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Michael TJF, Chan JS, Hughes S, Wright DFB, Coleshill MJ, Hughes DA, Day RO, Aslani P, Stocker SL. The experiences and perspectives of people with gout on urate self-monitoring. Health Expect 2024; 27:e14071. [PMID: 38742836 PMCID: PMC11092534 DOI: 10.1111/hex.14071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/26/2024] [Accepted: 04/28/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Gout management remains suboptimal despite safe and effective urate-lowering therapy. Self-monitoring of urate may improve gout management, however, the acceptability of urate self-monitoring by people with gout is unknown. The aim of this study was to explore the experiences of urate self-monitoring in people with gout. METHODS Semistructured interviews were conducted with people taking urate-lowering therapy (N = 30) in a 12-month trial of urate self-monitoring in rural and urban Australia. Interviews covered the experience of monitoring and its effect on gout self-management. Deidentified transcripts were analysed thematically. RESULTS Participants valued the ability to self-monitor and gain more understanding of urate control compared with the annual monitoring ordered by their doctors. Participants indicated that self-monitoring at home was easy, convenient and informed gout self-management behaviours such as dietary modifications, hydration, exercise and medication routines. Many participants self-monitored to understand urate concentration changes in response to feeling a gout flare was imminent or whether their behaviours, for example, alcohol intake, increased the risk of a gout flare. Urate concentrations were shared with doctors mainly when they were above target to seek management support, and this led to allopurinol dose increases in some cases. CONCLUSION Urate self-monitoring was viewed by people with gout as convenient and useful for independent management of gout. They believed self-monitoring achieved better gout control with a less restricted lifestyle. Urate data was shared with doctors at the patient's discretion and helped inform clinical decisions, such as allopurinol dose changes. Further research on implementing urate self-monitoring in routine care would enable an evaluation of its impact on medication adherence and clinical outcomes, as well as inform gout management guidelines. PATIENT OR PUBLIC CONTRIBUTION One person with gout, who was not a participant, was involved in the study design by providing feedback and pilot testing the semistructured interview guide. In response to their feedback, subsequent modifications to the interview guide were made to improve the understandability of the questions from a patient perspective. No additional questions were suggested.
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Affiliation(s)
- Toni J. F. Michael
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Jian S. Chan
- St Vincent's Clinical School Campus, Faculty of MedicineThe University of New South WalesSydneyNew South WalesAustralia
| | - Stephen Hughes
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Daniel F. B. Wright
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- St Vincent's Clinical School Campus, Faculty of MedicineThe University of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalSydneyNew South WalesAustralia
| | - Matthew J. Coleshill
- Black Dog Institute, Faculty of MedicineThe University of New South WalesSydneyNew South WalesAustralia
| | - Dyfrig A. Hughes
- Centre for Health Economics and Medicines Evaluation, North Wales Medical SchoolBangor UniversityWalesUK
| | - Richard O. Day
- St Vincent's Clinical School Campus, Faculty of MedicineThe University of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalSydneyNew South WalesAustralia
| | - Parisa Aslani
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Sophie L. Stocker
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalSydneyNew South WalesAustralia
- Sydney Infectious Diseases Institute, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Sydney Musculoskeletal Health, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
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Mchale S, Paterson M, Pearsons A, Neubeck L, Atherton I, Guthrie B, McKinstry B, Hanley J. Exploring the patient experience of remote hypertension management in Scotland during COVID-19: a qualitative study. BMJ Open 2023; 13:e078944. [PMID: 38070910 PMCID: PMC10729221 DOI: 10.1136/bmjopen-2023-078944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/10/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES The aim of this study was to understand how patients experienced hypertension management, with or without blood pressure (BP) telemonitoring, during the COVID-19 pandemic. DESIGN, METHODS, PARTICIPANTS AND SETTING This qualitative study conducted between April and November 2022 consisted of 43 semistructured telephone interviews (23 men and 20 women) from 6 primary care practices in one area of Scotland. RESULTS From the views of 25 participants with experience of using the Connect Me telemonitoring service and 18 participants without such experience, 5 themes were developed. These were: (1) navigating access to services. There were challenges to gaining timely and/or in-person access to services and a reluctance to attend clinical settings because participants were aware of their increased risk of contracting the COVID-19 virus. (2) Adapting National Health Service services. All six practices had adapted care provision in response to potential COVID-19 transmission; however, these adaptations disrupted routine management of in-person primary care hypertension, diabetes and/or asthma checks. (3) Telemonitoring feedback. Telemonitoring reduced the need to attend in-person primary care practices and supported access to remote healthcare monitoring and feedback. (4) Self-management. Many non-telemonitoring participants were motivated to use self-management strategies to track their BP using home monitoring equipment. Also, participants were empowered to self-manage lifestyle and hypertension medication. (5) Experience of having COVID-19. Some participants contracting the COVID-19 virus experienced an immediate increase in their BP while a few experienced ongoing increased BP readings. CONCLUSIONS The COVID-19 pandemic disrupted routine in-person care for patients with hypertension. Both telemonitoring and some non-telemonitoring patients were motivated to self-manage hypertension, including self-adjusting medication; however, only those with access to telemonitoring had increased access to hypertension monitoring and feedback. BP telemonitoring permitted routine care to continue for participants in this study and may offer a service useful in pandemic proofing hypertension healthcare in the future.
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Affiliation(s)
- Sheona Mchale
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, Midlothian, UK
| | - Mary Paterson
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, Midlothian, UK
| | - Alice Pearsons
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, Midlothian, UK
| | - Lis Neubeck
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, Midlothian, UK
| | - Iain Atherton
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, Midlothian, UK
| | - Bruce Guthrie
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Brian McKinstry
- Centre for Population Health Sciences, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Janet Hanley
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, Midlothian, UK
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Qualitative evaluation of rapid implementation of remote blood pressure self-monitoring in pregnancy during Covid-19. PLoS One 2023; 18:e0278156. [PMID: 36862687 PMCID: PMC9980805 DOI: 10.1371/journal.pone.0278156] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 11/10/2022] [Indexed: 03/03/2023] Open
Abstract
In March 2020, the World Health Organisation named the severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2), which causes corona virus disease 2019 (COVID -19), as a pandemic. Pregnant women were considered at increased risk of developing severe COVID-19 after viral infection. In response maternity services reduced face-to-face consultations with high-risk pregnant women by supplying blood pressure monitors for supported self-monitoring. This paper explores the experiences of patients and clinicians of the rapid roll-out of supported self-monitoring programme in Scotland during the first and second wave of the COVID-19 pandemic. We conducted semi-structured telephone interviews with high-risk women and healthcare professionals who were using supported self-monitoring of blood pressure (BP) In four case studies during the COVID-19 pandemic. 20 women, 15 midwives and 4 obstetricians took part in the interviews. Interviews with healthcare professionals showed that while implementation occurred at pace and at scale across the National Health Service (NHS) in Scotland, implementation differed locally, resulting in mixed experiences. Study Participants observed several barriers and facilitators to implementation. Women value the simplicity of use and convenience of the digital communications platforms while health professionals were more interested in their impact on reducing workload for both women and health professionals largely found self-monitoring acceptable, with only a few exceptions. These results show that rapid change can occur in the NHS at a national level when there is a shared motivation. While self-monitoring is acceptable to most women, decisions regarding self-monitoring should be made jointly and on an individual basis.
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Pealing L, Tucker KL, Fletcher B, Lawley E, Chappell LC, McManus RJ, Ziebland S. Perceptions and experiences of blood pressure self-monitoring during hypertensive pregnancy: A qualitative analysis of women's and clinicians' experiences in the OPTIMUM-BP trial. Pregnancy Hypertens 2022; 30:113-123. [PMID: 36174484 DOI: 10.1016/j.preghy.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Self-monitoring of blood pressure (BP) has been shown to be effective at improving BP control in the general population. The OPTIMUM-BP feasibility study was a prospective randomised controlled trial of self-monitoring of BP (SMBP) during hypertensive pregnancy. OBJECTIVE To explore experiences, perceptions, and use of the OPTIMUM-BP self-monitoring intervention. STUDY DESIGN Qualitative study within the OPTIMUM-BP feasibility trial. Semi-structured interviews with a purposive sample of pregnant women with chronic hypertension (n = 24) and their clinicians (n = 8) as well as 38 ethnographic observations of antenatal visits. RESULTS Women found self-monitoring of BP feasible and acceptable and were highly motivated and pro-active in their monitoring, reporting greater control and knowledge of BP and reassurance. Women's persistence with SMBP was driven by a perceived need to safeguard the pregnancy, particularly among those taking antihypertensive medication. Clinicians also described the intervention as acceptable, though BP variability could cause uncertainty. Clinicians used different heuristics to integrate home and clinic readings. Observations suggested close working relationships between women and clinicians were key for confident integration of self-monitoring. CONCLUSIONS Self-monitoring of BP was acceptable both to pregnant women with hypertension and their clinicians. More research is needed to understand BP variability within pregnancy to help interpret and integrate home BP readings for improved BP management. Clinical pathways that use BP self-monitoring should aim to maintain the continuity of care and relationships that are valued and appear pivotal for the confident and safe use of self-monitoring in pregnancy.
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Affiliation(s)
- L Pealing
- Nuffield Department of Primary Care Health Sciences, University of Oxford OX2 6GG, UK
| | - K L Tucker
- Nuffield Department of Primary Care Health Sciences, University of Oxford OX2 6GG, UK.
| | - B Fletcher
- Nuffield Department of Primary Care Health Sciences, University of Oxford OX2 6GG, UK
| | - E Lawley
- Nuffield Department of Primary Care Health Sciences, University of Oxford OX2 6GG, UK
| | - L C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London SE1 7EH, UK
| | - R J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford OX2 6GG, UK
| | - S Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford OX2 6GG, UK
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Vernon MM, Yang FM. Implementing a self-monitoring application during pregnancy and postpartum for rural and underserved women: A qualitative needs assessment study. PLoS One 2022; 17:e0270190. [PMID: 35853001 PMCID: PMC9295984 DOI: 10.1371/journal.pone.0270190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 06/07/2022] [Indexed: 11/27/2022] Open
Abstract
Background Georgia has one of the highest maternal mortality rates within the US. This study describes the qualitative needs assessment undertaken to understand the needs of rural and underserved women and their perspectives on implementing a self monitoring application during pregnancy and postpartum. Methods Qualitative methodology was used to conduct the needs assessment of 12 health care providers (nurses, nurse-midwives, patient care coordinators, and physicians) and 25 women from rural and underserved populations in Georgia was conducted to ascertain common themes on three topics: pregnancy care experiences, comfort with technology, and initial perspectives on the proposed VidaRPM application. Transcription, coding, and consensus were conducted using content analysis and a Cohen’s Kappa coefficient was calculated to identify level of overall agreement between raters for the representative quotes identified for each theme. Results The overall agreement for the representative quotes that were chosen for each theme was in strong agreement (κ = 0.832). The major provider feedback included the following regarding the VidaRPM app: inclusion of questions to monitor physical well-being, embedded valid and reliable educational resources, and multiple modalities. The overall feedback from the mothers regarding the VidaRPM application was the virtual aspect helped overcome the barriers to accessing care, comfort with both WiFi and technology, and sustainable utility. Discussion The needs of rural and underserved pregnant women and their providers were assessed to develop and refine the VidaRPM app. This qualitative study on the VidaRPM app is the first step towards closing the gap between providers and patients during prenatal and postpartum periods by empowering and educating women into the first-year postpartum living in rural and underserved areas.
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Affiliation(s)
- Marlo M. Vernon
- Cancer Prevention, Control, and Population Health, Georgia Cancer Center, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
- * E-mail:
| | - Frances M. Yang
- School of Nursing, University of Kansas Medical Center, Kansas City, KS, United States of America
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Treadwell JR, Rouse B, Reston J, Fontanarosa J, Patel N, Mull NK. Consumer Devices for Patient-Generated Health Data Using Blood Pressure Monitors for Managing Hypertension: Systematic Review. JMIR Mhealth Uhealth 2022; 10:e33261. [PMID: 35499862 PMCID: PMC9112087 DOI: 10.2196/33261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 02/07/2022] [Accepted: 03/17/2022] [Indexed: 11/13/2022] Open
Abstract
Background In the era of digital health information technology, there has been a proliferation of devices that collect patient-generated health data (PGHD), including consumer blood pressure (BP) monitors. Despite their widespread use, it remains unclear whether such devices can improve health outcomes. Objective We performed a systematic review of the literature on consumer BP monitors that collect PGHD for managing hypertension to summarize their clinical impact on health and surrogate outcomes. We focused particularly on studies designed to measure the specific effect of using a BP monitor independent of cointerventions. We have also summarized the process and consumer experience outcomes. Methods An information specialist searched PubMed, MEDLINE, and Embase for controlled studies on consumer BP monitors published up to May 12, 2020. We assessed the risk of bias using an adapted 9-item appraisal tool and performed a narrative synthesis of the results. Results We identified 41 different types of BP monitors used in 49 studies included for review. Device engineers judged that 38 (92%) of those devices were similar to the currently available consumer BP monitors. The median sample size was 222 (IQR 101-416) participants, and the median length of follow-up was 6 (IQR 3-12) months. Of the included studies, 18 (36%) were designed to isolate the clinical effects of BP monitors; 6 of the 18 (33%) studies evaluated health outcomes (eg, mortality, hospitalizations, and quality of life), and data on those outcomes were unclear. The lack of clarity was due to low event rates, short follow-up duration, and risk of bias. All 18 studies that isolated the effect of BP monitors measured both systolic and diastolic BP and generally demonstrated a decrease of 2 to 4 mm Hg in systolic BP and 1 to 3 mm Hg in diastolic BP compared with non–BP monitor groups. Adherence to using consumer BP monitors ranged from 38% to 89%, and ease of use and satisfaction ratings were generally high. Adverse events were infrequent, but there were a few technical problems with devices (eg, incorrect device alerts). Conclusions Overall, BP monitors offer small benefits in terms of BP reduction; however, the health impact of these devices continues to remain unclear. Future studies are needed to examine the effectiveness of BP monitors that transmit data to health care providers. Additional data from implementation studies may help determine which components are critical for sustained BP improvement, which in turn may improve prescription decisions by clinicians and coverage decisions by policy makers.
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Affiliation(s)
| | | | | | | | - Neha Patel
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Nikhil K Mull
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, PA, United States
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Turner K, Jo A, Wei G, Tabriz AA, Clary A, Jim HSL. Sharing patient-generated data with healthcare providers: findings from a 2019 national survey. J Am Med Inform Assoc 2021; 28:371-376. [PMID: 33180896 DOI: 10.1093/jamia/ocaa272] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/08/2020] [Accepted: 10/15/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Our study estimates the prevalence and predictors of wearable device adoption and data sharing with healthcare providers in a nationally representative sample. MATERIALS AND METHODS Data were obtained from the 2019 Health Information National Trend Survey. We conducted multivariable logistic regression to examine predictors of device adoption and data sharing. RESULTS The sample contained 4159 individuals, 29.9% of whom had adopted a wearable device in 2019. Among adopters, 46.3% had shared data with their provider. Individuals with diabetes (odds ratio [OR], 2.39; 95% CI, 1.66-3.45; P < .0001), hypertension (OR, 2.80; 95% CI, 2.12-3.70; P < .0001), and multiple chronic conditions (OR, 1.55; 95% CI, 1.03-2.32; P < .0001) had significantly higher odds of wearable device adoption. Individuals with a usual source of care (OR, 2.44; 95% CI, 1.95-3.04; P < .0001), diabetes (OR, 1.66; 95% CI, 1.32-2.08; P < .0001), and hypertension (OR, 1.78; 95% CI, 1.44-2.20; P < .0001) had significantly higher odds of sharing data with providers. DISCUSSION A third of individuals adopted a wearable medical device and nearly 50% of individuals who owned a device shared data with a provider in 2019. Patients with certain conditions, such as diabetes and hypertension, were more likely to adopt devices and share data with providers. Social determinants of health, such as income and usual source of care, negatively affected wearable device adoption and data sharing, similarly to other consumer health technologies. CONCLUSIONS Wearable device adoption and data sharing with providers may be more common than prior studies have reported; however, digital disparities were noted. Studies are needed that test implementation strategies to expand wearable device use and data sharing into care delivery.
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Affiliation(s)
- Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida, USA
| | - Ara Jo
- Department of Health Services Research, Management, and Policy, University of Florida, Gainesville, Florida, USA
| | - Grace Wei
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Amir Alishahi Tabriz
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Alecia Clary
- Center for Healthcare Transformation, Avalere Health, Washington DC, USA
| | - Heather S L Jim
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida, USA
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Shang Z, Arnaert A, Hindle Y, Debe Z, Côté-Leblanc G, Saadi A. Experiences of psychiatrists and support staff providing telemental health services to Indigenous peoples of Northern Quebec. BMC Health Serv Res 2021; 21:85. [PMID: 33485327 PMCID: PMC7825224 DOI: 10.1186/s12913-021-06072-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 01/11/2021] [Indexed: 01/01/2023] Open
Abstract
Background Due to regional, professional, and resource limitations, access to mental health care for Canada’s Indigenous peoples can be difficult. Telemental health (TMH) offers the opportunity to provide care across vast distances and has been proven to be as effective as face-to-face services. To our knowledge, there has been no qualitative study exploring the experiences of TMH staff serving the Indigenous peoples in Northern Quebec, Canada; which is the purpose of this study. Methods Using a qualitative descriptive design, the entire staff of a TMH clinic was recruited, comprising of four psychiatrists and four support staff. Individual semi-structured interviews were conducted through videoconferencing, and results were thematically analyzed. Results To address the mental health gap in Northern communities, all psychiatrists believe in the necessity of in-person care and note the synergistic effect of combining in-person care and TMH services. This approach to care allows psychiatrists to maintain both an insider and outsider identity. However, if a patient’s condition requires hospitalization, then the TMH staff face a new set of information sharing and communication challenges with the inpatient staff. TMH staff believe that the provision of culturally sensitive care to Northern patients at the inpatient unit is progressing; however, more work needs to be done. Despite the strong collegial atmosphere within the clinic and collective efforts to provide quality TMH services, all participants express a sense of frustration with the paper-based and scattered documentation system. Conclusion The TMH team works in cohesion to offer TMH services to Indigenous peoples; yet, automatization is needed to improve the workflow efficiency within the clinic and collaboration with the Northern clinics. More research is needed on the functioning of TMH teams and the separate but important roles of each team member. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06072-5.
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Affiliation(s)
- Zhida Shang
- Ingram School of Nursing, McGill University, Montréal, Québec, Canada.
| | - Antonia Arnaert
- Ingram School of Nursing, McGill University, Montréal, Québec, Canada
| | - Yvonne Hindle
- Centre Intégré Universitaire de Santé et Services Sociaux de l'Ouest-de-L'Île-de-Montréal, Montréal, Québec, Canada
| | - Zoumanan Debe
- Centre Intégré Universitaire de Santé et Services Sociaux de l'Ouest-de-L'Île-de-Montréal, Montréal, Québec, Canada
| | - Geneviève Côté-Leblanc
- Centre Intégré Universitaire de Santé et Services Sociaux de l'Ouest-de-L'Île-de-Montréal, Montréal, Québec, Canada
| | - Amine Saadi
- Centre Intégré Universitaire de Santé et Services Sociaux de l'Ouest-de-L'Île-de-Montréal, Montréal, Québec, Canada
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Eslami S, Khoshrounejad F, Golmakani R, Taherzadeh Z, Tohidinezhad F, Mostafavi SM, Ganjali R. Effectiveness of IT-based interventions on self-management in adult kidney transplant recipients: a systematic review. BMC Med Inform Decis Mak 2021; 21:2. [PMID: 33388049 PMCID: PMC7778800 DOI: 10.1186/s12911-020-01360-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/02/2020] [Indexed: 11/23/2022] Open
Abstract
Background Kidney transplant outcomes are broadly associated with transplant recipients’ capacity in following a complex and continuous self-management regimen. Health information technology has the potential to empower patients. This systematic review aimed to determine the impacts of IT-based interventions for self-management in kidney transplant recipients.
Methods A comprehensive investigation was performed in MEDLINE (via PubMed) and EMBASE (via Scopus) in April 2019. Eligible studies were the randomized controlled trials which aimed to design an automated IT-based intervention. All English papers including adult kidney transplant recipients were included. To assess the clinical trial’s quality, Cochrane Collaboration’s assessment tool was employed. The articles were integrated based on category of outcomes, characteristics of interventions, and their impact. The interventions were classified based on the used IT-based tools, including smart phones, coverage tools, computer systems, and a combination of several tools. The impact of interventions was defined as: (1) positive effect (i.e. statistically significant), and (2) no effect (i.e. not statistically significant). Results A total of 2392 articles were retrieved and eight publications were included for full-text analysis. Interventions include those involving the use of computerized systems (3 studies), smart phone application (3 studies), and multiple components (2 studies). The studies evaluated 30 outcomes in total, including 24 care process and 6 clinical outcomes. In 18 (80%) out of 30 outcomes, interventions had a statistically significant positive effect, 66% in process and 33% in clinical outcomes. Conclusions IT-based interventions (e.g. mobile health applications, wearable devices, and computer systems) can improve self-management in kidney transplant recipients (including clinical and care process outcomes). However, further evaluation studies are required to quantify the impact of IT-based self-management interventions on short- and long-term clinical outcomes as well as health care costs and patients' quality of life.
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Affiliation(s)
- Saeid Eslami
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Azadi Street, Mashhad, Iran.,Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Pharmaceutical Research Center, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farnaz Khoshrounejad
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Azadi Street, Mashhad, Iran
| | - Reza Golmakani
- Department of Emergency Medicine, Doctor Shariati Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zhila Taherzadeh
- Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fariba Tohidinezhad
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Azadi Street, Mashhad, Iran
| | - Sayyed Mostafa Mostafavi
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Azadi Street, Mashhad, Iran
| | - Raheleh Ganjali
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Azadi Street, Mashhad, Iran.
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Jacob C, Sanchez-Vazquez A, Ivory C. Factors Impacting Clinicians' Adoption of a Clinical Photo Documentation App and its Implications for Clinical Workflows and Quality of Care: Qualitative Case Study. JMIR Mhealth Uhealth 2020; 8:e20203. [PMID: 32965232 PMCID: PMC7542402 DOI: 10.2196/20203] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/05/2020] [Accepted: 08/17/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Mobile health (mHealth) tools have shown promise in clinical photo and wound documentation for their potential to improve workflows, expand access to care, and improve the quality of patient care. However, some barriers to adoption persist. OBJECTIVE This study aims to understand the social, organizational, and technical factors affecting clinicians' adoption of a clinical photo documentation mHealth app and its implications for clinical workflows and quality of care. METHODS A qualitative case study of a clinical photo and wound documentation app called imitoCam was conducted. The data were collected through 20 in-depth interviews with mHealth providers, clinicians, and medical informatics experts from 8 clinics and hospitals in Switzerland and Germany. RESULTS According to the study participants, the use of mHealth in clinical photo and wound documentation provides numerous benefits such as time-saving and efficacy, better patient safety and quality of care, enhanced data security and validation, and better accessibility. The clinical workflow may also improve when the app is a good fit, resulting in better collaboration and transparency, streamlined daily work, clinician empowerment, and improved quality of care. The findings included important factors that may contribute to or hinder adoption. Factors may be related to the material nature of the tool, such as the perceived usefulness, ease of use, interoperability, cost, or security of the app, or social aspects such as personal experience, attitudes, awareness, or culture. Organizational and policy barriers include the available clinical practice infrastructure, workload and resources, the complexity of decision making, training, and ambiguity or lack of regulations. User engagement in the development and implementation process is a vital contributor to the successful adoption of mHealth apps. CONCLUSIONS The promising potential of mHealth in clinical photo and wound documentation is clear and may enhance clinical workflow and quality of care; however, the factors affecting adoption go beyond the technical features of the tool itself to embrace significant social and organizational elements. Technology providers, clinicians, and decision makers should work together to carefully address any barriers to improve adoption and harness the potential of these tools.
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Affiliation(s)
- Christine Jacob
- Anglia Ruskin University, Cambridge, United Kingdom
- University of Applied Sciences Northwestern Switzerland, Brugg, Switzerland
| | - Antonio Sanchez-Vazquez
- Innovation and Management Practice Research Centre, Anglia Ruskin University, Cambridge, United Kingdom
| | - Chris Ivory
- Innovation and Management Practice Research Centre, Anglia Ruskin University, Cambridge, United Kingdom
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Leonardsen ACL, Hardeland C, Helgesen AK, Grøndahl VA. Patient experiences with technology enabled care across healthcare settings- a systematic review. BMC Health Serv Res 2020; 20:779. [PMID: 32838784 PMCID: PMC7446109 DOI: 10.1186/s12913-020-05633-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/06/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Healthcare services are facing extensive challenges due to the increased proportion of elderly persons and persons with chronic disease. Technology enabled care (TEC) is a collective term for telecare, telehealth, telemedicine, mobile (m)-, digital- and electronic (e) health services. TEC is increasingly seen as a solution to many of the challenges facing the health sector. Patient perspectives may provide a useful evaluation tool for new healthcare technologies that have limited clinical data to support their effectiveness. More studies need to be done to better understand the acceptance of technology in healthcare. This review aim to summarize empirical studies exploring patient experiences with TEC. Findings in this study can be used to better understand what is needed to develop, implement and improve such services. METHODS Systematic searches were conducted in the Pubmed, Psycinfo, Cinahl, Embase, Cochrane systematic reviews and Cochrane clinical trials databases. These studies were systematically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, subjected to quality appraisals using the Critical Appraisal Skills Program (CASP), and synthesized via integrative analysis. RESULTS After removal of duplicates, languages other than English, and non-scientific records, 4087 titles and abstracts were screened. After assessment against inclusion and exclusion criteria, 69 records were screened in full-text, and underwent quality appraisal. 21 records were included in the integrative analysis. Patients' experiences with TEC related to 1) technological features, namely functionality and appearance, and 2) evolving independence, namely empowerment, autonomy and security. Technological challenges lead to frustrations and negative experiences, while a stigmatizing appearance lead to patients not using the solution. Through the use of TECs, patients felt more empowered, learning about their condition, increasing awareness to their symptoms and treatment, and feeling more safe and self-efficient. Patient participation was seen as a central aspect of the development of the TECT, as well as when using it. CONCLUSION This review deepens the understanding of patients' experiences with technology enabled care solutions. Patients' experiences not only relate to the practical/technical element of the device or solution, but to how this impact on their everyday life. Patient participation in development and planned use of such solutions should be considered an integral part in healthcare quality initiatives.
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Affiliation(s)
| | - Camilla Hardeland
- Department of Health and Welfare, Ostfold University College, Postal box code (PB) 700, NO-1757 Halden, Norway
| | - Ann Karin Helgesen
- Department of Health and Welfare, Ostfold University College, Postal box code (PB) 700, NO-1757 Halden, Norway
| | - Vigdis A. Grøndahl
- Department of Health and Welfare, Ostfold University College, Postal box code (PB) 700, NO-1757 Halden, Norway
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Hammersley V, Parker R, Paterson M, Hanley J, Pinnock H, Padfield P, Stoddart A, Park HG, Sheikh A, McKinstry B. Telemonitoring at scale for hypertension in primary care: An implementation study. PLoS Med 2020; 17:e1003124. [PMID: 32555625 PMCID: PMC7299318 DOI: 10.1371/journal.pmed.1003124] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 05/22/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND While evidence from randomised controlled trials shows that telemonitoring for hypertension is associated with improved blood pressure (BP) control, healthcare systems have been slow to implement it, partly because of inadequate integration with existing clinical practices and electronic records. Neither is it clear if trial findings will be replicated in routine clinical practice at scale. We aimed to explore the feasibility and impact of implementing an integrated telemonitoring system for hypertension into routine primary care. METHODS AND FINDINGS This was a quasi-experimental implementation study with embedded qualitative process evaluation set in primary care in Lothian, Scotland. We described the overall uptake of telemonitoring and uptake in a subgroup of representative practices, used routinely acquired data for a records-based controlled before-and-after study, and collected qualitative data from staff and patient interviews and practice observation. The main outcome measures were intervention uptake, change in BP, change in clinician appointment use, and participants' views on features that facilitated or impeded uptake of the intervention. Seventy-five primary care practices enrolled 3,200 patients with established hypertension. In an evaluation subgroup of 8 practices (905 patients of whom 427 [47%] were female and with median age of 64 years [IQR 56-70, range 22-89] and median Scottish Index of Multiple Deprivation 2012 decile of 8 [IQR 6-10]), mean systolic BP fell by 6.55 mm Hg (SD 15.17), and mean diastolic BP by 4.23 mm Hg (SD 8.68). Compared with the previous year, participating patients made 19% fewer face-to-face appointments, compared with 11% fewer in patients with hypertension who were not telemonitoring. Total consultation time for participants fell by 15.4 minutes (SD 68.4), compared with 5.5 minutes (SD 84.4) in non-telemonitored patients. The convenience of remote collection of BP readings and integration of these readings into routine clinical care was crucial to the success of the implementation. Limitations include the fact that practices and patient participants were self-selected, and younger and more affluent than non-participating patients, and the possibility that regression to the mean may have contributed to the reduction in BP. Routinely acquired data are limited in terms of completeness and accuracy. CONCLUSIONS Telemonitoring for hypertension can be implemented into routine primary care at scale with little impact on clinician workload and results in reductions in BP similar to those in large UK trials. Integrating the telemonitoring readings into routine data handling was crucial to the success of this initiative.
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Affiliation(s)
- Vicky Hammersley
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Richard Parker
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Mary Paterson
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Janet Hanley
- School of Health and Social Care. Edinburgh Napier University, Edinburgh, United Kingdom
| | - Hilary Pinnock
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Paul Padfield
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrew Stoddart
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Brian McKinstry
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
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13
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Jacob C, Sanchez-Vazquez A, Ivory C. Social, Organizational, and Technological Factors Impacting Clinicians' Adoption of Mobile Health Tools: Systematic Literature Review. JMIR Mhealth Uhealth 2020; 8:e15935. [PMID: 32130167 PMCID: PMC7059085 DOI: 10.2196/15935] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/03/2019] [Accepted: 12/31/2019] [Indexed: 01/22/2023] Open
Abstract
Background There is a growing body of evidence highlighting the potential of mobile health (mHealth) in reducing health care costs, enhancing access, and improving the quality of patient care. However, user acceptance and adoption are key prerequisites to harness this potential; hence, a deeper understanding of the factors impacting this adoption is crucial for its success. Objective The aim of this review was to systematically explore relevant published literature to synthesize the current understanding of the factors impacting clinicians’ adoption of mHealth tools, not only from a technological perspective but also from social and organizational perspectives. Methods A structured search was carried out of MEDLINE, PubMed, the Cochrane Library, and the SAGE database for studies published between January 2008 and July 2018 in the English language, yielding 4993 results, of which 171 met the inclusion criteria. The Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and the Cochrane handbook were followed to ensure a systematic process. Results The technological factors impacting clinicians’ adoption of mHealth tools were categorized into eight key themes: usefulness, ease of use, design, compatibility, technical issues, content, personalization, and convenience, which were in turn divided into 14 subthemes altogether. Social and organizational factors were much more prevalent and were categorized into eight key themes: workflow related, patient related, policy and regulations, culture or attitude or social influence, monetary factors, evidence base, awareness, and user engagement. These were divided into 41 subthemes, highlighting the importance of considering these factors when addressing potential barriers to mHealth adoption and how to overcome them. Conclusions The study results can help inform mHealth providers and policymakers regarding the key factors impacting mHealth adoption, guiding them into making educated decisions to foster this adoption and harness the potential benefits.
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Affiliation(s)
- Christine Jacob
- Anglia Ruskin University, Cambridge, United Kingdom.,University of Applied Sciences Northwestern Switzerland, Brugg, Switzerland
| | - Antonio Sanchez-Vazquez
- Innovation and Management Practice Research Centre, Anglia Ruskin University, Cambridge, United Kingdom
| | - Chris Ivory
- Innovation and Management Practice Research Centre, Anglia Ruskin University, Cambridge, United Kingdom
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14
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Jacob C, Sanchez-Vazquez A, Ivory C. Social, Organizational, and Technological Factors Impacting Clinicians' Adoption of Mobile Health Tools: Systematic Literature Review. JMIR Mhealth Uhealth 2020. [PMID: 32130167 DOI: 10.2196/preprints.15935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND There is a growing body of evidence highlighting the potential of mobile health (mHealth) in reducing health care costs, enhancing access, and improving the quality of patient care. However, user acceptance and adoption are key prerequisites to harness this potential; hence, a deeper understanding of the factors impacting this adoption is crucial for its success. OBJECTIVE The aim of this review was to systematically explore relevant published literature to synthesize the current understanding of the factors impacting clinicians' adoption of mHealth tools, not only from a technological perspective but also from social and organizational perspectives. METHODS A structured search was carried out of MEDLINE, PubMed, the Cochrane Library, and the SAGE database for studies published between January 2008 and July 2018 in the English language, yielding 4993 results, of which 171 met the inclusion criteria. The Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and the Cochrane handbook were followed to ensure a systematic process. RESULTS The technological factors impacting clinicians' adoption of mHealth tools were categorized into eight key themes: usefulness, ease of use, design, compatibility, technical issues, content, personalization, and convenience, which were in turn divided into 14 subthemes altogether. Social and organizational factors were much more prevalent and were categorized into eight key themes: workflow related, patient related, policy and regulations, culture or attitude or social influence, monetary factors, evidence base, awareness, and user engagement. These were divided into 41 subthemes, highlighting the importance of considering these factors when addressing potential barriers to mHealth adoption and how to overcome them. CONCLUSIONS The study results can help inform mHealth providers and policymakers regarding the key factors impacting mHealth adoption, guiding them into making educated decisions to foster this adoption and harness the potential benefits.
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Affiliation(s)
- Christine Jacob
- Anglia Ruskin University, Cambridge, United Kingdom
- University of Applied Sciences Northwestern Switzerland, Brugg, Switzerland
| | - Antonio Sanchez-Vazquez
- Innovation and Management Practice Research Centre, Anglia Ruskin University, Cambridge, United Kingdom
| | - Chris Ivory
- Innovation and Management Practice Research Centre, Anglia Ruskin University, Cambridge, United Kingdom
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15
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Band R, Hinton L, Tucker KL, Chappell LC, Crawford C, Franssen M, Greenfield S, Hodgkinson J, McCourt C, McManus RJ, Sandall J, Santos MD, Velardo C, Yardley L. Intervention planning and modification of the BUMP intervention: a digital intervention for the early detection of raised blood pressure in pregnancy. Pilot Feasibility Stud 2019; 5:153. [PMID: 31890265 PMCID: PMC6925434 DOI: 10.1186/s40814-019-0537-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 11/28/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hypertensive disorders in pregnancy, particularly pre-eclampsia, pose a substantial health risk for both maternal and foetal outcomes. The BUMP (Blood Pressure Self-Monitoring in Pregnancy) interventions are being tested in a trial. They aim to facilitate the early detection of raised blood pressure through self-monitoring. This article outlines how the self-monitoring interventions in the BUMP trial were developed and modified using the person-based approach to promote engagement and adherence. METHODS Key behavioural challenges associated with blood pressure self-monitoring in pregnancy were identified through synthesising qualitative pilot data and existing evidence, which informed guiding principles for the development process. Social cognitive theory was identified as an appropriate theoretical framework. A testable logic model was developed to illustrate the hypothesised processes of change associated with the intervention. Iterative qualitative feedback from women and staff informed modifications to the participant materials. RESULTS The evidence synthesis suggested women face challenges integrating self-monitoring into their lives and that adherence is challenging at certain time points in pregnancy (for example, starting maternity leave). Intervention modification included strategies to address adherence but also focussed on modifying outcome expectancies, by providing messages explaining pre-eclampsia and outlining the potential benefits of self-monitoring. CONCLUSIONS With an in-depth understanding of the target population, several methods and approaches to plan and develop interventions specifically relevant to pregnant women were successfully integrated, to address barriers to behaviour change while ensuring they are easy to engage with, persuasive and acceptable.
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Affiliation(s)
- Rebecca Band
- Academic unit of psychology, University of Southampton, Southampton, SO17 1BJ UK
| | - Lisa Hinton
- Nuffield Department of Primary Care Health Sciences, Radcliffe Infirmary Quarter University of Oxford, Oxford, OX2 6GG UK
| | - Katherine L. Tucker
- Nuffield Department of Primary Care Health Sciences, Radcliffe Infirmary Quarter University of Oxford, Oxford, OX2 6GG UK
| | - Lucy C. Chappell
- Division of Women and Children’s Health, King’s College London, London, SE1 7EH UK
| | - Carole Crawford
- Nuffield Department of Primary Care Health Sciences, Radcliffe Infirmary Quarter University of Oxford, Oxford, OX2 6GG UK
| | - Marloes Franssen
- Nuffield Department of Primary Care Health Sciences, Radcliffe Infirmary Quarter University of Oxford, Oxford, OX2 6GG UK
| | - Sheila Greenfield
- Institute of Applied Health, University of Birmingham, Birmingham, B15 2TT UK
| | - James Hodgkinson
- Institute of Applied Health, University of Birmingham, Birmingham, B15 2TT UK
| | - Christine McCourt
- Centre for Maternal and Child Health, School of Health Sciences, City University, London, EC1R IUW UK
| | - Richard J. McManus
- Nuffield Department of Primary Care Health Sciences, Radcliffe Infirmary Quarter University of Oxford, Oxford, OX2 6GG UK
| | - Jane Sandall
- Division of Women and Children’s Health, King’s College London, London, SE1 7EH UK
| | - Mauro Dala Santos
- Institute of Biomedical Engineering, Department of Engineering Science, Building, University of Oxford, Oxford, OX3 7DQ UK
| | - Carmelo Velardo
- Institute of Biomedical Engineering, Department of Engineering Science, Building, University of Oxford, Oxford, OX3 7DQ UK
| | - Lucy Yardley
- Academic unit of psychology, University of Southampton, Southampton, SO17 1BJ UK
- School of Psychological Science, University of Bristol, Bristol, UK
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16
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Allen ME, Irizarry T, Einhorn J, Kamarck TW, Suffoletto BP, Burke LE, Rollman BL, Muldoon MF. SMS-facilitated home blood pressure monitoring: A qualitative analysis of resultant health behavior change. PATIENT EDUCATION AND COUNSELING 2019; 102:2246-2253. [PMID: 31262674 PMCID: PMC6851464 DOI: 10.1016/j.pec.2019.06.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Hypertension is largely asymptomatic and, as a result, patients often fail to sufficiently engage in medication adherence and other health behaviors to control their blood pressure (BP). This study explores the mechanisms by which MyBP, an automated SMS-facilitated home blood pressure monitoring (HBPM) program, helps facilitate healthy behavior changes. METHODS A thematic analysis of transcribed audio-recordings from semi-structured post-intervention interviews (n = 40) was conducted. RESULTS Three primary themes were identified as contributing most to patients' decision to initiate a behavior change: 1) increased hypertension literacy attributed to educational videos presented at enrollment, 2) increased day-to-day salience of blood pressure levels as a result of consistent HBPM, and 3) use of BP readings as feedback, with high readings triggering motivations to make behavior changes. These themes and most accompanying sub-themes correspond to constructs in the Health Belief Model and Social Cognitive Theory. CONCLUSION Patient-centered HBPM interventions such asMyBP appear to promote improvements in hypertension self-management via several mechanisms consistent with recognized models of behavior change. PRACTICE IMPLICATIONS SMS-supported HBPM, paired with video-based education, may provide a simple and scalable way of encouraging health behavior adherence in hypertensive patients.
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Affiliation(s)
- Matthew E Allen
- University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Taya Irizarry
- Department of Health & Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA.
| | - Julian Einhorn
- Department of Psychology, University of Pittsburgh School of Arts and Sciences, Pittsburgh, PA, USA.
| | - Thomas W Kamarck
- Department of Psychology, University of Pittsburgh School of Arts and Sciences, Pittsburgh, PA, USA.
| | - Brian P Suffoletto
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Lora E Burke
- Department of Health & Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA; Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
| | - Bruce L Rollman
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Center for Behavioral Health and Smart Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Matthew F Muldoon
- Division of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Heart and Vascular Institute Hypertension Center, UPMC Health System, Pittsburgh, PA, USA.
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Ando H, Ashcroft-Kelso H, Halhead R, Chakrabarti B, Young CA, Cousins R, Angus RM. Experience of telehealth in people with motor neurone disease using noninvasive ventilation. Disabil Rehabil Assist Technol 2019; 16:490-496. [PMID: 31512539 DOI: 10.1080/17483107.2019.1659864] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Evidence is emerging that telehealth provides timely and cost-effective support for individuals with motor neurone disease (MND). However, little is known about the subjective experience of using telehealth. This study was designed to examine the experiences of using telemonitoring in patients with MND on noninvasive ventilation (NIV). METHODS Semi-structured interviews were conducted with seven patients (five males; mean age = 63 yrs; median illness duration = 14 m), who used a telemonitoring device for 24 weeks. Caregivers were present at five of the interviews; they supported communications and provided their feedback. Interviews were audio recorded and transcribed verbatim. Thematic analysis was conducted to find overarching themes. RESULTS Five themes were identified: Benefits of Timely Intervention, Reducing the Unnecessary, Increased Self-Awareness, Taking Initiative, and Technical Challenges. Overall, timely interventions were observed as a result of regular monitoring, contributing to both physical and psychological well-being of the participants. The patient-caregiver dyads suggested that telemonitoring could reduce costs, save time and ameliorate hassles associated with attending hospital appointments. Participants articulated that telemonitoring enabled symptom awareness and interpretation; the device also enabled the participants to raise concerns and/or requests to the healthcare professionals via the messaging system. Participants confirmed that the telemonitoring device was easy to use, despite some technical issues. CONCLUSIONS Telemonitoring was positively experienced. The findings suggest this approach is empowering and effective in promoting patients' well-being, while potentially reducing unnecessary clinical contact.Implications for RehabilitationCare for people with MND demands a flexible approach to accommodate the diversity of clinical needs and relentless physical deterioration.Telehealth allows clinicians to provide person-centred care for everyone with MND through frequent monitoring.Holistic and rehabilitative service facilitated by telehealth is generally acceptable and preferred to routine appointments among MND NIV patients.Telehealth promotes time efficient engagement with professionals that leads to symptom awareness and interpretation, while benefiting physical and psychological well-being of MND NIV patients.
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Affiliation(s)
- Hikari Ando
- Department of Respiratory Medicine, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Helen Ashcroft-Kelso
- Ventilation Inpatient Centre, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | | | | | | | - Rosanna Cousins
- Department of Psychology, Liverpool Hope University, Liverpool, UK
| | - Robert M Angus
- Chest Centre, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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Liu H, Mohammed A, Shanthosh J, News M, Laba TL, Hackett ML, Peiris D, Jan S. Process evaluations of primary care interventions addressing chronic disease: a systematic review. BMJ Open 2019; 9:e025127. [PMID: 31391188 PMCID: PMC6687007 DOI: 10.1136/bmjopen-2018-025127] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Process evaluations (PEs) alongside randomised controlled trials of complex interventions are valuable because they address questions of for whom, how and why interventions had an impact. We synthesised the methods used in PEs of primary care interventions, and their main findings on implementation barriers and facilitators. DESIGN Systematic review using the UK Medical Research Council guidance for PE as a guide. DATA SOURCES Academic databases (MEDLINE, SCOPUS, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, EMBASE and Global Health) were searched from 1998 until June 2018. ELIGIBILITY CRITERIA We included PE alongside randomised controlled trials of primary care interventions which aimed to improve outcomes for patients with non-communicable diseases. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened and conducted the data extraction and synthesis, with a third reviewer checking a sample for quality assurance. RESULTS 69 studies were included. There was an overall lack of consistency in how PEs were conducted and reported. The main weakness is that only 30 studies were underpinned by a clear intervention theory often facilitated by the use of existing theoretical frameworks. The main strengths were robust sampling strategies, and the triangulation of qualitative and quantitative data to understand an intervention's mechanisms. Findings were synthesised into three key themes: (1) a fundamental mismatch between what the intervention was designed to achieve and local needs; (2) the required roles and responsibilities of key actors were often not clearly understood; and (3) the health system context-factors such as governance, financing structures and workforce-if unanticipated could adversely impact implementation. CONCLUSION Greater consistency is needed in the reporting and the methods of PEs, in particular greater use of theoretical frameworks to inform intervention theory. More emphasis on formative research in designing interventions is needed to align the intervention with the needs of local stakeholders, and to minimise unanticipated consequences due to context-specific barriers. PROSPERO REGISTRATION NUMBER CRD42016035572.
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Affiliation(s)
- Hueiming Liu
- University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Alim Mohammed
- The George Institute for Global Health, Hyderabad, India
| | - Janani Shanthosh
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Madeline News
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Tracey-Lea Laba
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- Menzies Centre for Health Policy, University of Sydney, Sydney, New South Wales, Australia
| | - Maree L Hackett
- University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - David Peiris
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Stephen Jan
- University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
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Hui CY, Creamer E, Pinnock H, McKinstry B. Apps to Support Self-Management for People With Hypertension: Content Analysis. JMIR Mhealth Uhealth 2019; 7:e13257. [PMID: 31162124 PMCID: PMC6746067 DOI: 10.2196/13257] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 03/07/2019] [Accepted: 04/08/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Home blood pressure monitoring (HBPM) is one component of effective supported self-management, which may potentially be mediated by mobile apps. OBJECTIVE The aim of this study was to identify the self-management features (HBPM and broader support strategies) offered by currently available apps and to determine the features associated with download frequency and user ratings. METHODS We searched Google Play store, Apple App store, National Health Services Apps Library and myhealthapps.net (first search on February 1, 2018; updated August 18, 2018). We included high blood pressure apps available in the United Kingdom and extracted their features, number of downloads, and the average users' rating from the app stores. We mapped the features to the holistic Practical Reviews In Self-Management Support (PRISMS) taxonomy of self-management support. We employed a regression analysis to determine if any features were associated with download frequency or user rating. RESULTS We included 151 apps. The 3 most common features were as follows: monitoring blood pressure (BP) and charting logs; lifestyle (exercise or dietary) advice; and providing information about hypertension. The other 11 components of the PRISMS taxonomy were rarely featured. There was little evidence to support associations between specific features and the download statistics and rating scores, with only 2 uncommon features achieving borderline significant associations. The presence of social support features, such as a forum, was weakly but significantly (R2=.04, P=.02) correlated with the number of downloads. Apps designed specifically for particular BP monitors/smart watches were weakly associated with a higher rating score (R2=.05, P<.001). Apps with more ratings were associated with more downloads (R2=.91, P<.001). CONCLUSIONS The functionality of currently available apps is limited to logging BP, offering lifestyle advice, and providing information about hypertension. Future app development should consider broadening the remit to produce a system that can respond flexibly to the diversity of support that enables people to self-manage their hypertension.
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Affiliation(s)
- Chi Yan Hui
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, United Kingdom
| | - Emily Creamer
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, United Kingdom
| | - Hilary Pinnock
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, United Kingdom
| | - Brian McKinstry
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, United Kingdom
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Palacholla RS, Fischer N, Coleman A, Agboola S, Kirley K, Felsted J, Katz C, Lloyd S, Jethwani K. Provider- and Patient-Related Barriers to and Facilitators of Digital Health Technology Adoption for Hypertension Management: Scoping Review. JMIR Cardio 2019; 3:e11951. [PMID: 31758771 PMCID: PMC6834226 DOI: 10.2196/11951] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 12/13/2018] [Accepted: 01/16/2019] [Indexed: 01/14/2023] Open
Abstract
Background The uptake of digital health technology (DHT) has been surprisingly low in clinical practice. Despite showing great promise to improve patient outcomes and disease management, there is limited information on the factors that contribute to the limited adoption of DHT, particularly for hypertension management. Objective This scoping review provides a comprehensive summary of barriers to and facilitators of DHT adoption for hypertension management reported in the published literature with a focus on provider- and patient-related barriers and facilitators. Methods This review followed the methodological framework developed by Arskey and O’Malley. Systematic literature searches were conducted on PubMed or Medical Literature Analysis and Retrieval System Online, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medica database. Articles that reported on barriers to and/or facilitators of digital health adoption for hypertension management published in English between 2008 and 2017 were eligible. Studies not reporting on barriers or facilitators to DHT adoption for management of hypertension were excluded. A total of 2299 articles were identified based on the above criteria after removing duplicates, and they were assessed for eligibility. Of these, 2165 references did not meet the inclusion criteria. After assessing 134 studies in full text, 98 studies were excluded (full texts were either unavailable or studies did not fulfill the inclusion criteria), resulting in a final set of 32 articles. In addition, 4 handpicked articles were also included in the review, making it a total of 36 studies. Results A total of 36 studies were selected for data extraction after abstract and full-text screening by 2 independent reviewers. All conflicts were resolved by a third reviewer. Thematic analysis was conducted to identify major themes pertaining to barriers and facilitators of DHT from both provider and patient perspectives. The key facilitators of DHT adoption by physicians that were identified include ease of integration with clinical workflow, improvement in patient outcomes, and technology usability and technical support. Technology usability and timely technical support improved self-management and patient experience, and positive impact on patient-provider communication were most frequently reported facilitators for patients. Barriers to use of DHTs reported by physicians include lack of integration with clinical workflow, lack of validation of technology, and lack of technology usability and technical support. Finally, lack of technology usability and technical support, interference with patient-provider relationship, and lack of validation of technology were the most commonly reported barriers by patients. Conclusions Findings suggest the settings and context in which DHTs are implemented and individuals involved in implementation influence adoption. Finally, to fully realize the potential of digitally enabled hypertension management, there is a greater need to validate these technologies to provide patients and providers with reliable and accurate information on both clinical outcomes and cost effectiveness.
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Affiliation(s)
- Ramya Sita Palacholla
- Partners HealthCare Pivot Labs, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Massachusetts General Hospital, Boston, MA, United States
| | - Nils Fischer
- Partners HealthCare Pivot Labs, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Amanda Coleman
- American Medical Association, Chicago, IL, United States
| | - Stephen Agboola
- Partners HealthCare Pivot Labs, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Massachusetts General Hospital, Boston, MA, United States
| | | | - Jennifer Felsted
- Partners HealthCare Pivot Labs, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Chelsea Katz
- American Medical Association, Chicago, IL, United States
| | - Stacy Lloyd
- American Medical Association, Chicago, IL, United States
| | - Kamal Jethwani
- Partners HealthCare Pivot Labs, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Massachusetts General Hospital, Boston, MA, United States
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21
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Ware P, Dorai M, Ross HJ, Cafazzo JA, Laporte A, Boodoo C, Seto E. Patient Adherence to a Mobile Phone-Based Heart Failure Telemonitoring Program: A Longitudinal Mixed-Methods Study. JMIR Mhealth Uhealth 2019; 7:e13259. [PMID: 30806625 PMCID: PMC6412156 DOI: 10.2196/13259] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 01/25/2019] [Accepted: 02/11/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Telemonitoring (TM) can improve heart failure (HF) outcomes by facilitating patient self-care and clinical decision support. However, these outcomes are only possible if patients consistently adhere to taking prescribed home readings. OBJECTIVE The objectives of this study were to (1) quantify the degree to which patients adhered to taking prescribed home readings in the context of a mobile phone-based TM program and (2) explain longitudinal adherence rates based on the duration of program enrollment, patient characteristics, and patient perceptions of the TM program. METHODS A mixed-methods explanatory sequential design was used to meet the 2 research objectives, and all explanatory methods were guided by the unified theory of acceptance and use of technology 2 (UTAUT2). Overall adherence rates were calculated as the proportion of days patients took weight, blood pressure, heart rate, and symptom readings over the total number of days they were enrolled in the program up to 1 year. Monthly adherence rates were also calculated as the proportion of days patients took the same 4 readings over each 30-day period following program enrollment. Next, simple and multivariate regressions were performed to determine the influence of time, age, sex, and disease severity on adherence rates. Additional explanatory methods included questionnaires at 6 and 12 months probing patients on the perceived benefits and ease of use of the TM program, an analysis of reasons for patients leaving the program, and semistructured interviews conducted with a purposeful sampling of patients (n=24) with a range of adherence rates and demographics. RESULTS Overall average adherence was 73.6% (SD 25.0) with average adherence rates declining over time at a rate of 1.4% per month (P<.001). The multivariate regressions found no significant effect of sex and disease severity on adherence rates. When grouping patients' ages by decade, age was a significant predictor (P=.04) whereby older patients had higher adherence rates over time. Adherence rates were further explained by patients' perceptions with regard to the themes of (1) performance expectancy (improvements in HF management and peace of mind), (2) effort expectancy (ease of use and technical issues), (3) facilitating conditions (availability of technical support and automated adherence calls), (4) social influence (support from family, friends, and trusted clinicians), and (5) habit (degree to which taking readings became automatic). CONCLUSIONS The decline in adherence rates over time is consistent with findings from other studies. However, this study also found adherence to be the highest and most consistent over time in older age groups and progressively lower over time for younger age groups. These findings can inform the design and implementation of TM interventions that maximize patient adherence, which will enable a more accurate evaluation of impact and optimization of resources. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/resprot.9911.
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Affiliation(s)
- Patrick Ware
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, Toronto, ON, Canada
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Mala Dorai
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Heather J Ross
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Joseph A Cafazzo
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, Toronto, ON, Canada
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Audrey Laporte
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, Toronto, ON, Canada
- Canadian Centre for Health Economics, Toronto, ON, Canada
| | - Chris Boodoo
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, Toronto, ON, Canada
| | - Emily Seto
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, Toronto, ON, Canada
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada
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22
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Ware P, Ross HJ, Cafazzo JA, Laporte A, Gordon K, Seto E. User-Centered Adaptation of an Existing Heart Failure Telemonitoring Program to Ensure Sustainability and Scalability: Qualitative Study. JMIR Cardio 2018; 2:e11466. [PMID: 31758774 PMCID: PMC6857927 DOI: 10.2196/11466] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/14/2018] [Accepted: 10/22/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Telemonitoring interventions for the management of heart failure have seen limited adoption in Canadian health systems, but isolated examples of telemonitoring programs do exist. An example of such a program was launched in a specialty heart failure clinic in Toronto, Canada, and a recent implementation evaluation concluded that reducing the cost of delivering the program is necessary to ensure its sustainability and scalability. OBJECTIVE The objectives of this study were to (1) understand which components of the telemonitoring program could be modified to reduce costs and adapted to other contexts while maintaining program fidelity and (2) describe the changes made to the telemonitoring program to enable its sustainability within the initial implementation site and scalability to other health organizations. METHODS Semistructured interviews probed the experiences of patients (n=23) and clinicians (n=8) involved in the telemonitoring program to identify opportunities for cost reduction and resource optimization. Ideas for adapting the program were informed by the interview results and prioritized based on (1) potential impact for sustainability and scalability, (2) feasibility, and (3) perceived risks to negatively impacting the program's ability to yield desired health outcomes. RESULTS A total of 5 themes representing opportunities for cost reduction were discussed, including (1) Bring Your Own Device (BYOD), (2) technical support, (3) clinician role, (4) duration of enrollment, and (5) intensity of monitoring. The hardware used for the telemonitoring system and the modalities of providing technical support were found to be highly adaptable, which supported the decision to implement a BYOD model, whereby patients used their own smartphone, weight scale, and blood pressure cuff. Changes also included the development of a website aimed at reducing the burden on a technical support telehealth analyst. In addition, the interviews suggested that although it is important to have a clinician who is part of a patient's circle of care monitoring telemonitoring alerts, the skill level and experience were moderately adaptable. Thus, a registered nurse was determined to be more cost-effective and was hired to replace the existing nurse practitioners in the frontline management of telemonitoring alerts and take over the technical support role from a telehealth analyst. CONCLUSIONS This study provides a user-centered example of how necessary cost-reduction actions can be taken to ensure the sustainability and scalability of telemonitoring programs. In addition, the findings offer insights into what components of a telemonitoring program can be safely adapted to ensure its integration in various clinical settings.
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Affiliation(s)
- Patrick Ware
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Heather J Ross
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Joseph A Cafazzo
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Audrey Laporte
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Canadian Centre for Health Economics, Toronto, ON, Canada
| | - Kayleigh Gordon
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Emily Seto
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada
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23
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Albrecht L, Wood PW, Fradette M, McAlister FA, Rabi D, Boulanger P, Padwal R. Usability and Acceptability of a Home Blood Pressure Telemonitoring Device Among Community-Dwelling Senior Citizens With Hypertension: Qualitative Study. JMIR Aging 2018; 1:e10975. [PMID: 31518242 PMCID: PMC6716488 DOI: 10.2196/10975] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/14/2018] [Accepted: 06/21/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Hypertension is a major cause of cardiovascular disease in older individuals. To ensure that blood pressure (BP) levels are within the optimal range, accurate BP monitoring is required. Contemporary hypertension clinical practice guidelines strongly endorse the use of home BP measurement as a preferred method of BP monitoring for individuals with hypertension. The benefits of home BP monitoring may be optimized when measurements are telemonitored to care providers; however, this may be challenging for older individuals with less technological capabilities. OBJECTIVE The objective of this qualitative study was to examine the usability and acceptability of a home BP telemonitoring device among senior citizens. METHODS We conducted a qualitative descriptive study. Following a 1-week period of device use, individual, semistructured interviews were conducted. Interview audio recordings were anonymized, de-identified, and transcribed verbatim. We performed thematic analysis on interview transcripts. RESULTS Seven senior citizens participated in the usability testing of the home BP telemonitoring device. Participants comprised females (n=4) and males (n=3) with a mean age of 86 years (range, 70-95 years). Overall, eight main themes were identified from the interviews: (1) positive features of the device; (2) difficulties or problems with the device; (3) device was simple to use; (4) comments about wireless capability and components; (5) would recommend device to someone else; (6) would use device in future; (7) suggestions for improving the device; and (8) assistance to use device. Additional subthemes were also identified. CONCLUSIONS Overall, the home BP telemonitoring device had very good usability and acceptability among community-dwelling senior citizens with hypertension. To enhance its long-term use, few improvements were noted that may mitigate some of the relatively minor challenges encountered by the target population.
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Affiliation(s)
- Lauren Albrecht
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Peter W Wood
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Miriam Fradette
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Doreen Rabi
- Departments of Medicine, Community Health and Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Pierre Boulanger
- Department of Computing Science, University of Alberta, Edmonton, AB, Canada
| | - Raj Padwal
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
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24
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Implementing telemonitoring in primary care: learning from a large qualitative dataset gathered during a series of studies. BMC FAMILY PRACTICE 2018; 19:118. [PMID: 30021535 PMCID: PMC6052602 DOI: 10.1186/s12875-018-0814-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 06/29/2018] [Indexed: 01/09/2023]
Abstract
Background Telemonitoring for long term conditions such as hypertension and diabetes has not been widely adopted despite evidence of efficacy in trials and policy support. The Telescot programme comprised a series of seven trials and observational studies of telemonitoring for long term conditions in primary care, all with an explanatory qualitative component which had been analysed and published separately. There were changes to the models of care within and between studies and combining datasets would provide a longitudinal view of the evolution of primary care based telemonitoring services that was not available in the individual studies, as well as allowing comparison across the different conditions monitored. We aimed to explore what drove changes to the way telemonitoring was implemented, compare experience of telemonitoring across the range of long term conditions, and identify what issues, in the experience of the participants, need to be considered in implementing new telemonitoring systems. Method Synthesis and thematic reanalysis of transcribed qualitative interview and focus group data from the Telescot programme adopting an interpretive description approach. All transcribed and coded text was re-read and data relating to the experience of the telemonitoring services, perceptions of future use and strategies for implementation were recoded into one consistent system. This was analysed thematically. Results The combined dataset contained transcribed qualitative interview and focus group data from 181 patients and 109 professionals. Four major themes were identified, using data, empowering patients, adjusting the model of care and system design. Conclusion Telemonitoring was valued by patients who found it empowering and convenient. This, combined with initial professional concern that increased surveillance may create dependency led to the development of a more patient led service. However, despite a number of initial concerns being addressed as the service evolved, primary care professionals identified a number of barriers to widespread routine adoption of telemonitoring, many of which could be addressed by improved system design.
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25
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Nathan HL, Boene H, Munguambe K, Sevene E, Akeju D, Adetoro OO, Charanthimath U, Bellad MB, de Greeff A, Anthony J, Hall DR, Steyn W, Vidler M, von Dadelszen P, Chappell LC, Sandall J, Shennan AH. The CRADLE vital signs alert: qualitative evaluation of a novel device designed for use in pregnancy by healthcare workers in low-resource settings. Reprod Health 2018; 15:5. [PMID: 29304812 PMCID: PMC5756409 DOI: 10.1186/s12978-017-0450-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/27/2017] [Indexed: 11/10/2022] Open
Abstract
Background Vital signs measurement can identify pregnant and postpartum women who require urgent treatment or referral. In low-resource settings, healthcare workers have limited access to accurate vital signs measuring devices suitable for their environment and training. The CRADLE Vital Signs Alert (VSA) is a novel device measuring blood pressure and pulse that is accurate in pregnancy and designed for low-resource settings. Its traffic light early warning system alerts healthcare workers to the need for escalation of care for women with hypertension, haemorrhage or sepsis. This study evaluated the usability and acceptability of the CRADLE VSA device. Methods Evaluation was conducted in community and primary care settings in India, Mozambique and Nigeria and tertiary hospitals in South Africa. Purposeful sampling was used to convene 155 interviews and six focus groups with healthcare workers using the device (n = 205) and pregnant women and their family members (n = 41). Interviews and focus groups were conducted in the local language and audio-recorded, transcribed and translated into English for analysis. Thematic analysis was undertaken using an a priori thematic framework, as well as an inductive approach. Results Most healthcare workers perceived the CRADLE device to be easy to use and accurate. The traffic lights early warning system was unanimously reported positively, giving healthcare workers confidence with decision-making and a sense of professionalism. However, a minority in South Africa described manual inflation as tiring, particularly when measuring vital signs in obese and hypertensive women (n = 4) and a few South African healthcare workers distrusted the device’s accuracy (n = 7). Unanimously, pregnant women liked the CRADLE device. The traffic light early warning system gave women and their families a better understanding of the importance of vital signs in pregnancy and during the postpartum period. Conclusion The CRADLE device was well accepted by healthcare workers from a range of countries and levels of facility, including those with no previous vital signs measurement experience. The device motivated women to attend primary care and encouraged them to accept treatment and referral.
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Affiliation(s)
- Hannah L Nathan
- Department of Women and Children's Health, King's College London, London, UK.
| | - Helena Boene
- Centro de Investigação em Saúde da Manhiça (CISM), Vila da Manhiça, Moçambique
| | - Khatia Munguambe
- Centro de Investigação em Saúde da Manhiça (CISM), Vila da Manhiça, Moçambique.,Universidade Eduardo Mondlane, Faculdade de Medicina, Av. Salvador Allende, 702 R/C, Maputo, Moçambique
| | - Esperança Sevene
- Centro de Investigação em Saúde da Manhiça (CISM), Vila da Manhiça, Moçambique.,Universidade Eduardo Mondlane, Faculdade de Medicina, Av. Salvador Allende, 702 R/C, Maputo, Moçambique
| | - David Akeju
- Department of Sociology, University of Lagos, Lagos, Nigeria
| | | | - Umesh Charanthimath
- KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | | | - Annemarie de Greeff
- Department of Women and Children's Health, King's College London, London, UK
| | - John Anthony
- Maternity Centre, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - David R Hall
- Department of Obstetrics and Gynaecology, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Wilhelm Steyn
- Department of Obstetrics and Gynaecology, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, and the Child and Family Research Institute, University of British Columbia, Vancouver, Canada
| | - Peter von Dadelszen
- Department of Women and Children's Health, King's College London, London, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, London, UK
| | - Jane Sandall
- Department of Women and Children's Health, King's College London, London, UK
| | - Andrew H Shennan
- Department of Women and Children's Health, King's College London, London, UK
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26
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Hinton L, Tucker KL, Greenfield SM, Hodgkinson JA, Mackillop L, McCourt C, Carver T, Crawford C, Glogowska M, Locock L, Selwood M, Taylor KS, McManus RJ. Blood pressure self-monitoring in pregnancy (BuMP) feasibility study; a qualitative analysis of women's experiences of self-monitoring. BMC Pregnancy Childbirth 2017; 17:427. [PMID: 29258469 PMCID: PMC5735874 DOI: 10.1186/s12884-017-1592-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 11/23/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Hypertensive disorders in pregnancy are a leading cause of maternal and fetal morbidity worldwide. Raised blood pressure (BP) affects 10% of pregnancies worldwide, of which almost half develop pre-eclampsia. The proportion of pregnant women who have risk factors for pre-eclampsia (such as pre-existing hypertension, obesity and advanced maternal age) is increasing. Pre-eclampsia can manifest itself before women experience symptoms and can develop between antenatal visits. Incentives to improve early detection of gestational hypertensive disorders are therefore strong and self-monitoring of blood pressure (SMBP) in pregnancy might be one means to achieve this, whilst improving women's involvement in antenatal care. The Blood Pressure Self-Monitoring in Pregnancy (BuMP) study aimed to evaluate the feasibility and acceptability of SMBP in pregnancy. METHODS To understand women's experiences of SMBP during pregnancy, we undertook a qualitative study embedded within the BuMP observational feasibility study. Women who were at higher risk of developing hypertension and/or pre-eclampsia were invited to take part in a study using SMBP and also invited to take part in an interview. Semi-structured interviews were conducted at the women's homes in Oxfordshire and Birmingham with women who were self-monitoring their BP as part of the BuMP feasibility study in 2014. Interviews were conducted by a qualitative researcher and transcribed verbatim. A framework approach was used for analysis. RESULTS Fifteen women agreed to be interviewed. Respondents reported general willingness to engage with monitoring their own BP, feeling that it could reduce anxiety around their health during pregnancy, particularly if they had previous experience of raised BP or pre-eclampsia. They felt able to incorporate self-monitoring into their weekly routines, although this was harder post-partum. Self-monitoring of BP made them more aware of the risks of hypertension and pre-eclampsia in pregnancy. Feelings of reassurance and empowerment were commonly reported by the women in our sample. CONCLUSIONS SMBP in pregnancy was both acceptable and feasible to women in this small pilot study.
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Affiliation(s)
- Lisa Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Woodstock Rd, Oxford, OX2 6GG, UK. .,Oxford NIHR Biomedical Research Centre, The Joint Research Office, The Churchill Hospital, Block 60, Old Road, Headington, Oxford, OX3 7LE, UK.
| | - Katherine L Tucker
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Sheila M Greenfield
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - James A Hodgkinson
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Lucy Mackillop
- Oxford University Hospitals NHS Trust, Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Christine McCourt
- City, University of London, Northampton Square, London, EC1V 0HB, UK
| | - Trisha Carver
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Carole Crawford
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Margaret Glogowska
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Louise Locock
- Health Services Research Unit, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Mary Selwood
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Kathryn S Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Woodstock Rd, Oxford, OX2 6GG, UK
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Hanlon P, Daines L, Campbell C, McKinstry B, Weller D, Pinnock H. Telehealth Interventions to Support Self-Management of Long-Term Conditions: A Systematic Metareview of Diabetes, Heart Failure, Asthma, Chronic Obstructive Pulmonary Disease, and Cancer. J Med Internet Res 2017; 19:e172. [PMID: 28526671 PMCID: PMC5451641 DOI: 10.2196/jmir.6688] [Citation(s) in RCA: 302] [Impact Index Per Article: 43.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 02/22/2017] [Accepted: 03/09/2017] [Indexed: 12/28/2022] Open
Abstract
Background Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions. Objective The objectives of this metareview were to (1) assess the impact of telehealth interventions to support self-management on disease control and health care utilization, and (2) identify components of telehealth support and their impact on disease control and the process of self-management. Our goal was to synthesise evidence for telehealth-supported self-management of diabetes (types 1 and 2), heart failure, asthma, chronic obstructive pulmonary disease (COPD) and cancer to identify components of effective self-management support. Methods We performed a metareview (a systematic review of systematic reviews) of randomized controlled trials (RCTs) of telehealth interventions to support self-management in 6 exemplar long-term conditions. We searched 7 databases for reviews published from January 2000 to May 2016 and screened identified studies against eligibility criteria. We weighted reviews by quality (revised A Measurement Tool to Assess Systematic Reviews), size, and relevance. We then combined our results in a narrative synthesis and using harvest plots. Results We included 53 systematic reviews, comprising 232 unique RCTs. Reviews concerned diabetes (type 1: n=6; type 2, n=11; mixed, n=19), heart failure (n=9), asthma (n=8), COPD (n=8), and cancer (n=3). Findings varied between and within disease areas. The highest-weighted reviews showed that blood glucose telemonitoring with feedback and some educational and lifestyle interventions improved glycemic control in type 2, but not type 1, diabetes, and that telemonitoring and telephone interventions reduced mortality and hospital admissions in heart failure, but these findings were not consistent in all reviews. Results for the other conditions were mixed, although no reviews showed evidence of harm. Analysis of the mediating role of self-management, and of components of successful interventions, was limited and inconclusive. More intensive and multifaceted interventions were associated with greater improvements in diabetes, heart failure, and asthma. Conclusions While telehealth-mediated self-management was not consistently superior to usual care, none of the reviews reported any negative effects, suggesting that telehealth is a safe option for delivery of self-management support, particularly in conditions such as heart failure and type 2 diabetes, where the evidence base is more developed. Larger-scale trials of telehealth-supported self-management, based on explicit self-management theory, are needed before the extent to which telehealth technologies may be harnessed to support self-management can be established.
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Affiliation(s)
- Peter Hanlon
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Luke Daines
- Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Christine Campbell
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Brian McKinstry
- E-Health Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - David Weller
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Hilary Pinnock
- Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
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Morton K, Dennison L, May C, Murray E, Little P, McManus RJ, Yardley L. Using digital interventions for self-management of chronic physical health conditions: A meta-ethnography review of published studies. PATIENT EDUCATION AND COUNSELING 2017; 100:616-635. [PMID: 28029572 PMCID: PMC5380218 DOI: 10.1016/j.pec.2016.10.019] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 09/16/2016] [Accepted: 10/19/2016] [Indexed: 05/15/2023]
Abstract
OBJECTIVES To understand the experiences of patients and healthcare professionals (HCPs) using self-management digital interventions (DIs) for chronic physical health conditions. METHODS A systematic search was conducted in 6 electronic databases. Qualitative studies describing users' experiences of self-management DIs were included, and authors' interpretations were synthesised using meta-ethnography. RESULTS 30 papers met the inclusion criteria, covering a range of DIs and chronic conditions, including hypertension, asthma and heart disease. The review found that patients monitoring their health felt reassured by the insight this provided, and perceived they had more meaningful consultations with the HCP. These benefits were elicited by simple tele-monitoring systems as well as multifaceted DIs. Patients appeared to feel more reliant on HCPs if they received regular feedback from the HCP. HCPs focused mainly on their improved clinical control, and some also appreciated patients' increased understanding of their condition. CONCLUSIONS Patients using self-management DIs tend to feel well cared for and perceive that they adopt a more active role in consultations, whilst HCPs focus on the clinical benefits provided by DIs. PRACTICE IMPLICATIONS DIs can simultaneously support patient condition management, and HCPs' control of patient health. Tele-monitoring physiological data can promote complex behaviour change amongst patients.
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Affiliation(s)
- Katherine Morton
- Academic unit of Psychology, University of Southampton, Southampton, UK.
| | - Laura Dennison
- Academic unit of Psychology, University of Southampton, Southampton, UK.
| | - Carl May
- Faculty of Health Sciences, University of Southampton, Southampton, UK.
| | - Elizabeth Murray
- Research Department of Primary Care and Population Health, University College London, London, UK.
| | - Paul Little
- Primary Care Research, University of Southampton, Southampton, UK.
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Lucy Yardley
- Academic unit of Psychology, University of Southampton, Southampton, UK.
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Schwamm LH, Chumbler N, Brown E, Fonarow GC, Berube D, Nystrom K, Suter R, Zavala M, Polsky D, Radhakrishnan K, Lacktman N, Horton K, Malcarney MB, Halamka J, Tiner AC. Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement From the American Heart Association. Circulation 2017; 135:e24-e44. [DOI: 10.1161/cir.0000000000000475] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating the use of telemedicine in cardiovascular and stroke care and to provide consensus policy suggestions. We evaluate the effectiveness of telehealth in advancing healthcare quality, identify legal and regulatory barriers that impede telehealth adoption or delivery, propose steps to overcome these barriers, and identify areas for future research to ensure that telehealth continues to enhance the quality of cardiovascular and stroke care. The result of these efforts is designed to promote telehealth models that ensure better patient access to high-quality cardiovascular and stroke care while striving for optimal protection of patient safety and privacy.
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Bradbury K, Morton K, Band R, May C, McManus R, Little P, Yardley L. Understanding how primary care practitioners perceive an online intervention for the management of hypertension. BMC Med Inform Decis Mak 2017; 17:5. [PMID: 28069041 PMCID: PMC5223423 DOI: 10.1186/s12911-016-0397-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In order to achieve successful implementation an intervention needs to be acceptable and feasible to its users and must overcome barriers to behaviour change. The Person-Based Approach can help intervention developers to improve their interventions to ensure more successful implementation. This study provides an example of using the Person-Based Approach to refine a digital intervention for hypertension (HOME BP). METHODS Our Person-Based Approach involved conducting qualitative focus groups with practice staff to explore their perceptions of HOME BP and to identify any potential barriers to implementation of the HOME BP procedures. We took an iterative approach moving between data collection, analysis and modifications to the HOME BP intervention, followed by further data collection. The data was analysed using thematic analysis. RESULTS Many aspects of HOME BP appeared to be acceptable, persuasive and feasible to implement. Practitioners perceived benefits in using HOME BP, including that it could empower patients to self-manage their health, potentially overcome clinical inertia around prescribing medication and save both the patient and practitioner time. However, practitioners also had some concerns. Some practitioners were concerned about the accuracy of patients' home blood pressure readings, or the potential for home monitoring to cause patients anxiety and therefore increase consultations. Some GPs lacked confidence in choosing multiple medication changes, or had concerns about unanticipated drug interactions. A few nurses were concerned that the model of patient support they were asked to provide was not consistent with their perceived role. Modifications were made to the intervention based on this feedback, which appeared to help overcome practitioners' concerns and improve the acceptability and feasibility of the intervention. CONCLUSIONS This paper provides a detailed example of using the Person-Based Approach to refine HOME BP, demonstrating how we improved the acceptability and feasibility of HOME BP based on feedback from practice staff. This demonstration may be useful to others developing digital interventions.
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Affiliation(s)
- Katherine Bradbury
- Academic unit of psychology, University of Southampton, Southampton, UK.
| | - Katherine Morton
- Academic unit of psychology, University of Southampton, Southampton, UK
| | - Rebecca Band
- Academic unit of psychology, University of Southampton, Southampton, UK
| | - Carl May
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Richard McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Little
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Academic unit of psychology, University of Southampton, Southampton, UK
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Improving management and effectiveness of home blood pressure monitoring: a qualitative UK primary care study. Br J Gen Pract 2016; 65:e776-83. [PMID: 26500326 DOI: 10.3399/bjgp15x687433] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Self-monitoring blood pressure (SMBP) is becoming an increasingly prevalent practice in UK primary care, yet there remains little conceptual understanding of why patients with hypertension engage in self-monitoring. AIM To identify psychological factors or processes prompting the decision to self-monitor blood pressure. DESIGN AND SETTING A qualitative study of patients previously participating in a survey study about SMBP from four general practices in the West Midlands. METHOD Taped and transcribed in-depth interviews with 16 patients (6 currently monitoring, 2 used to self-monitor, and 8 had never self-monitored). Thematic analysis was undertaken. RESULTS Three main themes emerged: 'self' and 'living with hypertension' described the emotional element of living with an asymptomatic condition; 'self-monitoring behaviour and medication' described overall views about self-monitoring, current practice, reasons for monitoring, and the impact on medication adherence; and 'the GP-patient transaction' described the power relations affecting decisions to self-monitor. Self-monitoring was performed by some as a protective tool against the fears of a silent but serious condition, whereas others self-monitor simply out of curiosity. People who self-monitored tended not to discuss this with their nurse or GP, partly due to perceiving minimal or no interest from their clinician about home monitoring, and partly due to fear of being prescribed additional medication. CONCLUSION The decision to self-monitor appeared often to be an individual choice with no schedule or systems to integrate it with other medical care. Better recognition by clinicians that patients are self-monitoring, perhaps utilising the results in shared decision-making, might help integrate it into daily practice.
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Patients' and clinicians' views on the optimum schedules for self-monitoring of blood pressure: a qualitative focus group and interview study. Br J Gen Pract 2016; 66:e819-e830. [PMID: 27381484 DOI: 10.3399/bjgp16x686149] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 04/24/2016] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Self-monitoring of blood pressure is common but guidance on how it should be carried out varies and it is currently unclear how such guidance is viewed. AIM To explore patients' and healthcare professionals' (HCPs) views and experiences of the use of different self-monitoring regimens to determine what is acceptable and feasible, and to inform future recommendations. DESIGN AND SETTING Thirteen focus groups and four HCP interviews were held, with a total of 66 participants (41 patients and 25 HCPs) from primary and secondary care with and without experience of self-monitoring. METHOD Standard and shortened self-monitoring protocols were both considered. Focus groups and interviews were recorded, transcribed verbatim, and analysed using the constant comparative method. RESULTS Patients generally supported structured schedules but with sufficient flexibility to allow adaptation to individual routine. They preferred a shorter (3-day) schedule to longer (7-day) regimens. Although HCPs could describe benefits for patients of using a schedule, they were reluctant to recommend a specific schedule. Concerns surrounded the use of different schedules for diagnosis and subsequent monitoring. Appropriate education was seen as vital by all participants to enable a self-monitoring schedule to be followed at home. CONCLUSION There is not a 'one size fits all approach' to developing the optimum protocol from the perspective of users and those implementing it. An approach whereby patients are asked to complete the minimum number of readings required for accurate blood pressure estimation in a flexible manner seems most likely to succeed. Informative advice and guidance should incorporate such flexibility for patients and professionals alike.
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Padwal R, McAlister FA, Wood PW, Boulanger P, Fradette M, Klarenbach S, Edwards AL, Holroyd-Leduc JM, Alagiakrishnan K, Rabi D, Majumdar SR. Telemonitoring and Protocolized Case Management for Hypertensive Community-Dwelling Seniors With Diabetes: Protocol of the TECHNOMED Randomized Controlled Trial. JMIR Res Protoc 2016; 5:e107. [PMID: 27343147 PMCID: PMC4938881 DOI: 10.2196/resprot.5775] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 04/03/2016] [Indexed: 12/22/2022] Open
Abstract
Background Diabetes and hypertension are devastating, deadly, and costly conditions that are very common in seniors. Controlling hypertension in seniors with diabetes dramatically reduces hypertension-related complications. However, blood pressure (BP) must be lowered carefully because seniors are also susceptible to low BP and attendant harms. Achieving “optimal BP control” (ie, avoiding both undertreatment and overtreatment) is the ultimate therapeutic goal in such patients. Regular BP monitoring is required to achieve this goal. BP monitoring at home is cheap, convenient, widely used, and guideline endorsed. However, major barriers prevent proper use. These may be overcome through use of BP telemonitoring—the secure teletransmission of BP readings to a health portal, where BP data are summarized for provider and patient use, with or without protocolized case management. Objective To examine the incremental effectiveness, safety, cost-effectiveness, usability, and acceptability of home BP telemonitoring, used with or without protocolized case management, compared with “enhanced usual care” in community-dwelling seniors with diabetes and hypertension. Methods A 300-patient, 3-arm, pragmatic randomized controlled trial with blinded outcome ascertainment will be performed in seniors with diabetes and hypertension living independently in seniors’ residences in greater Edmonton. Consenting patients will be randomized to usual care, home BP telemonitoring alone, or home BP telemonitoring plus protocolized pharmacist case management. Usual care subjects will receive a home BP monitor but neither they nor their providers will have access to teletransmitted data. In both telemonitored arms, providers will receive telemonitored BP data summaries. In the case management arm, pharmacist case managers will be responsible for reviewing teletransmitted data and initiating guideline-concordant and protocolized changes in BP management. Results Outcomes will be ascertained at 6 and 12 months. Within-study-arm change scores will be calculated and compared between study arms. These include: (1) clinical outcomes: proportion of subjects with a mean 24-hour ambulatory systolic BP in the optimal range (110-129 mmHg in patients 65-79 years and 110-139 mmHg in those ≥80 years: primary outcome); additional ambulatory and home BP outcomes; A1c and lipid profile; medications, cognition, health care use, cardiovascular events, and mortality. (2) Safety outcomes: number of serious episodes of hypotension, syncope, falls, and electrolyte disturbances (requiring third party assistance or medical attention). (3) Humanistic outcomes: quality of life, satisfaction, and medication adherence. (4) Economic outcomes: incremental costs, incremental cost-utility, and cost per mmHg change in BP of telemonitoring ± case management compared with usual care (health payor and societal perspectives). (5) Intervention usability and acceptability to patients and providers. Conclusion The potential benefits of telemonitoring remain largely unstudied and unproven in seniors. This trial will comprehensively assess the impact of home BP telemonitoring across a range of outcomes. Results will inform the value of implementing home-based telemonitoring within supportive living residences in Canada. Trial Registration Clinicaltrials.gov NCT02721667; https://clinicaltrials.gov/ct2/show/NCT02721667 (Archived by Webcite at http://www.webcitation.org/6i8tB20Mc)
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Affiliation(s)
- Raj Padwal
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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Swendeman D, Farmer S, Mindry D, Lee SJ, Medich M. HIV Care Providers' Attitudes regarding Mobile Phone Applications and Web-Based Dashboards to support Patient Self-Management and Care Coordination: Results from a Qualitative Feasibility Study. ACTA ACUST UNITED AC 2016; 2. [PMID: 28066820 PMCID: PMC5217706 DOI: 10.16966/2380-5536.127] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In-depth qualitative interviews were conducted with healthcare providers (HCPs) from five HIV medical care coordination teams in a large Los Angeles County HIV clinic, including physicians, nurses, and psychosocial services providers. HCPs reported on the potential utility, acceptability, and barriers for patient self-monitoring and notifications via mobile phones, and web-based dashboards for HCPs. Potential benefits included: 1) enhancing patient engagement, motivation, adherence, and self-management; and 2) improving provider-patient relationships and HCP care coordination. Newly diagnosed and patients with co-morbidities were highest priorities for mobile application support. Facilitators included universal mobile phone ownership and use of smartphones or text messaging. Patient-level barriers included concerns about low motivation and financial instability for consistent use by some patients. Organizational barriers, cited primarily by physicians, included concerns about privacy protections, easy dashboard access, non-integrated electronic records, and competing burdens in limited appointment times. Psychosocial services providers were most supportive of the proposed mobile tools.
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Affiliation(s)
- Dallas Swendeman
- Center for HIV Identification, Prevention, and Treatment Services (CHIPTS), Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine at UCLA, and Department of Epidemiology, UCLA Fielding School of Public Health, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA 90024, USA
| | - Shu Farmer
- Center for HIV Identification, Prevention, and Treatment Services (CHIPTS), Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine at UCLA, and Department of Epidemiology, UCLA Fielding School of Public Health, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA 90024, USA
| | - Deborah Mindry
- Center for Culture and Health, Department of Psychiatry and Biobehavioral Science, NPI-Semel Institute for Neuroscience, 760 Westwood Plaza, Box 62, Los Angeles, CA 90024-1759, USA
| | - Sung-Jae Lee
- Center for HIV Identification, Prevention, and Treatment Services (CHIPTS), Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine at UCLA, and Department of Epidemiology, UCLA Fielding School of Public Health, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA 90024, USA
| | - Melissa Medich
- Center for HIV Identification, Prevention, and Treatment Services (CHIPTS), Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine at UCLA, and Department of Epidemiology, UCLA Fielding School of Public Health, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA 90024, USA
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Fletcher BR, Hinton L, Hartmann-Boyce J, Roberts NW, Bobrovitz N, McManus RJ. Self-monitoring blood pressure in hypertension, patient and provider perspectives: A systematic review and thematic synthesis. PATIENT EDUCATION AND COUNSELING 2016; 99:210-219. [PMID: 26341941 DOI: 10.1016/j.pec.2015.08.026] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 08/12/2015] [Accepted: 08/20/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To systematically review the qualitative evidence for patient and clinician perspectives on self-measurement of blood pressure (SMBP) in the management of hypertension focussing on: how SMBP was discussed in consultations; the motivation for patients to start self-monitoring; how both patients and clinicians used SMBP to promote behaviour change; perceived barriers and facilitators to SMBP use by patients and clinicians. METHODS Medline, Embase, PsycINFO, Cinahl, Web of Science, SocAbs were searched for empirical qualitative studies that met the review objectives. Reporting of included studies was assessed using the COREQ framework. All relevant data from results/findings sections of included reports were extracted, coded inductively using thematic analysis, and overarching themes across studies were abstracted. RESULTS Twelve studies were included in the synthesis involving 358 patients and 91 clinicians. Three major themes are presented: interpretation, attribution and action; convenience and reassurance v anxiety and uncertainty; and patient autonomy and empowerment improve patient-clinician alliance. CONCLUSIONS SMBP was successful facilitating the interaction in consultations about hypertension, bridging a potential gap in the traditional patient-clinician relationship. PRACTICE IMPLICATIONS Uncertainty could be reduced by providing information specifically about how to interpret SMBP, what variation is acceptable, adjustment for home-clinic difference, and for patients what they should be concerned about and how to act.
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Affiliation(s)
- Benjamin R Fletcher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Lisa Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia W Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Niklas Bobrovitz
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Omboni S, Ferrari R. The role of telemedicine in hypertension management: focus on blood pressure telemonitoring. Curr Hypertens Rep 2016; 17:535. [PMID: 25790799 DOI: 10.1007/s11906-015-0535-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This review aims at updating and critically assessing the role of telemedicine, and in particular, of home blood pressure telemonitoring (HBPT), in the management of the hypertensive patient. Result from several randomized trials suggest that HBPT represents a promising tool for improving blood pressure (BP) control of hypertensive patients, in particular, those at high risk. Most studies documented a significant BP reduction with regular HBPT compared to usual care. HBPT interventions showed a very high degree of acceptance by patients, helped improving the patients' quality of life, and were associated with lower medical costs than standard care, even though such costs were offset by those of the technology, thus reducing the overall cost-effectiveness of HBPT. The high heterogeneity of the technologies, study designs, and type of patients in the various studies suggest that further well-designed, large cohort, prospective studies are needed to identify key elements of HBPT approach to be able to give impact on specific outcomes. Likely, patients who need a constant monitoring of multiple vital signs and a tight BP control, such as high risk patients with chronic diseases (ischemic heart disease or heart failure, diabetes, etc.), as well as non-adherent patients, may particularly benefit from HBPT. In general, HBPT can be an advantageous choice when a network among healthcare professionals (doctors, nurses, and pharmacists) is needed to improve the screening and management of hypertension and related comorbidities and to achieve an effective prevention of cardiovascular diseases in the community.
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Affiliation(s)
- Stefano Omboni
- Clinical Research Unit, Italian Institute of Telemedicine, Via Colombera 29, 21048, Solbiate Arno, Varese, Italy,
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Abdullah A, Liew SM, Hanafi NS, Ng CJ, Lai PSM, Chia YC, Loo CK. What influences patients' acceptance of a blood pressure telemonitoring service in primary care? A qualitative study. Patient Prefer Adherence 2016; 10:99-106. [PMID: 26869773 PMCID: PMC4734809 DOI: 10.2147/ppa.s94687] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Telemonitoring of home blood pressure (BP) is found to have a positive effect on BP control. Delivering a BP telemonitoring service in primary care offers primary care physicians an innovative approach toward management of their patients with hypertension. However, little is known about patients' acceptance of such service in routine clinical care. OBJECTIVE This study aimed to explore patients' acceptance of a BP telemonitoring service delivered in primary care based on the technology acceptance model (TAM). METHODS A qualitative study design was used. Primary care patients with uncontrolled office BP who fulfilled the inclusion criteria were enrolled into a BP telemonitoring service offered between the period August 2012 and September 2012. This service was delivered at an urban primary care clinic in Kuala Lumpur, Malaysia. Twenty patients used the BP telemonitoring service. Of these, 17 patients consented to share their views and experiences through five in-depth interviews and two focus group discussions. An interview guide was developed based on the TAM. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was used for analysis. RESULTS Patients found the BP telemonitoring service easy to use but struggled with the perceived usefulness of doing so. They expressed confusion in making sense of the monitored home BP readings. They often thought about the implications of these readings to their hypertension management and overall health. Patients wanted more feedback from their doctors and suggested improvement to the BP telemonitoring functionalities to improve interactions. Patients cited being involved in research as the main reason for their intention to use the service. They felt that patients with limited experience with the internet and information technology, who worked out of town, or who had an outdoor hobby would not be able to benefit from such a service. CONCLUSION Patients found BP telemonitoring service in primary care easy to use but needed help to interpret the meanings of monitored BP readings. Implementations of BP telemonitoring service must tackle these issues to maximize the patients' acceptance of a BP telemonitoring service.
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Affiliation(s)
- Adina Abdullah
- Department of Primary Care Medicine, Faculty of Medicine, University Malaya Primary Care Research Group, University of Malaya, Kuala Lumpur, Malaysia
- Correspondence: Adina Abdullah, Department of Primary Care Medicine, Faculty of Medicine, University Malaya Primary Care Research Group, University of Malaya, Wilayah Persekutuan, 50603 Kuala Lumpur, Malaysia, Email
| | - Su May Liew
- Department of Primary Care Medicine, Faculty of Medicine, University Malaya Primary Care Research Group, University of Malaya, Kuala Lumpur, Malaysia
| | - Nik Sherina Hanafi
- Department of Primary Care Medicine, Faculty of Medicine, University Malaya Primary Care Research Group, University of Malaya, Kuala Lumpur, Malaysia
| | - Chirk Jenn Ng
- Department of Primary Care Medicine, Faculty of Medicine, University Malaya Primary Care Research Group, University of Malaya, Kuala Lumpur, Malaysia
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, Faculty of Medicine, University Malaya Primary Care Research Group, University of Malaya, Kuala Lumpur, Malaysia
| | - Yook Chin Chia
- Department of Primary Care Medicine, Faculty of Medicine, University Malaya Primary Care Research Group, University of Malaya, Kuala Lumpur, Malaysia
| | - Chu Kiong Loo
- Department of Artificial Intelligence, Faculty of Computer Science and Information Technology, University of Malaya, Kuala Lumpur, Malaysia
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Hanley J, Fairbrother P, McCloughan L, Pagliari C, Paterson M, Pinnock H, Sheikh A, Wild S, McKinstry B. Qualitative study of telemonitoring of blood glucose and blood pressure in type 2 diabetes. BMJ Open 2015; 5:e008896. [PMID: 26700275 PMCID: PMC4691739 DOI: 10.1136/bmjopen-2015-008896] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To explore the experiences of patients and professionals taking part in a randomised controlled trial (RCT) of blood glucose, blood pressure (BP) and weight telemonitoring in type 2 diabetes supported by primary care, and identify factors facilitating or hindering the effectiveness of the intervention and those likely to influence its potential translation to routine practice. DESIGN Qualitative study adopting an interpretive descriptive approach. PARTICIPANTS 23 patients, 6 nurses and 4 doctors who were participating in a RCT of blood glucose and BP telemonitoring. A maximum variation sample of patients from within the trial based on age, sex and deprivation status of the practice was sought. SETTING 12 primary care practices in Scotland and England. METHOD Data were collected via recorded semistructured interviews. Analysis was inductive with themes presented within an overarching thematic framework. Multiple strategies were employed to ensure that the analysis was credible and trustworthy. RESULTS Telemonitoring of blood glucose, BP and weight by people with type 2 diabetes was feasible. The data generated by telemonitoring supported self-care decisions and medical treatment decisions. Motivation to self-manage diet was increased by telemonitoring of blood glucose, and the 'benign policing' aspect of telemonitoring was considered by patients to be important. The convenience of home monitoring was very acceptable to patients although professionals had some concerns about telemonitoring increasing workload and costs. CONCLUSIONS Telemonitoring of blood glucose, BP and weight in primary care is a promising way of improving diabetes management which would be highly acceptable to the type of patients who volunteered for this study. TRIAL REGISTRATION NUMBER ISRCTN71674628; Pre-results.
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Affiliation(s)
- Janet Hanley
- Department of Nursing Midwifer and Social Care, Edinburgh Napier University, Edinburgh, UK
- Edinburgh Health Services Research Unit, Edinburgh, UK
| | | | - Lucy McCloughan
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Claudia Pagliari
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Mary Paterson
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Hilary Pinnock
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Sarah Wild
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
- Department of Public Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Brian McKinstry
- Edinburgh Health Services Research Unit, Edinburgh, UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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Harvey J, Dopson S, McManus RJ, Powell J. Factors influencing the adoption of self-management solutions: an interpretive synthesis of the literature on stakeholder experiences. Implement Sci 2015; 10:159. [PMID: 26566623 PMCID: PMC4644277 DOI: 10.1186/s13012-015-0350-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 11/10/2015] [Indexed: 11/10/2022] Open
Abstract
Background In a research context, self-management solutions, which may range from simple book diaries to complex telehealth packages, designed to facilitate patients in managing their long-term conditions, have often shown cost-effectiveness, but their implementation in practice has frequently been challenging. Methods We conducted an interpretive qualitative synthesis of relevant articles identified through systematic searches of bibliographic databases in July 2014. We searched PubMed (Medline/NLM), Web of Science, LISTA (EBSCO), CINAHL, Embase and PsycINFO. Coding and analysis was inductive, using the framework method to code and to categorise themes. We took a sensemaking approach to the interpretation of findings. Results Fifty-eight articles were selected for synthesis. Results showed that during adoption, factors identified as facilitators by some were experienced as barriers by others, and facilitators could change to barriers for the same adopter, depending on how adopters rationalise the solutions within their context when making decisions about (retaining) adoption. Sometimes, when adopters saw and experienced benefits of a solution, they continued using the solution but changed their minds when they could no longer see the benefits. Thus, adopters placed a positive value on the solution if they could constructively rationalise it (which increased adoption) and attached a negative rationale (decreasing adoption) if the solution did not meet their expectations. Key factors that influenced the way adopters rationalised the solutions consisted of costs and the added value of the solution to them and moral, social, motivational and cultural factors. Conclusions Considering ‘barriers’ and ‘facilitators’ for implementation may be too simplistic. Implementers could instead iteratively re-evaluate how potential facilitators and barriers are being experienced by adopters throughout the implementation process, to help adopters to retain constructive evaluations of the solution. Implementers need to pay attention to factors including (a) cost: how much resource will the intervention cost the patient or professional; (b) moral: to what extent will people adhere because they want to be ‘good’ patients and professionals; (c) social: the expectations of patients and professionals regarding the interactive support they will receive; (d) motivational: motivations to engage with the intervention and (e) cultural: how patients and professionals learn and integrate new skills into their daily routines, practices and cultures.
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Affiliation(s)
- J Harvey
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock road, Oxford, OX2 6GG, UK.
| | - S Dopson
- Saïd Business School, University of Oxford, Park End Street, Oxford, OX1 1HP, UK.
| | - R J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock road, Oxford, OX2 6GG, UK.
| | - J Powell
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock road, Oxford, OX2 6GG, UK.
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Flodgren G, Rachas A, Farmer AJ, Inzitari M, Shepperd S. Interactive telemedicine: effects on professional practice and health care outcomes. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [PMID: 26343551 DOI: 10.1002/14651858.cd002098.pub2.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care. OBJECTIVES To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation). SEARCH METHODS We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies. SELECTION CRITERIA We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions. DATA COLLECTION AND ANALYSIS For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes. MAIN RESULTS We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups. AUTHORS' CONCLUSIONS The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.
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Affiliation(s)
- Gerd Flodgren
- Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Roosevelt Drive, Headington, Oxford, Oxfordshire, UK, OX3 7LF
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Flodgren G, Rachas A, Farmer AJ, Inzitari M, Shepperd S. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2015; 2015:CD002098. [PMID: 26343551 PMCID: PMC6473731 DOI: 10.1002/14651858.cd002098.pub2] [Citation(s) in RCA: 342] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care. OBJECTIVES To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation). SEARCH METHODS We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies. SELECTION CRITERIA We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions. DATA COLLECTION AND ANALYSIS For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes. MAIN RESULTS We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups. AUTHORS' CONCLUSIONS The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.
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Affiliation(s)
- Gerd Flodgren
- Norwegian Institute of Public HealthThe Norwegian Knowledge Centre for the Health ServicesPilestredet Park 7OsloNorway0176
| | - Antoine Rachas
- European Hospital Georges Pompidou and Paris Descartes UniversityDepartment of IT and Public Health20‐40 Rue leBlancParisFrance75908
| | - Andrew J Farmer
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory Quarter, Walton StreetOxfordUKOX2 6GG
| | - Marco Inzitari
- Parc Sanitari Pere Virgili and Universitat Autònoma de BarcelonaDepartment of Healthcare/Medicinec Esteve Terrades 30BarcelonaSpain08023
| | - Sasha Shepperd
- University of OxfordNuffield Department of Population HealthRosemary Rue Building, Old Road CampusHeadingtonOxfordOxfordshireUKOX3 7LF
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Hanley J, Fairbrother P, Krishan A, McCloughan L, Padfield P, Paterson M, Pinnock H, Sheikh A, Sudlow C, Todd A, McKinstry B. Mixed methods feasibility study for a trial of blood pressure telemonitoring for people who have had stroke/transient ischaemic attack (TIA). Trials 2015; 16:117. [PMID: 25873155 PMCID: PMC4404620 DOI: 10.1186/s13063-015-0628-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 03/03/2015] [Indexed: 11/24/2022] Open
Abstract
Background Good blood pressure (BP) control reduces the risk of recurrence of stroke/transient ischaemic attack (TIA). Although there is strong evidence that BP telemonitoring helps achieve good control, none of the major trials have considered the effectiveness in stroke/TIA survivors. We therefore conducted a feasibility study for a trial of BP telemonitoring for stroke/TIA survivors with uncontrolled BP in primary care. Method Phase 1 was a pilot trial involving 55 patients stratified by stroke/TIA randomised 3:1 to BP telemonitoring for 6 months or usual care. Phase 2 was a qualitative evaluation and comprised semi-structured interviews with 16 trial participants who received telemonitoring and 3 focus groups with 23 members of stroke support groups and 7 carers. Results Overall, 125 patients (60 stroke patients, 65 TIA patients) were approached and 55 (44%) patients were randomised including 27 stroke patients and 28 TIA patients. Fifty-two participants (95%) attended the 6-month follow-up appointment, but one declined the second daytime ambulatory blood pressure monitoring (ABPM) measurement resulting in a 93% completion rate for ABPM − the proposed primary outcome measure for a full trial. Adherence to telemonitoring was good; of the 40 participants who were telemonitoring, 38 continued to provide readings throughout the 6 months. There was a mean reduction of 10.1 mmHg in systolic ABPM in the telemonitoring group compared with 3.8 mmHg in the control group, which suggested the potential for a substantial effect from telemonitoring. Our qualitative analysis found that many stroke patients were concerned about their BP and telemonitoring increased their engagement, was easy, convenient and reassuring. Conclusions A full-scale trial is feasible, likely to recruit well and have good rates of compliance and follow-up. Trial Registration ISRCTN61528726 15/12/2011. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0628-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Janet Hanley
- Edinburgh Napier University, Sighthill Campus, Sighthill Court, Edinburgh, EH11 4BN, UK. .,Edinburgh Health Services Research Unit/Edinburgh Clinical Trials Unit, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, UK.
| | - Peter Fairbrother
- NHS Lothian, C/O Telescot Programme, Centre for Population Health Sciences, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9DX, UK.
| | - Ashma Krishan
- Edinburgh Health Services Research Unit/Edinburgh Clinical Trials Unit, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, UK.
| | - Lucy McCloughan
- Telescot Programme, Centre for Population Health Sciences, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9DX, UK.
| | - Paul Padfield
- Telescot Programme, Centre for Population Health Sciences, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9DX, UK.
| | - Mary Paterson
- Telescot Programme, Centre for Population Health Sciences, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9DX, UK.
| | - Hilary Pinnock
- Telescot Programme, Centre for Population Health Sciences, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9DX, UK.
| | - Aziz Sheikh
- Telescot Programme, Centre for Population Health Sciences, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9DX, UK.
| | - Cathie Sudlow
- Telescot Programme, Centre for Population Health Sciences, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9DX, UK.
| | - Allison Todd
- NHS Lothian, C/O Telescot Programme, Centre for Population Health Sciences, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9DX, UK.
| | - Brian McKinstry
- Edinburgh Health Services Research Unit/Edinburgh Clinical Trials Unit, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, UK. .,Telescot Programme, Centre for Population Health Sciences, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9DX, UK.
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Hübner U. What Are Complex eHealth Innovations and How Do You Measure Them? Position Paper. Methods Inf Med 2014; 54:319-27. [PMID: 25510406 DOI: 10.3414/me14-05-0001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 10/20/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVES eHealth and innovation are often regarded as synonyms - not least because eHealth technologies and applications are new to their users. This position paper challenges this view and aims at exploring the nature of eHealth innovation against the background of common definitions of innovation and facts from the biomedical and health informatics literature. A good understanding of what constitutes innovative eHealth developments allows the degree of innovation to be measured and interpreted. METHODS To this end, relevant biomedical and health informatics literature was searched mainly in Medline and ACM digital library. This paper presents seven facts about implementing and applying new eHealth developments hereby drawing on the experience published in the literature. RESULTS The facts are: 1. eHealth innovation is relative. 2. Advanced clinical practice is the yardstick. 3. Only used and usable eHealth technology can give birth to eHealth innovatio. 4. One new single eHealth function does not make a complex eHealth innovation. 5. eHealth innovation is more evolution than revolution. 6. eHealth innovation is often triggered behind the scenes; and 7. There is no eHealth innovation without sociocultural change. CONCLUSIONS The main conclusion of the seven facts is that eHealth innovations have many ingredients: newness, availability, advanced clinical practice with proven outcomes, use and usability, the supporting environment, other context factors and the stakeholder perspectives. Measuring eHealth innovation is thus a complex matter. To this end we propose the development of a composite score that expresses comprehensively the nature of eHealth innovation and that breaks down its complexity into the three dimensions: i) eHealth adoption, ii) partnership with advanced clinical practice, and iii) use and usability of eHealth. In order to better understand the momentum and mechanisms behind eHealth innovation the fourth dimension, iv) eHealth supporting services and means, needs to be studied. Conceptualising appropriate measurement instruments also requires eHealth innovation to be distinguished from eHealth sophistication, performance and quality, although innovation is intertwined with these concepts. The demanding effort for defining eHealth innovation and measuring it properly seem worthwhile and promise advances in creating better systems. This paper thus intends to stimulate the necessary discussion.
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Affiliation(s)
- U Hübner
- U. Hübner, Health Informatics Research Group, Hochschule Osnabrück, Caprivistr. 30A, 49076 Osnabrück, Germany, E-mail:
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Guise V, Anderson J, Wiig S. Patient safety risks associated with telecare: a systematic review and narrative synthesis of the literature. BMC Health Serv Res 2014; 14:588. [PMID: 25421823 PMCID: PMC4254014 DOI: 10.1186/s12913-014-0588-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 11/10/2014] [Indexed: 12/04/2022] Open
Abstract
Background Patient safety risk in the homecare context and patient safety risk related to telecare are both emerging research areas. Patient safety issues associated with the use of telecare in homecare services are therefore not clearly understood. It is unclear what the patient safety risks are, how patient safety issues have been investigated, and what research is still needed to provide a comprehensive picture of risks, challenges and potential harm to patients due to the implementation and use of telecare services in the home. Furthermore, it is unclear how training for telecare users has addressed patient safety issues. A systematic review of the literature was conducted to identify patient safety risks associated with telecare use in homecare services and to investigate whether and how these patient safety risks have been addressed in telecare training. Methods Six electronic databases were searched in addition to hand searches of key items, reference tracking and citation tracking. Strict inclusion and exclusion criteria were set. All included items were assessed according to set quality criteria and subjected to a narrative synthesis to organise and synthesize the findings. A human factors systems framework of patient safety was used to frame and analyse the results. Results 22 items were included in the review. 11 types of patient safety risks associated with telecare use in homecare services emerged. These are in the main related to the nature of homecare tasks and practices, and person-centred characteristics and capabilities, and to a lesser extent, problems with the technology and devices, organisational issues, and environmental factors. Training initiatives related to safe telecare use are not described in the literature. Conclusions There is a need to better identify and describe patient safety risks related to telecare services to improve understandings of how to avoid and minimize potential harm to patients. This process can be aided by reframing known telecare implementation challenges and user experiences of telecare with the help of a human factors systems approach to patient safety.
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Affiliation(s)
- Veslemøy Guise
- Department of Health Studies, University of Stavanger, Kjell Arholms gate, 4036, Stavanger, Norway.
| | - Janet Anderson
- Department of Health Studies, University of Stavanger, Kjell Arholms gate, 4036, Stavanger, Norway. .,Florence Nightingale School of Nursing and Midwifery, Kings College London, London, UK.
| | - Siri Wiig
- Department of Health Studies, University of Stavanger, Kjell Arholms gate, 4036, Stavanger, Norway.
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Progress toward the prevention and treatment of atrial fibrillation: A summary of the Heart Rhythm Society Research Forum on the Treatment and Prevention of Atrial Fibrillation, Washington, DC, December 9-10, 2013. Heart Rhythm 2014; 12:e5-e29. [PMID: 25460864 DOI: 10.1016/j.hrthm.2014.11.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Indexed: 02/07/2023]
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Davidson E, Simpson CR, Demiris G, Sheikh A, McKinstry B. Integrating telehealth care-generated data with the family practice electronic medical record: qualitative exploration of the views of primary care staff. Interact J Med Res 2013; 2:e29. [PMID: 24280631 PMCID: PMC3869047 DOI: 10.2196/ijmr.2820] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 09/14/2013] [Accepted: 11/04/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Telehealth care is increasingly being employed in the management of long-term illness. Current systems are largely managed via "stand-alone" websites, which require additional log-ons for clinicians to view their patients' symptom records and physiological measurements leading to frustrating delays and sometimes failure to engage with the record. However, there are challenges to the full integration of patient-acquired data into family physicians' electronic medical records (EMR) in terms of reliability, how such data can best be summarized and presented to avoid overload to the clinicians, and how clarity of responsibility is managed when multiple agencies are involved. OBJECTIVE We aimed to explore the views of primary care clinicians on the acceptability, clinical utility, and, in particular, the benefits and risks of integrating patient-generated telehealth care data into the family practice EMR and to explore how these data should be summarized and presented in order to facilitate use in routine care. METHODS In our qualitative study, we carried out semi-structured interviews with clinicians with experience of and naïve to telehealth care following demonstration of pilot software, which illustrated various methods by which data could be incorporated into the EMR. RESULTS We interviewed 20 clinicians and found 2 overarching themes of "workload" and "safety". Although clinicians were largely positive about integrating telehealth care data into the EMR, they were concerned about the potential increased workload and safety issues, particularly in respect to error due to data overload. They suggested these issues could be mitigated by good system design that summarized and presented data such that they facilitated seamless integration with clinicians' current routine processes for managing data flows, and ensured clear lines of communication and responsibility between multiple professionals involved in patients' care. CONCLUSIONS Family physicians and their teams are likely to be receptive to and see the benefits of integrating telehealth-generated data into the EMR. Our study identified some of the key challenges that must be overcome to facilitate integration of telehealth care data. This work particularly underlines the importance of actively engaging with clinicians to ensure that systems are designed that align well with existing practice data-flow management systems and facilitate safe multiprofessional patient care.
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Affiliation(s)
- Emma Davidson
- eHealth Group, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, United Kingdom
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Stoddart A, Hanley J, Wild S, Pagliari C, Paterson M, Lewis S, Sheikh A, Krishan A, Padfield P, McKinstry B. Telemonitoring-based service redesign for the management of uncontrolled hypertension (HITS): cost and cost-effectiveness analysis of a randomised controlled trial. BMJ Open 2013; 3:e002681. [PMID: 23793650 PMCID: PMC3657667 DOI: 10.1136/bmjopen-2013-002681] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Accepted: 04/11/2013] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To compare the costs and cost-effectiveness of managing patients with uncontrolled blood pressure (BP) using telemonitoring versus usual care from the perspective of the National Health Service (NHS). DESIGN Within trial post hoc economic evaluation of data from a pragmatic randomised controlled trial using an intention-to-treat approach. SETTING 20 socioeconomically diverse general practices in Lothian, Scotland. PARTICIPANTS 401 primary care patients aged 29-95 with uncontrolled daytime ambulatory blood pressure (ABP) (≥135/85, but <210/135 mm Hg). INTERVENTION Participants were centrally randomised to 6 months of a telemonitoring service comprising of self-monitoring of BP transmitted to a secure website for review by the attending nurse/doctor and patient, with optional automated patient decision-support by text/email (n=200) or usual care (n-201). Randomisation was undertaken with minimisation for age, sex, family practice, use of three or more hypertension drugs and self-monitoring history. MAIN OUTCOME MEASURES Mean difference in total NHS costs between trial arms and blinded assessment of mean cost per 1 mm Hg systolic BP point reduced. RESULTS Home telemonitoring of BP costs significantly more than usual care (mean difference per patient £115.32 (95% CI £83.49 to £146.63; p<0.001)). Increased costs were due to telemonitoring service costs, patient training and additional general practitioner and nurse consultations. The mean cost of systolic BP reduction was £25.56/mm Hg (95% CI £16.06 to £46.89) per patient. CONCLUSIONS Over the 6-month trial period, supported telemonitoring was more effective at reducing BP than usual care but also more expensive. If clinical gains are maintained, these additional costs would be very likely to be compensated for by reductions in the cost of future cardiovascular events. Longer-term modelling of costs and outcomes is required to fully examine the cost-effectiveness implications. TRIAL REGISTRATION International Standard Randomised Controlled Trials, number ISRCTN72614272.
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Affiliation(s)
- Andrew Stoddart
- Edinburgh Clinical Trials Unit, University of Edinburgh, Western General Hospital, Edinburgh, Midlothian, UK
| | - Janet Hanley
- School of Nursing, Midwifery and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Sarah Wild
- The University of Edinburgh, Centre for Population Health Sciences, Edinburgh, UK
| | - Claudia Pagliari
- The University of Edinburgh, Centre for Population Health Sciences, Edinburgh, UK
| | - Mary Paterson
- The University of Edinburgh, Centre for Population Health Sciences, Edinburgh, UK
| | - Steff Lewis
- The University of Edinburgh, Centre for Population Health Sciences, Edinburgh, UK
| | - Aziz Sheikh
- The University of Edinburgh, Centre for Population Health Sciences, Edinburgh, UK
| | - Ashma Krishan
- Edinburgh Clinical Trials Unit, University of Edinburgh, Western General Hospital, Edinburgh, Midlothian, UK
| | | | - Brian McKinstry
- The University of Edinburgh, Centre for Population Health Sciences, Edinburgh, UK
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McKinstry B, Hanley J, Wild S, Pagliari C, Paterson M, Lewis S, Sheikh A, Krishan A, Stoddart A, Padfield P. Telemonitoring based service redesign for the management of uncontrolled hypertension: multicentre randomised controlled trial. BMJ 2013; 346:f3030. [PMID: 23709583 PMCID: PMC3663293 DOI: 10.1136/bmj.f3030] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2013] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To determine if an intervention consisting of telemonitoring and supervision by usual primary care clinicians of home self measured blood pressure and optional patient decision support leads to clinically important reductions in daytime systolic and diastolic ambulatory blood pressure in patients with uncontrolled blood pressure. DESIGN Multicentre randomised controlled trial. SETTING 20 primary care practices in south east Scotland. PARTICIPANTS 401 people aged 29-95 years with uncontrolled blood pressure (mean daytime ambulatory measurement ≥ 135/85 mm Hg but ≤ 210/135 mm Hg). INTERVENTION Self measurement and transmission of blood pressure readings to a secure website for review by the attending nurse or doctor and participant, with optional automated patient decision support by text or email for six months. MAIN OUTCOME MEASURES Blinded assessment of mean daytime systolic ambulatory blood pressure six months after randomisation. RESULTS 200 participants were randomised to the intervention and 201 to usual care; primary outcome data were available for 90% of participants (182 and 177, respectively). The mean difference in daytime systolic ambulatory blood pressure adjusted for baseline and minimisation factors between intervention and usual care was 4.3 mm Hg (95% confidence interval 2.0 to 6.5; P=0.0002) and for daytime diastolic ambulatory blood pressure was 2.3 mm Hg (0.9 to 3.6; P=0.001), with higher values in the usual care group. The intervention was associated with a mean increase of one general practitioner (95% confidence interval 0.5 to 1.6; P=0.0002) and 0.6 (0.1 to 1.0; P=0.01) practice nurse consultations during the course of the study. CONCLUSIONS Supported self monitoring by telemonitoring is an effective method for achieving clinically important reductions in blood pressure in patients with uncontrolled hypertension in primary care settings. However, it was associated with increase in use of National Health Service resources. Further research is required to determine if the reduction in blood pressure is maintained in the longer term and if the intervention is cost effective. TRIAL REGISTRATION Current Controlled Trials ISRCTN72614272.
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Affiliation(s)
- Brian McKinstry
- Centre for Population Health Sciences, Medical School, University of Edinburgh, Edinburgh EH8 9AG, UK.
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