TElehealth in CHronic disease: mixed-methods study to develop the TECH conceptual model for intervention design and evaluation

Symptom-related screening programme for early detection of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the SYSPPE study

BACKGROUND

Chronic thromboembolic pulmonary hypertension (CTEPH) is the most severe long-term complication of acute pulmonary embolism (PE). We aimed to evaluate the impact of a symptom screening programme to detect CTEPH in PE survivors.

METHODS

This was a multicentre cohort study of patients diagnosed with acute symptomatic PE between January 2017 and December 2018 in 16 centres in Spain. Patients were contacted by phone 2 years after the index PE diagnosis. Those with dyspnoea corresponding to a New York Heart Association (NYHA)/WHO scale≥II, visited the outpatient clinic for echocardiography and further diagnostic tests including right heart catheterisation (RHC). The primary outcome was the new diagnosis of CTEPH confirmed by RHC.

RESULTS

Out of 1077 patients with acute PE, 646 were included in the symptom screening. At 2 years, 21.8% (n=141) reported dyspnoea NYHA/WHO scale≥II. Before symptom screening protocol, five patients were diagnosed with CTEPH following routine care. In patients with NYHA/WHO scale≥II, after symptom screening protocol, the echocardiographic probability of pulmonary hypertension (PH) was low, intermediate and high in 76.6% (n=95), 21.8% (n=27) and 1.6% (n=2), respectively. After performing additional diagnostic test in the latter 2 groups, 12 additional CTEPH cases were confirmed.

CONCLUSIONS

The implementation of this simple strategy based on symptom evaluation by phone diagnosed more than doubled the number of CTEPH cases. Dedicated follow-up algorithms for PE survivors help diagnosing CTEPH earlier.

TRIAL REGISTRATION NUMBER

NCT03953560.

Effect of Chronic Disease Home Telehealth Monitoring in the Veterans Health Administration on Healthcare Utilization and Mortality

BACKGROUND

The high prevalence of chronic diseases, including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM), accounts for a large burden of cost and poor health outcomes in US hospitals, and home telehealth (HT) monitoring has been proposed to improve outcomes.

OBJECTIVE

To measure the association between HT initiation and 12-month inpatient hospitalizations, emergency department (ED) visits, and mortality in veterans with CHF, COPD, or DM.

DESIGN

Comparative effectiveness matched cohort study.

PATIENTS

Veterans aged 65 years and older treated for CHF, COPD, or DM.

MAIN MEASURES

We matched veterans initiating HT with veterans with similar demographics who did not use HT (1:3). Our outcome measures included a 12-month risk of inpatient hospitalization, ED visits, and all-cause mortality.

KEY RESULTS

A total of 139,790 veterans with CHF, 65,966 with COPD, and 192,633 with DM were included in this study. In the year after HT initiation, the risk of hospitalization was not different in those with CHF (adjusted odds ratio [aOR] 1.01, 95% confidence interval [95%CI] 0.98-1.05) or DM (aOR 1.00, 95%CI 0.97-1.03), but it was higher in those with COPD (aOR 1.15, 95%CI 1.09-1.21). The risk of ED visits was higher among HT users with CHF (aOR 1.09, 95%CI 1.05-1.13), COPD (1.24, 95%CI 1.18-1.31), and DM (aOR 1.03, 95%CI 1.00-1.06). All-cause 12-month mortality was lower in those initiating HT monitoring with CHF (aOR 0.70, 95%CI 0.67-0.73) and DM (aOR 0.79, 95%CI 0.75-0.83), but higher in COPD (aOR 1.08, 95%CI 1.00-1.16).

CONCLUSIONS

The initiation of HT was associated with increased ED visits, no change in hospitalizations, and lower all-cause mortality in patients with CHF or DM, while those with COPD had both higher healthcare utilization and all-cause mortality.

Preliminary Clinical Outcomes of the Hello Sunday Morning Alcohol and Wellbeing Self-Assessment: Feasibility and Acceptability Study

BACKGROUND

Alcohol-related injuries and diseases are a leading cause of morbidity and mortality worldwide. Early intervention is essential given the chronic, relapsing nature of alcohol use disorders. There is significant potential for widely accessible web-based screening tools to help individuals determine where they stand in terms of alcohol use and provide support recommendations. Screening and brief interventions (SBIs) provide individuals with a stigma-free opportunity to learn and think about the potential risks of drinking and prompt help-seeking behavior by incorporating behavior change techniques. Furthermore, as excessive alcohol use and mental health problems often occur concurrently, SBIs for both conditions simultaneously can potentially address a critical gap in alcohol and mental health treatment.

OBJECTIVE

We investigated the feasibility, acceptability, and clinical outcomes of participants completing the Alcohol and Wellbeing Self-assessment (A&WS), a web-based SBI.

METHODS

The A&WS is freely available on the Hello Sunday Morning website as part of an uncontrolled observational prospective study. Feasibility was assessed based on the number of respondents who commenced and subsequently completed the A&WS. Acceptability was measured via participant feedback to determine overall satisfaction, perceived helpfulness, and likelihood of recommending the A&WS to others. Clinical outcomes were measured in two ways: (1) self-reported changes in alcohol consumption (Alcohol Use Disorders Identification Test score) or psychological distress (Kessler Psychological Distress Scale score) over time and (2) help seeking-both self-reported and immediate web-based help seeking. Preliminary baseline data collected for the first 9 months (March 2022 to December 2022) of the study were reported, including the 3-month follow-up outcomes.

RESULTS

A total of 17,628 participants commenced the A&WS, and of these, 14,419 (81.8%) completed it. Of those 14,419 who completed the A&WS, 1323 (9.18%) agreed to participate in the follow-up research. Acceptability was high, with 78.46% (1038/1323) reporting high satisfaction levels overall; 95.62% (1265/1323) found the A&WS easy to use and would recommend the tool to others. The 1-, 2-, and 3-month follow-ups were completed by 28.57% (378/1323), 21.09% (279/1323), and 17.61% (233/1323) of the participants, respectively. Significant reductions in the Alcohol Use Disorders Identification Test Consumption subscale (P<.001) and Kessler Psychological Distress Scale scores (P<.001) were observed over the 3-month follow-up period.

CONCLUSIONS

Our results suggest that the A&WS is a highly feasible and acceptable digital SBI that may support individuals in making changes to their alcohol consumption and improve their psychological well-being. In the absence of a control group, positive clinical outcomes cannot be attributed to the A&WS, which should now be subjected to a randomized controlled trial. This scalable, freely available tool has the potential to reach a large number of adults who might not otherwise access help while complementing the alcohol and mental health treatment ecosystem.

Stakeholders' perceptions of a nurse-led telehealth case management intervention in primary care for patients with complex care needs: a qualitative descriptive study

OBJECTIVE

With the onset of the COVID-19 pandemic, telehealth case management (TCM) was introduced in primary care for patients requiring care by distance. While not all healthcare needs can be addressed via telehealth, the use of information and communication technology to support healthcare delivery has the potential to contribute to the management of patients with chronic conditions and associated complex care needs. However, few qualitative studies have documented stakeholders' perceptions of TCM. This study aimed to describe patients', primary care providers' and clinic managers' perceptions of the use of a nurse-led TCM intervention for primary care patients with complex care needs.

DESIGN

Qualitative descriptive study.

SETTING

Three primary care clinics in three Canadian provinces.

PARTICIPANTS

Patients with complex care needs (n=30), primary care providers (n=11) and clinic managers (n=2) participated in qualitative individual interviews and focus groups.

INTERVENTION

TCM intervention was delivered by nurse case managers over a 6-month period.

RESULTS

Participants' perceptions of the TCM intervention were summarised in three themes: (1) improved patient access, comfort and sense of reassurance; (2) trusting relationships and skilled nurse case managers; (3) activities more suitable for TCM. TCM was a generally accepted mode of primary care delivery, had many benefits for patients and providers and worked well for most activities that do not require physical assessment or treatment. Participants found TCM to be useful and a viable alternative to in-person care.

CONCLUSIONS

TCM improves access to care and is successful when a relationship of trust between the nurse case manager and patient can develop over time. Healthcare policymakers and primary care providers should consider the benefits of TCM and promote this mode of delivery as a complement to in-person care for patients with complex care needs.

Effect evaluation of a tele-neurologic intervention in primary care in a rural area in Germany-the NeTKoH study protocol of a stepped-wedge cluster randomized trial

BACKGROUND

Neurological disorders account for a large and increasing proportion of the global burden of disease. Therefore, it is important to strengthen the management of neurologic care, particularly in rural areas. The use of tele-neurology in primary care in rural areas is internationally considered to have the potential to increase access to health care services and improve the quality of care in these underserved areas. NeTKoH aims to address the existing knowledge gap regarding the effects of a tele-neurologic intervention in primary care under real-world conditions in a rural area in Germany.

METHODS

NeTKoH is a cluster-randomized controlled trial with a stepped-wedge design involving 33 outpatient general practitioner's (GP) offices (clusters) in a rural area in Northeast Germany. During 11 predetermined steps, all clusters are randomized before they cross over into groups from the control to the intervention arm. The targeted sample size is 1,089 patients with neurologic symptoms that are continuously being recruited. In the intervention arm, tele-neurologic consultations will be provided via a face-to-face video conferencing system with a neurologic expert at a university hospital. The control arm will receive usual care. The primary outcome is the proportion of neurologic problems being solved at the GP's office. Secondary outcomes will comprise hospital stays and days, time until neurologic specialist appointments and diagnostics, patients' health status and quality of life, outpatient and inpatient referrals. A concurrent observational study, together with a process, implementation, and health economic evaluation, will also be conducted.

DISCUSSION

Using a stepped-wedge cluster design in a real-life situation can help with logistic challenges and enhance the motivation of the participating GPs, as all, at some point, will be in the intervention phase. With the additional implementation evaluation pertaining to external validity, an observational study, and a health economic evaluation, NeTKoH will be able to provide an extensive evaluation for health policy decision-makers regarding the uptake into standard care.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00024492). Date registered: September 28, 2021. Date and protocol version: June 2023, version 1.

Enabling Patients as Partners on Virtual Teams: A Scoping Review

Developing partnerships among patients and healthcare providers improves quality of virtual care. Successful patient engagement is influenced by digital literacy. Although adults (35-64) with chronic health challenges may be motivated to use virtual services, they may not have the required skills or orientation to effectively participate on their virtual team. This scoping review aimed to identify resources available to enable adults with chronic health challenges to participate as partners on their virtual teams. Peer-reviewed and grey literature data from 2011 to 2022 were searched. A total of 432 peer-reviewed and 357 grey literature sources were retrieved and screened, and 14 and 84 sources, respectively, met the inclusion criteria. Relevant information from the sources was extracted and analyzed in duplicate and synthesized qualitatively. Key findings include (1) virtual workflow processes/frameworks, (2) 'webside manner' guidelines which emphasize "the how" as opposed to "the what" of facilitating team interactions, and (3) virtual patient support personnel. Overall, analyses suggest there are persisting gaps to be addressed in synchronous virtual care resources for adults with chronic health challenges.

Effects of non-drug interventions on anxiety and depression in patients with heart failure: A systematic review based on Bayesian network meta-analysis

BACKGROUND

To discuss the effect of non-drug interventions on anxiety and depression in patients with heart failure (HF) through Bayesian network meta-analysis.

METHODS

Relevant literature was searched from PubMed, Web of Science, Embase and Medline from database establishment to October 2022 by a computer. Next, a screening was performed on randomized controlled trials (RCTs) for the effect of non-drug interventions on anxiety and depression in HF patients, followed by a collection of the related data. This meta-analysis was conducted based on Bayesian network, and the statistical analysis was conducted using R4.2 software.

RESULTS

A total of 23 papers were enrolled into this study. The results of Bayesian network meta-analysis showed that compared with the control group and the structured video conferencing support (SVCS) group, telephone case management (TCM) could effectively reduce the anxiety and depression of HF patients. The ranking results revealed that TCM may be the most effective intervention to lower the risk of depression in HF patients, followed by Tai Chi Chuan and Chi Kung training (TCC) and structured telephone support (STS).

CONCLUSION

TCM is the most effective intervention to prevent HF patients from anxiety and depression.

Advancing multimorbidity management in primary care: a narrative review

BACKGROUND

Multimorbidity, defined as the coexistence of two or more chronic conditions in the same individual, is becoming a crucial health issue in primary care. Patients with multimorbidity utilize health care at a higher rate and have higher mortality rates and poorer quality of life compared to patients with single diseases.

AIMS

To explore evidence on how to advance multimorbidity management, with a focus on primary care. Primary care is where a large number of patients with multimorbidity are managed and is considered to be a gatekeeper in many health systems.

METHODS

A narrative review was conducted using four major electronic databases consisting of PubMed, Cochrane, World Health Organization database, and Google scholar. In the first round of reviews, priority was given to review papers summarizing the current issues and challenges in the management of multimorbidity. Thematic analysis using an inductive approach was used to build a framework on how to advance management. The second round of review focused on original articles providing evidence within the primary care context.

RESULTS

The review found that advancing multimorbidity management in primary care requires a health system approach and a patient-centered approach. The health systems approach includes three major areas: (i) improves access to care, (ii) promotes generalism, and (iii) provides a decision support system. For the patient-centered approach, four key aspects are essential for multimorbidity management: (i) promoting doctor-patient relationship, (ii) prioritizing health problems and sharing decision-making, (iii) supporting self-management, and (iv) integrating care.Advancement of multimorbidity management in primary care requires integrating concepts of multimorbidity management guidelines with concepts of patient-centered and chronic care models. This simple integration provides an overarching framework for advancing the health care system, connecting the processes of individualized care plans, and integrating care with other providers, family members, and the community.

Foresight study on online health community: The perspective of knowledge empowerment for patients with chronic diseases

Patient empowerment is an indispensable precondition for patients to self-manage their disease. The article takes the position that patients are empowered for disease self-management through patient knowledge empowerment when sharing knowledge. One of the most important instruments to successfully empower a patient to manage a chronic disease and maintain social relations, which are also a precondition for the prevention of chronic illnesses, is the possibility to access online health communities (OHCs) and participate in them. The aim of the article is to model possible development scenarios of OHCs as enablers of patient knowledge in relation to other digital health technologies (DHTs). A foresight methodology was used to achieve the goal, employing a technology scanning approach after selecting 10 foresight studies, which resulted in four future scenario models for the empowerment of patients wcith chronic diseases through digital health communities. They reveal options for the future interoperability of OHCs with other DHTs and highlight their importance and significance for the healthcare system as a technology for balancing patient self-efficacy and social relations as well as the need to maintain and develop them.

First experience of a hemophilia monitoring platform: florio HAEMO

Background

florio HAEMO is a new hemophilia treatment monitoring application consisting of a patient smartphone application (app) and a web‐based dashboard for healthcare professionals, providing several novel features, including activity tracking, wearable connectivity, kids and caregiver mode, and real‐time pharmacokinetic factor level estimation.

Objectives

To assess intuitiveness, ease‐of‐use, and patient preference of florio HAEMO in Central Europe using a cross‐sectional survey.

Methods

This survey was conducted in six Central European countries between 9 December 2020 and 24 May 2021. The online questionnaire included 17 questions about overall satisfaction, ease‐of‐use, intuitiveness, and patient preference. Adults or children with hemophilia on regular prophylaxis and using the florio HAEMO app for a minimum of 1 week were invited to complete the online questionnaire by their treating physician.

Results

Sixty‐six participants took part in the survey. The median duration for all respondents using the florio HAEMO app was 3 to 4 weeks. Overall, 89.4% of users reported being very satisfied or rather satisfied after using florio HAEMO. Of the 23 respondents who had switched from another hemophilia app, 87.0% indicated that they strongly preferred or preferred using florio HAEMO. Most florio HAEMO users reported that the app was very easy or rather easy to use (97.0%) and intuitive (94.0%). florio HAEMO had a positive impact on daily living, with 78.8% of users reporting that the app was very important or rather important to them.

Conclusions

This survey suggests that florio HAEMO is an easy‐to‐use and intuitive app to assist self‐management of home prophylaxis.

Frameworks for implementation, uptake and use of digital health interventions in ethnic minority populations: a scoping review using cardiometabolic disease as a case study. (Preprint)

Background

Digital health interventions have become increasingly common across health care, both before and during the COVID-19 pandemic. Health inequalities, particularly with respect to ethnicity, may not be considered in frameworks that address the implementation of digital health interventions. We considered frameworks to include any models, theories, or taxonomies that describe or predict implementation, uptake, and use of digital health interventions.

Objective

We aimed to assess how health inequalities are addressed in frameworks relevant to the implementation, uptake, and use of digital health interventions; health and ethnic inequalities; and interventions for cardiometabolic disease.

Methods

SCOPUS, PubMed, EMBASE, Google Scholar, and gray literature were searched to identify papers on frameworks relevant to the implementation, uptake, and use of digital health interventions; ethnically or culturally diverse populations and health inequalities; and interventions for cardiometabolic disease. We assessed the extent to which frameworks address health inequalities, specifically ethnic inequalities; explored how they were addressed; and developed recommendations for good practice.

Results

Of 58 relevant papers, 22 (38%) included frameworks that referred to health inequalities. Inequalities were conceptualized as society-level, system-level, intervention-level, and individual. Only 5 frameworks considered all levels. Three frameworks considered how digital health interventions might interact with or exacerbate existing health inequalities, and 3 considered the process of health technology implementation, uptake, and use and suggested opportunities to improve equity in digital health. When ethnicity was considered, it was often within the broader concepts of social determinants of health. Only 3 frameworks explicitly addressed ethnicity: one focused on culturally tailoring digital health interventions, and 2 were applied to management of cardiometabolic disease.

Conclusions

Existing frameworks evaluate implementation, uptake, and use of digital health interventions, but to consider factors related to ethnicity, it is necessary to look across frameworks. We have developed a visual guide of the key constructs across the 4 potential levels of action for digital health inequalities, which can be used to support future research and inform digital health policies.

A script for the telepractice of speech-language therapy and audiology services - what was learnt from the COVID-19 pandemic

ABSTRACT In this study, a script for the telepractice of speech language pathology and audiology services for adult patients at home, is presented. This tool was developed in three stages and used for a community project during the COVID-19 pandemic. A literature search was performed to identify the facilitators and barriers to remote patient care before implementing telepractice at a primary health care unit. This practical experience led to further discussions about the facilitators of clinical performance and different ways to remotely offer quality assessments and rehabilitation. Divided into three sections, the final script was organized into twenty items. To provide comprehensive patient care, detailed discussions were held about each item to verify the effectiveness and quality of the teleconsultations, for the script to be written. This guide is intended to be used as a tool for speech language pathology and audiology telepractice. However, it must be adapted to the cultural and social realities of the professionals and patients who use it. Additionally, it does not constitute a closed set of practices and procedures and should be updated as new procedures and technologies become available.

Roteiro pré, durante e pós teleconsulta fonoaudiológica - o que aprendemos com a pandemia da COVID-19

RESUMO Apresenta-se um roteiro de atuação em telessaúde para atendimento fonoaudiológico de pacientes adultos em domicílio que foi aplicado em um projeto comunitário durante a Pandemia da COVID-19. O roteiro foi desenvolvido em três etapas distintas. A partir de uma revisão de literatura para a identificação de facilitadores e barreiras para o atendimento de pacientes via telessaúde, foi feita a implementação de um serviço de telefonoaudiologia em uma Unidade Básica de Saúde, possibilitando a experiência para a discussão mediante a prática de facilitadores para a atuação clínica e maneiras de qualificar a teleconsulta fonoaudiológica. Por fim, deu-se a elaboração do roteiro, organizado em 20 itens, divididos em três seções. A sua elaboração incluiu, além da escrita, a discussão detalhada de cada item elencado, considerando a efetividade das ações propostas, qualificação das teleconsultas e integralidade do atendimento do paciente. O roteiro apresentado se propõe a ser suporte para a atuação em telefonoaudiologia. Entretanto, deve ser adaptado à realidade cultural e social dos profissionais e pacientes que a esta forma de atuação forem expostos. Visto que não se trata de um conjunto de práticas e procedimentos fechados em si, deverá ser atualizado conforme novos procedimentos e tecnologias estejam acessíveis para a atuação em telefonoaudiologia.

Telehealth in Primary Health Care: A Scoping Review of the Literature

BACKGROUND

The use of telehealth as a viable mobility to deliver quality services steadily increases in various levels of the health system. Despite the increasing use of telemedicine in secondary and tertiary health care services, there is a long way to go in the use of this technology in public health and primary health care (PHC). This study aimed to explore the features, approaches, and various dimensions of telehealth in PHC.

METHODS

A scoping review was conducted using the Arksey and O'Malley framework. A search was conducted in three bibliographic databases including PubMed, Web of Sciences, and Scopus and in Google Scholar to collect papers published in November 2018 to 2000. Data were extracted according to a predefined form and check for completeness and accuracy by a second reviewer.

RESULTS

Through reviewing papers, the authors extracted information on the general characteristics and features of telehealth services, kinds of PHC services delivered via telehealth, hardware and software facilities used for providing health care through telehealth services packages, as well as their benefits, outcomes and obstacles.

CONCLUSION

Telehealth can be used for different purposes of PHC through deploying a full range of communication channels available to the public. Due to the opportunistic use of existing devices and platforms, telehealth can provide scalable PHC services nationwide and worldwide. However, implementing telehealth in PHC faces challenges from technical, organizational, and human perspectives. Digital equity (in terms of technology access and e-health literacy) is required to expand telehealth services to the populations in underserved areas.

Remote Monitoring Systems for Patients With Chronic Diseases in Primary Health Care: Systematic Review

Background

The digital age, with digital sensors, the Internet of Things (IoT), and big data tools, has opened new opportunities for improving the delivery of health care services, with remote monitoring systems playing a crucial role and improving access to patients. The versatility of these systems has been demonstrated during the current COVID-19 pandemic. Health remote monitoring systems (HRMS) present various advantages such as the reduction in patient load at hospitals and health centers. Patients that would most benefit from HRMS are those with chronic diseases, older adults, and patients that experience less severe symptoms recovering from SARS-CoV-2 viral infection.

Objective

This paper aimed to perform a systematic review of the literature of HRMS in primary health care (PHC) settings, identifying the current status of the digitalization of health processes, remote data acquisition, and interactions between health care personnel and patients.

Methods

A systematic literature review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines to identify articles that explored interventions with HRMS in patients with chronic diseases in the PHC setting.

Results

The literature review yielded 123 publications, 18 of which met the predefined inclusion criteria. The selected articles highlighted that sensors and wearables are already being used in multiple scenarios related to chronic disease management at the PHC level. The studies focused mostly on patients with diabetes (9/26, 35%) and cardiovascular diseases (7/26, 27%). During the evaluation of the implementation of these interventions, the major difficulty that stood out was the integration of information into already existing systems in the PHC infrastructure and in changing working processes of PHC professionals (83%).

Conclusions

The PHC context integrates multidisciplinary teams and patients with often complex, chronic pathologies. Despite the theoretical framework, objective identification of problems, and involvement of stakeholders in the design and implementation processes, these interventions mostly fail to scale up. Despite the inherent limitations of conducting a systematic literature review, the small number of studies in the PHC context is a relevant limitation. This study aimed to demonstrate the importance of matching technological development to the working PHC processes in interventions regarding the use of sensors and wearables for remote monitoring as a source of information for chronic disease management, so that information with clinical value is not lost along the way.

Potential Utility of School-Based Telehealth in the Era of COVID-19

BACKGROUND

The COVID-19 pandemic presents unique opportunities for preexisting school telemedicine programs to reach pediatric populations that might otherwise experience a lapse in health care services.

METHODS

A retrospective analysis of one of the largest school-based telemedicine programs in the country, based in the Dallas-Fort Worth (DFW), Texas was conducted that included 7021 pediatric patients who engaged in telehealth visits from 2014 to 2019.

RESULTS

Asthma or other respiratory disease was the primary diagnosis (28.4%), followed by injury or trauma (18.4%), digestive disorders (6.9%), and ear/eye/skin disease (6.9%). More participants were from the North (34.4%) and West (33.2%) ISD compared to the South (20.6%) and East (11.7%) schools. Likewise, the majority of COVID-19 cases were in the North (61.8%) and West (31.6%) DFW regions, leading to 989 (59.9%) and 551 (33.4%) deaths, respectively.

CONCLUSIONS

School-based telehealth programs have the potential to reach large pediatric populations most in need of health care due to COVID-19-related lapses in services, and to address COVID-19-related health issues as schools reopen. In the future, utilization could be expanded to contact tracing, testing, and screening for COVID-19.

Keeping adults physically active after Falls Management Exercise (FaME) programmes end: development of a physical activity maintenance intervention

Background

Falls prevention exercise programmes help to improve muscle strength, balance and physical function, and reduce falling rates in older adults. Improvements in muscle strength, balance and physical function are reversed if older adults do not continue to be physically active after falls prevention exercise programmes end. This paper describes the design process of an intervention that aimed to maintain physical activity in older adults exiting falls prevention exercise programmes.

Methods

The development of the Keeping Adults Physically Active (KAPA) intervention and its implementation plan was guided by Bartholomew’s Intervention Mapping approach. The intervention mapping approach involved (1) performing a needs assessment and developing intervention objectives using previous literature; (2) identifying theory-based intervention strategies from a systematic review and the National Institute of Clinical Excellence guidelines; and (3) designing the KAPA intervention and its implementation plan with the guidance from an expert steering group.

Results

The KAPA intervention comprised of six group sessions of motivational interviewing, delivered monthly by trained and mentor-supported falls prevention practitioners. Intervention sessions lasted up to 90 min and were delivered in community settings over a 6-month duration. Participant manuals, illustrated exercise books, physical activity diaries and pedometers supported the KAPA intervention.

Conclusions

The intervention development process, consisting of Bartholomew’s Intervention Mapping approach and the input from an expert steering group, was successful in creating the evidence-based KAPA intervention ready to be evaluated in a feasibility trial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00844-w.

Smartphone Applications Designed to Improve Older People's Chronic Pain Management: An Integrated Systematic Review

(1) Background: Older people’s chronic pain is often not well managed because of fears of side-effects and under-reporting. Telehealth interventions, in the form of smartphone applications, are attracting much interest in the management of chronic diseases, with new and evolving approaches in response to current population demographics. However, the extent to which telehealth interventions may be used to promote and effect the self-management of chronic pain is not established. (2) Aim: To provide an objective review of the existing quantitative and qualitative evidence pertaining to the benefits of smartphone applications for the management of chronic pain in older people. (3) Methods: A literature search was undertaken using PubMed, Medline, CINAHL, Embase, PsychINFO, the Cochrane database, Science Direct and references of retrieved articles. The data were independently extracted by two reviewers from the original reports. (4) Results: This integrative systematic review identified 10 articles considering smartphone applications related to self-management of chronic pain among older adults. (5) Conclusions: It is important for future research to not only examine the effects of smartphone initiatives, but also to compare their safety, acceptability, efficacy and cost–benefit ratio in relation to existing treatment modalities.

Web-based early intervention for children with motor difficulties aged 3–8 years old using multimodal rehabilitation (WECARE): protocol of a patient-centred pragmatic randomised trial of paediatric telerehabilitation to support families

Introduction

Mild motor difficulties in children are underdiagnosed despite being highly prevalent, leaving such children often underserved and at higher risk for secondary consequences such as cardiovascular disease and anxiety. Evidence suggests that early patient-oriented interventions, coaching parents and providing children with early stimulation should be provided, even in the absence of a diagnosis. Such interventions may be effectively delivered via telerehabilitation.

Methods and analysis

A family-centred, pragmatic randomised controlled trial will be carried out to evaluate the real-world effectiveness of a Web-based Early intervention for Children using multimodAl REhabilitation (WECARE). Families of children with motor difficulties, 3–8 years of age, living in Quebec, Canada, and receiving no public rehabilitation services (n=118) will be asked to determine up to 12 performance goals, evaluated using the Canadian Occupational Performance Measure (COPM, the primary outcome). Families will be randomised to receive either usual care or the WECARE intervention. The WECARE intervention will be delivered for 1 year via a web-based platform. Families will have access to videoconferences with an assigned rehabilitation therapist using a collaborative coaching approach, a private chat function, a forum open to all intervention arm participants and online resources pertaining to child development. Participants will be asked to re-evaluate the child’s COPM performance goals every 3 months up to 1 year post allocation. The COPM results will be analysed using a mixed Poisson regression model. Secondary outcomes include measures of the child’s functional ability, parental knowledge and skills and health-related quality of life, as well as qualitative outcomes pertaining to parental satisfaction and service delivery trajectories. Investigators and quantitative data analysts will be blinded to group allocation.

Ethics and dissemination

The CIUSSS de l’Estrie—CHUS ethics committee approved this trial (2020-3429). Study results will be communicated via peer-reviewed journal publications, conference presentations and stakeholder-specific knowledge transfer activities.

Trial registration number

NCT04254302.

Telehealth Diabetes Prevention Intervention for the Next Generation of African American Youth: Protocol for a Pilot Trial

Background

In 1999, type 2 diabetes mellitus (T2DM) was identified as an emerging epidemic in youth, and racial and ethnic minority youth were identified with high risk. Two decades later, no gold standard T2DM prevention intervention has been established for this population.

Objective

This study tests the efficacy of a telehealth diabetes prevention intervention for African American (AA) families with children with risk for T2DM. Concurrently, investigators aim to evaluate an implementation strategy for the uptake of the intervention by the University of Mississippi Medical Center’s (UMMC) pediatric weight management clinic.

Methods

This single-arm trial will enroll 20 parents with overweight or obesity of children (8-11 years) with overweight or obesity, both of whom are at risk for T2DM. Parents will meet in small groups (5 parents per group) weekly for 11 weeks and then monthly for 4 monthly maintenance sessions via videoconference using Wi-Fi–enabled iPads with cellular connectivity. The intervention will be adapted from the National Diabetes Prevention Program and Power to Prevent, a diabetes prevention program tailored for AA families. The same lifestyle intervention facilitated by a racially concordant lifestyle coach trained in the Diabetes Prevention Program will be delivered to all groups (n=4). Participants will be recruited in-person during patient encounters at the UMMC’s pediatric weight management clinic. Sessions will consist of dietary and physical activity behavior change strategies facilitated using problem-solving and goal-setting skills. The implementation strategy has 2 targets: the pediatric weight management clinic site and clinical team and parents of children at risk for T2DM engaged in intensive obesity treatment to prevent T2DM. The multifaceted implementation protocol includes 4 discrete strategies: creating a new clinical team, changing the service site, intervening with families, and promoting organizational readiness for change.

Results

Recruitment and enrollment began in December 2020, and the intervention is scheduled to be delivered to the first cohort of parents in March 2021. The results are expected to be submitted for publication beginning in November 2021 through 2022. The primary outcome measure for the pilot trial will include changes from baseline to 12 and 30 weeks in the child BMI z score and parent BMI. The implementation evaluation will include multiple measures of feasibility, acceptability, appropriateness, fidelity, and efficacy. This protocol was approved by the UMMC’s Institutional Review Board (#2020V0249).

Conclusions

The proposed intervention approach is supported by the scientific literature and is scalable given the current and future health care subsidies for telehealth. Findings from this pilot trial will begin to address critical barriers to defining a gold standard lifestyle intervention for AA families with children at risk for T2DM. If effective, the intervention could be feasibly disseminated to treat obesity and prevent T2DM in high-risk AA pediatric populations.

International Registered Report Identifier (IRRID)

PRR1-10.2196/25699

Mapping the role of digital health technologies in the case detection, management, and treatment outcomes of neglected tropical diseases: a scoping review

BACKGROUND

Neglected tropical diseases (NTDs) are a diverse group of communicable diseases that principally impact the world's poorest people. The use of digital health technologies is an emerging and promising way to improve disease prevention, diagnosis, case detection, treatment delivery, and patient follow-up and facilitating health facility appointments thereby improving health outcomes. While the growing implementation of digital health technologies is evident, there is a lack of comprehensive evidence on the impact of digital health technologies in the control of NTDs. The main objective of this review was to map different pieces of evidence on the use of digital health technologies for case detection, management, and treatment outcome of the neglected tropical diseases.

METHODS

We conducted a scoping review guided by the Joanna Briggs Institute guidelines. The studies were searched using electronic databases like MEDLINE (PubMed), Science Direct, Cochrane Library, and manual searching engines. Two authors extracted the data and compared the results. Discrepancies were resolved by discussion or the third reviewer made the decision. We produced the distribution of geographical locations, residents (setting), types of publications, and digital health technologies used on neglected tropical diseases using tables and graphs.

FINDINGS

A total of 996 potentially relevant studies were generated from the initial search, and six studies were found to satisfy all the inclusion criteria and included in the final review. The review found that telehealth, eHealth, mHealth, telemedicine, and electronic health record were used digital health technologies to assess their impact on case detection, disease management, and treatment outcome of neglected tropical diseases. Mobile health was a feasible digital health technology for lymphatic filariasis patient identification and mHealth, eHealth, and electronic health records found to improve the service access, outcomes, and monitoring of visceral leishmaniasis at the community health system.

CONCLUSION

The scoping review identified that there were limited studies to see the impact of digital health technologies on case detection, management, and treatment outcomes for neglected tropical diseases. We also found that digital health technologies like ehealth, electronic medical linkage, telemed, and telehealth were practicable for patient identification, for treatment and diagnosis through contact with health professionals and teleconsultation, and support in improving health service delivery at the community-health system for managing the disease in both rural and urban settings.

Digital health interventions for chronic diseases: a scoping review of evaluation frameworks

Background

Monitoring and evaluations of digital health (DH) solutions for the management of chronic diseases are quite heterogeneous and evidences around evaluating frameworks are inconsistent. An evidenced-based framework is needed to inform the evaluation process and rationale of such interventions. We aimed to explore the nature, extent and components of existing DH frameworks for chronic diseases.

Methods

This review was conducted based on the five steps of Arksey and O’Malley’s scoping review methodology. Out of 172 studies identified from, PubMed, Embase and Web of Science, 11 met our inclusion criteria. The reviewed studies developed DH frameworks for chronic diseases and published between 2010 and 2018.

Results

According to WHO guidelines for monitoring and evaluation of DH interventions, we identified seven Conceptual frameworks, two Results frameworks, one Logical framework and one Theory of change. The frameworks developed for providing interventions such as self-management, achieving personal goals and reducing relapse for cardiovascular disease, diabetes, chronic obstructive pulmonary disease and severe mental health. A few studies reported evaluation of the frameworks using randomised clinical trials (n=3) and feasibility testing via Likert scale survey (n=2). A wide range of outcomes were reported including access to care, cost-effectiveness, behavioural outcomes, patient–provider communications, technology acceptance and user experience.

Conclusion

There is a lack of evidence on the application of consistent DH frameworks. Future research should address the use of evidence-based frameworks into the research design, monitoring and evaluation process. This review explores the nature of DH frameworks for the management of chronic diseases and provides examples to guide monitoring and evaluation of interventions.

Patient's Perspectives of Telepsychiatry: The Past, Present and Future

Access to mental health care has significant disparities due to treatment gap, more so particularly for the remotely residing, physically vulnerable, aging populations. Adoption of technology will enable more people to receive specialty care addressing distance, transportation and cost-related barriers to treatment engagement from the comfort of home. Telemedicine has been regarded as "electronic personal protective equipment" by reducing the number of physical contacts and risk contamination for patients during COVID-19 crisis. This review aimed to give a broad view of patients' perception of the use of telepsychiatry in terms of clinical outcome, cost-effectiveness, and solutions to address patients' challenges with the adoption of technology. Over the years, telepsychiatry, both in synchronous and asynchronous modalities, had shown to improve patients' adherence to treatment, follow-up rates, and clinical symptoms, overcome stigma and discrimination, and save cost expenses accessing health care with better satisfaction and usability outcomes. Its utility is widespread such as in delivering care emergency evaluation, crisis intervention, conducting neuropsychological assessments, psychotherapy, promoting lifestyle modification, enhancing self-efficacy, and overcoming patients' linguistic and cultural barriers to care. However, patients' privacy and confidentiality and psychiatrists' legal liability remain as matter of major concern in digital platform. To keep up with the pace of technology and patients' expectations, a more agile approach is essential to develop, improve, and evaluate telepsychiatric interventions.

Dietitians Australia position statement on telehealth

It is the position of Dietitians Australia that clients can receive high‐quality and effective dietetic services such as Medical Nutrition Therapy (MNT) delivered via telehealth. Outcomes of telehealth‐delivered dietetic consultations are comparable to those delivered in‐person, without requiring higher levels of additional training nor compromising quality of service provision. Dietitians Australia recommends that policy makers and healthcare funders broaden the recognition for telehealth‐delivered dietetic consultations as a responsive and cost‐effective alternative or complement to traditional in‐person delivery of dietetic services. The successful implementation of telehealth can help to address health and service inequalities, improve access to effective nutrition services, and support people with chronic disease to optimise their diet‐related health and well‐being, regardless of their location, income or literacy level, thereby addressing current inequities.

Using videoconsultations to deliver dietary advice to children with chronic kidney disease: a qualitative study of parent and child perspectives

BACKGROUND

Children with chronic kidney disease require specialist renal paediatric dietetic care, regardless of disease severity or geographical location; however, under-resourcing makes this challenging. Videoconsultation may offer a solution but research exploring its acceptability is limited. The present study explored parent/carer and child perspectives of videoconsultation as an alternative or supplement to existing regional dietetic care.

METHODS

Children and families using a regional paediatric nephrology service were recruited through purposeful sampling techniques. Renal paediatric dietitians used existing hospital software to host videoconsultations with families. Perspectives were subsequently explored in telephone interviews with the children, their parents and separately with the renal dietitians. Data were transcribed verbatim and an inductive framework analysis conducted.

RESULTS

Twelve families took part in the study, comprising 13 parents and five children (aged 9 months to 14 years). Two renal dietitians were also interviewed. Six themes emerged which were 'Logistics', 'Understanding Information', 'Family Engagement', 'Establishing Trust', 'Willingness to Change' and 'Preferences'. Satisfaction with the videoconsultations was high, with no data security fears and only minor privacy concerns. Parents reported that screen-sharing software enhanced their understanding, generating greater discussion and engagement compared to clinic and telephone contacts. Parents praised efficiencies and  improved access to specialist advice, requesting that videoconsultations supplement care. Children preferred videoconsultations outright.

CONCLUSIONS

Dietetic videoconsultations were acceptable to families and perceived to be a feasible, high-quality complement to regional specialist dietetic care. Enhanced understanding and engagement might improve self-care in adolescents. The acceptability and feasibility of videoconsultations could address inequitable regional service provision.

Effectiveness of Telemedicine Intervention for Chronic Obstructive Pulmonary Disease in China: A Systematic Review and Meta-Analysis

Background: Telemedicine market in China has been rapidly developing. However, no systematic review has been published in China. Details of the implementation of telemedicine interventions in the chronic obstructive pulmonary disease (COPD) in China have not been described, and the effectiveness of telemedicine interventions is still unclear. Therefore, in this review, we describe the implementation details of telemedicine intervention in China and access the efficacy of telemedicine. Materials and Methods: A literature search was conducted in Embase, Cochrane Library, PubMed, China National Knowledge Infrastructure (CNKI), Wan Fang Data, and China Science and Technology Journal Database by July 9, 2018. Results: A total number of 24 studies were meta-analyzed. There are many differences during the implementation of telemedicine in China. Quality of life in the group of the telemedicine intervention was better than that in the control group (mean difference = -4.93 [95% confidence interval; CI -6.86 to -3.01], p < 0.00001), but the heterogeneity is high (I² = 86%, p = 0.0001). The rates of hospitalization were lower than those in the control group (odds ratio = 0.24 [95% CI 0.20-0.29], p < 0.00001), and the heterogeneity was low (I² = 25%, p = 0.14). Conclusion: The implementation of telemedicine in China has not yet been standardized. Nonetheless, results of our review indicated that telemedicine in China can improve the quality of life and reduce the rates of hospitalization in COPD patients.

Liver transplant recipients' experiences and perspectives of a telehealth-delivered lifestyle programme: A qualitative study

INTRODUCTION

Dietary modification and exercise are encouraged to address cardiometabolic risk factors after solid organ transplantation. However, the lived experience of attempting positive lifestyle changes for liver transplant recipients is not known. The aim of this study was to explore the experiences of liver transplant recipients and their perspectives of a 12-week telehealth lifestyle programme and assess the feasibility of this innovative health service.

METHODS

Focus groups and one-on-one interviews were conducted with participants who had completed a 12-week, group-based, telehealth-delivered diet and exercise programme and thematic qualitative analysis was used to code and theme the data.

RESULTS

In total, 19 liver transplant recipients participated in the study (25-68 years, median time since transplant 4.4 years, 63% male). Overarching themes included: (a) 'broad telehealth advantages' which highlighted that telehealth reduced the perceived burdens of face-to-face care; (b) 'impact of employment' which identified employment as a competing priority and appeared to effect involvement with the programme; (c) 'adapting Mediterranean eating pattern to meet individual needs' which identified the adaptability of the Mediterranean diet supported by sessions with the dietitian; (d) 'increasing exercise confidence' which recognised that a tailored approach facilitated confidence and acceptability of the exercise component of the programme.

DISCUSSION

A telehealth lifestyle programme delivered by dietitians and exercise physiologists is an acceptable alternative to face-to-face care that can meet the needs of liver transplant recipients. There is a need to further innovate and broaden the scope of routine service delivery beyond face-to-face consultations.

Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis

Background

In 2012, a series of systematic reviews summarised the evidence regarding interventions to reduce preventable hospital admissions. Although intervention effects were dependent on context, the reviews revealed a consistent picture of reduction across different interventions targeting cardiovascular and respiratory conditions. The research reported here sought to provide an in-depth understanding of how interventions that have been shown to reduce admissions for these conditions may work, with a view to supporting their effective implementation in practice.

Objectives

To map the available evidence on interventions used in the UK NHS to reduce preventable admissions for cardiovascular and respiratory conditions and to conduct a realist synthesis of implementation evidence related to these interventions.

Methods

For the mapping review, six databases were searched for studies published between 2010 and October 2017. Studies were included if they were conducted in the UK, the USA, Canada, Australia or New Zealand; recruited adults with a cardiovascular or respiratory condition; and evaluated or described an intervention that could reduce preventable admissions or re-admissions. A descriptive summary of key characteristics of the included studies was produced. The studies included in the mapping review helped to inform the sampling frame for the subsequent realist synthesis. The wider evidence base was also engaged through supplementary searching. Data extraction forms were developed using appropriate frameworks (an implementation framework, an intervention template and a realist logic template). Following identification of initial programme theories (from the theoretical literature, empirical studies and insights from the patient and public involvement group), the review team extracted data into evidence tables. Programme theories were examined against the individual intervention types and collectively as a set. The resultant hypotheses functioned as synthesised statements around which an explanatory narrative referenced to the underpinning evidence base was developed. Additional searches for mid-range and overarching theories were carried out using Google Scholar (Google Inc., Mountain View, CA, USA).

Results

A total of 569 publications were included in the mapping review. The largest group originated from the USA. The included studies from the UK showed a similar distribution to that of the map as a whole, but there was evidence of some country-specific features, such as the prominence of studies of telehealth. In the realist synthesis, it was found that interventions with strong evidence of effectiveness overall had not necessarily demonstrated effectiveness in UK settings. This could be a barrier to using these interventions in the NHS. Facilitation of the implementation of interventions was often not reported or inadequately reported. Many of the interventions were diverse in the ways in which they were delivered. There was also considerable overlap in the content of interventions. The role of specialist nurses was highlighted in several studies. The five programme theories identified were supported to varying degrees by empirical literature, but all provided valuable insights.

Limitations

The research was conducted by a small team; time and resources limited the team’s ability to consult with a full range of stakeholders.

Conclusions

Overall, implementation appears to be favoured by support for self-management by patients and their families/carers, support for services that signpost patients to consider alternatives to seeing their general practitioner when appropriate, recognition of possible reasons why patients seek admission, support for health-care professionals to diagnose and refer patients appropriately and support for workforce roles that promote continuity of care and co-ordination between services.

Future work

Research should focus on understanding discrepancies between national and international evidence and the transferability of findings between different contexts; the design and evaluation of implementation strategies informed by theories about how the intervention being implemented might work; and qualitative research on decision-making around hospital referrals and admissions.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Addressing cost and time barriers in chronic disease management through telemedicine: an exploratory research in select low- and middle-income countries

BACKGROUND

Despite evidence supporting telehealth provision in developed countries, there is limited evidence regarding its economic benefits for patients living in areas where access and cost present major barriers to health care, particularly in low- and middle-income countries (LMICs). This study explores the economic benefits of telemedicine for patients, in terms of cost and times savings, and its potential role in improving chronic disease outcomes.

METHODS

This retrospective cross-sectional study compared telemedicine services with hypothetical in-person consultations, with a focus on patient travel time and travel cost savings. A database containing teleconsultation visits (N = 25,182) conducted at health facilities in remote regions of Afghanistan, Pakistan, Tajikistan, and the Kyrgyz Republic, was analyzed. A two-sample homoscedastic t test was used to determine differences between the two groups. A one-way sensitivity analysis was also conducted, presuming in-person teleconsultations at 90%, 75%, and 50%.

RESULTS

The study extracted data from 25,182 teleconsultation visits (12,814 males; 12,368 females). The cumulative patient savings through the program amounted to USD 9,175,132, and 1,876,146 h, or 213.1 years. A significant difference was seen between the two groups in terms of mean time savings (p-value <0.05), and a nearly significant difference was observed in terms of mean cost savings (p-value = 0.05).

CONCLUSIONS

This study suggests that considerable economic benefits imparted to patients in low-resource settings of LMICs via accessing telemedicine. Telemedicine has great potential to improve chronic disease outcomes in low-resource areas by reducing socioeconomic barriers related to cost and access, and increasing uptake of services, thereby enabling early intervention and long-term management.

Identifying Frameworks for Validation and Monitoring of Consensual Behavioral Intervention Technologies: Narrative Review

BACKGROUND

Changing health behaviors, such as smoking, unhealthy eating, inactivity, and alcohol abuse, may have a greater impact on population health than any curative strategy. One of the suggested strategies is the use of behavioral intervention technologies (BITs). They open up new opportunities in the area of prevention and therapy and have begun to show benefits in the durable change of health behaviors in patients or those at risk. A consensual and international paradigm was adopted by health authorities for drugs 50 years ago. It guides their development from research units to their authorization and surveillance. BITs' generalization brings into question their upstream evaluation before being placed on the market and their downstream monitoring once on the market; this is especially the case in view of the marketing information provided by manufacturers and the scarcity and methodological limits of scientific studies on these tools.

OBJECTIVE

This study aims to identify and categorize the frameworks for the validation and monitoring of BITs proposed in the literature.

METHODS

We conducted a narrative literature review using MEDLINE, PsycINFO, and Web of Science. The review items included the following: name, publication year, name of the creator (ie, first author), country, funding organization, health focus, target group, and design (ie, linear, iterative, evolutive, and/or concurrent). The frameworks were then categorized based on (1) translational research thanks to a continuum of steps and (2) the three paradigms that may have inspired the frameworks: biomedical, engineering, and/or behavioral.

RESULTS

We identified 46 frameworks besides the classic US Food and Drug Administration (FDA) five-phase drug development model. A total of 57% (26/46) of frameworks were created in the 2010s and 61% (28/46) involved the final user in an early and systematic way. A total of 4% (2/46) of frameworks had a linear-only sequence of their phases, 37% (17/46) had a linear and iterative structure, 33% (15/46) added an evolutive structure, and 24% (11/46) were associated with a parallel process. Only 12 out of 46 (26%) frameworks covered the continuum of steps and 12 (26%) relied on the three paradigms.

CONCLUSIONS

To date, 46 frameworks of BIT validation and surveillance coexist, besides the classic FDA five-phase drug development model, without the predominance of one of them or convergence in a consensual model. Their number has increased exponentially in the last three decades. Three dangerous scenarios are possible: (1) anarchic continuous development of BITs that depend on companies amalgamating health benefits and usability (ie, user experience, data security, and ergonomics) and limiting implementation to several countries; (2) the movement toward the type of framework for drug evaluation centered on establishing its effectiveness before marketing authorization to guarantee its safety for users, which is heavy and costly; and (3) the implementation of a framework reliant on big data analysis based on a posteriori research and an autoregulation of a market, but that does not address the safety risk for the health user, as the market will not regulate safety or efficacy issues. This paper recommends convergence toward an international validation and surveillance framework based on the specificities of BITs, not equivalent to medical devices, to guarantee their effectiveness and safety for users.

Turning the oil tanker: a novel approach to shifting perspectives in medical practice

Although health care is encouraged to follow an evidence-based approach, there are perceived instances where suboptimal practice persists in the presence of better options due to an inherent resistance to change within many health care systems. To continue striving for clinical excellence, it is important to identify deficient practices and make appropriate corrections by implementing new and improved techniques and treatments. Bringing about change, however, tends to be a long, arduous process consisting of several small and successive deviations from the norm, analogous to "turning the oil tanker". Analyzing the methods employed by successful health care innovators has allowed the development of a "three-pronged" approach to overcoming resistance to change: 1) a determined opinion leader with a network or like-minded opinion leaders; 2) the presentation of hard evidence with adequate praise for current practice and the generation of clearly worded, specific guidelines; and 3) the use of simple reminders and continuous analysis of outcomes. Employing this three-pronged approach could lead to faster and more successful implementation of change within the health care system.

The impact of telehealth care on health-related quality of life of patients with heart failure: Results from the Danish TeleCare North heart failure trial

AIM

The aim of this study was to assess the impact on health-related quality of life (HRQoL) of a telehealth care solution compared with usual practice of patients with heart failure (HF).

METHODS

A randomized controlled trial with a telehealth care solution (Telekit) as the intervention (with a focus on self-empowerment achieved by engaging patients in their own illness through self-monitoring) combined with usual care and usual care as the control. The primary outcome was a change in HRQoL as measured by the Short Form-36 (SF-36) questionnaire Physical Component Summary (PCS) score. Secondary outcomes were changes in HRQoL as measured by the SF-36 questionnaire Mental Component Summary (MSC) score and the HF disease-specific questionnaire Kansas City Cardiomyopathy Questionnaire 12 (KCCQ12) score, all of which were assessed from baseline to approximately 12 months' follow-up between the two groups. Outcomes were assessed via unadjusted and adjusted analyses.

RESULTS

At baseline, 299 (145 interventions, 154 controls) patients were enrolled. In the primary analysis (n = 299), the adjusted intervention effects were PCS -0.81 (95% CI -2.7-1.1), MCS 4.66 (95% CI 1.8-7.5) and KCCQ12 3.67 (95% CI -0.7-8.1). Only the change in MCS was statistically significant. An unadjusted analysis replicated the primary analysis. Complete case analyses (n = 193) generally resulted in a lower intervention effect on the PCS score, but the difference remained statistically insignificant.

CONCLUSIONS

Only the MCS score was significantly higher in the telehealth care group compared to the control group.ClinicalTrials.gov (NCT02860013), July 28, 2016.

Clinical decision support improves quality of care in patients with ulcerative colitis

BACKGROUND

Decision support tools may facilitate shared decision-making and improve quality of care.

AIM

To assess the effectiveness of a decision support tool on improving quality of care in ulcerative colitis.

METHODS

A prospective quality of care intervention was conducted at two Australian hospitals comparing out-patient-based ulcerative colitis care with, and without, a tablet-based decision support tool. This included questions on disease activity management; psychological well-being; and preventive care, with 13 process indicators relevant to each domain. Participants included adult out-patients with mild-to-moderate ulcerative colitis and their clinicians who were divided into two cohorts. The first cohort were followed up immediately after their clinical review to check whether their clinician had discussed the 13 process indicators during the consultation. The second cohort of patients used the decision support tool immediately prior to their consultation which then generated a suggested management plan for the patient and clinician to discuss during the consultation. Management between the 2 cohorts was compared to assess the effectiveness of the decision support tool in improving the primary outcome, defined as the proportion of quality process indicators used for ulcerative colitis care, with and without the decision support tool.

RESULTS

Thirteen physicians and 100 patients participated. Fifty patients were managed without the decision support tool using standard care (median age 40; 44% male), and 50 patients used the decision support tool (median age 40; 46% male) over a 20-week period. Increase in the median use of process indicators overall was observed following use of the decision support tool (27% vs 100%; P < 0.001). Improvements were seen in psychological well-being management (30% vs 100%; P < 0.001), preventive care (16% vs 100%; P < 0.001) and process indicators related to disease activity management (50% vs 100%; P < 0.001). The decision support tool was found to be usable and acceptable. Shared decision-making was greater in the post-intervention group (mean decision conflict score of 18.0 vs 33.5; P = 0.002).

CONCLUSIONS

The decision support tool substantially improved the quality of the delivery of care. Decision support tools have the potential to minimise errors of omission via a standardised approach to care.

Implementing new models of care: Lessons from the new care models programme in England

In 2014, the body that leads the National Health Service in England published a new strategic vision for the National Health Service. A major part of this strategy was a three-year-long national programme to develop new care models to coordinate care across primary care, community services and hospitals that could be replicated across the country. Local 'vanguard sites' were selected to develop five types of new care model with support from a national team. The new care models programme provided support for local leaders to enable them to collaborate to improve care for their local populations. We interviewed leaders in the vanguard sites to better understand how they made changes to care locally. Drawing on the insights from these interviews and the literature on cross-organisational change and improvement we devised a framework of 10 lessons for health and care leaders seeking to develop and implement new models of care. The framework emphasises the importance of developing relationships and building capability locally to enable areas to continuously develop and test new ideas.

Planning Telehealth for Older Adults With Atrial Fibrillation in Rural Communities: Understanding Stakeholder Perspectives

Older adults with atrial fibrillation (AF) in rural communities have less access to cardiac specialty care. Telehealth offers a viable approach to provide cardiac care, yet little is known about patients’ and providers’ views on telehealth’s potential to support rural patients with AF. This qualitative descriptive study examines patient and health providers’ perspectives, an important first step in planning a telehealth initiative. Eight patients with AF, along with one partner from rural communities, were recruited through an urban-based AF clinic. Five providers were recruited through professional practice leads in the health region. Semistructured telephone interviews were conducted with both stakeholder groups. The overriding theme was variability in patient and provider receptiveness to telehealth. Receptiveness reflected differences in past experience with telehealth, in perceived adequacy of rural health services, and in perceived gaps in AF care. These are important considerations in planning effective and sustainable telehealth in rural communities.

Development of an intervention to reduce antibiotic use for childhood coughs in UK primary care using critical synthesis of multi-method research

Background

Overuse of antibiotics contributes to the global threat of antimicrobial resistance. Antibiotic stewardship interventions address this threat by reducing the use of antibiotics in occasions or doses unlikely to be effective. We aimed to develop an evidence-based, theory-informed, intervention to reduce antibiotic prescriptions in primary care for childhood respiratory tract infections (RTI). This paper describes our methods for doing so.

Methods

Green and Krueter’s Precede/Proceed logic model was used as a framework to integrate findings from a programme of research including 5 systematic reviews, 3 qualitative studies, and 1 cohort study. The model was populated using a strength of evidence approach, and developed with input from stakeholders including clinicians and parents.

Results

The synthesis produced a series of evidence-based statements summarizing the quantitative and qualitative evidence for intervention elements most likely to result in changes in clinician behaviour. Current evidence suggests that interventions which reduce clinical uncertainty, reduce clinician/parent miscommunication, elicit parent concerns, make clear delayed or no-antibiotic recommendations, and provide clinicians with alternate treatment actions have the best chance of success. We designed a web-based within-consultation intervention to reduce clinician uncertainty and pressure to prescribe, designed to be used when children with RTI present to a prescribing clinician in primary care.

Conclusions

We provide a worked example of methods for the development of future complex interventions in primary care, where multiple factors act on multiple actors within a complex system. Our synthesis provided intervention guidance, recommendations for practice, and highlighted evidence gaps, but questions remain about how best to implement these recommendations. The funding structure which enabled a single team of researchers to work on a multi-method programme of related studies (NIHR Programme Grant scheme) was key in our success.

Trial registration

The feasibility study accompanying this intervention was prospectively registered with the ISRCTN registry (ISRCTN23547970), on 27 June 2014.

Electronic supplementary material

The online version of this article (10.1186/s12874-017-0455-9) contains supplementary material, which is available to authorized users.

Cost-effectiveness of telehealthcare to patients with chronic obstructive pulmonary disease: results from the Danish 'TeleCare North' cluster-randomised trial

OBJECTIVES

To investigate the cost-effectiveness of a telehealthcare solution in addition to usual care compared with usual care.

DESIGN

A 12-month cost-utility analysis conducted alongside a cluster-randomised trial.

SETTING

Community-based setting in the geographical area of North Denmark Region in Denmark.

PARTICIPANTS

26 municipality districts define randomisation clusters with 13 districts in each arm. 1225 patients with chronic obstructive pulmonary disease were enrolled, of which 578 patients were randomised to telehealthcare and 647 to usual care.

INTERVENTIONS

In addition to usual care, patients in the intervention group received a set of telehealthcare equipment and were monitored by a municipality-based healthcare team. Patients in the control group received usual care.

MAIN OUTCOME MEASURE

Incremental costs per quality-adjusted life-years gained from baseline up to 12 months follow-up.

RESULTS

From a healthcare and social sector perspective, the adjusted mean difference in total costs between telehealthcare and usual care was €728 (95% CI -754 to 2211) and the adjusted mean difference in quality-adjusted life-years gained was 0.0132 (95% CI -0.0083 to 0.0346). The incremental cost-effectiveness ratio was €55 327 per quality-adjusted life-year gained. Decision-makers should be willing to pay more than €55 000 to achieve a probability of cost-effectiveness >50%. This conclusion is robust to changes in the definition of hospital contacts and reduced intervention costs. Only in the most optimistic scenario combining the effects of all sensitivity analyses, does the incremental cost-effectiveness ratio fall below the UK thresholds values (€21 068 per quality-adjusted life-year).

CONCLUSIONS

Telehealthcare is unlikely to be a cost-effective addition to usual care, if it is offered to all patients with chronic obstructive pulmonary disease and if the willingness-to-pay threshold values from the National Institute for Health and Care Excellence are applied.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01984840, 14 November 2013.

Exploring patient experiences and perspectives of a heart failure telerehabilitation program: A mixed methods approach

OBJECTIVES

To describe patient experiences and perspectives of a group-based heart failure (HF) telerehabilitation program delivered to the homes via online video-conferencing.

BACKGROUND

Limited information currently exists on patient experiences of telerehabilitation for HF. Patient feedback and end-user perspectives provide important information regarding the acceptability of this new delivery model which may have a substantial impact on future uptake.

METHODS

We used mixed-methods design with purposive sampling of patients with HF. We used self-report surveys and semi-structured interviews to measure patient experiences and perspectives following a 12-week telerehabilitation program. The telerehabilitation program encompassed group-based exercise and education, and were delivered in real-time via videoconferencing. Interviews were transcribed and coded, with thematic analysis undertaken.

RESULTS

Seventeen participants with HF (mean age [SD] of 69 [12] years and 88% males) were recruited. Participants reported high visual clarity and ease of use for the monitoring equipment. Major themes included motivating and inhibiting influences related to telerehabilitation and improvement suggestions. Participants liked the health benefits, access to care and social support. Participants highlighted a need for improved audio clarity and connectivity as well computer training for those with limited computer experience. The majority of participants preferred a combined face-to-face and online delivery model.

CONCLUSION

Participants in this study reported high visual clarity and ease-of-use, but provided suggestions for further improvements in group-based video telerehabilitation for HF.

Using digital interventions for self-management of chronic physical health conditions: A meta-ethnography review of published studies

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.

The effectiveness of telemedicine in the management of chronic heart disease - a systematic review

OBJECTIVE

The primary objective of this systematic review is to assess the effectiveness of telemedicine in managing chronic heart disease patients concerning improvement in varied health attributes.

DESIGN

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard.

SETTING

We adopted a logical search process used in two main research databases, the Cumulative Index to Nursing and Allied Health Literature and PubMed (MEDLINE). Four reviewers meticulously screened 151 abstracts to determine relevancy and significance to our research objectives. The final sample in the literature review consisted of 20 articles.

MAIN OUTCOME MEASURES

We looked for improved medical outcomes as the main outcome measure.

RESULTS

Our results indicated that telemedicine is highly associated with the reduction in hospitalisations and readmissions (9 of 20 articles, 45%). The other significant attributes most commonly encountered were improved mortality and cost-effectiveness (both 40%) and improved health outcomes (35%). Patient satisfaction occurred the least in the literature, mentioned in only 2 of 20 articles (10%). There was no significant mention of an increase in patient satisfaction because of telemedicine.

CONCLUSIONS

We concluded that telemedicine is considered to be effective in quality measures such as readmissions, moderately effective in health outcomes, only marginally effective in customer satisfaction. Telemedicine shows promise on an alternative modality of care for cardiovascular disease, but additional exploration should continue to quantify the quality measures.

Digital health system for personalised COPD long-term management

Background

Recent telehealth studies have demonstrated minor impact on patients affected by long-term conditions. The use of technology does not guarantee the compliance required for sustained collection of high-quality symptom and physiological data. Remote monitoring alone is not sufficient for successful disease management. A patient-centred design approach is needed in order to allow the personalisation of interventions and encourage the completion of daily self-management tasks.

Methods

A digital health system was designed to support patients suffering from chronic obstructive pulmonary disease in self-managing their condition. The system includes a mobile application running on a consumer tablet personal computer and a secure backend server accessible to the health professionals in charge of patient management. The patient daily routine included the completion of an adaptive, electronic symptom diary on the tablet, and the measurement of oxygen saturation via a wireless pulse oximeter.

Results

The design of the system was based on a patient-centred design approach, informed by patient workshops. One hundred and ten patients in the intervention arm of a randomised controlled trial were subsequently given the tablet computer and pulse oximeter for a 12-month period. Patients were encouraged, but not mandated, to use the digital health system daily. The average used was 6.0 times a week by all those who participated in the full trial. Three months after enrolment, patients were able to complete their symptom diary and oxygen saturation measurement in less than 1 m 40s (96% of symptom diaries). Custom algorithms, based on the self-monitoring data collected during the first 50 days of use, were developed to personalise alert thresholds.

Conclusions

Strategies and tools aimed at refining a digital health intervention require iterative use to enable convergence on an optimal, usable design. ‘Continuous improvement’ allowed feedback from users to have an immediate impact on the design of the system (e.g., collection of quality data), resulting in high compliance with self-monitoring over a prolonged period of time (12-month). Health professionals were prompted by prioritisation algorithms to review patient data, which led to their regular use of the remote monitoring website throughout the trial.

Trial registration

Trial registration: ISRCTN40367841. Registered 17/10/2012.

An evidence-based approach to the use of telehealth in long-term health conditions: development of an intervention and evaluation through pragmatic randomised controlled trials in patients with depression or raised cardiovascular risk

Background

Health services internationally are exploring the potential of telehealth to support the management of the growing number of people with long-term conditions (LTCs).

Aim

To develop, implement and evaluate new care programmes for patients with LTCs, focusing on two common LTCs as exemplars: depression or high cardiovascular disease (CVD) risk.

Methods

Development

We synthesised quantitative and qualitative evidence on the effectiveness of telehealth for LTCs, conducted a qualitative study based on interviews with patients and staff and undertook a postal survey to explore which patients are interested in different forms of telehealth. Based on these studies we developed a conceptual model [TElehealth in CHronic disease (TECH) model] as a framework for the development and evaluation of the Healthlines Service for patients with LTCs.

Implementation

The Healthlines Service consisted of regular telephone calls to participants from health information advisors, supporting them to make behaviour change and to use tailored online resources. Advisors sought to optimise participants’ medication and to improve adherence.

Evaluation

The Healthlines Service was evaluated with linked pragmatic randomised controlled trials comparing the Healthlines Service plus usual care with usual care alone, with nested process and economic evaluations. Participants were adults with depression or raised CVD risk recruited from 43 general practices in three areas of England. The primary outcome was response to treatment and the secondary outcomes included anxiety (depression trial), individual risk factors (CVD risk trial), self-management skills, medication adherence, perceptions of support, access to health care and satisfaction with treatment.

Trial results

Depression trial

In total, 609 participants were randomised and the retention rate was 86%. Response to treatment [Patient Health Questionnaire 9-items (PHQ-9) reduction of ≥ 5 points and score of < 10 after 4 months] was higher in the intervention group (27%, 68/255) than in the control group (19%, 50/270) [odds ratio 1.7, 95% confidence interval (CI) 1.1 to 2.5;p = 0.02]. Anxiety also improved. Intervention participants reported better access to health support, greater satisfaction with treatment and small improvements in self-management, but not improved medication adherence.

CVD risk trial

In total, 641 participants were randomised and the retention rate was 91%. Response to treatment (maintenance of/reduction in QRISK®2 score after 12 months) was higher in the intervention group (50%, 148/295) than in the control group (43%, 124/291), which does not exclude a null effect (odds ratio 1.3, 95% CI 1.0 to 1.9;p = 0.08). The intervention was associated with small improvements in blood pressure and weight, but not smoking or cholesterol. Intervention participants were more likely to adhere to medication, reported better access to health support and greater satisfaction with treatment, but few improvements in self-management.

The Healthlines Service was likely to be cost-effective for CVD risk, particularly if the benefits are sustained, but not for depression. The intervention was implemented largely as planned, although initial delays and later disruption to delivery because of the closure of NHS Direct may have adversely affected participant engagement.

Conclusion

The Healthlines Service, designed using an evidence-based conceptual model, provided modest health benefits and participants valued the better access to care and extra support provided. This service was cost-effective for CVD risk but not depression. These findings of small benefits at extra cost are consistent with previous pragmatic research on the implementation of comprehensive telehealth programmes for LTCs.

Trial registration

Current Controlled Trials ISRCTN14172341 (depression trial) and ISRCTN27508731 (CVD risk trial).

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Mixed methods for telehealth research

Mixed methods research is important to health services research because the integrated qualitative and quantitative investigation can give a more comprehensive understanding of complex interventions such as telehealth than can a single-method study. Further, mixed methods research is applicable to translational research and program evaluation. Study designs relevant to telehealth research are described and supported by examples. Quality assessment tools, frameworks to assist in the reporting and review of mixed methods research, and related methodologies are also discussed.

Cost-effectiveness of telehealth for patients with raised cardiovascular disease risk: evidence from the Healthlines randomised controlled trial

OBJECTIVES

To investigate the cost-effectiveness of a telehealth intervention for primary care patients with raised cardiovascular disease (CVD) risk.

DESIGN

A prospective within-trial patient-level economic evaluation conducted alongside a randomised controlled trial.

SETTING

Patients recruited through primary care, and intervention delivered via telehealth service.

PARTICIPANTS

Adults with a 10-year CVD risk ≥20%, as measured by the QRISK2 algorithm, with at least 1 modifiable risk factor.

INTERVENTION

A series of up to 13 scripted, theory-led telehealth encounters with healthcare advisors, who supported participants to make behaviour change, use online resources, optimise medication and improve adherence. Participants in the control arm received usual care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Cost-effectiveness measured by net monetary benefit at the end of 12 months of follow-up, calculated from incremental cost and incremental quality-adjusted life years (QALYs). Productivity impacts, participant out-of-pocket expenditure and the clinical outcome were presented in a cost-consequences framework.

RESULTS

641 participants were randomised-325 to receive the telehealth intervention in addition to usual care and 316 to receive only usual care. 18% of participants had missing data on either costs, utilities or both. Multiple imputation was used for the base case results. The intervention was associated with incremental mean per-patient National Health Service (NHS) costs of £138 (95% CI 66 to 211) and an incremental QALY gain of 0.012 (95% CI -0.001 to 0.026). The incremental cost-effectiveness ratio was £10 859. Net monetary benefit at a cost-effectiveness threshold of £20 000 per QALY was £116 (95% CI -58 to 291), and the probability that the intervention was cost-effective at this threshold value was 0.77. Similar results were obtained from a complete case analysis.

CONCLUSIONS

There is evidence to suggest that the Healthlines telehealth intervention was likely to be cost-effective at a threshold of £20 000 per QALY.

TRIAL REGISTRATION NUMBER

ISRCTN27508731; Results. Prospectively registered 05 July 2012.

Cost-effectiveness of telehealth for patients with depression: evidence from the Healthlines randomised controlled trial

BACKGROUND

Depression is a prevalent long-term condition that is associated with substantial resource use. Telehealth may offer a cost-effective means of supporting the management of people with depression.

AIMS

To investigate the cost-effectiveness of a telehealth intervention ('Healthlines') for patients with depression.

METHOD

A prospective patient-level economic evaluation conducted alongside a randomised controlled trial. Patients were recruited through primary care, and the intervention was delivered via a telehealth service. Participants with a confirmed diagnosis of depression and PHQ-9 score ≥10 were recruited from 43 English general practices. A series of up to 10 scripted, theory-led, telephone encounters with health information advisers supported participants to effect a behaviour change, use online resources, optimise medication and improve adherence. The intervention was delivered alongside usual care and was designed to support rather than duplicate primary care. Cost-effectiveness from a combined health and social care perspective was measured by net monetary benefit at the end of 12 months of follow-up, calculated from incremental cost and incremental quality-adjusted life years (QALYs). Cost-consequence analysis included cost of lost productivity, participant out-of-pocket expenditure and the clinical outcome.

RESULTS

A total of 609 participants were randomised - 307 to receive the Healthlines intervention plus usual care and 302 to receive usual care alone. Forty-five per cent of participants had missing quality of life data, 41% had missing cost data and 51% of participants had missing data on either cost or utility, or both. Multiple imputation was used for the base-case analysis. The intervention was associated with incremental mean per-patient National Health Service/personal social services cost of £168 (95% CI £43 to £294) and an incremental QALY gain of 0.001 (95% CI -0.023 to 0.026). The incremental cost-effectiveness ratio was £132 630. Net monetary benefit at a cost-effectiveness threshold of £20 000 was -£143 (95% CI -£164 to -£122) and the probability of the intervention being cost-effective at this threshold value was 0.30. Productivity costs were higher in the intervention arm, but out-of-pocket expenses were lower.

CONCLUSIONS

The Healthlines service was acceptable to patients as a means of condition management, and response to treatment after 4 months was higher for participants randomised to the intervention. However, the positive average intervention effect size was modest, and incremental costs were high relative to a small incremental QALY gain at 12 months. The intervention is not likely to be cost-effective in its current form.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.

Being Human: A Qualitative Interview Study Exploring Why a Telehealth Intervention for Management of Chronic Conditions Had a Modest Effect

Background

Evidence of benefit for telehealth for chronic conditions is mixed. Two linked randomized controlled trials tested the Healthlines Service for 2 chronic conditions: depression and high risk of cardiovascular disease (CVD). This new telehealth service consisted of regular telephone calls from nonclinical, trained health advisers who followed standardized scripts generated by interactive software. Advisors facilitated self-management by supporting participants to use Web-based resources and helped to optimize medication, improve treatment adherence, and encourage healthier lifestyles. Participants were recruited from primary care. The trials identified moderate (for depression) or partial (for CVD risk) effectiveness of the Healthlines Service.

Objective

An embedded qualitative study was undertaken to help explain the results of the 2 trials by exploring mechanisms of action, context, and implementation of the intervention.

Methods

Qualitative interview study of 21 staff providing usual health care or involved in the intervention and 24 patients receiving the intervention.

Results

Interviewees described improved outcomes in some patients, which they attributed to the intervention, describing how components of the model on which the intervention was based helped to achieve benefits. Implementation of the intervention occurred largely as planned. However, contextual issues in patients’ lives and some problems with implementation may have reduced the size of effect of the intervention. For depression, patients’ lives and preferences affected engagement with the intervention: these largely working-age patients had busy and complex lives, which affected their ability to engage, and some patients preferred a therapist-based approach to the cognitive behavioral therapy on offer. For CVD risk, patients’ motivations adversely affected the intervention whereby some patients joined the trial for general health improvement or from altruism, rather than motivation to make lifestyle changes to address their specific risk factors. Implementation was not optimal in the early part of the CVD risk trial owing to technical difficulties and the need to adapt the intervention for use in practice. For both conditions, enthusiastic and motivated staff offering continuity of intervention delivery tailored to individual patients’ needs were identified as important for patient engagement with telehealth; this was not delivered consistently, particularly in the early stages of the trials. Finally, there was a lack of active engagement from primary care.

Conclusions

The conceptual model was supported and could be used to develop further telehealth interventions for chronic conditions. It may be possible to increase the effectiveness of this, and similar interventions, by attending to the human as well as the technical aspects of telehealth: offering it to patients actively wanting the intervention, ensuring continuity of delivery by enthusiastic and motivated staff, and encouraging active engagement from primary care staff.

Effectiveness of an integrated telehealth service for patients with depression: a pragmatic randomised controlled trial of a complex intervention

BACKGROUND

Many countries are exploring the potential of telehealth interventions to manage the rising number of people with chronic disorders. However, evidence of the effectiveness of telehealth is ambiguous. Based on an evidence-based conceptual framework, we developed an integrated telehealth service (the Healthlines Service) for chronic disorders and assessed its effectiveness in patients with depression. We aimed to compare the Healthlines Depression Service plus usual care with usual care alone.

METHODS

This study was a pragmatic, multicentre, randomised controlled trial with participants recruited from 43 general practices in three areas of England. To be eligible, participants needed to have access to the internet and email, a Patient Health Questionnaire 9 (PHQ-9) score of at least 10, and a confirmed diagnosis of depression. Participants were individually assigned (1:1) to either the Healthlines Depression Service plus usual care or usual care alone. Random assignment was done by use of a web-based automated randomisation system, stratified by site and minimised by practice and PHQ-9 score. Participants were aware of their allocation, but outcomes were analysed masked. The Healthlines Service consisted of regular telephone calls from non-clinical, trained health advisers who followed standardised scripts generated by interactive software. After an initial assessment and goal-setting telephone call, the advisers called each participant on six occasions over 4 months, and then made up to three more calls at intervals of roughly 2 months to provide reinforcement and to detect relapse. Advisers supported participants in the use of online resources (including computerised cognitive behavioural therapy) and sought to encourage healthier lifestyles, optimise medication, and improve treatment adherence. The primary outcome was the proportion of participants responding to the intervention (defined as PHQ-9 <10 and reduction in PHQ-9 of ≥5 points) at 4 months after randomisation. The primary analysis was based on the intention-to-treat principle without imputation and all serious adverse events were investigated. This trial is registered with Current Controlled Trials, number ISRCTN 14172341.

FINDINGS

Between July 24, 2012, and July 31, 2013, we recruited 609 participants, randomly assigning 307 to the Healthlines Service plus usual care and 302 to usual care. Primary outcome data were available for 525 (86%) participants. At 4 months, 68 (27%) of 255 individuals in the intervention group had a treatment response compared with 50 (19%) of 270 individuals in the usual care group (adjusted odds ratio 1·7, 95% CI 1·1-2·5, p=0·019). Compared with usual care alone, intervention participants reported improvements in anxiety, better access to support and advice, greater satisfaction with the support they received, and improvements in self-management and health literacy. During the trial, 70 adverse events were reported by participants, one of which was related to the intervention (increased anxiety from discussing depression) and was not serious.

INTERPRETATION

This telehealth service based on non-clinically trained health advisers supporting patients in use of internet resources was both acceptable and effective compared with usual care. Our results provide support for the development and assessment of similar interventions in other chronic disorders to expand care provision.

FUNDING

National Institute for Health Research (NIHR).