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Shi B, Li G, Wu S, Ge H, Zhang X, Chen S, Pan Y, He Q. Assessing the Effectiveness of eHealth Interventions to Manage Multiple Lifestyle Risk Behaviors Among Older Adults: Systematic Review and Meta-Analysis. J Med Internet Res 2024; 26:e58174. [PMID: 39083787 PMCID: PMC11325121 DOI: 10.2196/58174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/24/2024] [Accepted: 06/01/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Developing adverse lifestyle behaviors increases the risk of a variety of chronic age-related diseases, including cardiovascular disease, obesity, and Alzheimer disease. There is limited evidence regarding the effectiveness of eHealth-based multiple health behavior change (MHBC) interventions to manage lifestyle risk behaviors. OBJECTIVE The purpose of this systematic evaluation was to assess the effectiveness of eHealth MHBC interventions in changing ≥2 major lifestyle risk behaviors in people aged ≥50 years. METHODS The literature search was conducted in 6 electronic databases-PubMed, Embase, Web of Science, Scopus, Cochrane Library, and SPORTDiscus-from inception to May 1, 2024. Eligible studies were randomized controlled trials of eHealth interventions targeting ≥2 of 6 behaviors of interest: alcohol use, smoking, diet, physical activity (PA), sedentary behavior, and sleep. RESULTS A total of 34 articles with 35 studies were included. eHealth-based MHBC interventions significantly increased smoking cessation rates (odds ratio 2.09, 95% CI 1.62-2.70; P<.001), fruit intake (standardized mean difference [SMD] 0.18, 95% CI 0.04-0.32; P=.01), vegetable intake (SMD 0.17, 95% CI 0.05-0.28; P=.003), self-reported total PA (SMD 0.22, 95% CI 0.02-0.43; P=.03), and objectively measured moderate to vigorous PA (SMD 0.25, 95% CI 0.09-0.41; P=.002); in addition, the interventions decreased fat intake (SMD -0.23, 95% CI -0.33 to -0.13; P<.001). No effects were observed for alcohol use, sedentary behavior, or sleep. A sensitivity analysis was conducted to test the robustness of the pooled results. Moreover, the certainty of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework. CONCLUSIONS eHealth-based MHBC interventions may be a promising strategy to increase PA, improve diet, and reduce smoking among older adults. However, the effect sizes were small. Further high-quality, older adult-oriented research is needed to develop eHealth interventions that can change multiple behaviors. TRIAL REGISTRATION PROSPERO International Prospective Register of Systematic Reviews CRD42023444418; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023444418.
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Affiliation(s)
- Beibei Shi
- School of Physical Education, Shandong University, Jinan, China
| | - Guangkai Li
- School of Physical Education, Shandong University, Jinan, China
| | - Shuang Wu
- School of Physical Education, Shandong University, Jinan, China
| | - Hongli Ge
- School of Physical Education, Shandong University, Jinan, China
| | - Xianliang Zhang
- School of Physical Education, Shandong University, Jinan, China
| | - Si Chen
- School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yang Pan
- School of Physical Education, Shandong University, Jinan, China
| | - Qiang He
- School of Physical Education, Shandong University, Jinan, China
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Sakima A, Akagi Y, Akasaki Y, Fujii T, Haze T, Kawakami-Mori F, Kitajima K, Kobayashi Y, Matayoshi T, Sakaguchi T, Yamazato M, Abe M, Ohya Y, Arima H. Effectiveness of digital health interventions for telemedicine/telehealth for managing blood pressure in adults: a systematic review and meta-analysis. Hypertens Res 2024:10.1038/s41440-024-01792-7. [PMID: 38977877 DOI: 10.1038/s41440-024-01792-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 06/15/2024] [Indexed: 07/10/2024]
Abstract
This systematic review and meta-analysis included randomized controlled trials or observational studies that compare digital health interventions (DHIs) for telemedicine/telehealth versus usual care for managing blood pressure (BP) in adults. We searched PubMed, Cochrane CENTRAL, and IchuShi-Web, and used a random-effects meta-analysis of the weighted mean difference (MD) between the comparison groups to pool data from the included studies. The outcome included the pooled MD of office BP from baseline to each follow-up period. This meta-analysis considered 117 studies with 68677 participants as eligible. The 3-month intervention period reduced office systolic BP (SBP) compared with usual care in 38 studies (MD: -3.21 mmHg [95% confidence interval: -4.51 to -1.90]), with evidence of heterogeneity. Office SBP across intervention periods demonstrated comparable effects (3-, 6- [54 studies], 12- [43 studies], and >12-month periods [9 studies]). The benefits for office diastolic BP were similar to those for office SBP. Additionally, the interventions significantly reduced the office SBP compared with the control, regardless of the mode of intervention delivery (smartphone apps [38 studies], text messages [35 studies], and websites [34 studies]) or type of facility (medical [74 studies] vs. non-medical [33 studies]). The interventions were more effective in 41 hypertension cohorts compared with 66 non-hypertension cohorts (-4.81 mmHg [-6.33, -3.29] vs. -2.17 mmHg [-3.15, -1.19], P = 0.006 for heterogeneity). In conclusion, DHIs for telemedicine/telehealth improved BP management compared with usual care. The effectiveness with heterogeneity should be considered, as prudent for implementing evidence-based medicine. This meta-analysis considered 117 studies with 68677 participants eligible. The DHIs for telemedicine/telehealth reduced office BP compared with usual care, regardless of intervention duration, intervention delivery mode, facility type, and cohort type. Additionally, the DHIs reduced the risk of uncontrolled BP compared with usual care, regardless of intervention duration, intervention delivery mode, and facility type. BP blood pressure, DHI digital health intervention, MD mean difference, RR risk ratio, SBP systolic blood pressure.
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Affiliation(s)
- Atsushi Sakima
- Health Administration Center, University of the Ryukyus, Okinawa, Japan.
| | - Yuya Akagi
- Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuichi Akasaki
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Takako Fujii
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Tatsuya Haze
- YCU Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital, Kanagawa, Japan
| | - Fumiko Kawakami-Mori
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mitsui Memorial Hospital, Tokyo, Japan
| | - Ken Kitajima
- Department of Cardiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yusuke Kobayashi
- Co-Creation Innovation Center, Yokohama City University, Kanagawa, Japan
| | | | - Takashi Sakaguchi
- Department of Pediatrics, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | | | - Makiko Abe
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yusuke Ohya
- University Hospital of the Ryukyus, Okinawa, Japan
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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Agyei EEYF, Ekpezu A, Oinas-Kukkonen H. Persuasive Systems Design Trends in Coronary Heart Disease Management: Scoping Review of Randomized Controlled Trials. JMIR Cardio 2024; 8:e49515. [PMID: 38896840 PMCID: PMC11222763 DOI: 10.2196/49515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/21/2023] [Accepted: 05/01/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Behavior change support systems (BCSSs) have the potential to help people maintain healthy lifestyles and aid in the self-management of coronary heart disease (CHD). The Persuasive Systems Design (PSD) model is a framework for designing and evaluating systems designed to support lifestyle modifications and health behavior change using information and communication technology. However, evidence for the underlying design principles behind BCSSs for CHD has not been extensively reported in the literature. OBJECTIVE This scoping review aims to identify existing health BCSSs for CHD, report the characteristics of these systems, and describe the persuasion context and persuasive design principles of these systems based on the PSD framework. METHODS Using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines, 3 digital databases (Scopus, Web of Science, and MEDLINE) were searched between 2010 to 2022. The major inclusion criteria for studies were in accordance with the PICO (Population, Intervention, Comparison, and Outcome) approach. RESULTS Searches conducted in the databases identified 1195 papers, among which 30 were identified as eligible for the review. The most interesting characteristics of the BCSSs were the predominant use of primary task support principles, followed by dialogue support and credibility support and the sparing use of social support principles. Theories of behavior change such as the Social Cognitive Theory and Self-Efficacy Theory were used often to underpin these systems. However, significant trends in the use of persuasive system features on par with behavior change theories could not be established from the reviewed studies. This points to the fact that there is still no theoretical consensus on how best to design interventions to promote behavior change in patients with CHD. CONCLUSIONS Our results highlight key software features for designing BCSSs for the prevention and management of CHD. We encourage designers of behavior change interventions to evaluate the techniques that contributed to the success of the intervention. Future research should focus on evaluating the effectiveness of the interventions, persuasive design principles, and behavior change theories using research methodologies such as meta-analysis.
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Affiliation(s)
- Eunice Eno Yaa Frimponmaa Agyei
- Oulu Advanced Research on Service and Information Systems, Faculty of Information Technology and Electrical Engineering, University of Oulu, Oulu, Finland
| | - Akon Ekpezu
- Oulu Advanced Research on Service and Information Systems, Faculty of Information Technology and Electrical Engineering, University of Oulu, Oulu, Finland
| | - Harri Oinas-Kukkonen
- Oulu Advanced Research on Service and Information Systems, Faculty of Information Technology and Electrical Engineering, University of Oulu, Oulu, Finland
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Redfern J, Tu Q, Hyun K, Hollings MA, Hafiz N, Zwack C, Free C, Perel P, Chow CK. Mobile phone text messaging for medication adherence in secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2024; 3:CD011851. [PMID: 38533994 PMCID: PMC10966941 DOI: 10.1002/14651858.cd011851.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
BACKGROUND Cardiovascular diseases (CVDs) are the leading cause of death globally, accounting for almost 18 million deaths annually. People with CVDs have a five times greater chance of suffering a recurrent cardiovascular event than people without known CVDs. Although drug interventions have been shown to be cost-effective in reducing the risk of recurrent cardiovascular events, adherence to medication remains suboptimal. As a scalable and cost-effective approach, mobile phone text messaging presents an opportunity to convey health information, deliver electronic reminders, and encourage behaviour change. However, it is uncertain whether text messaging can improve medication adherence and clinical outcomes. This is an update of a Cochrane review published in 2017. OBJECTIVES To evaluate the benefits and harms of mobile phone text messaging for improving medication adherence in people with CVDs compared to usual care. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, four other databases, and two trial registers. We also checked the reference lists of all primary included studies and relevant systematic reviews and meta-analyses. The date of the latest search was 30 August 2023. SELECTION CRITERIA We included randomised controlled trials (RCTs) with participants with established arterial occlusive events. We included trials investigating interventions using short message service (SMS) or multimedia messaging service (MMS) with the aim of improving adherence to medication for the secondary prevention of cardiovascular events. The comparator was usual care. We excluded cluster-RCTs and quasi-RCTs. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were medication adherence, fatal cardiovascular events, non-fatal cardiovascular events, and combined CVD event. Secondary outcomes were low-density lipoprotein cholesterol for the effect of statins, blood pressure for antihypertensive drugs, heart rate for the effect of beta-blockers, urinary 11-dehydrothromboxane B2 for the antiplatelet effects of aspirin, adverse effects, and patient-reported experience. We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS We included 18 RCTs involving a total of 8136 participants with CVDs. We identified 11 new studies in the review update and seven studies in the previous version of the review. Participants had various CVDs including acute coronary syndrome, coronary heart disease, stroke, myocardial infarction, and angina. All studies were conducted in middle- and high-income countries, with no studies conducted in low-income countries. The mean age of participants was 53 to 64 years. Participants were recruited from hospitals or cardiac rehabilitation facilities. Follow-up ranged from one to 12 months. There was variation in the characteristics of text messages amongst studies (e.g. delivery method, frequency, theoretical grounding, content used, personalisation, and directionality). The content of text messages varied across studies, but generally included medication reminders and healthy lifestyle information such as diet, physical activity, and weight loss. Text messages offered advice, motivation, social support, and health education to promote behaviour changes and regular medication-taking. We assessed risk of bias for all studies as high, as all studies had at least one domain at unclear or high risk of bias. Medication adherence Due to different evaluation score systems and inconsistent definitions applied for the measurement of medication adherence, we did not conduct meta-analysis for medication adherence. Ten out of 18 studies showed a beneficial effect of mobile phone text messaging for medication adherence compared to usual care, whereas the other eight studies showed either a reduction or no difference in medication adherence with text messaging compared to usual care. Overall, the evidence is very uncertain about the effects of mobile phone text messaging for medication adherence when compared to usual care. Fatal cardiovascular events Text messaging may have little to no effect on fatal cardiovascular events compared to usual care (odds ratio 0.83, 95% confidence interval (CI) 0.47 to 1.45; 4 studies, 1654 participants; low-certainty evidence). Non-fatal cardiovascular events We found very low-certainty evidence that text messaging may have little to no effect on non-fatal cardiovascular events. Two studies reported non-fatal cardiovascular events, neither of which found evidence of a difference between groups. Combined CVD events We found very low-certainty evidence that text messaging may have little to no effect on combined CVD events. Only one study reported combined CVD events, and did not find evidence of a difference between groups. Low-density lipoprotein cholesterol Text messaging may have little to no effect on low-density lipoprotein cholesterol compared to usual care (mean difference (MD) -1.79 mg/dL, 95% CI -4.71 to 1.12; 8 studies, 4983 participants; very low-certainty evidence). Blood pressure Text messaging may have little to no effect on systolic blood pressure (MD -0.93 mmHg, 95% CI -3.55 to 1.69; 8 studies, 5173 participants; very low-certainty evidence) and diastolic blood pressure (MD -1.00 mmHg, 95% CI -2.49 to 0.50; 5 studies, 3137 participants; very low-certainty evidence) when compared to usual care. Heart rate Text messaging may have little to no effect on heart rate compared to usual care (MD -0.46 beats per minute, 95% CI -1.74 to 0.82; 4 studies, 2946 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS Due to limited evidence, we are uncertain if text messaging reduces medication adherence, fatal and non-fatal cardiovascular events, and combined cardiovascular events in people with cardiovascular diseases when compared to usual care. Furthermore, text messaging may result in little or no effect on low-density lipoprotein cholesterol, blood pressure, and heart rate compared to usual care. The included studies were of low methodological quality, and no studies assessed the effects of text messaging in low-income countries or beyond the 12-month follow-up. Long-term and high-quality randomised trials are needed, particularly in low-income countries.
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Affiliation(s)
- Julie Redfern
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- The George Institute for Global Health, University of New South Wales, Sydney , Australia
| | - Qiang Tu
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Karice Hyun
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Cardiology, Concord Hospital, Sydney , Australia
| | - Matthew A Hollings
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Nashid Hafiz
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Clara Zwack
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Caroline Free
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Pablo Perel
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Clara K Chow
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Cardiology, Westmead Hospital, Sydney, Australia
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Puljević C, Meciar I, Holland A, Stjepanović D, Snoswell CL, Thomas EE, Morphett K, Kang H, Chan G, Grobler E, Gartner CE. Systematic review and meta-analysis of text messaging interventions to support tobacco cessation. Tob Control 2024:tc-2023-058323. [PMID: 38448226 DOI: 10.1136/tc-2023-058323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/21/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE To review randomised controlled trials (RCTs) investigating the effectiveness of text message-based interventions for smoking cessation, including the effects of dose (number of text messages) and concomitant use of behavioural or pharmacological interventions. DATA SOURCES We searched seven databases (PubMed, CINAHL, PsycINFO, Scopus, EMBASE, Cochrane Library and Web of Science), Google Scholar and the reference lists of relevant publications for RCTs. Eligible studies included participants aged ≥15 years who smoked tobacco at enrolment. STUDY SELECTION One reviewer screened titles and abstracts and two reviewers independently screened full texts of articles. DATA EXTRACTION One of three reviewers independently extracted data on study and intervention characteristics and smoking abstinence rates using Qualtrics software. DATA SYNTHESIS 30 of the 40 included studies reported higher rates of smoking cessation among those receiving text messaging interventions compared with comparators, but only 10 were statistically significant. A meta-analysis of seven RCTs found that participants receiving text messages were significantly more likely to quit smoking compared with participants in no/minimal intervention or 'usual care' conditions (risk ratio 1.87, 95% CI 1.52 to 2.29, p <0.001). Three trials found no benefit from a higher dose of text messages on smoking cessation. Two trials that tested the added benefit of text messaging to pharmacotherapy reported outcomes in favour of adding text messaging. CONCLUSIONS Findings suggest that text messaging-based interventions are effective at promoting smoking cessation. Further research is required to establish if any additional benefit is gained from an increased number of text messages or concurrent pharmacotherapy or behavioural counselling.
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Affiliation(s)
- Cheneal Puljević
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Herston, Queensland, Australia
| | - Isabel Meciar
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Herston, Queensland, Australia
| | - Alice Holland
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Herston, Queensland, Australia
| | - Daniel Stjepanović
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Herston, Queensland, Australia
- National Centre for Youth Substance Use Research, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Centaine L Snoswell
- Centre for Online Health, Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Emma E Thomas
- Centre for Online Health, Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Kylie Morphett
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Herston, Queensland, Australia
| | - Heewon Kang
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Herston, Queensland, Australia
- Seoul National University Institute of Health and Environment, Seoul, South Korea
| | - Gary Chan
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Herston, Queensland, Australia
- National Centre for Youth Substance Use Research, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Etienne Grobler
- Department of Psychology, University of Cape Town, Cape Town, South Africa
| | - Coral E Gartner
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Herston, Queensland, Australia
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Acevedo M, Varleta P, Casas-Cordero C, Berríos A, Navarrete C, Valentino G, Lopez R, Smith SC. Mobile-phone text messaging to promote ideal cardiovascular health in women. Open Heart 2023; 10:e002214. [PMID: 36759011 PMCID: PMC9923351 DOI: 10.1136/openhrt-2022-002214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
OBJECTIVE Ideal cardiovascular health (CVH) was developed to promote CVH as a key component of primordial prevention. Mobile short message service (SMS) is useful for improving health behaviours. We aim to test the effectiveness of SMS intervention in women to improve CVH. METHODS In a single-blinded, randomised, controlled study, 620 women, aged 35-70 years, without cardiovascular disease, were enrolled in SMS intervention versus no SMS. CVH metrics by self-report, and biochemical laboratory, anthropometric and blood pressure measurements were collected during home visits at baseline and 9 months. Women were categorised as having poor (0-2), intermediate (3-4) or ideal (5-7) CVH according to the number of ideal CVH metrics. Participants were randomised 1:1 to SMS intervention versus control. SMS was sent every 5-6 days for 9 months. The primary outcome was the difference in the proportion of women with ideal CVH between SMS and control groups at 9 months. Rates of intermediate CVH, poor CVH and each of the seven ideal CV health metrics at 9 months were key secondary endpoints. RESULTS At 9 months, there was no significant difference between groups for the primary outcome (16.3% at baseline and 13.3% at 9 months, and 10.1% and 11.1%, in SMS and control groups, respectively, adjusted RR 1.0; 95% CI 0.6 to 1.6). Similarly, there were no significant differences between groups for the key secondary endpoints. SMS had an acceptance rate of 94.9%. CONCLUSIONS Behavioural SMS intervention did not improve rates of ideal CVH in women, despite being feasible and well received. TRIAL REGISTRATION NUMBER 6377.
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Affiliation(s)
- Monica Acevedo
- Fundación SOCHICAR (Sociedad Chilena de Cardiología y Cirugía Cardiovascular), Santiago, Chile
- División de Enfermedades Cardiovasculares, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Paola Varleta
- Fundación SOCHICAR (Sociedad Chilena de Cardiología y Cirugía Cardiovascular), Santiago, Chile
- Centro Cardiovascular, Hospital DIPRECA, Las Condes, Chile
| | - Carolina Casas-Cordero
- Instituto de Sociología, Pontificia Universidad Católica de Chile, Santiago, Chile
- Instituto de Sociología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Amalia Berríos
- Fundación SOCHICAR (Sociedad Chilena de Cardiología y Cirugía Cardiovascular), Santiago, Chile
| | - Carlos Navarrete
- Departamento de Matemáticas, Universidad de La Serena, La Serena, Chile
| | - Giovanna Valentino
- Carrera de Nutrición y Dietética, Ciencias de la Salud, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Rosario Lopez
- Carrera de Kinesiología, Facultad de Ciencias de la Salud, Universidad San Sebastián - Campus Bellavista, Santiago de Chile, Chile
| | - Sidney C Smith
- Cardiovascular Department, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Zhou H, Wang X, Yang Y, Chen Z, Zhang L, Zheng C, Shao L, Tian Y, Cao X, Hu Z, Tian Y, Chen L, Cai J, Gu R, Wang Z. Effect of a Multicomponent Intervention Delivered on a Web-Based Platform on Hypertension Control: A Cluster Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2245439. [PMID: 36477479 PMCID: PMC9856259 DOI: 10.1001/jamanetworkopen.2022.45439] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE The prevalence of hypertension is high and still increasing across the world, while the control rate remains low in many countries. Emerging technology, such as telemedicine, may offer additional support to change the unsatisfactory situation. OBJECTIVE To establish a multicomponent intervention delivered on a web-based telemedicine platform and oriented with the Chinese hypertension management guidelines and to evaluate the effect of the intervention on blood pressure (BP) control for patients with hypertension. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized clinical trial of a hypertension management program was conducted at 66 community health centers in China from October 1, 2018, to May 31, 2020, with a 12-month follow-up. Patients with hypertension were blinded to randomization and were randomized to either the intervention group or control group. Hypertension was diagnosed at mean systolic BP (SBP) and diastolic BP (DBP) readings higher than 140 and 90 mm Hg or with use of antihypertensive medication. Evaluation of the intervention effect was based on the principle of modified intention to treat. INTERVENTIONS Multicomponent intervention was delivered on a web-based platform and consisted of a primary prevention program for cardiovascular disease and standardized management for hypertension. MAIN OUTCOMES AND MEASURES The primary outcome was the change in BP control rate (SBP and DBP levels <140 and 90 mm Hg, or <130 and 80 mm Hg for patients with diabetes) from baseline to the 12-month follow-up among patients with hypertension in the intervention and control groups. RESULTS A total of 4118 patients (mean [SD] age, 61.6 [9.4] years; 2265 women [55.0%]) were included in the analysis, with 2985 in the intervention group and 1133 in the control group. The BP control rate at baseline was 22.8% in the intervention group and 22.5% in the control group. After 12 months of the intervention, the BP control rate for the intervention group compared with the control group was significantly higher (47.4% vs 30.2%; odds ratio, 1.18; 95% CI, 1.13-1.24; P < .001). The intervention effect on SBP level was -10.1 mm Hg (95% CI, -11.7 to -8.5 mm Hg; P < .001) and on DBP level was -1.8 mm Hg (95% CI, -2.8 to -0.8 mm Hg; P < .001). CONCLUSIONS AND RELEVANCE Results of this trial showed that a multicomponent intervention delivered on a web-based platform improved BP control rate and lowered BP level more than usual care alone. Such a telemedicine program may provide a new, effective way to treat patients with hypertension in the community and may generate public health benefits across diverse populations. TRIAL REGISTRATION Chinese Clinical Trial Registry Identifier: ChiCTR1800017791.
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Affiliation(s)
- Haoqi Zhou
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
- Department of Biostatistics, Peking University, Beijing, China
| | - Xin Wang
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Yang
- Cardiovascular Center, Beijing Huaxin Hospital, the First Hospital of Tsinghua University, Beijing, China
| | - Zuo Chen
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Linfeng Zhang
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Congyi Zheng
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Lan Shao
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Ye Tian
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xue Cao
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Zhen Hu
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yixin Tian
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Lu Chen
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jiayin Cai
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Runqing Gu
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
- School of Population Medicine and Public Health, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Zengwu Wang
- Division of Prevention and Community Health, National Center for Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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8
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Cameron J, Lannin NA, Harris D, Andrew NE, Kilkenny MF, Purvis T, Thrift AG, Thayabaranathan T, Ellery F, Sookram G, Hackett M, Kneebone I, Drummond A, Cadilhac DA. A mixed-methods feasibility study of a new digital health support package for people after stroke: the Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke (ReCAPS) intervention. Pilot Feasibility Stud 2022; 8:241. [PMID: 36401336 PMCID: PMC9675218 DOI: 10.1186/s40814-022-01197-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/31/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Evidence for digital health programmes to support people living with stroke is growing. We assessed the feasibility of a protocol and procedures for the Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke (ReCAPS) trial. METHODS We conducted a mixed-method feasibility study. Participants with acute stroke were recruited from three hospitals (Melbourne, Australia). Eligibility: Adults with stroke discharged from hospital to home within 10 days, modified Rankin Score 0-4 and prior use of Short Message System (SMS)/email. While in hospital, recruited participants contributed to structured person-centred goal setting and completed baseline surveys including self-management skills and health-related quality of life. Participants were randomised 7-14 days after discharge via REDCap® (1:1 allocation). Following randomisation, the intervention group received a 12-week programme of personalised electronic support messages (average 66 messages sent by SMS or email) aligned with their goals. The control group received six electronic administrative messages. Feasibility outcomes included the following: number of patients screened and recruited, study retainment, completion of outcome measures and acceptability of the ReCAPS intervention and trial procedures (e.g. participant satisfaction survey, clinician interviews). Protocol fidelity outcomes included number of goals developed (and quality), electronic messages delivered, stop messages received and engagement with messages. We undertook inductive thematic analysis of interview/open-text survey data and descriptive analysis of closed survey questions. RESULTS Between November 2018 and October 2019, 312 patients were screened; 37/105 (35%) eligible patients provided consent (mean age 61 years; 32% female); 33 were randomised (17 to intervention). Overall, 29 (88%) participants completed the12-week outcome assessments with 12 (41%) completed assessments in the allocated timeframe and 16 also completing the satisfaction survey (intervention=10). Overall, trial participants felt that the study was worthwhile and most would recommend it to others. Six clinicians participated in one of three focus group interviews; while they reported that the trial and the process of goal setting were acceptable, they raised concerns regarding the additional time required to personalise goals. CONCLUSION The study protocol and procedures were feasible with acceptable retention of participants. Consent and goal personalisation procedures should be centralised for the phase III trial to reduce the burden on hospital clinicians. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12618001468213 (date 31/08/2018); Universal Trial Number: U1111-1206-7237.
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Affiliation(s)
- Janette Cameron
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3 Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia
| | - Natasha A Lannin
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
- Alfred Health, Melbourne, Australia
| | - Dawn Harris
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3 Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia
| | - Nadine E Andrew
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3 Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia
- Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Clayton, Australia
| | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3 Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
| | - Tara Purvis
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3 Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3 Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia
| | - Tharshanah Thayabaranathan
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3 Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia
| | - Fiona Ellery
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
| | - Garveeta Sookram
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3 Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia
| | - Maree Hackett
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Ian Kneebone
- Graduate School of Health, University of Technology Sydney, Ultimo, Australia
| | - Avril Drummond
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 3 Hudson Institute Building, 27-31 Wright Street, Clayton, VIC, 3168, Australia.
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia.
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Kosowicz L, Tran K, Khanh TT, Dang TH, Pham VA, Ta Thi Kim H, Thi Bach Duong H, Nguyen TD, Phuong AT, Le TH, Ta VA, Wickramasinghe N, Schofield P, Zelcer J, Pham Le T, Nguyen TA. Lessons for Vietnam on the use of digital technologies to support patient-centred care in low- and middle-income countries in the Asia Pacific Region: A scoping review (Preprint). J Med Internet Res 2022; 25:e43224. [PMID: 37018013 PMCID: PMC10132046 DOI: 10.2196/43224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/11/2023] [Accepted: 02/01/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND A rapidly aging population, a shifting disease burden and the ongoing threat of infectious disease outbreaks pose major concerns for Vietnam's health care system. Health disparities are evident in many parts of the country, especially in rural areas, and the population faces inequitable access to patient-centered health care. Vietnam must therefore explore and implement advanced solutions to the provision of patient-centered care, with a view to reducing pressures on the health care system simultaneously. The use of digital health technologies (DHTs) may be one of these solutions. OBJECTIVE This study aimed to identify the application of DHTs to support the provision of patient-centered care in low- and middle-income countries in the Asia-Pacific region (APR) and to draw lessons for Vietnam. METHODS A scoping review was undertaken. Systematic searches of 7 databases were conducted in January 2022 to identify publications on DHTs and patient-centered care in the APR. Thematic analysis was conducted, and DHTs were classified using the National Institute for Health and Care Excellence evidence standards framework for DHTs (tiers A, B, and C). Reporting was in line with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. RESULTS Of the 264 publications identified, 45 (17%) met the inclusion criteria. The majority of the DHTs were classified as tier C (15/33, 45%), followed by tier B (14/33, 42%) and tier A (4/33, 12%). At an individual level, DHTs increased accessibility of health care and health-related information, supported individuals in self-management, and led to improvements in clinical and quality-of-life outcomes. At a systems level, DHTs supported patient-centered outcomes by increasing efficiency, reducing strain on health care resources, and supporting patient-centered clinical practice. The most frequently reported enablers for the use of DHTs for patient-centered care included alignment of DHTs with users' individual needs, ease of use, availability of direct support from health care professionals, provision of technical support as well as user education and training, appropriate governance of privacy and security, and cross-sectorial collaboration. Common barriers included low user literacy and digital literacy, limited user access to DHT infrastructure, and a lack of policies and protocols to guide the implementation and use of DHTs. CONCLUSIONS The use of DHTs is a viable option to increase equitable access to quality, patient-centered care across Vietnam and simultaneously reduce pressures on the health care system. Vietnam can take advantage of the lessons learned by other low- and middle-income countries in the APR when developing a national road map to digital health transformation. Recommendations that Vietnamese policy makers may consider include emphasizing stakeholder engagement, strengthening digital literacy, supporting the improvement of DHT infrastructure, increasing cross-sectorial collaboration, strengthening governance of cybersecurity, and leading the way in DHT uptake.
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Affiliation(s)
- Leona Kosowicz
- Social Gerontology Division, National Ageing Research Institute, Parkville, Australia
| | - Kham Tran
- Social Gerontology Division, National Ageing Research Institute, Parkville, Australia
| | - Toan Tran Khanh
- Department of Family Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Thu Ha Dang
- Social Gerontology Division, National Ageing Research Institute, Parkville, Australia
- School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
| | | | - Hue Ta Thi Kim
- New Horizon Palliative Care Company Limited, Hanoi, Vietnam
- Hanoi University of Science and Technology, Hanoi, Vietnam
| | | | | | | | | | - Van Anh Ta
- New Horizon Palliative Care Company Limited, Hanoi, Vietnam
| | - Nilmini Wickramasinghe
- Iverson Health Innovation Research Institute, Swinburne University of Technology, Melbourne, Australia
| | - Penelope Schofield
- School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
| | - John Zelcer
- Iverson Health Innovation Research Institute, Swinburne University of Technology, Melbourne, Australia
| | - Tuan Pham Le
- Department of Family Medicine, Hanoi Medical University, Hanoi, Vietnam
- Military and Civil Medical Association of Vietnam, Hanoi, Vietnam
| | - Tuan Anh Nguyen
- Social Gerontology Division, National Ageing Research Institute, Parkville, Australia
- School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, Australia
- Health Strategy and Policy Institute, Ministry of Health of Vietnam, Hanoi, Vietnam
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10
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Shi W, Ghisi GLM, Zhang L, Hyun K, Pakosh M, Gallagher R. Systematic review, meta‐analysis and meta‐regression to determine the effects of patient education on health behaviour change in adults diagnosed with coronary heart disease. J Clin Nurs 2022. [DOI: 10.1111/jocn.16519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/03/2022] [Accepted: 08/17/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Wendan Shi
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
- Charles Perkins Centre, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
| | - Gabriela L. M. Ghisi
- Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute University Health Network Toronto Ontario Canada
| | - Ling Zhang
- Charles Perkins Centre, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
| | - Karice Hyun
- School of Health Sciences, Faculty of Medicine and Health University of Sydney Sydney New South Wales Australia
| | - Maureen Pakosh
- Library & Information Services, Toronto Rehabilitation Institute University Health Network Toronto Ontario Canada
| | - Robyn Gallagher
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
- Charles Perkins Centre, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
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11
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Chan NPT, Lai AYK, Choy HK, Cheung DYT, Wan ANT, Cheng VYH, Chan KY, Lau YK, Yung CY, Cheung GOC, Lam TH. Feasibility and Potential Effectiveness of a Smartphone Zero-Time Exercise Intervention for Promoting Physical Activity and Fitness in Patients With Coronary Heart Disease: A Pilot Randomized Controlled Trial. Front Public Health 2022; 10:865712. [PMID: 35910893 PMCID: PMC9330491 DOI: 10.3389/fpubh.2022.865712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 06/20/2022] [Indexed: 12/02/2022] Open
Abstract
Background Zero-time Exercise (ZTEx), a simple strength- and stamina-enhancing physical activity (PA) requiring no extra equipment, can potentially increase PA and fitness. This pilot trial examined the feasibility and potential effectiveness of a smartphone ZTEx intervention to promote PA and fitness in patients with coronary heart disease (CHD). Methods A parallel-group assessor-blinded pilot randomized controlled trial was conducted on Chinese patients with stable coronary heart disease (CHD) in three cardiology clinics. The experimental group received a 15-min brief individual face-to-face session and a 12-week ZTEx instant messaging with 28 picture e-messages and a smartphone ZTEx application (ZTExApp). The control group received the same duration of individual session and number and format of e-messages, but the content was healthy eating and breathing exercise. The feasibility was assessed based on: attrition rate, usage, response rate and perception of the intervention. The outcome evaluation included primary outcome (PA), fitness, exercise self-efficacy and intention, perceived happiness and health, and quality of life. A linear mixed model was used with intention-to-treat analysis adjusting for sex, age and baseline values. A semi-structured interview was conducted to collect feedback from the experiment group. Results One hundred thirty-nine patients (mean age 59.8 ± 6.6; 71.2% male) were randomized to the experimental group (n = 70) or control group (n = 69), and 80% (56/70) and 82% (57/69) of patients completed the 12-week follow-up assessment, respectively. The attrition rate was 18.7%. The experimental group reported that ZTEx was feasible to integrate PA into their daily life and appreciated the picture e-messages, and 95% of them sent feedback to us, but only 19.6% (13/70) of the participants entered their PA information into the e-diary of the ZTExApp. The experimental group had a significantly greater increase in time spent walking [mean difference (95% CI): 155.3 (10.1, 300.4), P = 0.04, Cohen's d = 0.34] than the control group. Conclusions This pilot study showed using a brief ZTEx face-to-face session with picture e-messages empowered patients with CHD to integrate PA into daily life. Future definitive trials with a longer follow-up and a more user-friendly ZTExApp interface are necessary to determine the effectiveness of the smartphone ZTEx intervention in enhancing PA and related outcomes. Trial Registration The research protocol was registered at the Hong Kong University Clinical Trials Registry (HKUCTR) on 22 Jul 2016 (Study identifier: HKUCTR-2165) and was also retrospectively registered at the National Institutes of Health (identifier number: NCT03464331) on 14 March 2018.
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Affiliation(s)
- Noel P. T. Chan
- School of Nursing, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, Hong Kong SAR, China
| | - Agnes Y. K. Lai
- School of Nursing, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- *Correspondence: Agnes Y. K. Lai
| | - Hau K. Choy
- Faculty of Medicine, Poznon University of Medical Sciences, Poznan, Poland
| | - Derek Y. T. Cheung
- School of Nursing, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Alice N. T. Wan
- School of Nursing, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- Aberdeen Kai Fong Welfare Association Services Centre, Aberdeen, Hong Kong SAR, China
| | - Victor Y. H. Cheng
- Division of Cardiology, Department of Medicine and Geriatrics, Pok Oi Hospital, New Territories, Hong Kong SAR, China
| | - Ka Y. Chan
- Intensive Care Unit, Hong Kong Sanatorium Hospital, Happy Valley, Hong Kong SAR, China
| | - Yuk K. Lau
- Private Practice, Hong Kong, Hong Kong SAR, China
| | - Chi Y. Yung
- Division of Cardiology, Department of Medicine, Ruttonjee and Tang Shiu Kin Hospitals, Wan Chai, Hong Kong SAR, China
| | - George O. C. Cheung
- School of Nursing, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - T. H. Lam
- School of Public Health, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
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12
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Blood pressure management through application-based telehealth platforms: a systematic review and meta-analysis. J Hypertens 2022; 40:1249-1256. [PMID: 35762467 DOI: 10.1097/hjh.0000000000003164] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Hypertension management has several challenges, including poor compliance with medications and patients being lost to follow-up. Recently, remote patient monitoring and telehealth technologies have emerged as promising methods of blood pressure management. We aimed to investigate the role of application-based telehealth programs in optimizing blood pressure management. METHODS Searches were performed in December 2020 using three databases: Cochrane Central Register of Controlled Trials, Embase and Ovid MEDLINE. All randomized controlled trials that included remote blood pressure management programmes were eligible for inclusion. Studies were included if blood pressure data were available for both the intervention and control groups. Following PRISMA guidelines, data were independently collected by two reviewers. Data were pooled using a random-effects model. The primary study outcomes were mean SBP and DBP changes for the intervention and control groups. RESULTS Eight hundred and seventy-nine distinct articles were identified and 18 satisfied inclusion and exclusion criteria. Overall, a mean weighted decrease of 7.07 points (SBP) and 5.07 points (DBP) was found for the intervention group, compared with 3.11 point (SBP) and 3.13 point (DBP) decreases in the control group. Forest plots were constructed and effect sizes were also calculated. Mean change effect sizes of 1.1 (SBP) and 0.98 (DBP) were found, representing 86 and 85% of the intervention group having greater SBP or DBP changes, respectively, when compared with the control group. DISCUSSION Remote patient monitoring technologies may represent a promising avenue for hypertension management. Future research is needed to evaluate the benefits in different disease-based patient subgroups.
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13
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Hategeka C, Adu P, Desloge A, Marten R, Shao R, Tian M, Wei T, Kruk ME. Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review. PLoS Med 2022; 19:e1004055. [PMID: 35877677 PMCID: PMC9359585 DOI: 10.1371/journal.pmed.1004055] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 08/08/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs). METHODS AND FINDINGS On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework. CONCLUSIONS Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.
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Affiliation(s)
- Celestin Hategeka
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Prince Adu
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Allissa Desloge
- School of Public Health, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Robert Marten
- Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland
| | | | - Maoyi Tian
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- School of Public Health, Harbin Medical University, Harbin, China
| | - Ting Wei
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Margaret E. Kruk
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
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14
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Demir Avci Y, Gözüm S, Karadag E. Effect of Telehealth Interventions on Blood Pressure Control: A Meta-analysis. Comput Inform Nurs 2022; 40:402-410. [PMID: 35120370 DOI: 10.1097/cin.0000000000000852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to find out the effects of telehealth interventions on blood pressure control by conducting a meta-analysis. Six databases were used. The literature review covered the period between December 1, 2020, and January 26, 2021. The meta-analysis was conducted by comprehensive Meta-Analysis Software version 2.2. Categorical variables were analyzed by odds ratios at a confidence interval of 95%. In data formatting and analysis, independent groups (sample size, P value); independent groups (mean, SD); Cohen's d, SE; and paired groups (N, P value) were used. The bias risk was assessed based on the Revised Cochrane Risk-of-Bias Tool for Randomized Trials. Total sample size including 22 studies was 11 120. It was determined that interventions performed through telehealth applications had a significant effect on blood pressure control (odds ratio = -0.14; 95% confidence interval = -0.20 to -0.08; P < .001). In telehealth applications, blood pressure values decreased more when the application was performed through a Web site (-0.31; 95% confidence interval = -0.49 to -0.13), duration of the intervention was 12 months or shorter (-0.18; 95% confidence interval = -0.28 to -0.010), stroke developed in case of hypertension (-0.31, 95% confidence interval = -0.76 to 0.12), and the study was conducted in the Far East countries (-0.24; 95% confidence interval = 0.40 to -0.07). Interventions with telehealth applications are effective in blood pressure management. PROSPERO ID: CRD42021228536.
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Affiliation(s)
- Yasemin Demir Avci
- Author Affiliations: Department of Public Health Nursing, Faculty of Nursing (Dr Demir Avci), Department of Public Health Nursing, Faculty of Nursing (Dr Gözüm), and Department of Educational Sciences, Faculty of Education (Dr Karadag˘), Akdeniz University, Antalya, Turkey
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15
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Chow CK, Klimis H, Thiagalingam A, Redfern J, Hillis GS, Brieger D, Atherton J, Bhindi R, Chew DP, Collins N, Andrew Fitzpatrick M, Juergens C, Kangaharan N, Maiorana A, McGrady M, Poulter R, Shetty P, Waites J, Hamilton Craig C, Thompson P, Stepien S, Von Huben A, Rodgers A. Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome: The TEXTMEDS Randomized Clinical Trial. Circulation 2022; 145:1443-1455. [PMID: 35533220 DOI: 10.1161/circulationaha.121.056161] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND TEXTMEDS (Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome) examined the effects of text message-delivered cardiac education and support on medication adherence after an acute coronary syndrome. METHODS TEXTMEDS was a single-blind, multicenter, randomized controlled trial of patients after acute coronary syndrome. The control group received usual care (secondary prevention as determined by the treating clinician); the intervention group also received multiple motivational and supportive weekly text messages on medications and healthy lifestyle with the opportunity for 2-way communication (text or telephone). The primary end point of self-reported medication adherence was the percentage of patients who were adherent, defined as >80% adherence to each of up to 5 indicated cardioprotective medications, at both 6 and 12 months. RESULTS A total of 1424 patients (mean age, 58 years [SD, 11]; 79% male) were randomized from 18 Australian public teaching hospitals. There was no significant difference in the primary end point of self-reported medication adherence between the intervention and control groups (relative risk, 0.93 [95% CI, 0.84-1.03]; P=0.15). There was no difference between intervention and control groups at 12 months in adherence to individual medications (aspirin, 96% vs 96%; β-blocker, 84% vs 84%; angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 77% vs 80%; statin, 95% vs 95%; second antiplatelet, 84% vs 84% [all P>0.05]), systolic blood pressure (130 vs 129 mm Hg; P=0.26), low-density lipoprotein cholesterol (2.0 vs 1.9 mmol/L; P=0.34), smoking (P=0.59), or exercising regularly (71% vs 68%; P=0.52). There were small differences in lifestyle risk factors in favor of intervention on body mass index <25 kg/m2 (21% vs 18%; P=0.01), eating ≥5 servings per day of vegetables (9% vs 5%; P=0.03), and eating ≥2 servings per day of fruit (44% vs 39%; P=0.01). CONCLUSIONS A text message-based program had no effect on medical adherence but small effects on lifestyle risk factors. REGISTRATION URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364448; Unique identifier: ANZCTR ACTRN12613000793718.
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Affiliation(s)
- Clara K Chow
- Westmead Applied Research Institute (C.K.C., H.K., A.T., A.V.H., A.R.), University of Sydney, Australia.,Department of Cardiology, Westmead Hospital, Sydney, Australia (C.K.C., H.K., A.T.)
| | - Harry Klimis
- Westmead Applied Research Institute (C.K.C., H.K., A.T., A.V.H., A.R.), University of Sydney, Australia.,Department of Cardiology, Westmead Hospital, Sydney, Australia (C.K.C., H.K., A.T.)
| | - Aravinda Thiagalingam
- Westmead Applied Research Institute (C.K.C., H.K., A.T., A.V.H., A.R.), University of Sydney, Australia.,Department of Cardiology, Westmead Hospital, Sydney, Australia (C.K.C., H.K., A.T.)
| | - Julie Redfern
- Faculty of Medicine and Health (J.R., R.B., M.A.F., M.M.), University of Sydney, Australia
| | - Graham S Hillis
- University of Western Australia, Perth (G.S.H., P.T.).,Department of Cardiology, Royal Perth Hospital, Australia (G.S.H.)
| | - David Brieger
- ANZAC Research Institute (D.B.), University of Sydney, Australia
| | - John Atherton
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia (J.A.).,The University of Queensland, Brisbane, Australia (J.A., C.H.C.)
| | - Ravinay Bhindi
- Faculty of Medicine and Health (J.R., R.B., M.A.F., M.M.), University of Sydney, Australia.,Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (R.B.)
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia (D.P.C., N.K.)
| | | | | | - Craig Juergens
- Faculty of Medicine, The University of New South Wales, Sydney, Australia (C.J.).,Department of Cardiology, Liverpool Hospital, Sydney, Australia (C.J.)
| | - Nadarajah Kangaharan
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia (D.P.C., N.K.).,Department of Cardiology, Royal Darwin Hospital, Darwin, Australia (N.K.).,Menzies School of Health Research, Darwin, Australia (N.K.)
| | - Andrew Maiorana
- Allied Health Department, Fiona Stanley Hospital, Perth, Australia (A.M.).,School of Allied Health, Curtin University, Perth, Australia (A.M.)
| | - Michele McGrady
- Faculty of Medicine and Health (J.R., R.B., M.A.F., M.M.), University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (M.M.)
| | - Rohan Poulter
- Department of Cardiology, Sunshine Coast University Hospital, Brisbane, Australia (R.P.)
| | - Pratap Shetty
- Department of Cardiology, Wollongong and Shellharbour Hospitals, Wollongong, Australia (P.S.)
| | | | - Christian Hamilton Craig
- The University of Queensland, Brisbane, Australia (J.A., C.H.C.).,Department of Cardiology, Prince Charles Hospital, Brisbane, Australia (C.H.C.)
| | - Peter Thompson
- University of Western Australia, Perth (G.S.H., P.T.).,Department of Cardiology, Sir Charles Gairdner Hospital, Perth, Australia (P.T.).,Harry Perkins Institute of Medical Research, Perth, Australia (P.T.)
| | - Sandrine Stepien
- The George Institute for Global Health, Sydney, Australia (C.K.C., H.K., A.R., G.S.H., S.S., A.R.)
| | - Amy Von Huben
- Westmead Applied Research Institute (C.K.C., H.K., A.T., A.V.H., A.R.), University of Sydney, Australia
| | - Anthony Rodgers
- Westmead Applied Research Institute (C.K.C., H.K., A.T., A.V.H., A.R.), University of Sydney, Australia
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16
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Choi JY, Kim JB, Lee S, Lee SJ, Shin SE, Park SH, Park EJ, Kim W, Na JO, Choi CU, Rha SW, Park CG, Seo HS, Ahn J, Jeong HG, Kim EJ. A Smartphone App (AnSim) With Various Types and Forms of Messages Using the Transtheoretical Model for Cardiac Rehabilitation in Patients With Coronary Artery Disease: Development and Usability Study. JMIR Med Inform 2021; 9:e23285. [PMID: 34878987 PMCID: PMC8693185 DOI: 10.2196/23285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 03/27/2021] [Accepted: 10/10/2021] [Indexed: 12/05/2022] Open
Abstract
Background Despite strong evidence of clinical benefit, cardiac rehabilitation (CR) programs are currently underutilized and smartphone-based CR strategies are thought to address this unmet need. However, data regarding the detailed process of development are scarce. Objective This study focused on the development of a smartphone-based, patient-specific, messaging app for patients who have undergone percutaneous coronary intervention (PCI). Methods The AnSim app was developed in collaboration with a multidisciplinary team that included cardiologists, psychiatrists, nurses, pharmacists, nutritionists, and rehabilitation doctors and therapists. First, a focus group interview was conducted, and the narratives of the patients were analyzed to identify their needs and preferences. Based on the results, health care experts and clinicians drafted messages into 5 categories: (1) general information regarding cardiovascular health and medications, (2) nutrition, (3) physical activity, (4) destressing, and (5) smoking cessation. In each category, 90 messages were developed according to 3 simplified steps of the transtheoretical model of behavioral change: (1) precontemplation, (2) contemplation and preparation, and (3) action and maintenance. After an internal review and feedback from potential users, a bank of 450 messages was developed. Results The focus interview was conducted with 8 patients with PCI within 1 year, and 450 messages, including various forms of multimedia, were developed based on the transtheoretical model of behavioral change in each category. Positive feedback was obtained from the potential users (n=458). The mean Likert scale score was 3.95 (SD 0.39) and 3.91 (SD 0.39) for readability and usefulness, respectively, and several messages were refined based on the feedback. Finally, the patient-specific message delivery system was developed according to the baseline characteristics and stages of behavioral change in each participant. Conclusions We developed an app (AnSim), which includes a bank of 450 patient-specific messages, that provides various medical information and CR programs regarding coronary heart disease. The detailed process of multidisciplinary collaboration over the course of the study provides a scientific basis for various medical professionals planning smartphone-based clinical research.
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Affiliation(s)
- Jah Yeon Choi
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji Bak Kim
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sunki Lee
- Division of Cardiology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Dongtan, Republic of Korea
| | - Seo-Joon Lee
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Eon Shin
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | | | - Eun Jin Park
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Woohyeun Kim
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jin Oh Na
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Cheol Ung Choi
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Chang Gyu Park
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hong Seog Seo
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jeonghoon Ahn
- Department of Health Convergence, Ewha Womans University, Seoul, Republic of Korea
| | - Hyun-Ghang Jeong
- Department of Psychiatry, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Eung Ju Kim
- Sports Medical Center, Seoul, Republic of Korea
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17
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Klimis H, Thiagalingam A, McIntyre D, Marschner S, Von Huben A, Chow CK. Text messages for primary prevention of cardiovascular disease: The TextMe2 randomized clinical trial. Am Heart J 2021; 242:33-44. [PMID: 34428440 DOI: 10.1016/j.ahj.2021.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/10/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Primary prevention guidelines emphasize the importance of lifestyle modification, but many at high-risk have suboptimal cardiovascular risk factor (CVRF) control. Text message support may improve control, but the evidence is sparse. Our objective was to determine the impact of text messages on multiple CVRFs in a moderate-high risk primary prevention cohort. METHODS This study was a single-blind randomized clinical trial comparing semi-personalized text message-based support to standard care. A random sample of adults with 10-year absolute cardiovascular risk score ≥10% and without coronary heart disease, referred from February 2019 to January 2020, were recruited from an outpatient cardiology clinic in a large tertiary hospital in Sydney, Australia. Patients were randomized 1:1 to intervention or control. Intervention participants received 4 texts per week over 6 months, and standard care, with content covering: diet, physical activity, smoking, general cardiovascular health, and medication adherence. Controls received standard care only. Content was semipersonalized (smoking status, vegetarian or not-vegetarian, physical ability, taking medications or not) and delivered randomly using automated software. The primary outcome was the difference in the proportion of patients who have ≥3 uncontrolled CVRFs (out of: low-density lipoprotein cholesterol >2.0 mmol/L, blood pressure >140/90 mm Hg, body mass index ≥25 kg/m2, physical inactivity, current smoker) at 6 months adjusted for baseline. Secondary outcomes included differences in biomedical and behavioral CVRFs. RESULTS Among 295 eligible participants, 246 (mean age, 58.6 ± 10.7 years; 39.4% female) were randomized to intervention (n = 124) or control (n = 122). At 6 months, there was no significant difference in the proportion of patients with ≥3 uncontrolled CVRFs (adjusted relative risk [RR] 0.98; 95% confidence interval [CI] 0.75-1.29; P = .88). Intervention participants were less likely to be physically inactive (adjusted RR 0.72; 95% CI 0.57-0.92; P = .01), but there were no significant changes in other single CVRFs. More intervention participants reduced the number of uncontrolled CVRFs at 6-months from baseline than controls (86% vs 75%; RR 1.15; 95% CI 1.00-1.32; P = .04). CONCLUSIONS In moderate-high cardiovascular risk primary prevention, text message-based support did not significantly reduce the proportion of patients with ≥3 uncontrolled CVRFs. However, the program did motivate behavior change and significantly improved cardiovascular risk factor control overall. Larger multicenter studies are needed.
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Affiliation(s)
- Harry Klimis
- Westmead Applied Research Centre and Faculty of Medicine and Health, University of Sydney, Westmead, NSW, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia.
| | - Aravinda Thiagalingam
- Westmead Applied Research Centre and Faculty of Medicine and Health, University of Sydney, Westmead, NSW, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
| | - Daniel McIntyre
- Westmead Applied Research Centre and Faculty of Medicine and Health, University of Sydney, Westmead, NSW, Australia
| | - Simone Marschner
- Westmead Applied Research Centre and Faculty of Medicine and Health, University of Sydney, Westmead, NSW, Australia
| | - Amy Von Huben
- Westmead Applied Research Centre and Faculty of Medicine and Health, University of Sydney, Westmead, NSW, Australia
| | - Clara K Chow
- Westmead Applied Research Centre and Faculty of Medicine and Health, University of Sydney, Westmead, NSW, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
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18
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Leutualy V, Trisyany Y, Nurlaeci N. Effectivity of Health Education with Telenursing on the Self-care Ability of Coronary Artery Disease Patients: A Systematic Review. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.7619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Coronary artery disease (CAD) develops chronically and progressively, causes recurrence and premature death, so a good knowledge of changes in self-care behavior by patients is needed. Telenursing can be a medium for health education to allow patients to receive information and for nurses to follow up on health conditions without being obstructed by distance, place, time, and carried out sustainably. So far, telenursing has not been reviewed as a recent intervention to deliver education to CAD patients.
AIM: This systematic review aimed to determine the effectiveness of health education interventions with telenursing on the self-care of CAD patients based on the implementation media.
METHODS: Systematic reviews were conducted based on items found in CINAHL EBSCO, PubMed, ScienceDirect, and Google Scholar from 2008 to 2019. The combination of keywords used Indonesian and English language. All articles were assessed using the Joanna Briggs Institute critical appraisal tool for randomized controlled trial (RCT) and quasi-experiment. After that, the study found was synthesized narratively.
RESULTS: A total of 11.319 titles were identified, and seven studies met inclusion criteria with 3313 participants. Six studies were RCT studies, and one was a quasi-experimental study. The results of the narrative synthesis conducted on seven articles showed that health education by telenursing was effective in improving self-care ability, such as maintaining blood pressure, body mass index, hemoglobin A1c levels, fasting blood glucose, and low-density lipoprotein within normal limits. In addition, there was also an increase in physical activity, dietary compliance (consumption of fruits, vegetables and fish), control of salt intake, smoking, and alcohol cessation. The media used were phone calls and text messages.
CONCLUSION: This review provides evidence that health education interventions effectively improve the self-care abilities of CAD patients with the media used are text messages and telephone calls.
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Bermon A, Uribe AF, Pérez-Rivero PF, Prieto-Merino D, Saaibi JF, Silva FA, Canon DI, Castillo-Gonzalez KM, Cáceres-Rivera DI, Guio E, Meneses-Castillo KJ, Castillo-Meza A, Atkins L, Horne R, Murray E, Serrano NC, Free C, Casas JP, Perel P. Efficacy and Safety of Text Messages Targeting Adherence to Cardiovascular Medications in Secondary Prevention: TXT2HEART Colombia Randomized Controlled Trial. JMIR Mhealth Uhealth 2021; 9:e25548. [PMID: 34319247 PMCID: PMC8367158 DOI: 10.2196/25548] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/22/2021] [Accepted: 05/21/2021] [Indexed: 11/25/2022] Open
Abstract
Background Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality worldwide, with a prevalence of approximately 100 million patients. There is evidence that antiplatelet agents and antihypertensive medications could reduce the risk of new vascular events in this population; however, treatment adherence is very low. An SMS text messaging intervention was recently developed based on behavior change techniques to increase adherence to pharmacological treatment among patients with a history of ASCVD. Objective This study aims to evaluate the efficacy and safety of an SMS text messaging intervention to improve adherence to cardiovascular medications in patients with ASCVD. Methods A randomized controlled clinical trial for patients with a prior diagnosis of cardiovascular events, such as acute myocardial infarction, unstable angina, cerebrovascular disease, or peripheral artery disease, in one center in Colombia was conducted. Patients randomized to the intervention arm were assigned to receive SMS text messages daily for the first 4 weeks, 5 SMS text messages on week 5, 3 SMS text messages each in weeks 6 and 7, and 1 SMS text message weekly from week 8 until week 52. In contrast, patients in the control arm received a monthly SMS text message reminding them of the next study appointment and the importance of the study, requesting information about changes in their phone number, and thanking them for participating in the study. The primary endpoint was the change in low-density lipoprotein cholesterol (LDL-C) levels, whereas the secondary endpoints were the changes in thromboxane B2 levels, heart rate, systolic and diastolic blood pressure, medication adherence, cardiac and noncardiac mortality, and hospitalization. Linear regression analyses and bivariate tests were performed. Results Of the 930 randomized patients, 805 (86.5%) completed follow-up and were analyzed for the primary endpoint. There was no evidence that the intervention changed the primary outcome (LDL-C levels; P=.41) or any of the secondary outcomes evaluated (all P>.05). There was also no evidence that the intervention was associated with adverse events. Conclusions In this study, there was no evidence that a behavior modification intervention delivered by SMS text messaging improved LDL-C levels, blood pressure levels, or adherence at 12 months. More research is needed to evaluate whether different SMS text messaging strategies, including personalized messages and different timings, are effective; future studies should include mixed methods to better understand why, for whom, and in which context (eg, health system or social environment) SMS text messaging interventions work (or not) to improve adherence in patients with ASCVD. Trial Registration ClinicalTrials.gov NCT03098186; https://clinicaltrials.gov/ct2/show/NCT03098186 International Registered Report Identifier (IRRID) RR2-10.1136/bmjopen-2018-028017
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Affiliation(s)
- Anderson Bermon
- Research Center, Fundación Cardiovascular de Colombia, Floridablanca, Colombia.,Epidemiology an Biostatistics, Escuela de Graduados, Universidad CES, Medellín, Colombia
| | - Ana Fernanda Uribe
- Faculty of Psychology, Universidad Pontificia Bolivariana - Seccional Bucaramanga, Floridablanca, Colombia
| | | | - David Prieto-Merino
- Epidemiology and Population Health Faculty, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Applied Statistical Methods in Medical Research Group, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Jose Federico Saaibi
- Departament of Cardiovascular Surgery, Division of Vascular and Endovascular Surgery, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Federico Arturo Silva
- Neurovascular Science Group, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Diana Ivonne Canon
- Departament of Cardiology, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | | | | | - Elizabeth Guio
- Metabolism and Genoma Laboratory, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | | | | | - Louise Atkins
- Research Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Robert Horne
- University College London School of Pharmacy, London, Colombia
| | - Elizabeth Murray
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Norma Cecilia Serrano
- Direction of Research, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Caroline Free
- Epidemiology and Population Health Faculty, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Juan Pablo Casas
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, MA, United States.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Pablo Perel
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
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20
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Chen Y, Ji M, Wu Y, Deng Y, Wu F, Lu Y. Individualized mobile health interventions for cardiovascular event prevention in patients with coronary heart disease: study protocol for the iCARE randomized controlled trial. BMC Cardiovasc Disord 2021; 21:340. [PMID: 34256698 PMCID: PMC8278759 DOI: 10.1186/s12872-021-02153-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/08/2021] [Indexed: 12/23/2022] Open
Abstract
Background Mobile health-based individualized interventions have shown potential effects in managing cardiovascular risk factors. This study aims to assess whether or not mHealth based individualized interventions delivered by an Individualized Cardiovascular Application system for Risk Elimination (iCARE) could reduce the incidence of major cardiovascular events in individuals with coronary heart disease. Methods This study is a large-scale, multi-center, parallel-group, open-label, randomized controlled clinical trial. This study will be conducted from September 2019 to December 2025. A total of 2820 patients with coronary heart disease will be recruited from two clinical sites and equally randomized into three groups: the intervention group and two control groups. All participants will be informed of six-time points (at 1, 3, 6, 12, 24, and 36 months after discharge) for follow-up visits. Over a course of 36 months, patients who are randomized to the intervention arm will receive individualized interventions delivered by a fully functional iCARE that using various visualization methods such as comics, videos, pictures, text to provide individualized interventions in addition to standard care. Patients randomized to control group 1 will receive interventions delivered by a modified iCARE that only presented in text in addition to routine care. Control group 2 will only receive routine care. The primary outcome is the incidence of major cardiovascular events within 3 years of discharge. Main secondary outcomes include changes in health behaviors, medication adherence, and cardiovascular health score. Discussion If the iCARE trial indeed demonstrates positive effects on patients with coronary heart disease, it will provide empirical evidence for supporting secondary preventive care in this population. Results will inform the design of future research focused on mHealth-based, theory-driven, intelligent, and individualized interventions for cardiovascular risk management. Trial registration Trial registered 24th December 2016 with the Chinese Clinical Trial Registry (ChiCTR-INR-16010242). URL: http://www.chictr.org.cn/showproj.aspx?proj=17398. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02153-9.
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Affiliation(s)
- Yuling Chen
- School of Nursing, Capital Medical University, 10 You-an-men Wai Xi-tou-tiao, Feng-Tai District, Beijing, 100069, China.,The fourth Ward of Coronary Heart Disease Center, Emergency Coronary Ward, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, 100029, China.,Cardiac Center, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongti South Road, Beijing, 100020, China
| | - Meihua Ji
- School of Nursing, Capital Medical University, 10 You-an-men Wai Xi-tou-tiao, Feng-Tai District, Beijing, 100069, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, 119 South Fourth Ring West Road, Feng-Tai District, Beijing, China
| | - Ying Wu
- School of Nursing, Capital Medical University, 10 You-an-men Wai Xi-tou-tiao, Feng-Tai District, Beijing, 100069, China.
| | - Ying Deng
- School of Nursing, Capital Medical University, 10 You-an-men Wai Xi-tou-tiao, Feng-Tai District, Beijing, 100069, China
| | - Fangqin Wu
- School of Nursing, Capital Medical University, 10 You-an-men Wai Xi-tou-tiao, Feng-Tai District, Beijing, 100069, China
| | - Yating Lu
- School of Nursing, Capital Medical University, 10 You-an-men Wai Xi-tou-tiao, Feng-Tai District, Beijing, 100069, China
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21
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Foccardi G, Vecchiato M, Neunhaeuserer D, Mezzaro M, Quinto G, Battista F, Duregon F, Carlon R, Ermolao A. Effectiveness of Text Messaging as an Incentive to Maintain Physical Activity after Cardiac Rehabilitation: A Randomized Controlled Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18126645. [PMID: 34205551 PMCID: PMC8296387 DOI: 10.3390/ijerph18126645] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/04/2021] [Accepted: 06/17/2021] [Indexed: 02/07/2023]
Abstract
Although the efficacy of cardiac rehabilitation (CR) is proven, the need to improve patients’ adherence has emerged. There are only a few studies that have investigated the effect of sending text messages after a CR period to stimulate subjects’ ongoing engagement in regular physical activity (PA). A randomized controlled pilot trial was conducted after CR, sending a daily PA text message reminder to an intervention group (IG), which was compared with a usual care control group (CG) during three months of follow-up. Thirty-two subjects were assessed pre- and post-study intervention with GPAQ, submaximal iso-watt exercise testing, a 30 s sit-to-stand test, a bilateral arm curl test, and a final survey on a seven-point Likert scale. A statistically significant difference in the increase of moderate PA time (Δ 244.7 (95% CI 189.1, 300.4) minutes, p < 0.001) and in the reduction of sedentary behavior time (Δ −77.5 (95% CI 104.9, −50.1) minutes, p = 0.004) was shown when the IG was compared with the CG. This was associated with an improvement in heart rate, blood pressure, and patients’ Borg rating on the category ratio scale 10 (CR10) in iso-watt exercise testing (all p < 0.05). Furthermore, only the IG did not show a worsening of the strength parameters in the follow-up leading to a change of the 30 s sit-to-stand test with a difference of +2.2 (95% CI 1.23, 3.17) repetitions compared to CG (p = 0.03). The telemedical intervention has been appreciated by the IG, whose willingness to continue with regular PA emerged to be superior compared to the CG. Text messages are an effective and inexpensive adjuvant after phase 2 CR that improves adherence to regular PA. Further studies are needed to confirm these results in a larger patient population and in the long term.
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Affiliation(s)
- Giulia Foccardi
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
- Clinical Network of Sports and Exercise Medicine of the Veneto Region, 35128 Padova, Italy
| | - Marco Vecchiato
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
- Clinical Network of Sports and Exercise Medicine of the Veneto Region, 35128 Padova, Italy
| | - Daniel Neunhaeuserer
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
- Clinical Network of Sports and Exercise Medicine of the Veneto Region, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-049-8217456
| | - Michele Mezzaro
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
| | - Giulia Quinto
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
- Clinical Network of Sports and Exercise Medicine of the Veneto Region, 35128 Padova, Italy
| | - Francesca Battista
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
- Clinical Network of Sports and Exercise Medicine of the Veneto Region, 35128 Padova, Italy
| | - Federica Duregon
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
| | - Roberto Carlon
- UOA Cardiology, Rehabilitation Cardiology, ASSL 6 “Euganea”, Cittadella Hospital, 35013 Cittadella, Italy;
| | - Andrea Ermolao
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35128 Padova, Italy; (G.F.); (M.V.); (M.M.); (G.Q.); (F.B.); (F.D.); (A.E.)
- Clinical Network of Sports and Exercise Medicine of the Veneto Region, 35128 Padova, Italy
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Ross ES, Sakakibara BM, Mackay MH, Whitehurst DGT, Singer J, Toma M, Corbett KK, Van Spall HGC, Rutherford K, Gheorghiu B, Code J, Lear SA. The Use of SMS Text Messaging to Improve the Hospital-to-Community Transition in Patients With Acute Coronary Syndrome (Txt2Prevent): Results From a Pilot Randomized Controlled Trial. JMIR Mhealth Uhealth 2021; 9:e24530. [PMID: 33988519 PMCID: PMC8164115 DOI: 10.2196/24530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/27/2021] [Accepted: 03/11/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Acute coronary syndrome (ACS) is a leading cause of hospital admission in North America. Many patients with ACS experience challenges after discharge that impact their clinical outcomes and psychosocial well-being. SMS text messaging has the potential to provide support to patients during this postdischarge period. OBJECTIVE This study pilot tested a 60-day SMS text messaging intervention (Txt2Prevent) for patients with ACS. The primary objective was to compare self-management domains between usual care and usual care plus Txt2Prevent. The secondary objectives were to compare medication adherence, health-related quality of life, self-efficacy, and health care resource use between groups. The third objective was to assess the feasibility of the study protocol and the acceptability of the intervention. METHODS This was a randomized controlled trial with blinding of outcome assessors. We recruited 76 patients with ACS from St. Paul's Hospital in Vancouver, Canada, and randomized them to 1 of 2 groups within 7 days of discharge. The Txt2Prevent program included automated 1-way SMS text messages about follow-up care, self-management, and healthy living. Data were collected during the index admission and at 60 days after randomization. The primary outcome was measured with the Health Education Impact Questionnaire (heiQ). Other outcomes included the EQ-5D-5L, EQ-5D-5L Visual Analog Scale, a modified Sullivan Cardiac Self-Efficacy Scale, and Morisky Medication Adherence Scale scores, and self-reported health care resource use. Analyses of covariance were used to test the effect of group assignment on follow-up scores (controlling for baseline) and were considered exploratory in nature. Feasibility was assessed with descriptive characteristics of the study protocol. Acceptability was assessed with 2 survey questions and semistructured interviews. RESULTS There were no statistically significant differences between the groups for the heiQ domains (adjusted mean difference [Txt2Prevent minus usual care] for each domain-Health-directed activity: -0.13, 95% CI -0.39 to 0.13, P=.31; Positive and active engagement in life: 0.03, 95% CI -0.19 to 0.25, P=.76; Emotional distress: 0.04, 95% CI -0.22 to 0.29, P=.77; Self-monitoring and insight: -0.14, 95% CI -0.33 to 0.05, P=.15; Constructive attitudes and approaches: -0.10, 95% CI -0.36 to 0.17, P=.47; Skill technique and acquisition: 0.05, 95% CI -0.18 to 0.27, P=.69; Social integration and support: -0.12, 95% CI -0.34 to 0.10, P=.27; and Health services navigation: -0.05, 95% CI -0.29 to 0.19, P=.69). For the secondary outcomes, there were no statistically significant differences in adjusted analyses except in 1 self-efficacy domain (Total plus), where the Txt2Prevent group had lower scores (mean difference -0.36, 95% CI -0.66 to -0.50, P=.03). The study protocol was feasible, but recruitment took longer than expected. Over 90% (29/31 [94%]) of participants reported they were satisfied with the program. CONCLUSIONS The Txt2Prevent study was feasible to implement; however, although exploratory, there were no differences between the 2 groups in adjusted analyses except for 1 self-efficacy domain. As the intervention appeared acceptable, there is potential in using SMS text messages in this context. The design of the intervention may need to be reconsidered to have more impact on outcome measures. TRIAL REGISTRATION ClinicalTrials.gov NCT02336919; https://clinicaltrials.gov/ct2/show/NCT02336919. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/resprot.6968.
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Affiliation(s)
- Emily S Ross
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Brodie M Sakakibara
- Centre for Chronic Disease Prevention and Management, University of British Columbia Okanagan, Kelowna, BC, Canada.,Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Martha H Mackay
- School of Nursing, University of British Columbia, Vancouver, BC, Canada.,Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - David G T Whitehurst
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mustafa Toma
- Division of Cardiology, Providence Health Care, Vancouver, BC, Canada
| | - Kitty K Corbett
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.,School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | - Kimberly Rutherford
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | | | - Jillianne Code
- Department of Curriculum and Pedagogy, University of British Columbia, Vancouver, BC, Canada
| | - Scott A Lear
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.,Division of Cardiology, Providence Health Care, Healthy Heart Program St Paul's Hospital, Vancouver, BC, Canada
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23
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Abstract
PURPOSE OF REVIEW To review existing mHealth-based interventions and examine their efficacy in reducing cardiovascular disease (CVD) risk factors. RECENT FINDINGS A total of 50 articles are included in this review. The majority of the mHealth interventions targeted a specific CVD risk factor, while 4 addressed 2 or more CVD risk factors. Of the 9 mHealth-supported weight loss intervention trials, 4 resulted in significant weight loss. Four out of 7 RCTs targeting improvement in physical activity reported significant improvement, while 4 of the 8 mHealth-supported smoking cessation intervention trials resulted in smoking abstinence. Of the 10 mHealth-based diabetes intervention trials, 5 reported significant reductions in HbA1c; however, only 3 out of the 9 antihypertension interventions resulted in significant reductions in blood pressure. There is a growing body of literature focused on mHealth interventions that address CVD risk factors. Despite the immense potential of mHealth interventions, evidence of their efficacy in mitigating cardiovascular risk is heterogeneous.
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24
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Xu Y, Ye H, Zhu Y, Du S, Xu G, Wang Q. The efficacy of mobile health in alleviating risk factors related to the occurrence and development of coronary heart disease: A systematic review and meta-analysis. Clin Cardiol 2021; 44:609-619. [PMID: 33724494 PMCID: PMC8119799 DOI: 10.1002/clc.23596] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/28/2021] [Accepted: 03/08/2021] [Indexed: 12/19/2022] Open
Abstract
The association between the efficacy of mobile health and the occurrence and development of coronary heart disease (CHD) is still unclear. Mobile health can alleviate the risk factors for CHD. PubMed, EMbase, Web of Science, The Cochrane Library, CNKI, WanFang, and VIP databases were searched from inception through May 28, 2020. Randomized controlled trials of the effect of mobile health in alleviating the risk factors of CHD's occurrence and development were included. Risks of bias were assessed by two independent reviewers by using the RevMan 5.3, GRADEpro, and RoB2.0 to generate findings. Meta-analyses were performed to investigate the effects of mobile health on risk factors for CHD. Subgroup analyses were conducted. Sixteen randomized controlled trials, including 3898 patients with CHD, were included. Meta-analysis results showed that mobile health can reduce BMI (mean difference [MD] = - 1.24, 95% CI = - 2.02 to - 0.45, p < .05), waist circumference (MD = - 4.40, 95% CI = - 4.72 to - 4.08, p < .00001), total cholesterol (TC) level (MD = - 0.43, 95% CI = - 0.64 to - 0.22, p < 0.00001), low-density lipoprotein cholesterol (LDL-C) level (MD = - 0.31, 95% CI = - 0.48 to - 0.15, p < .05), diastolic blood pressure (MD = - 2.01, 95% CI = - 3.40 to - 0.623, p < .05), and depression (MD = - 8.32, 95% CI = - 12.83 to - 3.81, p < .05) and increase high-density lipoprotein cholesterol level (MD = 0.16, 95% CI = 0.01 to 0.32, p < .05) with statistically significant differences. The results of subgroup analyses indicated that the simple mobile health intervention has more remarkable advantages in reducing BMI, TC, LDL-C, and systolic blood pressure than the complex mobile health intervention. Mobile health can alleviate the risk factors for CHD and has a certain effect on the prevention and recovery of CHD. Simple mobile health has a remarkable advantage. Limited by the quantity and quality of included studies, future research enrolling high-quality studies should be taken to verify the above conclusions.
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Affiliation(s)
- Yue Xu
- School of NursingNanjing university of Chinese MedicineNanjingJiangsu ProvinceChina
| | - Hui Ye
- School of NursingNanjing university of Chinese MedicineNanjingJiangsu ProvinceChina
| | - Yuan Zhu
- School of NursingNanjing university of Chinese MedicineNanjingJiangsu ProvinceChina
| | - Shizheng Du
- School of NursingNanjing university of Chinese MedicineNanjingJiangsu ProvinceChina
| | - Guihua Xu
- School of NursingNanjing university of Chinese MedicineNanjingJiangsu ProvinceChina
| | - Qing Wang
- School of NursingNanjing university of Chinese MedicineNanjingJiangsu ProvinceChina
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25
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Akinosun AS, Polson R, Diaz-Skeete Y, De Kock JH, Carragher L, Leslie S, Grindle M, Gorely T. Digital Technology Interventions for Risk Factor Modification in Patients With Cardiovascular Disease: Systematic Review and Meta-analysis. JMIR Mhealth Uhealth 2021; 9:e21061. [PMID: 33656444 PMCID: PMC7970167 DOI: 10.2196/21061] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 11/08/2020] [Accepted: 12/01/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Approximately 50% of cardiovascular disease (CVD) cases are attributable to lifestyle risk factors. Despite widespread education, personal knowledge, and efficacy, many individuals fail to adequately modify these risk factors, even after a cardiovascular event. Digital technology interventions have been suggested as a viable equivalent and potential alternative to conventional cardiac rehabilitation care centers. However, little is known about the clinical effectiveness of these technologies in bringing about behavioral changes in patients with CVD at an individual level. OBJECTIVE The aim of this study is to identify and measure the effectiveness of digital technology (eg, mobile phones, the internet, software applications, wearables, etc) interventions in randomized controlled trials (RCTs) and determine which behavior change constructs are effective at achieving risk factor modification in patients with CVD. METHODS This study is a systematic review and meta-analysis of RCTs designed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) statement standard. Mixed data from studies extracted from selected research databases and filtered for RCTs only were analyzed using quantitative methods. Outcome hypothesis testing was set at 95% CI and P=.05 for statistical significance. RESULTS Digital interventions were delivered using devices such as cell phones, smartphones, personal computers, and wearables coupled with technologies such as the internet, SMS, software applications, and mobile sensors. Behavioral change constructs such as cognition, follow-up, goal setting, record keeping, perceived benefit, persuasion, socialization, personalization, rewards and incentives, support, and self-management were used. The meta-analyzed effect estimates (mean difference [MD]; standard mean difference [SMD]; and risk ratio [RR]) calculated for outcomes showed benefits in total cholesterol SMD at -0.29 [-0.44, -0.15], P<.001; high-density lipoprotein SMD at -0.09 [-0.19, 0.00], P=.05; low-density lipoprotein SMD at -0.18 [-0.33, -0.04], P=.01; physical activity (PA) SMD at 0.23 [0.11, 0.36], P<.001; physical inactivity (sedentary) RR at 0.54 [0.39, 0.75], P<.001; and diet (food intake) RR at 0.79 [0.66, 0.94], P=.007. Initial effect estimates showed no significant benefit in body mass index (BMI) MD at -0.37 [-1.20, 0.46], P=.38; diastolic blood pressure (BP) SMD at -0.06 [-0.20, 0.08], P=.43; systolic BP SMD at -0.03 [-0.18, 0.13], P=.74; Hemoglobin A1C blood sugar (HbA1c) RR at 1.04 [0.40, 2.70], P=.94; alcohol intake SMD at -0.16 [-1.43, 1.10], P=.80; smoking RR at 0.87 [0.67, 1.13], P=.30; and medication adherence RR at 1.10 [1.00, 1.22], P=.06. CONCLUSIONS Digital interventions may improve healthy behavioral factors (PA, healthy diet, and medication adherence) and are even more potent when used to treat multiple behavioral outcomes (eg, medication adherence plus). However, they did not appear to reduce unhealthy behavioral factors (smoking, alcohol intake, and unhealthy diet) and clinical outcomes (BMI, triglycerides, diastolic and systolic BP, and HbA1c).
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Affiliation(s)
- Adewale Samuel Akinosun
- Department of Nursing and Midwifery, Institute of Health Research and Innovation, Centre for Health Science, University of the Highlands and Islands, Inverness, United Kingdom
| | - Rob Polson
- Highland Health Sciences Library, Centre for Health Science, University of the Highlands and Islands, Inverness, United Kingdom
| | - Yohanca Diaz-Skeete
- School of Health and Science, Dundalk Institute of Technology, Dundalk, Ireland
| | - Johannes Hendrikus De Kock
- Department of Nursing and Midwifery, Institute of Health Research and Innovation, Centre for Health Science, University of the Highlands and Islands, Inverness, United Kingdom
| | - Lucia Carragher
- School of Health and Science, Dundalk Institute of Technology, Dundalk, Ireland
| | - Stephen Leslie
- Cardiology Unit, Raigmore Hospital, NHS Highlands, Inverness, United Kingdom
| | - Mark Grindle
- Department of Nursing and Midwifery, Institute of Health Research and Innovation, Centre for Health Science, University of the Highlands and Islands, Inverness, United Kingdom
| | - Trish Gorely
- Department of Nursing and Midwifery, Institute of Health Research and Innovation, Centre for Health Science, University of the Highlands and Islands, Inverness, United Kingdom
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26
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Golbus JR, Dempsey W, Jackson EA, Nallamothu BK, Klasnja P. Microrandomized Trial Design for Evaluating Just-in-Time Adaptive Interventions Through Mobile Health Technologies for Cardiovascular Disease. Circ Cardiovasc Qual Outcomes 2021; 14:e006760. [PMID: 33430608 DOI: 10.1161/circoutcomes.120.006760] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Smartphone and wearable device use is rising broadly and can be leveraged for chronic disease management. Just-in-time adaptive interventions promise to deliver personalized, dynamic interventions directly to patients through use of push notifications from mobile devices. Although just-in-time adaptive interventions are a powerful tool for shaping health behavior, their application to cardiovascular disease management has been limited as they can be challenging to design. Herein, we provide a general overview and conceptual framework for microrandomized trials, a novel experimental study design that can be used to optimize just-in-time adaptive interventions. Microrandomized trials leverage mobile devices to sequentially randomize participants to types or levels of an intervention to determine the effectiveness of an intervention and time-varying moderators of those effects. Microrandomized trials are an efficient study design that can be used to determine which intervention components to include in just-in-time adaptive interventions and to optimize their decision rules while maintaining the strength of causal inference associated with traditional randomized controlled trials.
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Affiliation(s)
- Jessica R Golbus
- Division of Cardiovascular Diseases, Department of Internal Medicine (J.R.G., B.K.N.), University of Michigan, Ann Arbor
| | - Walter Dempsey
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor (W.D.)
| | - Elizabeth A Jackson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Alabama at Birmingham (E.A.J.)
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Diseases, Department of Internal Medicine (J.R.G., B.K.N.), University of Michigan, Ann Arbor
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan (B.K.N.)
- The Center for Clinical Management and Research, Ann Arbor VA Medical Center, MI (B.K.N.)
| | - Predrag Klasnja
- School of Information (P.K.), University of Michigan, Ann Arbor
- Kaiser Permanente Washington Health Research Institute, Seattle (P.K.)
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27
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Out of office hours: scalable, on-demand, digital support for patients tapering prescription opioids. Pain 2020; 161:2252-2254. [PMID: 32501860 DOI: 10.1097/j.pain.0000000000001947] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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28
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Bhaskar S, Bradley S, Chattu VK, Adisesh A, Nurtazina A, Kyrykbayeva S, Sakhamuri S, Moguilner S, Pandya S, Schroeder S, Banach M, Ray D. Telemedicine as the New Outpatient Clinic Gone Digital: Position Paper From the Pandemic Health System REsilience PROGRAM (REPROGRAM) International Consortium (Part 2). Front Public Health 2020; 8:410. [PMID: 33014958 PMCID: PMC7505101 DOI: 10.3389/fpubh.2020.00410] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/10/2020] [Indexed: 12/11/2022] Open
Abstract
Technology has acted as a great enabler of patient continuity through remote consultation, ongoing monitoring, and patient education using telephone and videoconferencing in the coronavirus disease 2019 (COVID-19) era. The devastating impact of COVID-19 is bound to prevail beyond its current reign. The vulnerable sections of our community, including the elderly, those from lower socioeconomic backgrounds, those with multiple comorbidities, and immunocompromised patients, endure a relatively higher burden of a pandemic such as COVID-19. The rapid adoption of different technologies across countries, driven by the need to provide continued medical care in the era of social distancing, has catalyzed the penetration of telemedicine. Limiting the exposure of patients, healthcare workers, and systems is critical in controlling the viral spread. Telemedicine offers an opportunity to improve health systems delivery, access, and efficiency. This article critically examines the current telemedicine landscape and challenges in its adoption, toward remote/tele-delivery of care, across various medical specialties. The current consortium provides a roadmap and/or framework, along with recommendations, for telemedicine uptake and implementation in clinical practice during and beyond COVID-19.
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Affiliation(s)
- Sonu Bhaskar
- Pandemic Health System REsilience PROGRAM (REPROGRAM) Consortium, REPROGRAM Telemedicine Sub-committee, Sydney, NSW, Australia.,Department of Neurology, Liverpool Hospital and South Western Sydney Local Health District, Sydney, NSW, Australia.,Neurovascular Imaging Laboratory & NSW Brain Clot Bank, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,South Western Sydney Clinical School, The University of New South Wales, UNSW Medicine, Sydney, NSW, Australia
| | - Sian Bradley
- Pandemic Health System REsilience PROGRAM (REPROGRAM) Consortium, REPROGRAM Telemedicine Sub-committee, Sydney, NSW, Australia.,The University of New South Wales (UNSW) Medicine Sydney, South West Sydney Clinical School, Sydney, NSW, Australia
| | - Vijay Kumar Chattu
- Pandemic Health System REsilience PROGRAM (REPROGRAM) Consortium, REPROGRAM Telemedicine Sub-committee, Sydney, NSW, Australia.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, Toronto, ON, Canada
| | - Anil Adisesh
- Pandemic Health System REsilience PROGRAM (REPROGRAM) Consortium, REPROGRAM Telemedicine Sub-committee, Sydney, NSW, Australia.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, Toronto, ON, Canada
| | - Alma Nurtazina
- Pandemic Health System REsilience PROGRAM (REPROGRAM) Consortium, REPROGRAM Telemedicine Sub-committee, Sydney, NSW, Australia.,Department of Epidemiology and Biostatistics, Semey Medical University, Semey, Kazakhstan
| | - Saltanat Kyrykbayeva
- Pandemic Health System REsilience PROGRAM (REPROGRAM) Consortium, REPROGRAM Telemedicine Sub-committee, Sydney, NSW, Australia.,Department of Epidemiology and Biostatistics, Semey Medical University, Semey, Kazakhstan
| | - Sateesh Sakhamuri
- Pandemic Health System REsilience PROGRAM (REPROGRAM) Consortium, REPROGRAM Telemedicine Sub-committee, Sydney, NSW, Australia.,Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Sebastian Moguilner
- Pandemic Health System REsilience PROGRAM (REPROGRAM) Consortium, REPROGRAM Telemedicine Sub-committee, Sydney, NSW, Australia.,Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Shawna Pandya
- Pandemic Health System REsilience PROGRAM (REPROGRAM) Consortium, REPROGRAM Telemedicine Sub-committee, Sydney, NSW, Australia.,Alberta Health Services and Project PoSSUM, University of Alberta, Edmonton, AB, Canada
| | - Starr Schroeder
- Pandemic Health System REsilience PROGRAM (REPROGRAM) Consortium, REPROGRAM Telemedicine Sub-committee, Sydney, NSW, Australia.,Penn Medicine Lancaster General Hospital and Project PoSSUM, Lancaster, PA, United States
| | - Maciej Banach
- Pandemic Health System REsilience PROGRAM (REPROGRAM) Consortium, REPROGRAM Telemedicine Sub-committee, Sydney, NSW, Australia.,Polish Mother's Memorial Hospital Research Institute (PMMHRI), Łódz, Poland.,Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland.,Department of Hypertension, Medical University of Lodz, Łódz, Poland
| | - Daniel Ray
- Pandemic Health System REsilience PROGRAM (REPROGRAM) Consortium, REPROGRAM Telemedicine Sub-committee, Sydney, NSW, Australia.,Farr Institute of Health Informatics, University College London (UCL) & NHS Foundation Trust, Birmingham, United Kingdom
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Klimis H, Thiagalingam A, Chow CK. Text messages for primary prevention of cardiovascular disease: the TextMe2 randomised controlled trial protocol. BMJ Open 2020; 10:e036767. [PMID: 32341047 PMCID: PMC7204915 DOI: 10.1136/bmjopen-2020-036767] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Mobile health may be an effective means of delivering customised individually directed health promotion interventions for cardiovascular disease (CVD) primary prevention. The aim of this study is to evaluate the effectiveness of a lifestyle-focused text messaging programme for primary CVD prevention. METHODS AND ANALYSIS Single-blind randomised controlled trial with 6 months' follow-up in 246 patients with moderate-high absolute cardiovascular risk and without coronary heart disease recruited from a rapid access cardiology clinic. Participants will be randomised to receive either usual care or TextMe2 (text message-based prevention programme). The TextMe2 programme provides support, motivation and education on five topics: diet, physical activity, smoking, general cardiovascular health and medication adherence, and is delivered in four text messages per week over 6 months. The primary outcome is change in the proportion of patients who have three or more of five key modifiable risk factors that are uncontrolled (low-density lipoprotein >2.0 mmol/L, systolic blood pressure >140 mm Hg, body mass index >24.9 kg/m2, physical activity (less than the equivalent of 150 min of moderate intensity each week), current smoker). Secondary outcomes are changes in single biomedical risk factors, behavioural risk factors, quality of life, depression/anxiety scores, medication adherence, cardiovascular health literacy and hospital readmissions/representations. Analysis will be according to the intention-to-treat principle and full statistical analysis plan developed prior to data lock. ETHICS AND DISSEMINATION This study has been approved by the Western Sydney Local Health District Human Research Ethics Committee at Westmead (AU/RED/HREC/17/WMEAD/186). Results will be presented at scientific meetings and published in peer-reviewed publications. TRIAL REGISTRATION NUMBER ACTRN12618001153202.
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Affiliation(s)
- Harry Klimis
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Aravinda Thiagalingam
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Clara K Chow
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
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30
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Smartphone and social media-based cardiac rehabilitation and secondary prevention in China (SMART-CR/SP): a parallel-group, single-blind, randomised controlled trial. LANCET DIGITAL HEALTH 2019; 1:e363-e374. [DOI: 10.1016/s2589-7500(19)30151-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/06/2019] [Accepted: 09/13/2019] [Indexed: 02/07/2023]
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31
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Yang X, Kovarik CL. A systematic review of mobile health interventions in China: Identifying gaps in care. J Telemed Telecare 2019; 27:3-22. [PMID: 31319759 DOI: 10.1177/1357633x19856746] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Mobile health has a promising future in the healthcare system in most developed countries. China's rapidly developing mobile technology infrastructure offers an unprecedented opportunity for wide adoption of mobile health interventions in the delivery of effective and timely healthcare services. However, there is little data on the current extent of the mobile health landscape in China. The aim of this study was to systematically review the existing mobile health initiatives in China, characterise the technology used, disease categories targeted, location of the end user (urban versus rural), and examine the potential effects of mobile health on health system strengthening in China. Furthermore, we identified gaps in development and evaluation of the effectiveness of mobile health interventions. METHODS A systematic review of the literature published from 18 December 2015 - 3 April 2019 was conducted and yielded 2863 articles from English and Chinese retrieval database and trial registries, including PubMed, EMBASE, China National Knowledge of Infrastructure and World Health Organization International Clinical Trials Registry Platform. Studies were included if they used mobile health to support patient healthcare outcomes. RESULTS A total of 1129 full-text articles were assessed and 338 were included in this study. The review found that most studies targeted client education and behaviour change via applications (apps) (65.4%), including WeChat, and text messaging (short text messages) (19.8%) to improve patient medical treatment outcomes such as compliance and appointment reminders. The most common disease-specific mobile health interventions focused primarily on chronic disease management and behaviour change in cardiology (13.3%), endocrinology/diabetes (12.1%), behavioural health (11.8%), oncology (11.2%) and neurology (6.8%). The mobile health interventions related to nutrition (0.6%) and chronic respiratory diseases (1.6%) are underrepresented in mobile health in comparison to the burden of disease in China. The majority (90.0%) of the mobile health interventions were conducted exclusively in urban areas, with few opportunities reaching rural populations. CONCLUSIONS Overall, mobile health has a promising future in China, with recent rapid growth in initiatives. The majority are focused on education and behaviour change in the realm of chronic diseases and target patients in urban areas. The imbalance in mobile health between the urban and rural areas, as well as between population disease spectrum and health service delivery, pose substantial dilemmas. However, mobile health may be redirected to correct this imbalance, possibly improving access to healthcare services, and filling the gaps in order to improve health equity for the underserved populations in China.
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Affiliation(s)
- Xiaoshi Yang
- Department of Social Medicine, China Medical University, P.R. China.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, USA
| | - Carrie L Kovarik
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, USA
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32
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Affiliation(s)
- Jessica R Golbus
- Division of Cardiovascular Diseases, Department of Internal Medicine (J.R.G., B.K.N.), University of Michigan, Ann Arbor
| | - Predrag Klasna
- School of Information (P.K.), University of Michigan, Ann Arbor
- Kaiser Permanente Washington Health Research Institute, Seattle (P.K.)
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Diseases, Department of Internal Medicine (J.R.G., B.K.N.), University of Michigan, Ann Arbor
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP) and Department of Internal Medicine (B.K.N.), University of Michigan, Ann Arbor
- The Center for Clinical Management and Research, Ann Arbor VA Medical Center, MI (B.K.N.)
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