilitation in rural, remote, and culturally and linguistically diverse populations, our review indicates there is no need to rely on hospital-based strategies alone to deliver effective cardiac rehabilitation. Local healthcare systems should strive to integrate alternative models of cardiac rehabilitation, such as brief telehealth interventions tailored to individual's risk factor profiles as well as community- or home-based programmes, in order to ensure there are choices available for patients that best fit their needs, risk factor profile, and preferences.

Evaluation of different features of an eHealth application for personalized illness management support: cancer patients' use and appraisal of usefulness

OBJECTIVE

The purpose of this paper was to describe patients' use of a multi-component eHealth application, WebChoice, designed to support cancer patients in illness management. With WebChoice patients can monitor their symptoms, obtain individually tailored, evidence-based self-management support, ask questions to a clinical nurse specialist, communicate with other patients in a Forum, and use a diary.

METHODS

To better understand what components were most helpful, we analyzed user logs of breast and prostate cancer patients who participated in the experimental arm of an RCT to test effects of WebChoice on clinical outcomes. Patients could freely use the system for one year. After 6 months into the study, participants received questionnaires asking about reasons for using the different WebChoice components and their usefulness.

RESULTS

103 (64%) patients actively used WebChoice, on average 60 times. The Forum and asking questions to the nurse were used the most, yet there were large individual variations in use patterns. Also, patients used different WebChoice components for different reasons. The e-mail communication with nurses was valued highest.

DISCUSSION

Differences were found between breast and prostate cancer patients and between patients with a first time diagnosis and metastases or recurrences. The large variations among patients in their use of WebChoice components demonstrate that patients' needs for support vary.

CONCLUSION

The use patterns and patients' appraisals of usefulness in this study provide important insights into cancer patients' information and communication behavior that are important for further improvements and the design of eHealth applications for illness management support.

Songwriting via Skype

The provision of therapy to clients online is gaining strong recognition as effective in medicine, psychiatry, and other allied health fields. However, music therapists are yet to engage with this therapy context. Working with an adolescent with Asperger's Syndrome, we trialled an online songwriting intervention via videoconferencing software (in this case Skype Ltd) and compared the adolescent's participation with participation in a face-to-face context. A microanalysis of video footage combined with interview reflections from the treating therapist and adolescent were analysed to build a picture of engagement and skills in social interaction. Our investigation showed that the adolescent was highly engaged in the Skype session, offered more eye contact, was more creative in his lyric creations and was more confident to offer disagreeing statements. Further trials using online approaches are needed to ensure that music therapy approaches are aligning with practices occurring in other health disciplines and that therapy services can be accessed by those unable to attend music therapy clinics.

Influence of an early recovery telehealth intervention on physical activity and functioning after coronary artery bypass surgery among older adults with high disease burden

OBJECTIVE

Older adults with poor functioning preoperatively are at risk for delayed recovery and more impaired outcomes after coronary artery bypass surgery (CABS). The study objective was to determine whether a 6-week early recovery telehealth intervention, designed to improve self-efficacy and management related to symptoms after CABS, was effective in improving outcomes (physical activity, physiologic, and psychologic functioning) for older adults (aged > 65 years) with higher disease burden.

METHODS

A descriptive, repeated-measures experimental design was used. Follow-up data were collected at 3 and 6 weeks and 3 months after CABS. Subjects were drawn from a larger randomized clinical trial. Parent study subjects who had high disease burden preoperatively (physical component score of < 50 on the Medical Outcome Study Short Form-36 and RISKO score of > 6) were included (N = 55), with 23 subjects in the early recovery intervention group and 31 subjects in the usual care group (n = 31). Subjects ranged in age from 65 to 85 years (M = 71.6 + 5.1 years).

RESULTS

There was a significant main effect by group (F[1,209] = 4.66, P < .05). The intervention group had a least square means of 27.9 kcal/kg/d of energy expenditure compared with the usual care group of 26.6 kcal/kg/d per the RT3 accelerometer (Stayhealthy, Inc, Monrovia, CA). Both groups had significantly improved physical (F[2,171] = 3.26, P < .05) and role-physical (F[2,171] = 6.64, P < .005) functioning over time.

CONCLUSION

The subgroup of subjects undergoing CABS with high disease burden were responsive to an early recovery telehealth intervention. Improving patients' physical activity and functioning can reduce morbidity and mortality associated with poor functioning after cardiac events.

Health IT-enabled care for underserved rural populations: the role of nursing

This white paper explains the strong roles that nursing can play in using information technology (IT) to improve healthcare delivery in rural areas. The authors describe current challenges to providing care in rural areas, and how technology innovations can help rural communities to improve their health and health care. To maximize benefits, rural stakeholders (as individuals and groups) must collaborate to effect change. Because nonphysician providers deliver much of the health care in rural communities, this paper focuses on the critical roles of nurses on IT-enabled caremanagement teams. The authors propose changes in nursing practice, policy, and education to better prepare, encourage, and enable nurses to assume leadership roles in IT-enabled health care management in rural communities.

Cardiovascular risk reduction via telehealth: a feasibility study

BACKGROUND

Successful cardiovascular risk reduction (CVRR) requires ongoing care, which can be difficult for patients living outside urban areas. The authors tested the feasibility of CVRR using telehealth.

METHODS

Telehealth care (T group, n=9) was offered at three- to six-month intervals to patients referred from La Ronge, Saskatchewan (385 km northeast of Saskatoon, Saskatchewan). All patients who were referred to the project accepted. For the initial visit, the clinic travelled to La Ronge; all other visits were performed using telehealth (CommunityNet). Body measurements, blood pressure readings, fasting laboratory tests and food and exercise logs were completed in La Ronge. During the telehealth session, patients met with a nurse, a dietician, a fitness consultant and a physician. Changes in medication were faxed or telephoned to the local pharmacy. The T group's outcomes were compared with a control group (C group, n=15), which was offered usual care from La Ronge and had been referred to the clinic previously. Change in Framingham risk score, as well as patient and provider satisfaction, was assessed.

RESULTS

The groups were similar in age (T: 44.3+/-12.8 years, C: 48.3+/-14.3 years) and initial Framingham risk score (T: 12.0+/-13.0%, C: 11.1+/-10.0%). All nine T group patients completed two or more visits, while only eight of 15 patients the C group did so. Both groups achieved a small reduction in Framingham risk score (T: -1.9+/-5.0%, C: -2.0+/-6.1%). Those with the highest initial Framingham risk scores tended to show the greatest reduction. The T group's patient and health care provider comments were generally positive.

CONCLUSIONS

CVRR via telehealth is feasible and compares favourably with usual care. In particular, more complete follow-up occurs.