Randomized controlled feasibility trial of two telemedicine medication reminder systems for older adults with heart failure

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

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

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

PURPOSE

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

Effect and usability of mobile health applications for medication adherence in patients with heart failure: A systematic review

BACKGROUND

This review aimed to evaluate the effect of mobile health applications (apps) use on medication adherence in heart failure (HF) patients, and to verify their quality of use.

METHODS

We searched MEDLINE, Embase, Web of Science, Scopus, CINAHL, LILACS, Cochrane, Clinical Trial Registries, Google Scholar, ProQuest, Open Access Theses and dissertations (OATD), Annual Symposium Proceedings of the American Medical Informatics Association (AMIA).

RESULTS

Of the 836 records identified, eight studies (five randomized clinical trials (RCTs) and three observational studies) were included, totaling 484 participants, with a mean age ranging from 51.1 to 72 years and 65% were male. The apps improved medication adherence when compared with their comparators in only two RCTs (n = 111, Cohen d = 3.23, 95% confidence interval (CI) 2.66; 3.80 and n = 80, d = 1.20, 95% CI 0.71; 1.66), and two observational studies, one of them with large effect size (n = 142, Cohen d = 1.51, 95% CI 1.12; 1.90). Apps proved to be more effective interventions than their comparators allowed continuous monitoring of patients. All included studies used self-report measures to assess medication adherence behaviors and their results should be interpreted with caution, as such tools may cause social desirability bias or recall bias.

CONCLUSION

The included studies indicate a possible outcome in favor of the use of apps to improve medication adherence in HF patients, but with very low quality level of evidence. Further studies are needed to investigate the effects of the use of apps, optimal frequency and duration of its use in HF patients.

The Promise and Risks of mHealth in Heart Failure Care

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

Digital Transformation in the Diagnostics and Therapy of Cardiovascular Diseases: Comprehensive Literature Review

BACKGROUND

The digital transformation of our health care system has experienced a clear shift in the last few years due to political, medical, and technical innovations and reorganization. In particular, the cardiovascular field has undergone a significant change, with new broad perspectives in terms of optimized treatment strategies for patients nowadays.

OBJECTIVE

After a short historical introduction, this comprehensive literature review aimed to provide a detailed overview of the scientific evidence regarding digitalization in the diagnostics and therapy of cardiovascular diseases (CVDs).

METHODS

We performed an extensive literature search of the PubMed database and included all related articles that were published as of March 2022. Of the 3021 studies identified, 1639 (54.25%) studies were selected for a structured analysis and presentation (original articles: n=1273, 77.67%; reviews or comments: n=366, 22.33%). In addition to studies on CVDs in general, 829 studies could be assigned to a specific CVD with a diagnostic and therapeutic approach. For data presentation, all 829 publications were grouped into 6 categories of CVDs.

RESULTS

Evidence-based innovations in the cardiovascular field cover a wide medical spectrum, starting from the diagnosis of congenital heart diseases or arrhythmias and overoptimized workflows in the emergency care setting of acute myocardial infarction to telemedical care for patients having chronic diseases such as heart failure, coronary artery disease, or hypertension. The use of smartphones and wearables as well as the integration of artificial intelligence provides important tools for location-independent medical care and the prevention of adverse events.

CONCLUSIONS

Digital transformation has opened up multiple new perspectives in the cardiovascular field, with rapidly expanding scientific evidence. Beyond important improvements in terms of patient care, these innovations are also capable of reducing costs for our health care system. In the next few years, digital transformation will continue to revolutionize the field of cardiovascular medicine and broaden our medical and scientific horizons.

The use of technology to improve medication adherence in heart failure patients: a systematic review of randomised controlled trials

BACKGROUND

Heart failure is an ever-growing contributor to morbidity and mortality in the ageing population. Medication adherence rates among the HF population vary widely in the literature, with a reported range of 10-98%. Technologies have been developed to improve adherence to therapies and other clinical outcomes.

AIMS

This systematic review aims to investigate the effect of different technologies on medication adherence in patients with heart failure. It also aims to determine their impact on other clinical outcomes and examine the potential of these technologies in clinical practice.

METHODS

This systematic review was conducted using the following databases: PubMed Central UK, Embase, MEDLINE, CINAHL Plus, PsycINFO and Cochrane Library until October 2022. Studies were included if they were randomised controlled trials that used technology to improve medication adherence as an outcome in heart failure patients. The Cochrane Collaboration's Risk of Bias tool was used to assess individual studies. This review was registered with PROSPERO (ID: CRD42022371865).

RESULTS

A total of nine studies met the inclusion criteria. Two studies showed statistically significant improvement in medication adherence following their respective interventions. Eight studies had at least one statistically significant result in the other clinical outcomes it measured, including self-care, quality of life and hospitalisations. All studies that evaluated self-care management showed statistically significant improvement. Improvements in other outcomes, such as quality of life and hospitalisations, were inconsistent.

CONCLUSION

It is observable that there is limited evidence for using technology to improve medication adherence in heart failure patients. Further studies with larger study populations and validated self-reporting methods for medication adherence are required.

Examining standardized tools used for the evaluation of mobile health applications for cardiovascular disease

Cardiovascular disease is one of the leading causes of death worldwide. Scarce resources and rising costs are pushing healthcare systems to their limits. There is an urgency to develop, optimize and evaluate technologies that provide more effective care for patients. Modern technologies, such as mobile health (mHealth) applications, can provide relief as a key strategy. To integrate digital interventions into care structures, a detailed impact assessment of all professional mHealth applications is needed. The aim of this study is to analyze the standardized tools used in the field of cardiovascular disease. The results show that questionnaires, usage logs, and key indicators are predominantly used. Although the identified mHealth interventions are specific to cardiovascular disease and thus require particular questions to evaluate apps, the user readiness, usability, or quality of life criteria are non-specific. Therefore, the results contribute to understanding how different mHealth interventions can be assessed, categorized, evaluated, and accepted.

Exploring Differential Perceptions of Artificial Intelligence in Health Care Among Younger Versus Older Canadians: Results From the 2021 Canadian Digital Health Survey

BACKGROUND

The changing landscape of health care has led to the incorporation of powerful new technologies like artificial intelligence (AI) to assist with various services across a hospital. However, despite the potential outcomes that this tool may provide, little work has examined public opinion regarding their use.

OBJECTIVE

In this study, we aim to explore differences between younger versus older Canadians with regard to the level of comfort and perceptions around the adoption and use of AI in health care settings.

METHODS

Using data from the 2021 Canadian Digital Health Survey (n=12,052), items related to perceptions about the use of AI as well as previous experience and satisfaction with health care were identified. We conducted Mann-Whitney U tests to compare the level of comfort of younger versus older Canadians regarding the use of AI in health care for a variety of purposes. Multinomial logistic regression was used to predict the comfort ratings based on categorical indicators.

RESULTS

Younger Canadians had greater knowledge of AI, but older Canadians were more comfortable with AI applied to monitoring and predicting health conditions, decision support, diagnostic imaging, precision medicine, drug and vaccine development, disease monitoring at home, tracking epidemics, and optimizing workflow to save time. Additionally, for older respondents, higher satisfaction led to higher comfort ratings. Only 1 interaction effect was identified between previous experience, satisfaction, and comfort with AI for drug and vaccine development.

CONCLUSIONS

Older Canadians may be more open to various applications of AI within health care than younger Canadians. High satisfaction may be a critical criterion for comfort with AI, especially for older Canadians. Additionally, in the case of drug and vaccine development, previous experience may be an important moderating factor. We conclude that gaining a greater understanding of the perceptions of all health care users is integral to the implementation and sustainability of new and cutting-edge technologies in health care settings.

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

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

Mobile App Interventions to Improve Medication Adherence Among Type 2 Diabetes Mellitus Patients: A Systematic Review of Clinical Trials

BACKGROUND

Medication adherence in type 2 diabetes mellitus (T2DM) patients is often suboptimal resulting in complications. There has been a growing interest in using mobile apps for improving medication adherence.

OBJECTIVE

The objective of this work was to systematically review the clinical trials that have used mobile app-based interventions in T2DM patients for improving medication adherence.

METHODOLOGY

A systematic search was performed to identify published clinical trials between January 2008 and December 2020 in databases-PubMed, Cochrane Library, and Google Scholar. All studies were assessed for risk of bias using quality rating tool from the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Seven clinical studies having 649 participants were studied. The median sample size was 58 (range = 41-247) and the median age of participants was 53.2 (range = 48-69.4) years. All studies showed improvements in adherence; however, only three studies reported statically significant improvements in adherence measures. Selected studies were deemed as unclear in their risk of bias and the most common source of risk of bias among the studies was the absence of objective outcome assessment.

CONCLUSIONS

Mobile apps appear to be effective interventions to help improve medication adherence in T2DM patients compared with conventional care strategies. The features of the App to improvise medical adherence cannot be defined based on the meta-analysis because of heterogeneity of study designs and less number of sample size. Systematically planned studies would set up applicability of mobile apps in the clinical management of T2DM.

A Systematic Review of Compensation and Technology-Mediated Strategies to Maintain Older Adults' Medication Adherence

Elderly medication adherence is a challenge in health care. The elderly are often at higher risk for non-adherence, and more likely to be on multiple prescription medications for many comorbidities. This systematic review aimed to explore the current strategies for maintaining older adults' medication adherence with compensation and technology-mediated strategies. We conducted a systematic review to examine related articles published in the PubMed, Web of Science, and Scopus databases, as well as Google Scholar for additional reference sources by cross-reference review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to guide this review. A total of 217 articles were screened, and 27 studies fulfilled the inclusion criteria. Older adults applied a variety of methods to maintain or enhance their medication adherence. Three studies indicated compensation strategies, 19 studies reported technological assistance, two studies used other strategies (community-offered help or caregivers help), and three studies used a combination of compensation with another strategy or technology. Studies identified various compensation- and technology-based strategies carried out by older adults to help remind them to take medication. This review identified potential benefits of technology and compensation strategy implementation in older adults to increase medication adherence. Although we are conscious of the heterogeneity of the included studies, it remains challenging to determine which elements underpin the most effective approaches.

Effect of electronic reminders on patients' compliance during clear aligner treatment: an interrupted time series study

Patient compliance is relevant to achieving therapeutic goals during clear aligner therapy (CAT). The aim of this study was to evaluate the efficacy of remote electronic (e-)reminders and e-feedback on compliance during CAT using an interrupted time series (ITS) analysis. We used routinely collected mobile application data from a German healthtech company (PlusDental, Berlin). Our primary outcome was self-reported compliance (aligner wear time min. 22 h on 75% of their aligners were classified as fully compliant, min. 22 h on 50-74.9% of their aligners: fairly compliant; min. 22 h on < 50% of their aligners: poorly compliant). E-reminders and e-feedback were introduced in the 1st quarter of 2020. Compliance was assessed at semi-monthly intervals from June-December 2019 (n = 1899) and June-December 2020 (n = 5486), resulting in a pre- and post-intervention group. ITS and segmented regression modelling were used to estimate the effect on the change in levels and trends of poor compliance. Pre-intervention, poor compliance was at 24.47% (95% CI: 22.59% to 26.46%). After the introduction of e-reminders and e-feedback (i.e., post-intervention), the percentage of poorly compliant patients decreased substantially, levelling off at 9.32% (95% CI: 8.31% to 10.45%). E-reminders and e-feedback were effective for increasing compliance in CAT patients.Clinical Significance: Orthodontists and dentists may consider digital monitoring and e-reminders to improve compliance and increase treatment success.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Factors affecting medication adherence among older adults using tele-pharmacy services: a scoping review

Background

Medication adherence among older adults (aged 60 and above), particularly those with chronic conditions who take several medications, is critical, and tele-pharmacy services are a way to improve medication adherence. This study sought to determine the factors influencing medication adherence (MA) in older adults using tele-pharmacy services.

Method

The Joana Briggs Institute scoping review methodology was implemented. Searches were conducted in databases PubMed, Scopus, ProQuest, Web of Science, and Embase from 2000 to the present day, to identify both qualitative and quantitative studies focusing on the use of tele-pharmacy by older people. Factors impacting MA were extracted and analyzed into themes using a qualitative approach. A concept map was also designed summarising these factors.

Results

Of 7495 articles obtained in the initial search, 52 articles met the inclusion criteria. The analysis resulted in 5 themes and 21 sub-themes representing factors that impacted MA with tele-pharmacy. These themes are divided broadly into technology and user related factors. Technology factors included design of the tele-pharmacy intervention, commercial aspects, and adherence measurement method. User factors included user-health constraints, behaviors and perceptions.

Conclusion

Industry, policymakers, and stakeholders should consider using tele-pharmacy services for improving medication adherence among older adults; however, ensuring interventions facilitate communication between patients and health care teams, and are accompanied by user training and support, is essential for technology uptake and effectiveness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00960-w.

What are the demands of telegeriatrics medical services for elderly patients during the COVID-19 pandemic

Purpose

Elderly patients are associated with a higher risk of nosocomial cross infection during the COVID-19 pandemic. Providing medical services and primary care for elderly patients is a worldwide challenge. A new telegeriatrics system was established to provide medical services and primary care for elderly patients treated by family physicians. This study aimed to describe the operation mechanism of the new system and investigate the demands of telegeriatrics medical services for elderly patients treated by family physicians during the COVID-19 pandemic.

Methods

A total of 1,353 elderly patients (aged≥60) treated by family physicians were enrolled. The proportion of the top 10 diseases of elderly patients applying the new system was analyzed. Differences in main diseases between elderly patients applying telegeriatrics medical services and outpatients in hospitals were compared. Differences between the new telegeriatrics system in our study and telemedicine systems of other studies in other countries were analyzed.

Results

Constituent ratios of chronic kidney disease, type 2 diabetes mellitus, and coronary heart disease have the highest rate in elderly patients applying the new telegeriatrics system. Digestive diseases, cardiovascular diseases, and neurology diseases were the top three diseases of elderly outpatients.

Conclusion

This is the first time that a new telegeriatrics system has been applied to provide medical services for elderly patients treated by family physicians during the COVID-19 pandemic. Chronic kidney disease, Type 2 diabetes mellitus, and coronary heart disease were found to be the top three diseases of elderly patients applying telegeriatrics medical services during the COVID-19 pandemic, which were different from the outpatients in general hospitals. The new telegeriatrics system guarantees elderly patients get equal rights to medical services. Results will provide a basis for the government health administrative department to formulate new telegeriatrics policies for elderly patients.

The Effectiveness of Assistive Technologies for Older Adults and the Influence of Frailty: Systematic Literature Review of Randomized Controlled Trials

Background

The use of assistive technologies (ATs) to support older people has been fueled by the demographic change and technological progress in many countries. These devices are designed to assist seniors, enable independent living at home or in residential facilities, and improve quality of life by addressing age-related difficulties.

Objective

We aimed to evaluate the effectiveness of ATs on relevant outcomes with a focus on frail older adults.

Methods

A systematic literature review of randomized controlled trials evaluating ATs was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The Ovid Medline, PsycINFO, SocIndex, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and IEEEXplore databases were searched from January 1, 2009, to March 15, 2019. ATs were included when aiming to support the domains autonomy, communication, or safety of older people with a mean age ≥65 years. Trials performed within a laboratory setting were excluded. Studies were retrospectively categorized according to the physical frailty status of participants.

Results

A total of 19 trials with a high level of heterogeneity were included in the analysis. Six device categories were identified: mobility, personal disease management, medication, mental support, hearing, and vision. Eight trials showed significant effectiveness in all or some of the primary outcome measures. Personal disease management devices seem to be the most effective, with four out of five studies showing significant improvement of disease-related outcomes. Frailty could only be assessed for seven trials. Studies including participants with significant or severe impairment showed no effectiveness.

Conclusions

Different ATs show some promising results in well-functioning but not in frail older adults, suggesting that the evaluated ATs might not (yet) be suitable for this subgroup. The uncertainty of the effectiveness of ATs and the lack of high-quality research for many promising supportive devices were confirmed in this systematic review. Large studies, also including frail older adults, and clear standards are needed in the future to guide professionals, older users, and their relatives.

Trial Registration

PROSPERO CRD42019130249; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130249

MOBILE APP MAPPING FOR HEART FAILURE CARE: A SCOPING REVIEW

ABSTRACT Objective: to map mobile apps for care in heart failure. Method: this is a scoping review based on the method proposed by the Joanna Briggs Institute. The following research question was used: which mobile apps on heart failure are used by health professionals, people with heart failure and their family/caregivers? Health bases and portals were analyzed through the search with the descriptors “Heart Failure”, “Mobile Applications”, “Patients”, “Health Personnel”, “Family” and “Caregivers” and the keyword “Applications”. Forty-seven studies were selected for analysis. Results: a total of 47 published studies were analyzed, which allowed mapping 39 mobile applications from four continents, among which 20 (51.3%) were intended for co-management and 19 (48.7%) had as target population patients and health professionals; 23 (58.9%) applications did not use theoretical framework for its construction. The prevalent theme and resources involved daily care (36; 92.3%) and data management (37; 94.9%), respectively. Conclusion: the themes and resources of the applications assisted patients, family members and professionals in heart failure management. However, a gap was identified in several themes involving individuals and their surroundings, essential for comprehensive care.

Methods Used to Evaluate mHealth Applications for Cardiovascular Disease: A Quasi-Systematic Scoping Review

In the face of demographic change and constantly increasing health care costs, health care system decision-makers face ever greater challenges. Mobile health applications (mHealth apps) have the potential to combat this trend. However, in order to integrate mHealth apps into care structures, an evaluation of such apps is needed. In this paper, we focus on the criteria and methods of evaluating mHealth apps for cardiovascular disease and the implications for developing a widely applicable evaluation framework for mHealth interventions. Our aim is to derive substantiated patterns and starting points for future research by conducting a quasi-systematic scoping review of relevant peer-reviewed literature published in English or German between 2000 and 2021. We screened 4066 articles and identified n = 38 studies that met our inclusion criteria. The results of the data derived from these studies show that usability, motivation, and user experience were evaluated primarily using standardized questionnaires. Usage protocols and clinical outcomes were assessed primarily via laboratory diagnostics and quality-of-life questionnaires, and cost effectiveness was tested primarily based on economic measures. Based on these findings, we propose important considerations and elements for the development of a common evaluation framework for professional mHealth apps, including study designs, data collection tools, and perspectives.

Analysis of Apps With a Medication List Functionality for Older Adults With Heart Failure Using the Mobile App Rating Scale and the IMS Institute for Healthcare Informatics Functionality Score: Evaluation Study

Background

Managing the care of older adults with heart failure (HF) largely centers on medication management. Because of frequent medication or dosing changes, an app that supports these older adults in keeping an up-to-date list of medications could be advantageous. During the COVID-19 pandemic, HF outpatient consultations are taking place virtually or by telephone. An app with the capability to share a patient’s medication list with health care professionals before consultation could support clinical efficiency, for example, by reducing consultation time. However, the influence of apps on maintaining an up-to-date medication history for older adults with HF in Ireland remains largely unexplored.

Objective

The aims of this review are twofold: to review apps with a medication list functionality and to assess the quality of the apps included in the review using the Mobile App Rating Scale (MARS) and the IMS Institute for Healthcare Informatics functionality scale.

Methods

A systematic search of apps was conducted in June 2019 using the Google Play Store and iTunes App Store. The MARS was used independently by 4 researchers to assess the quality of the apps using an Android phone and an iPad. Apps were also evaluated using the IMS Institute for Healthcare Informatics functionality score.

Results

Google Play and iTunes App store searches identified 483 potential apps (292 from Google Play and 191 from iTunes App stores). A total of 6 apps (3 across both stores) met the inclusion criteria. Of the 6 apps, 4 achieved an acceptable MARS score (3/5). The Medisafe app had the highest overall MARS score (4/5), and the Medication List & Medical Records app had the lowest overall score (2.5/5). On average, the apps had 8 functions based on the IMS functionality criteria (range 5-11). A total of 2 apps achieved the maximum score for number of features (11 features) according to the IMS Institute for Healthcare Informatics functionality score, and 2 scored the lowest (5 features). Peer-reviewed publications were identified for 3 of the apps.

Conclusions

The quality of current apps with medication list functionality varies according to their technical aspects. Most of the apps reviewed have an acceptable MARS objective quality (ie, the overall quality of an app). However, subjective quality (ie, satisfaction with the apps) was poor. Only 3 apps are based on scientific evidence and have been tested previously. A total of 2 apps featured all the IMS Institute for Healthcare Informatics functionalities, and half did not provide clear instructions on how to enter medication data, did not display vital parameter data in an easy-to-understand format, and did not guide users on how or when to take their medication.

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

OBJECTIVE

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

INTRODUCTION

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

INCLUSION CRITERIA

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

METHODS

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

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020147816.

Use of mobile applications for heart failure self-management: a systematic review of experimental and qualitative studies (Preprint)

Background

Heart failure self-management is essential to avoid decompensation and readmissions. Mobile apps seem promising in supporting heart failure self-management, and there has been a rapid growth in publications in this area. However, to date, systematic reviews have mostly focused on remote monitoring interventions using nonapp types of mobile technologies to transmit data to health care providers, rarely focusing on supporting patient self-management of heart failure.

Objective

This study aims to systematically review the evidence on the effect of heart failure self-management apps on health outcomes, patient-reported outcomes, and patient experience.

Methods

Four databases (PubMed, Embase, CINAHL, and PsycINFO) were searched for studies examining interventions that comprised a mobile app targeting heart failure self-management and reported any health-related outcomes or patient-reported outcomes or perspectives published from 2008 to December 2021. The studies were independently screened. The risk of bias was appraised using Cochrane tools. We performed a narrative synthesis of the results. The protocol was registered on PROSPERO (International Prospective Register of Systematic Reviews; CRD42020158041).

Results

A total of 28 articles (randomized controlled trials [RCTs]: n=10, 36%), assessing 23 apps, and a total of 1397 participants were included. The most common app features were weight monitoring (19/23, 83%), symptom monitoring (18/23, 78%), and vital sign monitoring (15/23, 65%). Only 26% (6/23) of the apps provided all guideline-defined core components of heart failure self-management programs: education, symptom monitoring, medication support, and physical activity support. RCTs were small, involving altogether 717 participants, had ≤6 months of follow-up, and outcomes were predominantly self-reported. Approximately 20% (2/10) of RCTs reported a significant improvement in their primary outcomes: heart failure knowledge (P=.002) and self-care (P=.004). One of the RCTs found a significant reduction in readmissions (P=.02), and 20% (2/10) of RCTs reported higher unplanned clinic visits. Other experimental studies also found significant improvements in knowledge, self-care, and readmissions, among others. Less than half of the studies involved patients and clinicians in the design of apps. Engagement with the intervention was poorly reported, with only 11% (3/28) of studies quantifying app engagement metrics such as frequency of use over the study duration. The most desirable app features were automated self-monitoring and feedback, personalization, communication with clinicians, and data sharing and integration.

Conclusions

Mobile apps may improve heart failure self-management; however, more robust evaluation studies are needed to analyze key end points for heart failure. On the basis of the results of this review, we provide a road map for future studies in this area.

The impact of mobile applications on medication adherence: a systematic review

In 2008, Apple and Android launched their Application or "App" stores. Since then, there has been a growing interest in using mobile apps for improving medication adherence. However, research on the efficacy of apps, in terms of improved medication adherence and clinical outcome and/or patient-related outcome measures (PROMs) is scarce. The objective of this research was to systematically review the impact of apps on consumers' medication adherence and to determine the effect on clinical outcome and/or PROM(s). A systematic literature search was conducted to identify publications aimed at improving medication adherence published from January 2008 to April 2018. All studies were assessed for risk of bias using either the Risk Of Bias In Non-randomized Studies-of Interventions or the revised tool for Risk of Bias in randomized trials tool, depending on study design. Eleven randomized controlled trials (RCTs) and 10 non-RCTs were included. All 11 RCTs showed improvements in adherence; however, only seven reported statistically significant improvements in at least one adherence measure. Nine RCTs also demonstrated improvements in clinical outcome/PROM(s), of which five were statistically significant, whereas two RCTs did not report on clinical outcome/PROM(s). Only two studies using non-RCT study designs showed statistically significant improvements in all measures of adherence and clinical outcome/PROM(s). The risk of bias was moderate or serious for all included studies. Even though the use of an app may improve adherence, it is difficult to draw conclusions regarding the impact of apps on medication adherence due to the high degree of heterogeneity across studies, from the methodological design to the features of the app and the measure of adherence.

The effect of the mobile "blood pressure management application" on hypertension self-management enhancement: a randomized controlled trial

BACKGROUND

Self-management of hypertension is of great significance given its increasing incidence and its associated disabilities. In view of the increased use of mobile health in medicine, the present study evaluated the effect of a self-management application on patient adherence to hypertension treatment.

METHODS

This clinical trial was performed on 120 hypertensive patients who were provided with a mobile intervention for 8 weeks and followed up until the 24th week. Data on the primary outcome (adherence to treatment) and secondary outcomes (adherence to the DASH diet, regular monitoring of blood pressure, and physical activity) were collected using a questionnaire and a mobile application, respectively. The inter-group change difference over time was analyzed using repeated measures ANOVA (general linear model).

RESULTS

The treatment adherence score increased by an average of 5.9 (95% CI 5.0-6.7) in the intervention group compared to the control group. The scores of "adherence to the low-fat and low-salt diet plans" were 1.7 (95% CI 1.3-2.1) and 1.5 (95% CI 1.2-1.9), respectively. Moreover, moderate physical activity increased to 100.0 min (95% CI 61.7-138.3) per week in the intervention group.

CONCLUSION

The treatment and control of blood pressure require a multifaceted approach given its complexity and multifactorial nature. Considering the widespread use of smartphones, mHealth interventions can be effective in self-management and better patient adherence to treatments. Our results showed that this application can be used as a successful tool for hypertension self-management in patients attending public hospitals in developing countries.

TRIAL REGISTRATION

Iran Randomized Clinical Trial Center IRCT2015111712211N2 . Registered on 1 January 2016.

Digital Health: Unlocking Value in a Post-Pandemic World

The COVID-19 pandemic has forever changed health care, spurring a revolution in digital health technologies. Across the world, hundreds of thousands of health care systems are considering a central question: how do we connect with our patients? Digital health has been used as a stopgap in many cases to continue the essential functions of health systems. As the post-pandemic world and our "new normal" come into focus, further needs will have to be met with a digital patient interaction, with an eye toward value transformation. One barrier to fully leveraging digital tools is the lack of a framework for classifying the type of digital health care. This can limit our ability to design, deploy, evaluate, and communicate through digital means. This article presents 3 categories of digital health and their relationships to value metrics: (1) telehealth or direct care delivery, (2) digital access tools, and (3) digital monitoring. An evidence-based discussion reveals past successes, current promises, and future challenges in reducing defects in value through digital care. In the coming years, value transformation will become more crucial to the success of health care systems. By using the taxonomy in this article, health systems can better implement digital tools with a value-driven purpose. Defining the role of digital health in the post-pandemic world is needed to assist health systems and practices to build a bridge to value-based care.

Mobile Apps to Improve Medication Adherence in Cardiovascular Disease: Systematic Review and Meta-analysis

Background

Adherence rates of preventative medication for cardiovascular disease (CVD) have been reported as 57%, and approximately 9% of all CVD events in Europe are attributable to poor medication adherence. Mobile health technologies, particularly mobile apps, have the potential to improve medication adherence and clinical outcomes.

Objective

The objective of this study is to assess the effects of mobile health care apps on medication adherence and health-related outcomes in patients with CVD. This study also evaluates apps’ functionality and usability and the involvement of health care professionals in their use.

Methods

Electronic databases (MEDLINE [Ovid], PubMed Central, Cochrane Library, CINAHL Plus, PsycINFO [Ovid], Embase [Ovid], and Google Scholar) were searched for randomized controlled trials (RCTs) to investigate app-based interventions aimed at improving medication adherence in patients with CVD. RCTs published in English from inception to January 2020 were reviewed. The Cochrane risk of bias tool was used to assess the included studies. Meta-analysis was performed for clinical outcomes and medication adherence, with meta-regression analysis used to evaluate the impact of app intervention duration on medication adherence.

Results

This study included 16 RCTs published within the last 6 years. In total, 12 RCTs reported medication adherence as the primary outcome, which is the most commonly self-reported adherence. The duration of the interventions ranged from 1 to 12 months, and sample sizes ranged from 24 to 412. Medication adherence rates showed statistically significant improvements in 9 RCTs when compared with the control, and meta-analysis of the 6 RCTs reporting continuous data showed a significant overall effect in favor of the app intervention (mean difference 0.90, 95% CI 0.03-1.78) with a high statistical heterogeneity (I²=93.32%). Moreover, 9 RCTs assessed clinical outcomes and reported an improvement in systolic blood pressure, diastolic blood pressure, total cholesterol, and low-density lipoprotein cholesterol levels in the intervention arm. Meta-analysis of these clinical outcomes from 6 RCTs favored app interventions, but none were significant. In the 7 trials evaluating app usability, all were found to be acceptable. There was a great variation in the app characteristics. A total of 10 RCTs involved health care professionals, mainly physicians and nurses, in the app-based interventions. The apps had mixed functionality: 2 used education, 7 delivered reminders, and 7 provided reminders in combination with educational support.

Conclusions

Apps tended to increase medication adherence, but interventions varied widely in design, content, and delivery. Apps have an acceptable degree of usability; yet the app characteristics conferring usability and effectiveness are ill-defined. Future large-scale studies should focus on identifying the essential active components of successful apps.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42019121385; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=121385

Harnessing Mobile Health Technology for Secondary Cardiovascular Disease Prevention in Older Adults: A Scientific Statement From the American Heart Association

Secondary prevention of cardiovascular disease (CVD), the leading cause of morbidity and mortality, is critical to improving health outcomes and quality of life in our aging population. As mobile health (mHealth) technology gains universal leverage and popularity, it is becoming more user-friendly for older adults and an adjunct to manage CVD risk and improve overall cardiovascular health. With the rapid advances in mHealth technology and increasing technological engagement of older adults, a comprehensive understanding of the current literature and knowledge of gaps and barriers surrounding the impact of mHealth on secondary CVD prevention is essential. After a systematic review of the literature, 26 studies that used mHealth for secondary CVD prevention focusing on lifestyle behavior change and medication adherence in cohorts with a mean age of ≥60 years were identified. Improvements in health behaviors and medication adherence were observed, particularly when there was a short message service (ie, texting) component involved. Although mobile technologies are becoming more mainstream and are starting to blend more seamlessly with standard health care, there are still distinct barriers that limit implementation particularly in older adults, including affordability, usability, privacy, and security issues. Furthermore, studies on the type of mHealth that is the most effective for older adults with longer study duration are essential as the field continues to grow. As our population ages, identifying and implementing effective, widely accepted, cost-effective, and time-efficient mHealth interventions to improve CVD health in a vulnerable demographic group should be a top health priority.

Methodological features of quantitative studies on medication adherence in older patients with chronic morbidity: A systematic review

OBJECTIVES

The growing number of chronic, multimorbid older adults encourages healthcare systems to cope with polypharmacy and non-adherence. However, methodology on how to provide effective interventions to enhance medication adherence is still object of debate.

METHODS

To describe methodological features of quantitative studies concerning older adults' medication adherence, by means of a PRISMA systematic review (Scopus, PubMed, Medline). A specific focus was devoted to theoretical models and to the ABC Taxonomy model, as stated by the EMERGE guidelines.

RESULTS

55 papers were included. Most of the studies were conducted using randomized control trials (63.6%) and focused on a single disease only (72.7%). Most of the interventions were provided by a single professional figure (70.9%). Medication adherence was mainly evaluated by means of questionnaires (61.8%) and by clinical records (30.9%). Sixteen studies considered a theoretical model in the intervention framework. The Initiation phase (ABC Taxonomy) was the most neglected.

CONCLUSIONS

Future studies upon medication adherence should account real-life challenges such as multimorbidity, polypharmacy and interdisciplinarity, analyzing adherence as a complex, holistic process.

PRACTICE IMPLICATIONS

Theoretical models may be useful to enhance the soundness of the results, to ease their comparability, to calibrate tailored strategies and to plan patient-centered interventions.

Technology Acceptance in Mobile Health: Scoping Review of Definitions, Models, and Measurement

BACKGROUND

Designing technologies that users will be interested in, start using, and keep using has long been a challenge. In the health domain, the question of technology acceptance is even more important, as the possible intrusiveness of technologies could lead to patients refusing to even try them. Developers and researchers must address this question not only in the design and evaluation of new health care technologies but also across the different stages of the user's journey. Although a range of definitions for these stages exists, many researchers conflate related terms, and the field would benefit from a coherent set of definitions and associated measurement approaches.

OBJECTIVE

This review aims to explore how technology acceptance is interpreted and measured in mobile health (mHealth) literature. We seek to compare the treatment of acceptance in mHealth research with existing definitions and models, identify potential gaps, and contribute to the clarification of the process of technology acceptance.

METHODS

We searched the PubMed database for publications indexed under the Medical Subject Headings terms "Patient Acceptance of Health Care" and "Mobile Applications." We included publications that (1) contained at least one of the terms "acceptability," "acceptance," "adoption," "accept," or "adopt"; and (2) defined the term. The final corpus included 68 relevant studies.

RESULTS

Several interpretations are associated with technology acceptance, few consistent with existing definitions. Although the literature has influenced the interpretation of the concept, usage is not homogeneous, and models are not adapted to populations with particular needs. The prevalence of measurement by custom surveys suggests a lack of standardized measurement tools.

CONCLUSIONS

Definitions from the literature were published separately, which may contribute to inconsistent usage. A definition framework would bring coherence to the reporting of results, facilitating the replication and comparison of studies. We propose the Technology Acceptance Lifecycle, consolidating existing definitions, articulating the different stages of technology acceptance, and providing an explicit terminology. Our findings illustrate the need for a common definition and measurement framework and the importance of viewing technology acceptance as a staged process, with adapted measurement methods for each stage.

mHealth education interventions in heart failure

BACKGROUND

Heart failure (HF) is a chronic disease with significant impact on quality of life and presents many challenges to those diagnosed with the condition, due to a seemingly complex daily regimen of self-care which includes medications, monitoring of weight and symptoms, identification of signs of deterioration and follow-up and interaction with multiple healthcare services. Education is vital for understanding the importance of this regimen, and adhering to it. Traditionally, education has been provided to people with heart failure in a face-to-face manner, either in a community or a hospital setting, using paper-based materials or video/DVD presentations. In an age of rapidly-evolving technology and uptake of smartphones and tablet devices, mHealth-based technology (defined by the World Health Organization as mobile and wireless technologies to achieve health objectives) is an innovative way to provide health education which has the benefit of being able to reach people who are unable or unwilling to access traditional heart failure education programmes and services.

OBJECTIVES

To systematically review and quantify the potential benefits and harms of mHealth-delivered education for people with heart failure.

SEARCH METHODS

We performed an extensive search of bibliographic databases and registries (CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, IEEE Xplore, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) Search Portal), using terms to identify HF, education and mHealth. We searched all databases from their inception to October 2019 and imposed no restriction on language of publication.

SELECTION CRITERIA

We included studies if they were conducted as a randomised controlled trial (RCT), involving adults (≥ 18 years) with a diagnosis of HF. We included trials comparing mHealth-delivered education such as internet and web-based education programmes for use on smartphones and tablets (including apps) and other mobile devices, SMS messages and social media-delivered education programmes, versus usual HF care.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risks of bias, and extracted data from all included studies. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the odds ratio (OR) for dichotomous data with a 95% confidence interval (CI). We assessed heterogeneity using the I2 statistic and assessed the quality of evidence using GRADE criteria.

MAIN RESULTS

We include five RCTs (971 participants) of mHealth-delivered education interventions for people with HF in this review. The number of trial participants ranged from 28 to 512 participants. Mean age of participants ranged from 60 years to 75 years, and 63% of participants across the studies were men. Studies originated from Australia, China, Iran, Sweden, and The Netherlands. Most studies included participants with symptomatic HF, NYHA Class II - III. Three studies addressed HF knowledge, revealing that the use of mHealth-delivered education programmes showed no evidence of a difference in HF knowledge compared to usual care (MD 0.10, 95% CI -0.2 to 0.40, P = 0.51, I2 = 0%; 3 studies, 411 participants; low-quality evidence). One study assessing self-efficacy reported that both study groups had high levels of self-efficacy at baseline and uncertainty in the evidence for the intervention (MD 0.60, 95% CI -0.57 to 1.77; P = 0.31; 1 study, 29 participants; very low-quality evidence).Three studies evaluated HF self-care using different scales. We did not pool the studies due to the heterogenous nature of the outcome measures, and the evidence is uncertain. None of the studies reported adverse events. Four studies examined health-related quality of life (HRQoL). There was uncertainty in the evidence for the use of mHealth-delivered education on HRQoL (MD -0.10, 95% CI -2.35 to 2.15; P = 0.93, I2 = 61%; 4 studies, 942 participants; very low-quality evidence). Three studies reported on HF-related hospitalisation. The use of mHealth-delivered education may result in little to no difference in HF-related hospitalisation (OR 0.74, 95% CI 0.52 to 1.06; P = 0.10, I2 = 0%; 3 studies, 894 participants; low-quality evidence). We downgraded the quality of the studies due to limitations in study design and execution, heterogeneity, wide confidence intervals and fewer than 500 participants in the analysis.

AUTHORS' CONCLUSIONS

We found that the use of mHealth-delivered educational interventions for people with HF shows no evidence of a difference in HF knowledge; uncertainty in the evidence for self-efficacy, self-care and health-related quality of life; and may result in little to no difference in HF-related hospitalisations. The identification of studies currently underway and those awaiting classification indicate that this is an area of research from which further evidence will emerge in the short and longer term.

Effectiveness of Mobile Phone-Based Interventions for Improving Health Outcomes in Patients with Chronic Heart Failure: A Systematic Review and Meta-Analysis

Mobile phone-based interventions are increasingly used to prevent adverse health outcomes in heart failure patients. However, the effects of mobile phone-based interventions on the health outcomes of heart failure patients remain unclear. Our review aims to synthesize the randomized controlled trials (RCT) of mobile phone-based interventions for heart failure patients and identify the intervention features that are most effective. Electronic searches of RCTs published from January 2000 to July 2019 were conducted. Primary outcomes included all-cause mortality, readmission, emergency department visits, length of hospital stays, and quality of life. Secondary outcomes were self-care behaviors, including medication adherence and other clinical outcomes. A total of eight studies with varying methodological quality met the inclusion criteria and were analyzed. Voice call intervention was more frequently used compared with telemonitoring and short message services. Our meta-analysis showed that voice call interventions had significant effects on the length of hospital stays. However, no significant effects on all-cause mortality, readmission, emergency department visits, or quality of life were found. Compared to other mobile phone-based interventions, voice calls were more effective in reducing the length of hospital stay. Future studies are needed to identify which features of mobile phone-based intervention most effectively improve health outcomes.

Mobile Apps for Increasing Treatment Adherence: Systematic Review

BACKGROUND

It is estimated that 20% to 50% of patients do not take their medication correctly, and this leads to increased morbidity and inefficacy of therapeutic approaches. Fostering treatment adherence is a priority objective for all health systems. The growth of mobile apps to facilitate therapeutic adherence has significantly increased in recent years. However, the effectiveness of the apps for this purpose has not been evaluated.

OBJECTIVE

This study aimed to analyze whether mobile apps are perceived as useful for managing medication at home and if they actually contribute to increasing treatment adherence in patients.

METHODS

We carried out a systematic review of research published using Scopus, Cochrane Library, ProQuest, and MEDLINE databases and analyzed the information about their contribution to increasing therapeutic adherence and the perceived usefulness of mobile apps. This review examined studies published between 2000 and 2017.

RESULTS

Overall, 11 studies fulfilled the inclusion criteria. The sample sizes of these studies varied between 16 and 99 participants. In addition, 7 studies confirmed that the mobile app increased treatment adherence. In 5 of them, the before and after adherence measures suggested significant statistical improvements, when comparing self-reported adherence and missed dose with a percentage increase ranging between 7% and 40%. The users found mobile apps easy to use and useful for managing their medication. The patients were mostly satisfied with their use, with an average score of 8.1 out of 10.

CONCLUSIONS

The use of mobile apps helps increase treatment adherence, and they are an appropriate method for managing medication at home.

Negotiating contradictions: engaging disparate stakeholder demands in designing for active and healthy ageing

Purpose

Designing technologies for active and healthy ageing (AHA) requires a subtle understanding of end users (primary stakeholders) and healthcare professionals (secondary stakeholders). Often, their perspectives can be heterogeneous and contradictory. Identifying and negotiating them may be a challenge for designers. The purpose of this paper is to present our approach to understanding and negotiating contradictory stakeholder perspectives when designing AHA technologies for older adults.

Design/methodology/approach

The authors conducted an exploratory interview study with 15 community-dwelling older adults and 11 healthcare stakeholders, including doctors, health insurance agencies, policymakers and caregivers. The authors analyzed the interview material and negotiated contradictory perspectives.

Findings

Three major issues among stakeholders emerged: perspectives on AHA; perceived benefits and drawbacks of AHA technologies; and concerns about data privacy, control and trust.

Research limitations/implications

The results show the heterogeneity and contradictions in stakeholder perspectives on AHA technologies and how these perspectives may be negotiated. This could help understand and facilitate long-term use of AHA technologies among older adults.

Originality/value

This study alerts researchers to contradictory perspectives among older people and healthcare stakeholders and the importance of involving them in the design of AHA technologies.

Theoretical Advancements in mHealth: A Systematic Review of Mobile Apps

There are now few hundred thousand healthcare apps, yet there is a gap in our understanding of the theoretical mechanisms for which, and how, technological features translate into improved healthcare outcomes. In particular, the technological convergence, within mobile health (mHealth) apps, of the processes of mass and interpersonal communication, and human-computer interaction requires greater parsing in the literature. This paper analyzed 85 empirical studies on mHealth apps using the Input-Mechanism-Output model. We found in the literature that, firstly, there is a greater emphasis on technological inputs (87%) of accessibility, usability, usage, and data quality, than health outputs (52%) such as system process efficiencies and individual level behavioral or health outcomes. Secondly, there is little evidence of explanatory mechanisms (19%) of how the effects of mHealth apps are achieved. While we believe that successful apps would require research that incorporates technological inputs, theoretical mechanisms and health outputs, such studies are a rarity (n = 3). There is a minor increase in rigor with randomized control trials (n = 5), and a preponderance of discussion around social influence (n = 8) and gamification (n = 7), albeit in a scattered manner. We discuss the implications of the trend towards socialization and gamification findings in terms of future research, particularly in terms of study design guided by theoretical mechanisms.

What does the literature say about using electronic pillboxes for older adults? A systematic literature review

Purpose: The purpose of this study is to answer two research questions: (1) What is the clinical evidence for the reported outcomes in studies on electronic pillboxes for older adults? and (2) What is the technology readiness level (TRL) of the electronic pillboxes used, or intended to be used, for older adults?Methods: The scholarly literature was systematically searched and analyzed. Articles were included if they reported results about electronic pillboxes that were used or intended to be used for older adults' medication.Results: Clinical studies used commercially well-established electronic pillboxes with a high TRL. New electronic pillboxes in development had a low TRL. The discovered outcome was mainly adherence to medication. The overall mean adherence to medication regimens for all the studies using an electronic pillbox was higher than the gold standard of a good adherence level cut-off point (mean adherence 88.8%>80%). However, we found a large variation in this variable (SD = 10.7). With regard to an older adult population's adherence to medication regimens, for the outcome variable of those who had undergone a kidney transplant, the clinical evidence that electronic pillboxes have a positive impact was strong (1b); for those with a chronic hepatitis C medical condition, the clinical evidence was medium (3), and for those with arterial hypertension and multiple chronic (diabetes and hypertension) medical conditions, the clinical evidence was weak (5).Conclusion: More research is needed in this area using designs that provide greater validity.Implications for RehabilitationElectronic pillboxes with multiple reminders such as the "voice of a friend" or relative, which implies that electronic pillboxes which adopt "a social role" are advisable.An unequal level of clinical evidence that electronic pillboxes have a positive impact on the adherence outcome variable was found.For new electronic pillboxes still in development that specifically take into account older adults' needs, the TRL is still low; as a result, they could not be tested in real settings.

Mobile Technology Affinity in Renal Transplant Recipients

BACKGROUND

Medication nonadherence is a common problem in renal transplant recipients (RTRs). Mobile health approaches to improve medication adherence are a current trend, and several medication adherence apps are available. However, it is unknown whether RTRs use these technologies and to what extent. In the present study, the mobile technology affinity of RTRs was analyzed. We hypothesized significant age differences in mobile technology affinity and that mobile technology affinity is associated with better cognitive functioning as well as higher educational level.

METHODS

A total of 109 RTRs (63% male) participated in the cross-sectional study, with an overall mean age of 51.8 ± 14.2 years. The study included the Technology Experience Questionnaire (TEQ) for the assessment of mobile technology affinity, a cognitive test battery, and sociodemographic data.

RESULTS

Overall, 57.4% of the patients used a smartphone or tablet and almost 45% used apps. The TEQ sum score was 20.9 in a possible range from 6 (no affinity to technology) to 30 (very high affinity). Younger patients had significantly higher scores in mobile technology affinity. The only significant gender difference was found in having fun with using electronic devices: Men enjoyed technology more than women did. Mobile technology affinity was positively associated with cognitive functioning and educational level.

CONCLUSIONS

Young adult patients might profit most from mobile health approaches. Furthermore, high educational level and normal cognitive functioning promote mobile technology affinity. This should be kept in mind when designing mobile technology health (mHealth) interventions for RTRs. For beneficial mHealth interventions, further research on potential barriers and desired technologic features is necessary to adapt apps to patients' needs.

Using text message reminders in health care services: A narrative literature review

INTRODUCTION

Despite the extensive use of mHealth behavior change interventions, questions remain about the use of technology-based reminders in delivering health care services. Text messaging, or short message service (SMS), is one reminder method that has been extensively researched. Most SMS-reminder research is distributed across a range of health care outcomes. The aim of this article is to systematically review the aggregate impact of these reminders on overall health care outcomes.

METHODS

A systematic literature review was conducted and yielded 2316 articles. Studies were included if they used SMS reminders to support patient health care outcomes. Study methodology was aligned with the PRISMA guidelines for systematic reviews.

RESULTS

Following screening, 162 articles met inclusion criteria. Of these studies, 93 investigated medical compliance reminders and 56 investigated appointment reminders. The review found that nearly all the SMS-reminder studies helped improve patient medical compliance and appointment reminders. Additionally, researchers reported numerous benefits from using SMS reminders, including ease of use, relative inexpensiveness, and rapid and automated message delivery. Minimal risks were reported and most participants found the reminders to be acceptable.

DISCUSSION

Text messages appear to be an effective reminder mechanism to promote improved patient appointment and medical compliance. Reminders should continue to be evaluated and improved to determine the most effective timing and frequency of messages for improving outcomes.

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

Cardiovascular disease is a leading cause of morbidity and mortality worldwide, and a key barrier to improved outcomes is medication non-adherence. The aim of this study is to review the role of mobile health (mHealth) tools for improving medication adherence in patients with cardiovascular disease. We performed a systematic search for randomized controlled trials that primarily investigated mHealth tools for improving adherence to cardiovascular disease medications in patients with hypertension, coronary artery disease, heart failure, peripheral arterial disease, and stroke. We extracted and reviewed data on the types of mHealth tools used, preferences of patients and healthcare providers, the effect of the mHealth interventions on medication adherence, and the limitations of trials. We identified 10 completed trials matching our selection criteria, mostly with <100 participants, and ranging in duration from 1 to 18 months. mHealth tools included text messages, Bluetooth-enabled electronic pill boxes, online messaging platforms, and interactive voice calls. Patients and healthcare providers generally preferred mHealth to other interventions. All 10 studies reported that mHealth interventions improved medication adherence, though the magnitude of benefit was not consistently large and in one study was not greater than a telehealth comparator. Limitations of trials included small sample sizes, short duration of follow-up, self-reported outcomes, and insufficient assessment of unintended harms and financial implications. Current evidence suggests that mHealth tools can improve medication adherence in patients with cardiovascular diseases. However, high-quality clinical trials of sufficient size and duration are needed to move the field forward and justify use in routine care.

Technological methods to measure adherence to antiretroviral therapy and preexposure prophylaxis

PURPOSE OF REVIEW

The WHO's Consolidated Guidelines (2016) call for research on improved methods to proactively monitor adherence and identify those individuals who have the greatest needs for adherence support. This review aims to elucidate the latest technologies available to measure adherence to HIV antiretroviral therapy and preexposure prophylaxis against HIV infection and present their utility in various settings and populations.

RECENT FINDINGS

Within the last few years, advances have been made in the features of existing technology to measure adherence (real-time electronic adherence measurements), additional approaches have been developed (digital medicine systems) and improved (short message service surveys), and point of care testing for pharmacokinetic measures are under development.

SUMMARY

Technology advances in adherence measurement are promising for improved accuracy and, in some cases, the ability to intervene with adherence challenges in real time. This progress will greatly further our understanding of adherence behavior, as well as the ability to effectively link interventions with individuals who need them, thus maximizing the clinical and public health benefits of both antiretroviral therapy and preexposure prophylaxis.

The impact of medication nonadherence on the relationship between mortality risk and depression in heart failure

OBJECTIVE

Heart failure affects more than 5 million U.S. adults, and approximately 20% of individuals with heart failure experience depressive symptoms. Depression is detrimental to prognosis in heart failure, conferring approximately a 2-fold increase in mortality risk. Medication nonadherence may help explain this relationship because depressed patients are less likely to adhere to the medication regimen.

METHOD

Depression, electronically monitored medication adherence, and mortality were measured in a sample of 308 patients with heart failure participating in a study of self-management behavior. Cardiovascular and all-cause mortality data were obtained from the Centers for Disease Control and Prevention's National Death Index (median 2.9-year follow-up). Cox proportional hazards regression was used to assess the relationship between depression and mortality, with and without adjustment for age, gender, disease severity, and medication nonadherence.

RESULTS

In adjusted analyses, depression was associated with an increased all-cause mortality risk (hazard ratio 1.87; 95% confidence interval 1.04-3.37). Depression was not related to cardiovascular mortality, potentially because of a low number of cardiac-related deaths. When medication nonadherence was added to the model, nonadherence (hazard ratio 1.01; 95% confidence interval 1.004-1.02), but not depression, predicted all-cause mortality risk.

CONCLUSIONS

Depressive symptoms confer increased all-cause mortality risk in heart failure, and medication nonadherence contributes to this relationship. Depression and nonadherence represent potentially modifiable risk factors for poor prognosis. Future research is needed to understand whether interventions that concomitantly target these factors can improve outcomes. (PsycINFO Database Record

Smart Devices for Older Adults Managing Chronic Disease: A Scoping Review

BACKGROUND

The emergence of smartphones and tablets featuring vastly advancing functionalities (eg, sensors, computing power, interactivity) has transformed the way mHealth interventions support chronic disease management for older adults. Baby boomers have begun to widely adopt smart devices and have expressed their desire to incorporate technologies into their chronic care. Although smart devices are actively used in research, little is known about the extent, characteristics, and range of smart device-based interventions.

OBJECTIVE

We conducted a scoping review to (1) understand the nature, extent, and range of smart device-based research activities, (2) identify the limitations of the current research and knowledge gap, and (3) recommend future research directions.

METHODS

We used the Arksey and O'Malley framework to conduct a scoping review. We identified relevant studies from MEDLINE, Embase, CINAHL, and Web of Science databases using search terms related to mobile health, chronic disease, and older adults. Selected studies used smart devices, sampled older adults, and were published in 2010 or after. The exclusion criteria were sole reliance on text messaging (short message service, SMS) or interactive voice response, validation of an electronic version of a questionnaire, postoperative monitoring, and evaluation of usability. We reviewed references. We charted quantitative data and analyzed qualitative studies using thematic synthesis. To collate and summarize the data, we used the chronic care model.

RESULTS

A total of 51 articles met the eligibility criteria. Research activity increased steeply in 2014 (17/51, 33%) and preexperimental design predominated (16/50, 32%). Diabetes (16/46, 35%) and heart failure management (9/46, 20%) were most frequently studied. We identified diversity and heterogeneity in the collection of biometrics and patient-reported outcome measures within and between chronic diseases. Across studies, we found 8 self-management supporting strategies and 4 distinct communication channels for supporting the decision-making process. In particular, self-monitoring (38/40, 95%), automated feedback (15/40, 38%), and patient education (13/40, 38%) were commonly used as self-management support strategies. Of the 23 studies that implemented decision support strategies, clinical decision making was delegated to patients in 10 studies (43%). The impact on patient outcomes was consistent with studies that used cellular phones. Patients with heart failure and asthma reported improved quality of life. Qualitative analysis yielded 2 themes of facilitating technology adoption for older adults and 3 themes of barriers.

CONCLUSIONS

Limitations of current research included a lack of gerontological focus, dominance of preexperimental design, narrow research scope, inadequate support for participants, and insufficient evidence for clinical outcome. Recommendations for future research include generating evidence for smart device-based programs, using patient-generated data for advanced data mining techniques, validating patient decision support systems, and expanding mHealth practice through innovative technologies.

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

BACKGROUND

Worldwide at least 100 million people are thought to have prevalent cardiovascular disease (CVD). This population has a five times greater chance of suffering a recurrent cardiovascular event than people without known CVD. Secondary CVD prevention is defined as action aimed to reduce the probability of recurrence of such events. Drug interventions have been shown to be cost-effective in reducing this risk and are recommended in international guidelines. However, adherence to recommended treatments remains sub-optimal. In order to influence non-adherence, there is a need to develop scalable and cost-effective behaviour-change interventions.

OBJECTIVES

To assess the effects of mobile phone text messaging in patients with established arterial occlusive events on adherence to treatment, fatal and non-fatal cardiovascular events, and adverse effects.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, the Conference Proceedings Citation Index - Science on Web of Science on 7 November 2016, and two clinical trial registers on 12 November 2016. We contacted authors of included studies for missing information and searched reference lists of relevant papers. We applied no language or date restrictions.

SELECTION CRITERIA

We included randomised trials with at least 50% of the participants with established arterial occlusive events. We included trials investigating interventions using short message service (SMS) or multimedia messaging service (MMS) with the aim to improve adherence to medication for the secondary prevention of cardiovascular events. Eligible comparators were no intervention or other modes of communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. In addition, we attempted to contact all authors on how the SMS were developed.

MAIN RESULTS

We included seven trials (reported in 13 reports) with 1310 participants randomised. Follow-up ranged from one month to 12 months. Due to heterogeneity in the methods, population and outcome measures, we were unable to conduct meta-analysis on these studies. All seven studies reported on adherence, but using different methods and scales. Six out of seven trials showed a beneficial effect of mobile phone text messaging for medication adherence. Dale 2015a, reported significantly greater medication adherence score in the intervention group (Mean Difference (MD) 0.58, 95% confidence interval (CI) 0.19 to 0.97; 123 participants randomised) at six months. Khonsari 2015 reported less adherence in the control group (Relative Risk (RR) 4.09, 95% CI 1.82 to 9.18; 62 participants randomised) at eight weeks. Pandey 2014 (34 participants randomised) assessed medication adherence through self-reported logs with 90% adherence in the intervention group compared to 70% in the control group at 12 months. Park 2014a (90 participants randomised) reported a greater increase of the medication adherence score in the control group, but also measured adherence with an event monitoring system for a number of medications with adherence levels ranging from 84.1% adherence to 86.2% in the intervention group and 79.7% to 85.7% in the control group at 30 days. Quilici 2013, reported reduced odds of non-adherence in the intervention group (Odds Ratio (OR) 0.43, 95% CI 0.22 to 0.86, 521 participants randomised) at 30 days. Fang 2016, reported that participants given SMS alone had reduced odds of being non-adherent compared to telephone reminders (OR 0.40 95% CI 0.18 to 0.63; 280 patients randomised). Kamal 2015 reported higher levels of adherence in the intervention arm (adjusted MD 0.54, 95% CI 0.22 to 0.85; 200 participants randomised). Khonsari 2015 was the only study to report fatal cardiovascular events and only reported two events, both in the control arm. No study reported on the other primary outcomes. No study reported repetitive thumb injury or road traffic crashes or other adverse events that were related to the intervention.Four authors replied to our questionnaire on SMS development. No study reported examining causes of non-adherence or provided SMS tailored to individual patient characteristics.The included studies were small, heterogeneous and included participants recruited directly after acute events. All studies were assessed as having high risk of bias across at least one domain. Most of the studies came from high-income countries, with two studies conducted in an upper middle-income country (China, Malaysia), and one study from a lower middle-income country (Pakistan). The quality of the evidence was found to be very low. There was no obvious conflicts of interest from authors, although only two declared their funding.

AUTHORS' CONCLUSIONS

While the results of this systematic review are promising, there is insufficient evidence to draw conclusions on the effectiveness of text message-based interventions for adherence to medications for secondary prevention of CVD. Sufficiently powered, high-quality randomised trials are needed, particularly in low- and middle-income countries.

Developing and testing an electronic medication administration monitoring device for community dwelling seniors: a feasibility study

Background

Medication non-adherence, polypharmacy, and adverse drug events are major healthcare issues leading to significant morbidity, mortality, and healthcare expenditures. Currently, there are no methods to systematically track medication usage in community-dwelling seniors. The eDosette prototype was created to make medication use patterns visible via the Internet. This study aims to demonstrate feasibility, usability, and acceptability of the eDosette in community-dwelling seniors in primary care.

Methods

A 2-week feasibility study involving a convenience sample of 10 patients from an academic family medicine teaching unit in Hamilton, Ontario, Canada, was conducted over a 6-month period between April and October 2015. The eDosette transmitted hourly electronic data via the Internet on each participant’s pattern of medication use; this data was converted into an individualized medication administration record (MAR). Based on the MARs from the 10 participants, the frequency of missed medication doses, the time of dose administration, and each participant’s adherence rate for their prescribed medications could be determined. A medication adherence survey and a patient usability and acceptability survey were administered to all the participants of the study.

Results

The eDosette was able to record a participant’s medication use and transmit this data electronically via the Internet with sufficient quality to create participant-specific MARs. A total of 418 doses were captured by the eDosette throughout the study; only 5% (n = 22 doses) were missing information or had poor image quality. Analysis of the MARs revealed that 19% (n = 79 doses) were taken outside a 2-h window of the average dose administration time, and two doses were completely missed by all participants during this feasibility study. Participant feedback found the eDosette easy and acceptable to use. Participant feedback also identified hardware and software issues that require attention prior to a larger study.

Conclusions

The eDosette is a feasible and novel technology that can be successfully installed into the homes of community-dwelling seniors to help in monitoring actual medication use patterns. This study provided details for further device development and evidence to support the need for a larger pilot study on the eDosette’s impact on medication adherence.

Pillbox intervention fidelity in medication adherence research: A systematic review

BACKGROUND

Pillboxes are widely available, have evidence of effectiveness, but translating pillboxes in self-management interventions requires an understanding of intervention components.

PURPOSE

To review components of intervention design, interventionist training, delivery, receipt, enactment, and targeted behaviors in adherence studies.

METHODS

Five multidisciplinary databases were searched to find reports of controlled trials testing pillboxes and medication adherence interventions in adults managing medications. Details of treatment fidelity, that is, design, training, delivery, receipt, and enactment, were abstracted.

FINDINGS

A total of 38 articles reporting 40 studies were included. Treatment fidelity descriptions were often lacking, especially reporting receipt and enactment, important for both control and intervention groups. Clearly reported details are needed to avoid making assumptions when translating evidence.

CONCLUSION

These findings serve as a call to action to explicitly state intervention details. Lack of reported intervention detail is a barrier to translating which components of pillboxes work in influencing medication adherence behaviors and outcomes.

Comparing the effectiveness of the BPMAP (Blood Pressure Management Application) and usual care in self-management of primary hypertension and adherence to treatment in patients aged 30-60 years: study protocol for a randomized controlled trial

BACKGROUND

Hypertension is one of the most important and well-known risk factors for cardiovascular diseases. Unfortunately, in spite of effective treatments, adherence to the regular use of drugs and other nondrug treatments, such as lifestyle improvement, is often poor. This study evaluates the effectiveness of an educational, supportive intervention - in the form of a Blood Pressure Management Application (BPMAP) - on self-management in patients with primary hypertension on controlling the determinant factors of hypertension, and on adherence to treatment.

METHODS/DESIGN

A two-arm, parallel-design randomized controlled clinical trial will be conducted on 30 to 60 year-old patients with primary hypertension who are attending the Tehran Heart Center. One hundred and thirty-two (132) patients will be randomly assigned to the intervention and control (usual method) groups. The most important inclusion criteria are, having primary hypertension and being pharmacologically treated for it, and not having developed the complications of hypertension, such as myocardial infarction, cerebral stroke and cardiac insufficiency. The participants should be able to read Persian and be able to use the application. The most important outcomes of the study include adherence to treatment, weight control, and regular monitoring of blood pressure which are assessed in the primary assessment (baseline data questionnaire) and again at the 8th and 24th weeks. The intervention is a mobile application that has capabilities such as reminders and scientific and supportive information.

DISCUSSION

This application has been programmed to reduce many of the nonadherence factors of hypertension treatment. Therefore, the findings may contribute to a rise in adherence to treatment. If proven to have an appropriate impact, it may be extended for use in the national hypertension control plan.

TRIAL REGISTRATION

This study was registered in the Iran Randomized Clinical Trial Center under the number IRCT2015111712211N2 on 1 January 2016.

First steps in designing an all-in-one ICT-based device for persons with cognitive impairment: evaluation of the first mock-up

Background

This project Smart Assisted Living involving Informal careGivers++ (SALIG) intends to develop an ICT-based device for persons with cognitive impairment combined with remote support possibilities for significant others and formal caregivers. This paper presents the identification of the target groups’ needs and requirements of such device and the evaluation of the first mock-up, demonstrated in a tablet.

Methods

The inclusive design method that includes end-users in the design process was chosen. First, a scoping review was conducted in order to examine the target group’s need of an ICT-based device, and to gather recommendations regarding its design and functionalities. In order to capture the users’ requirements of the design and functionalities of the device three targeted focus groups were conducted. Based on the findings from the publications and the focus groups a user requirement specification was developed. After that a design concept and a first mock-up was developed in an iterative process. The mock-up was evaluated through interviews with persons with cognitive impairment, health care professionals and significant others. Data were analysed using content analysis.

Results

Several useful recommendations of the design and functionalities of the SALIG device for persons with cognitive impairment were identified. The main benefit of the mock-up was that it was a single device with a set of functionalities installed on a tablet and designed for persons with cognitive impairment. An additional benefit was that it could be used remotely by significant others and formal caregivers.

Conclusion

The SALIG device has the potentials to facilitate everyday life for persons with cognitive impairment, their significant others and the work situation for formal caregivers. The results may provide guidance in the development of different types of technologies for the target population and for people with diverse disabilities. Further work will focus on developing a prototype to be empirically tested by persons with cognitive impairment, their significant others and formal caregivers.